Effect of thoracic epidural analgesia on refractory angina pectoris: long-term home self-treatment

Effects of thoracic epidural analgesia on exercise-induced myocardial ischaemia in refractory angina pectoris

BACKGROUND

Thoracic epidural analgesia (TEDA) was offered to patients with refractory angina pectoris. Our primary objectives were to evaluate TEDAs´ influence on quality of life (QoL, base for power analysis), and hypothesising that TEDA with bupivacaine during 1 month counteracts exercise-induced myocardial hypoperfusion and increase physical performance.

METHODS

Patients with refractory angina and exercise inducible hypoperfusion, as demonstrated by myocardial perfusion imaging (MPI), were randomised to 1-month treatment with TEDA with bupivacaine (B-group, n = 9) or saline (P-group, n = 10) in a double-blind fashion. MPI and bicycle ergometry were performed before TEDA and after 1 month while subjective QoL on a visual analogue scale (VAS) reported by the patients was checked weekly.

RESULTS

During this month VAS (mean [95%CI]) increased similarly in both groups (B-group from 33 [18-50] to 54 [30-78] P < 0.05; P-group from 40 [19-61] to 48 [25-70] P < 0.05). The B-group reduced their exertional-induced myocardial hypoperfusion (from 32% [12-52] to 21% [3-39]; n = 9; P < 0.05), while the P-group showed no significant change (before 21% [6-35]; at 1 month 23% [6-40]; n = 10). MPI at rest did not change and no improvement in physical performance was detected in neither of the groups.

CONCLUSIONS

In refractory angina, TEDA with bupivacaine inhibits myocardial ischaemia in contrast to TEDA with saline. Regardless of whether bupivacaine or saline is applied intermittently every day, TEDA during 1 month improves the quality of life and reduces angina, even when physical performance remains low. A significant placebo effect has to be considered.

Treatment of Inoperable Coronary Disease and Refractory Angina: Spinal Stimulators, Epidurals, Gene Therapy, Transmyocardial Laser, and Counterpulsation

Intractable angina from refractory coronary disease is a severe form of myocardial ischemia for which revascularization provides no prognostic benefit. Inoperable coronary disease is also accompanied by a “vicious cycle” of myocardial dystrophy from a chronic alteration of the cardiac sympathetic tone and sensitization of damaged cardiac tissues. Several adjunctive treatments have demonstrated efficacy when revascularization is either unsuccessful or contraindicated. Spinal cord stimulation modifies the neurologic input and output of the heart by delivering a very low dose of electrical current to the dorsal columns of the high thoracic spinal cord. Neural fibers then release CGRP and other endogenous peptides to the coronary circulation reducing myocardial oxygen demand and enhancing vasodilation of collaterals to improve the myocardial blood flow of the most diseased regions of the heart. Randomized study has shown the survival data at five years is comparable to bypass for high-risk patients. Transmyocardial laser revascularization creates small channels into ischemic myocardium in an effort to enhance flow though studies have shown no improvement in prognosis over medical therapy alone. Enhanced external counterpulsation uses noninvasive pneumatic compression of the legs to improve diastolic filling of the coronary vessels and promote development of collateral flow. The compressor regimen requires thirty-five hours of therapy over a seven-week treatment period. Therapeutic angiogenesis requires injection of cytokines to promote neovascularization and improve myocardial perfusion into the regions affected by chronic ischemia. Phase 3 trials are pending. High thoracic epidural blockade produces a rapid and potent sympatholysis, coronary vasodilation and reduced myocardial oxygen demand in refractory coronary disease. This technique can be used as an adjunct to bypass surgery or medical therapy in chronic or acute unstable angina. Epidurals are easy to perform and often available for outpatient or inpatient use. The rapid anti-ischemic effect may complement therapeutic angiogenesis or other interventions with delayed onset to clinical benefit. A new era for interventional and implant cardiology is beginning to emerge as more clinicians, including cardiologists, gradually learn new procedures to safely provide more therapeutic options for patients suffering refractory angina.

Impact of epidural analgesia on quality of life and pain in advanced cancer patients

Patients with advanced cancer often experience chronic postoperative pain and poor quality of life. The objective of this study was to determine if epidural self-controlled analgesia reduced the incidence of chronic pain and improved the quality of life when compared with intravenous self-controlled analgesia. A total of 50 patients diagnosed with advanced cancer who received analgesia treatment were randomly divided into two groups, epidural self-controlled analgesia group (EA group, n = 26) and intravenous self-controlled analgesia group (IA group, n = 24). Visual analog scale (VAS) and Karnofsky score were used to assess the pain and the quality of life, respectively. A multifunction monitor was used to continuously record the physical signs of patients after treatment. The physical signs, such as heart failure, respiration, pulse, blood pressure, and oxygen saturation, in the two groups were better after analgesia treatment. Meanwhile, the respiration and oxygen saturation in the EA group were significantly improved compared with that of the IA group (p < .05). The VAS in the EA group was significantly lower than that in the IA group (p < .05), and the Karnofsky score in the EA group was significantly higher than that in the IA group (p < .05). Moreover, patients treated with EA felt more satisfied and experienced fewer complications than those with IA (p < .05). The epidural self-controlled analgesia may greatly improve the quality of life and relieve the pain in patients with advanced cancer.

Interventional treatment of pain in refractory angina. A review

BACKGROUND

Refractory angina is characterized by repeated attacks of chest pain in patients on maximal anti-anginal pharmacotherapy, with a professional conscensus that further surgical or radiological revascularization would be futile. Refractory angina is a serious but relatively uncommon health problem, with a reported incidence of approximately 30 patients per million people/year. In this condition simply treating the associated pain alone is important as this can improve exercise tolerance and quality of life.

METHODS

An extensive literature search using five different medical databases was performed and from this, eighty-three papers were considered appropriate to include within this review.

RESULTS AND CONCLUSION

Available literature highlights several methods of interventional pain treatment, including spinal cord stimulation and video-assisted upper thoracic sympathectomy which can provide good analgesia whilst improving physical activities and quality of life. The positive effect of spinal cord stimulation on the intensity of pain and quality of life has been confirmed in nine randomized controlled trials. Other potential treatment methods include stellate ganglion blocks, insertion of thoracic epidural or spinal catheters and transcutaneous electrical nerve stimulation. These approaches however appear more useful for diagnostic purposes and perhaps as short-term treatment measures.

Regional anesthesia and analgesia in critically ill patients: a systematic review

Regional anesthesia has become invaluable for the treatment of pain during and after a wide range of surgical procedures. However, its benefits in the nonsurgical setting have been less well studied. Regional anesthesia is an appealing modality for critically ill patients, providing focused and sustained pain control with beneficial systemic effect profiles. Indications for regional anesthesia in this patient group are not limited to surgical and postsurgical analgesia but expand to the management of trauma-related issues, medical conditions, and painful procedures at the bedside. Patients in the critical care unit present special challenges to the regional anesthesiologist, including coagulopathies, infections, immunocompromised states, sedation- and ventilation-associated problems, and factors potentially increasing the risk for systemic toxicity. This review is intended to evaluate the role of regional anesthesia in critically ill patients, to discuss potential benefits, and to provide a summary of the published evidence on the subject.

The anaesthesiologist in the intensive care unit

PURPOSE OF REVIEW

This review focuses on recent knowledge in areas of anaesthesia expertise which are indispensable to intensive care unit management, including airway management, vascular access, regional analgesia and the treatment of status asthmaticus and status epilepticus.

RECENT FINDINGS

Etomidate as the sole agent for intubation in the intensive care unit has a 90% success rate, while in a prehospital setting, the addition of succinylcholine to etomidate results in a 99% success rate. In determining successful intubation, capnography and laryngoscopic/fibreoptic visualization are superior to auscultation, while auscultation is as effective as the self-inflating bulb or transillumination with the lightwand. The dorsalis pedis artery is an effective alternative to radial artery cannulation, while arterial cannulation itself can result in major adverse effects if complications arise. Ultrasound guidance in the placement of central catheters results in an improved insertion success rate. Internal jugular and subclavian lines have similar risk of haemothorax or pneumothorax, while subclavian lines are associated with the lowest incidence of infection. Midazolam, thiopentone and propofol have all been found to be efficacious in terminating refractory status epilepticus, with thiopentone resulting in a lower incidence of breakthrough seizures or treatment failure but an increased incidence of hypotension. Inhalational anaesthesia using isoflurane or desflurane has also been found to be successful in refractory status epilepticus. In the management of status asthmaticus, limiting minute volume while tolerating hypercapnia and acidosis as well as the use of inhalational anesthesia have proven effective strategies in a number of refractory cases.

SUMMARY

The anaesthesiologist's unique knowledge and skills are ideally suited to the practical management of patients in a critical care setting as well as in the treatment of the critical phases of many illnesses.

The critically ill patient and regional anesthesia

PURPOSE OF REVIEW

The review presents an overview of indications, limitations and practical aspects of regional anesthesia and analgesia in critically ill medical and surgical patients.

RECENT FINDINGS

A Medline search from 1966 to 2006 with the search terms regional anesthesia, regional analgesia, critically ill and nerve blocks, as well as a search of the Cochrane Library, revealed no studies specifically designed to evaluate the use of regional anesthesia and analgesia in the intensive care unit setting. The available evidence is limited to case reports, cohort studies and expert opinions, and relies heavily on extrapolation from studies primarily designed to examine intraoperative management of surgical patients in whom an intensive care unit admission was part of the perioperative course.

SUMMARY

Regional anesthesia and analgesia in the critically ill can help to improve respiratory function, bowel function, mental status and patient comfort secondary to its opioid-sparing effects. Limitations for the use of regional anesthetic techniques are mainly associated with bleeding risks, hemodynamic side-effects, difficulties in neurologic assessment and the potential of local anesthetic toxicity.

One year follow-up of patients with refractory angina pectoris treated with enhanced external counterpulsation

Background

Enhanced external counterpulsation (EECP) is a non-invasive technique that has been shown to be effective in reducing both angina and myocardial ischemia in patients not responding to medical therapy and without revascularization alternatives. The aim of the present study was to assess the long-term outcome of EECP treatment at a Scandinavian centre, in relieving angina in patients with chronic refractory angina pectoris.

Methods

55 patients were treated with EECP. Canadian cardiovascular society (CCS) class, antianginal medication and adverse clinical events were collected prior to EECP, at the end of the treatment, and at six and 12 months after EECP treatment. Clinical signs and symptoms were recorded.

Results

EECP treatment significantly improved the CCS class in 79 ± 6% of the patients with chronic angina pectoris (p < 0.001). The reduction in CCS angina class was seen in patients with CCS class III and IV and persisted 12 months after EECP treatment. There was no significant relief in angina in patients with CCS class II prior to EECP treatment. 73 ± 7% of the patients with a reduction in CCS class after EECP treatment improved one CCS class, and 22 ± 7% of the patients improved two CCS classes. The improvement of two CCS classes could progress over a six months period and tended to be more prominent in patients with CCS class IV. In accordance with the reduction in CCS classes there was a significant decrease in the weekly nitroglycerin usage (p < 0.05).

Conclusion

The results from the present study show that EECP is a safe treatment for highly symptomatic patients with refractory angina. The beneficial effects were sustained during a 12-months follow-up period.

High thoracic epidural anesthesia and coronary artery disease in surgical and non-surgical patients

PURPOSE OF REVIEW

Even though high thoracic epidural anesthesia has been shown to be highly efficacious in the control of symptoms in refractory angina, its general use is still restricted. In patients who undergo coronary revascularization, however, the technique is becoming more and more popular. The present review outlines the use of high thoracic epidural anesthesia in patients with ischemic heart disease who underwent coronary revascularization in order to further reveal high thoracic epidural anesthesia's low complication rate and to analyze why physicians still refrain from using it more frequently.

RECENT FINDINGS

The incidence of severe hemodynamic complications after high thoracic epidural anesthesia is low in patients with coronary artery disease. The main advantage would be a myocardial sympathectomy leading to an improvement in the oxygen input-demand relationship. Likewise, a decrease in mortality due to respiratory complications could not be shown. In patients undergoing myocardial revascularization with full anticoagulation there is an increased risk of epidural hematoma formation. Its precise risk is difficult to evaluate. There is an overall low rate of epidural hematomas as a result of high thoracic epidural anesthesia. With the available data, the incidence has been estimated at between 1/1500 and 1/10,000.

SUMMARY

Epidural anesthesia does not decrease mortality or the incidence of myocardial infarction after coronary artery bypass grafting. It reduces the incidence of arrhythmias and respiratory complications and improves the quality of analgesia. High thoracic epidural anesthesia has been shown to be a safe and efficient technique for refractory angina that reduces the frequency of ischemic events and improves the clinical condition of patients.

Pain management strategies for patients undergoing extrapleural pneumonectomy

The role of anesthetic or analgesic technique in outcome remains controversial. The choice of anesthetic and postoperative analgesic plan plays a small, albeit important, role in perioperative care and a multimodal rehabilitation program. Pulmonary complications are the most important cause of morbidity and mortality after EPP. There is increasing evidence that TEA with local anesthetic agents and opioids is superior for the control of dynamic pain, plays a key role in early extubation and mobilization, reduces postoperative pulmonary complications, and has the potential to decrease the incidence of PTPS.