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LETTERS TO THE EDITOR

ContinuousInfusion of Prostaglandin E₁ and Epidural Analgesia fora Patient with Paroxysmal NocturnalHemoglobinuria

Departmentof AnesthesiologyNational Defense MedicalCollegeTokorozawa, Saitama,Japan Department ofAnesthesiaSelf Defense Force CentralHospitalSetagaya, Tokyo,Japan

To theEditor:

We read with great interest the article byKathirvel et al.(1), who reported arare, but important, case of anesthetic management for a patient withparoxysmal nocturnal hemoglobinuria (PNH). They succeeded in safely managingthe patient through the perioperative period. Although anesthesia itself is aknown risk factor for an episode of hemoglobinuria, there is scant informationin the literature regarding anesthetic care for a patient with PNH(1). We managed anesthesia in apatient diagnosed with PNH (2). Thepatient was a 63-yr-old man, who had been followed up for PNH and secondaryanemia for 2 yr before the surgery. He suffered repeated cholangitis andpancreatitis. An abnormality of the common bile duct was found and surgery wasscheduled. The patient had been treated with a morning dose of prednisolone 10mg orally. Preanesthetic examination showed mild anemia (8.5 mg/dL) and1–2 mg% hemoglobinuria every morning. Before inducing anesthesia, weadministered 500 mg prednisolone IV to prevent hemolysis. ProstaglandinE₁ (PGE₁) was infusedcontinuously during and after surgery until the third postoperative day at arate of 0.02 µg · kg ^-1 ·min^-1. Epidural analgesia was maintained withintermittent administration of mepivacaine and general anesthesia withisoflurane and 66% nitrous oxide. After the surgery, epidural administrationof bupivacaine with morphine was continued to alleviate pain with stable vitalsigns. The operation lasted 6 h, and urine hemoglobin did not increase duringor after surgery. PGE₁ is effective for preventinghemolysis and thrombosis in other disorders(3,4). Postoperativeepidural analgesia may be preferable for avoiding pain stress withoutrespiratory depression. In addition to steroid therapy, continuousadministration of PGE₁ and epidural analgesia might beeffective for safe anesthetic management of a patient withPNH.

References

1. KathirvelS, Prakash A,Lokesh NB,Sujatha P.The anesthetic management of a patient with paroxysmal nocturnalhemoglobinuria.Anesth Analg 2000;91:1029–31.[Abstract/Free Full Text]
2. AdachiY, Shizukuishi M,Fukuda I,et al.The anesthetic management for the patient with paroxysmal nocturnalhemoglobinuria [in Japanese].Gendai Iryo 1996;28 (suppl 2):1564–7.
3. DowdPM, Kovacs IB,Bland CJ,Kirby JD.Effect of prostaglandins I₂ andE₁ on red cell deformability in patients withRaynaud’s phenomenon and systemic sclerosis.BMJ 1981;283:350.
4. UmemuraK, Watanabe S,Kondo K, et al.Inhibitory effect of prostaglandin E₁ onintimal thickening following photochemically induced endothelial injury in therat femoral artery.Atherosclerosis 1997;130:11–6.[Web of Science][Medline]

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