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IS EPIDURAL ANAESTHESIA PANACEA?
D V Meher
Hon. Anaesthetist (Retd), JJ Group of Hospitals, Mumbai, Bombay Hospital, Mumbai

Shock and other critically ill patients with variety of diseases like burns, sepsis, haemorrhage, gangrene as well as cardiac, pulmonary, hepatic and renal diseases were treated with epidural anaesthesia. The effect was dramatic and miraculous. These patients did not require ICU, ventilatory support, antibiotics, multiplicity of drug therapy, sophisticated equipment to monitor cardiorespiratory function or costly investigations. The rationale is ‘hypoxia is the most important and perhaps the ultimate mechanism of disease’. Hypoxia means decrease in intracellular concentration of oxygen leading to decline in ATP production, cellular dysfunction and disease. Epidural anaesthesia produces vasodilation, hyperperfusion of tissues and cells and corrects tissue hypoxia and cures the disease. Therefore, one can logically conclude that epidural anaesthesia is panacea. It is not a mere fantasy. It is, slowly but certainly, an emerging reality.

INTRODUCTION

Generally, epidural anaesthesia (EA) is used for surgery and painless labour and delivery. It was during my practice of EA for painless labour, I came across patients associated with valvular heart disease, who are prone to ischaemic pain (angina) especially during stress. Here, I observed that the moment EA was administered for relief of labour pain the myocardial ischaemic pain disappeared dramatically (case 3). This inspired me to use EA in acute myocardial ischaemic pain in coronary artery disease. Here also the effect was dramatic as described in case report (case 5). EA was administered to a severe eclamptic patient. The convulsions stopped immediately. This encouraged me to use EA in severe tetanus and surprisingly, it produced dramatic effect. [1] Eclamptic patients are oliguric or anuric. After EA this patient secreted large quantity of urine. This surprised the plastic surgeon in whose nursing home this eclamptic patient was delivered under EA. He said, our burns patients also have the problem of oliguria or anuria. So, I decided to try EA in burns to produce diuresis. The effect was dramatic and miraculous. The burn wound which was exudating profusely, inspite of antibiotics and antishock treatment for three days, became absolutely dry within 24h (case 1) The paper was presented in international conf. On burns 1980. An asthmatic patient was in labour. She was being treated by physician with aminophylline and antibiotics. However, she did not get any relief nor could she make any progress in labour. In order to relieve her of labour distress, EA was administered. Soon after EA, asthma disappeared and she started breathing spontaneously, adequately and easily, and she delivered half an hour later. Asthmatic attack did not recur during her stay in hospital. This encouraged me to use EA to treat severe asthma, severe bronchospasm due to any cause, aspiration pneumonitis and chronic obstructive pulmonary disease. Here also the effect was dramatic (case reports). EA was administered in labour to a patient who was suffering from hepatitis. She delivered safely without expected postpartum haemorrhage. Surprisingly, she also recovered from hepatitis.

Hyperperfusion of affected liver cells after EA might have cured the disease. Brody et a [2] have demonstrated, in animal experiment that C Cl4 is not directly poisonous to liver. Sympathetic hyperactivity caused by the drug produces vaso-constriction, hypoperfusion and hypoxia of liver cells and necrosis. In denervated animal the drug did not produce any changes in liver cells. Necrosis was not seen even microscopically. This suggests that impaired tissue perfusion leading to hypoxia is the main cause of disease (hepatitis).

CASE REPORTS

Case 1

A 35 year man was in septic shock following severe burns (55 per cent body surface area involving arms, chest and thighs). On the fourth day of admission, he was profusely exudating from the burn wound despite antibiotics and antishock treatment for four days. After proper consent, EA (a single dose, 10 ml of 0.3 per cent bupivacaine hydrochloride) was administered in the second thoracic space to relieve pain and produce diuresis. Immediately after EA, which was administered in lying down position, the patient sat up in bed and grinned. This was followed by a miraculous response the next day. The infected and exudating burn surface was found absolutely dry. EA controlled shock. The increased tissue perfusion following EA improved cellular function and enhanced immune response. Exudation stopped and infection controlled by anti bacterial substances reaching the site of infection.

Case 2

A 22 year woman was admitted with septic shock due to septic peritonitis. Pus from peritoneal cavity was drained per vaginum under EA (10 ml of 0.5% bupivacaine hydrochloride injected at 4h interval through epidural catheter placed in lumbar region). Anaesthesia was continued for 12h (10 ml of 0.3% bupivacaine hydrochloride injected at 4h interval). After 12h of continuous EA the patient looked perfectly normal. The shock syndrome vanished. She complained that she was hungry and asked for food which was allowed. This suggests a remarkable recovery, from septic shock, just after 12h of continuous EA. Improved tissue perfusion after EA, improved GI tract function along with improvement in functions of other organs. Next day she was operated for hysterectomy. However, on the third day postoperatively, she developed septic shock with multiple organ failure which did not respond to intensive therapy, given earlier for three days, with mechanical ventilation and antibiotics. Therefore, EA (10 ml of 0.3% bupivacaine hydrochloride) was administered on 6th day of operation. The effect was dramatic. Urine flow resumed promptly along with improvement in haemodynamics. Pulmonary insufficiency relieved, infection controlled, metabolic derangement and electrolyte imbalance corrected. EA (10 ml of 0.3% bupivacaine hydrochloride as top-up doses at 4h interval) was continued for 48h. She recovered completely. This suggests that EA is most rationale and effective treatment of postoperative shock and therefore must be continued after major surgery.

Case 3

A 19 year primigravida with aortic incompetence was in respiratory distress (cardiac asthma) during labour. Her respiratory rate was 60 per minute, pulse rate 120 and arterial pressure 140/40 mm Hg. She complained of severe pain in the chest. As soon as EA was administered for caesarean operation (14 ml of 0.5% bupivacaine hydrochloride) she was totally free from pain in the chest. This suggests an unloading effect on embarrassed heart of peripheral vasodilation following EA. This unloading therapy is very powerful tool to optimize cardiac performance and prevent occult and insidious subendocardial ischaemic injury. During operation her arterial pressure ranged between 100 and 80 mm Hg systolic. Her pulse rate was 85 per minute. Haemodynamics remained stable after completion of operation. Anginal pain is a frequent accompaniment of valvular diseases. With the stress of labour superimposed on cardiac lesion the patient was in severe distress due to anginal pain and not because of labour pain since the patient expressed her desire to deliver vaginally provided her chest pain was relieved. EA protects cardiac patient against consequences of stress namely, congestive cardiac failure, pulmonary oedema and death.

Case 4

A 30 year primigravida had developed C.C.F. in 7th month of her pregnancy. She was treated successfully. When she was admitted with labour pains, at full term, her systolic BP was 140 mm Hg. Pulse rate was 110 and her neck veins were distended. She had aortic regurgitation. After EA her BP was 120/60 and pulse rate 96 per minute. During second stage of labour, she was monitored by the cardiologist who was thrilled to see the improved E.C.G. pattern and haemodynamic stability. Her delivery was uneventful. The protection of diseased myocardium provided by EA, instilled so much confidence in the cardiologist that when he attended a similar type of patient with cardiac disease who was being delivered under EA, he did not bother to monitor the heart. When asked pointedly, he put his hand on patient’s pulse and said ‘there is no need.’

Case 5

A 55 year man was admitted with myocardial ischaemic pain. When three days of conventional therapy failed to give him complete relief from pain, EA (16 ml of 0.3% bupivacaine hydrochloride) a single dose was administered through epidural catheter placed in lumbar region. He got immediate and com plete relief from pain in the chest. His systolic BP decreased from 150 mm Hg to 110, but remained unchanged thereafter. He slept soundly through the night. EA was repeated on the next two days even though he was free from symptoms. He was discharged from the hospital after complete recovery. EA decreases myocardial contractility, heart rate preload and afterload - a potent source of ischaemia.

Case 6

An 18 year patient looked very ill and toxic. He had high fever, tachycardia and tachypnoea. There were signs of congestion in the lungs. His BP was 115 mm Hg systolic. Lumbar EA (a single dose, 14 ml of 0.5% bupivacaine hydrochloride) was administered for laparotomy for closure of perforated intestinal ulcers - a complication of typhoid fever. During operation, his BP, pulse and respiratory rate had decreased but were within normal limit and stable. He did not require postoperative intensive care. He recovered completely.

Case 7

A 45 year woman was operated under general anaesthesia for subacute obstruction following hysterectomy. On completion of operation, the tracheal tube was removed after complete reversal of myoneural blocking drug and thorough toileting of pharynx and trachea. However, she got cyanosed after a short while. Therefore, she was ventilated for some time and allowed to breath spontaneously. The author noticed the patient breathing laboriously. The auscultation of chest confirmed the presence of severe bronchospasm. Immediately, EA, a single dose (16 ml of 1% lignocaine hydrochloride) was administered through lumbar region. The effect was dramatic. She started breathing spontaneously, easily and adequately, to maintain pink colour without oxygen. Wheezing had disappeared. Despite such dramatic effect the EA therapy had to stop on the advise of patient’s physician. She was later, kept on ventilator for a week.

Case 8

A 38 year woman with chronic asthma was admitted for radium insertion in cervical canal. Aminophylline drip was started as a precautionary measure. Thiopentone injection (1/4 gm in 10 ml) was injected iv and the operation proceeded. The patient was oxygenated with face mask. However, the author could not inflate the lungs. The patient became blue. Bronchospasm did not respond to direct injection of aminophylline and hydrocortisone. Therefore, she was immediately turned on a side and 16 ml of 1% lignocaine hydrochloride was administered epidurally through lumbar region. The moment she was on her back, she started breathing spontaneously, easily and adequately and maintained her pink colour without oxygen. EA is the most rational and effective treatment for asthma as well as chronic obstructive pulmonary disease.

Case 9

A 32 year woman was admitted with trismus, tonic rigidity and severe reflex muscle spasms. Despite antitetanus therapy, spasms continued. She was looking anxious with perspiration all over. She was turned on a side and thoracic EA (10 ml of 0.3% bupivacaine hydrochloride) was administered. The moment she was on her back, the spasms stopped. She relaxed and started breathing spontaneously and easily and adequately. She folded her hands in gratitude and asked for water to drink. Drinking did not provoke spasms. Thus, feeding problem was solved. Her haemodynamics were stable. EA was continued until she was completely free from spasms. Post tetanus complications were absent. The contrast between wide awake and cooperative patient under EA and comatose patient under heavy sedation and total paralysis with IPPV who despite skilled nursing is liable to develop pulmonary complication, is most striking. Besides, underlying disease, sympathetic hyperactivity, continues unabated.

Case 10

A 22 year woman was admitted with severe dyspnoea. Her nails were blue despite oxygen given by nasal catheter. She could not lie down because of respiratory distress. She was three months pregnant and was to undergo termination of pregnancy. As soon as lumbar EA (10 ml of 0.5% of bupivacaine hydrochloride) was administered, in sitting posture, she started breathing easily and adequately. She grinned and lay down quietly. Her nails turned pink without oxygen. She was suffering from chronic obstructive pulmonary disease (COPD).

Case 11

A 76 year woman was admitted with gangrene of both legs. She was severely diabetic with the history of myocardial ischaemia. The wound was oozing profusely, despite antibiotics and antidiabetic treatment given earlier for three days. The dressing had to be changed frequently. Lumbar EA (10 ml of 0.3% bupivacaine hydrochloride) was administered on fourth day of admission. The next day the wound was dry. Improved tissue perfusion, following EA improved cellular and immune function. Exudation stopped, infection controlled and recovery process hastened.

Case 12

Eclampsia is a life threatening disease. It is an excellent example of multiple organ failure syndrome which responds dramatically to EA. A patient, 30 year-old was admitted with history of severe headache, epigastric pain and blurring of vision. Her BP was 200/110 mm Hg. She was unconscious and developed convulsions in nursing home.

Convulsions stopped immediately after lumber EA. Her BP decreased to 100 mm Hg systolic. Rapid infusion of 5% glucose in water, prevented further drop in BP. Within an hour after EA she delivered spontaneously. Her haemodynamics remained stable. She passed large quantity of urine. Next day she was conscious and almost normal. EA brings about miraculous transformation in such a major and potentially lethal disease. There is no need for multiplicity of drug therapy advocated by some specialists.

Case 13

A 35 year woman was operated for tuberculoma of caecum. Postoperatively, she developed faecal fistula. She was languishing in the hospital for almost a month because she could not be operated for repair of fistula since she had developed cachexia along with bedsores which did not respond to antibiotics. However, on author’s suggestion, she was operated under EA. The operation was successful but what is more surprising was that the bedsores which did not respond to antibiotics, healed. The patient, who had become cachectic, improved beyond recognition just two weeks after operation. Increased tissue perfusion and oxygenation that follows EA, increases generation of immunoproteins, improves systemic immunity and eliminates infection. This is the most beneficial effect of EA where antibiotics have failed to control infection.

Case 14

A 32 year parturient was in haemorrhagic shock following uterine rupture. She was pale and sweating profusely. Her pulse barely perceptible. She was resuscitated by infusion of 500 ml of fresh blood. When her BP was around 80 mm Hg systolic EA (14 ml of 0.5% bupivacaine hydrochloride) was administered for laparotomy. Intravenous infusion of 5% dextrose in water was allowed to run rapidly. Her BP decreased to 65 mm Hg systolic. Within next five minutes it further decreased to 60 mm Hg but thereafter remained steady during operation. Pulse rate was 80 per minute but with wide pulse pressure. Laparotomy revealed a foetus within placenta lying in the peritoneal cavity which was full of liquor mixed with blood. The uterus with transverse tear, was firmly contracted. No active bleeding was seen. After quick subtotal hysterectomy, 500 ml of blood was infused rapidly. At the close of operation, her BP was 80 mm Hg systolic. Postoperative recovery was excellent.

Pathophysiology

Shock is an extreme form of critical illness. Shock and critical illness begin with circulatory impairment leading to hypoxia of tissues and cells ] Tissue hypoxia is frequently seen in critically ill patients Sludging is the most dominant phenomenon seen in shock and critically ill. It impairs tissue perfusion and produces tissue hypoxia. [4,6] Tissue hypoxia predisposes the critically ill patient to infection and multiple organ failure [7] (MOF). MOF is seen in shock and critically ill patients with variety of diseases like sepsis, septic shock, trauma, burns, head injury and shock from variety of causes. [8] It is manifested by failure of number of organs like lungs, liver, kidneys and these are the frequent causes of death in patients admitted to critical care unit. [8,9] Monitoring and therapeutic measures that breach the physical barrier, which normally protects the organism from invasion by bacteria and viruses, through various catheters, are responsible for infection and sepsis in critically ill who are already in hypoxia. [10] Further, multiple immunological abnormalities have been identified in critically ill patients suffering from haemorrhage, trauma, burns and shock all due to hypoxia. [11] Critically ill patients who are immuno-suppressed [12,13] are easily vulnerable to infection and sepsis and often resistant to most potent antibiotics. [14] The essential problem in ciritcally ill patient is failure of host defenses, which depend on antibacterial substances circulating through contaminated wound, in defense against bacterial invasion. Therefore, failure of tissue perfusion and hypoxia are the main causes of failure of host defenses that lead to infection, sepsis and their complications (MOF) in critically ill patients.

Thus, tissue hypoxia is the most important and perhaps the ultimate mechanism of variety of diseases seen in critically ill patients. Tissue hypoxia causes decline in production of adenosine triphosphate (ATP), an energy essential for cellular and organ function. In tissue hypoxia, cellular and organ dysfunction ensues and disease is produced.

DISCUSSION

Shock and critically ill patients with variety of diseases were treated with EA. In all these patients the response was dramatic. Surprisingly, these patients did not require ICU, ventilatory support, antibiotics, sophisticated equipment to monitor cardiac and respiratory functions, costly investigations and multiplicity of drug therapy. This therapy of EA is based on a fundamental principle in medicine viz, disease did not exist except as a reaction to injury, and reaction, not the injury, produces manifestations of disease. [15] It sends the message, loud and clear, ‘stop reaction to cure the disease’. EA does just that. It stops reaction by denervation of man and cures the disease.

For a long time, physicians have been treating hepatitis, pancreatitis, gastritis and nephritis as an individual disease. However, Prof. Hans Selye says that when you examine these affected organs under microscope, the cellular changes in them are essentially the same. Surely, this gives food for thought. How could so many conditions, so vastly different and yet be the same, in the sense that they are all inflammation - the process that brings unity into diversity of diseases. [16] There appears to be a strong link between ischaemic tissue and process of inflammation. [17] Inflammation may be a part of ischaemic process or may serve to augment and accelerate the ischaemic process. Alterations seen in ischaemic cell are similar in liver cell, muscle cell or kidney cell because, every cell is derived from a cell [18] and therefore, muscle cell and liver cell, this view is now dead as dodo. [19] Thus, hypoxia/ischaemia is the main underlying cause of a disease. This suggests that any therapy which can provide adequate oxygen and nutrient to hypoxic tissue and cell will correct hypoxia and restore cellular and organ function and cure the disease. EA achieves this goal by providing hyperperfusion to hypoxic tissues and cells and at the same time quickly removes accumulated acid metabolites via kidneys, which are functioning better under EA and thus sets in motion the instant and rapid recovery process. Therefore, it is not surprising that dramatic and miraculous response of patient and instant relief followed by rapid recovery achieved by EA in shock and critically ill patients with variety of diseases reported earlier.

CONCLUSION

EA was administered to treat shock and other critically ill patients with variety of diseases. It produced dramatic and miraculous response. It is a simple and most rational therapy which is almost totally effective and above all can be managed even single handed in emergency by an anaesthetist. EA obviates the need for ICU, sophisticated equipment like respirator, and cardioscope to monitor and manage cardiorespiratory function. Similarly, the need for instant blood-gas analysis was hardly ever required, and surprisingly, EA achieved miracle by producing instant relief and cure in almost all patients. EA has opened a new horizon for the medical profession. It makes impossible possible and possible practicable. It should be given a fair trial in many intractable diseases like rabies, virus hepatitis, cancer, food poisoning, liquor tragedy, disaster medicine and terminally ill patients. Only, widespread use of this technique will prove its usefulness and efficacy.

REFERENCES

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  12. Edward, Abrahm. Immunologic mechanism underlying sepsis in critically ill surgical patient. Surg Clin North Am 1995; 65 : 991.
  13. Walton B. Effects of anesthesia and surgery on immune status. Br J Anesth 1979; 51 : 37.
  14. Pinching AJ. Recent advances in immunologic therapy : Plasma exchange and immuno suppression. Br J Anesth 1979; 51 : 21.
  15. Hill RB. Pathobiology and disease. In : Hill RB. Lavia MF. (eds.). Principles of Pathobiology. New York : Oxford University Press. 1980; 3-20.
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  17. Cyril MG. Tissue oxygenation in low-flow states during hypoxemia. Crit Care Med 1993; S44-8.
  18. Wilmer EN. The cell in medical science. Beck F, Lloyed JB (eds.) London Academic Press. 1 : 3.
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