Denervation of the extrinsic cardiac sympathetic nervous system as a treatment modality for arrhythmia.

Denervation of the extrinsic cardiac sympathetic nervous system is a method of altering the autonomic tone experienced by the heart and vasculature. It has been studied and employed as a therapy for cardiac disease for decades. Currently, there is a high level of interest in using cardiac denervation for treatment of arrhythmias. This review describes the anatomy and physiology of the cardiac autonomic nervous system followed by a discussion of the mechanistic studies which provide a basis for the therapeutic use of sympathetic denervation. The clinical research supporting its use in human arrhythmias is then appraised, covering the standard indications, such as long QT syndrome, as well as future possibilities. Last, a detailed account of the methods for performing surgical cardiac denervation and percutaneous stellate ganglion anesthetic block is provided, including the complications of each procedure. An understanding of the anatomy and physiology of the cardiac autonomic nervous system along with the techniques of surgical denervation and percutaneous anesthetic block will allow the clinician to effectively discuss and implement these therapies.

Dual-epidural catheter technique and perioperative outcomes after Ivor-Lewis esophagectomy.

BACKGROUND: Ivor-Lewis esophagectomy is associated with significant postoperative analgesic requirements and perioperative complications. A dual-epidural technique may improve perioperative outcomes compared with single thoracic epidural analgesia. METHODS: This study identified all cases of Ivor-Lewis esophagectomy over a 3-year period. Eighty-one patients undergoing Ivor-Lewis esophagectomy who received general anesthesia supplemented by neuraxial analgesia with dual-epidural catheters (DECs) were matched 1:1 with patients who received general anesthesia and a single thoracic epidural catheter. Primary outcomes included quality of analgesia at rest and with movement on each of the first 3 postoperative days. Secondary outcomes included adverse events and the incidence of 4 major postoperative complications (anastomotic leak, pulmonary complications, atrial fibrillation, and sepsis). RESULTS: A DEC technique significantly improved analgesia (evidenced by reduced pain with movement on each of the first 3 postoperative days) when compared with a single epidural catheter technique. The placement of DECs did not increase catheter-related adverse events. A DEC technique was associated with a 50% reduction in the combined rate of major postoperative complications (36% vs. 18%; odds ratio, 0.40; P = 0.01) and increased number of hospital-free days measured at day 28 (21.2 vs. 22.3; P = 0.04). CONCLUSIONS: The DEC technique improved postoperative analgesia and reduced the incidence of major postoperative complications and hospital length of stay in patients undergoing Ivor-Lewis esophagectomy. Future studies should evaluate the efficacy of this technique in a controlled randomized clinical trial.

"Broken heart syndrome" after separation (from OxyContin).

We describe a 61-year-old woman with "broken heart syndrome" (Takotsubo-like cardiomyopathy) after abrupt postsurgical withdrawal of OxyContin. Her medical history was remarkable for long-term opiold dependence associated with the treatment of multi-Joint degenerative osteoarthritis. The patient presented to the emergency department 1 day after discharge from the hospital following total knee arthroplasty revision with acute-onset dyspnea and mild chest pain. She had precordial ST-segment elevation characteristic of acute myocardial infarction and elevated cardiac biomarkers. Emergency coronary angiography revealed no major coronary atherosclerosis. However, the left ventricular ejection fraction was severely decreased (26%), and new regional wall motion abnormalities typical of broken heart syndrome were noted. In addition to resuming her opioid therapy, she was treated supportively with bilevel positive airway pressure, diuretic therapy, morphine, aspirin, metoprolol, enalaprilat, intravenous heparin, nitroglycerin infusion, and dopamine infusion. Ventricular systolic function recovered completely by the fourth hospital day. To our knowledge, broken heart syndrome after opioid withdrawal has not been reported previously in an adult. Our case illustrates the importance of continuing adequate opiate therapy perioperatively in the increasing number of opioid-dependent patients to prevent potentially life-threatening complications such as broken heart syndrome.

Epidural abscess and meningitis after epidural corticosteroid injection.

Epidural abscess with and without associated meningitis after epidural corticosteroid injections for radicular back pain is a rarely reported complication. We report the occurrence of an epidural abscess and meningitis in a 70-year-old man after 2 epidural corticosteroid injections for treatment of acute radicular lumbar back pain. At the time of diagnosis, cerebrospinal fluid cultures grew Staphylococcus aureus, and the patient was treated with intravenous antibiotics. Possible predisposing factors for the development of an epidural abscess and meningitis in this patient include a 2-year history of neutropenia and an accidental dural puncture that occurred during performance of the first epidural injection. A literature search identified 11 reported cases of epidural abscess, 2 of epidural abscess and meningitis, and 1 of meningitis attributed to epidural corticosteroid injections. Eight of the 14 reported patients were immunocompromised, and 8 (67%) of the 12 in whom cultures of blood, cerebrospinal fluid, or epidural pus were performed had results positive for S. aureus. Antibiotic prophylaxis for S. aureus should be considered for immunocompromised patients undergoing epidural corticosteroid injections.

Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial.

CONTEXT: Pancreatic cancer is an aggressive tumor associated with high mortality. Optimal pain control may improve quality of life (QOL) for these patients. OBJECTIVE: To test the hypothesis that neurolytic celiac plexus block (NCPB) vs opioids alone improves pain relief, QOL, and survival in patients with unresectable pancreatic cancer. DESIGN, SETTING, AND PATIENTS: Double-blind, randomized clinical trial conducted at Mayo Clinic, Rochester, Minn. Enrolled (October 1997 and January 2001) were 100 eligible patients with unresectable pancreatic cancer experiencing pain. Patients were followed up for at least 1 year or until death. INTERVENTION: Patients were randomly assigned to receive either NCPB or systemic analgesic therapy alone with a sham injection. All patients could receive additional opioids managed by a clinician blinded to the treatment assignment. MAIN OUTCOME MEASURES: Pain intensity (0-10 numerical rating scale), QOL, opioid consumption and related adverse effects, and survival time were assessed weekly by a blinded observer. RESULTS: Mean (SD) baseline pain was 4.4 (1.7) for NCPB vs 4.1 (1.8) for opioids alone. The first week after randomization, pain intensity and QOL scores were improved (pain intensity, P< or =.01 for both groups; QOL, P<.001 for both groups), with a larger decrease in pain for the NCPB group (P =.005). From repeated measures analysis, pain was also lower for NCPB over time (P =.01). However, opioid consumption (P =.93), frequency of opioid adverse effects (all P>.10), and QOL (P =.46) were not significantly different between groups. In the first 6 weeks, fewer NCPB patients reported moderate or severe pain (pain intensity rating of > or =5/10) vs opioid-only patients (14% vs 40%, P =.005). At 1 year, 16% of NCPB patients and 6% of opioid-only patients were alive. However, survival did not differ significantly between groups (P =.26, proportional hazards regression). CONCLUSION: Although NCPB improves pain relief in patients with pancreatic cancer vs optimized systemic analgesic therapy alone, it does not affect QOL or survival.