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Abstract
High Thoracic Epidural Analgesia (HTEA) is hypothesized to act directly through its effects on the cardiac afferent sympathetic nerves and act indirectly by altering determinants of coronary flow and myocardial demands. This eventually results in improvement of regional and global ventricular function in ischemic patients. The aim of the study was to determine the hemodynamic effects, changes in myocardial functions associated with HTEA, and also its effect on pain relief.
Patients and methods:- A total of 64 patients with acute coronary syndrome (recent MI or unstable angina) who did not receive thrombolytic treatment or anticoagulants were studied’. After patients cannulation and sampling, the electrodes of the trans-thoracic myocardial bio-impedance were applied and baseline readings were recorded. Patients received thoracic epidural analgesia through the thoracic 3-4 or 4-5 interspaces that allowed bilateral neuraxial block of T1-T5. 1.5 ml of analgesic solution was given per segment ”average volume 6-10 ml of Bupivacaine0.25% and 1-2 mg Morphine sulphate” titrated to maintain analgesia with a sensory level of Tl-2 dermatome. Anticoagulants were administered 60 min. after catheter insertion. Measurements were taken on patient admission, and at 2,3,12,24,48 hours after epidural injection.
Results: The pain relief, as indicated by a significant decrease in the visual analogue scores in group 1 and group 3 compared with group 2 and 4 (l.4±l.l) and (3.1±0.9) to (5.2±1.0) and (4.9±0.6), respectively, was accompanied by a decrease in heart rate and a slight decrease then stability of mean blood pressure, indicating cardiac sympathetic blockade. These changes were associated with a significant decrease of the mean levels of systemic vascular index and end diastolic volume index in group 1 and 3 with a significant increase in ejection fraction and stability in cardiac index mean values in both groups respectively. Total intravenous morphine consumption was significantly reduced in patients in group 1 and 3 compared to the patients in groups 2 and 4 throughout the first 48 hours after admission (l0±6.45 and 10±4.91 to 25±7.46 and 35±6.01, respectively).
Conclusion: HTEA is beneficial in early management of patients with acute coronary syndrome either unstable angina or acute myocardial infarction as it offers significant dramatic pain relief associated with hemodynamic improvement and stability without significant side effects that would limit its use among such patients..