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LETTERS TO THE EDITOR

Sympathectomy for Acute Pulmonary Embolism

Department of Anesthesia and Perioperative Care, UCSF Medical Center, San Francisco, CA

To the Editor:

In the December issue, Jahn et al. report improvement in cardiovascular indices after thoracic epidural analgesia in a sheep model of pulmonary embolism (PE) (1). Sympathetic blockade in PE is a logical approach because initial pulmonary vasoconstriction in PE may be sympathetically mediated (2). However, the mode of sympathetic blockade chosen by the authors will have limited applicability in humans, given that the initial treatment of acute PE often includes thrombolytic and/or anticoagulative therapy (3) and thus harbors the risk of thoracic epidural hematoma formation. An alternative, potentially less dangerous, mode of sympathetic blockade after PE is a stellate ganglion block. Several reports from the 1940s and 50s exist on the dramatic effects of unilateral stellate ganglion block in the setting of acute PE in man (4–6). The risk/benefit ratio of a unilateral stellate ganglion block does not seem quite as prohibitive as that of a thoracic epidural in the setting of ongoing thrombolytic or anticoagulant therapy. The potential of this therapeutic modality has not been systematically evaluated. If successful in models like Jahn’s, stellate ganglion block after PE could potentially be translated into the clinical setting.

References

1. Jahn UR, Waurick R, van Aken H. Thoracic but not lumbar, epidural anesthesia improves cardiopulmonary function in ovine pulmonary embolism. Anesth Analg 2001; 93: 1460–5.[Abstract/Free Full Text]
2. Aviado DM, Aviado DG. The Bezold-Jarisch Reflex. A historical perspective of cardiopulmonary reflexes. Ann N Y Acad Sci 2001; 940: 48–58.[Web of Science][Medline]
3. Task force on pulmonary embolism, European Society of Cardiology. Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 2000; 21: 1301–36.[Free Full Text]
4. Bageant WE, Rapee LA. The treatment of pulmonary embolus by stellate block. Anesthesiology 1947; 8: 500–5.[Web of Science]
5. Faxon HH, Flynn JH, Anderson RM. Stellate block as an adjunct to the treatment of pulmonary embolism. N Engi J Med 1951; 244: 586–590.
6. Hickcox CB, Tovell RM, Rashkind R, et al. The stellate ganglion: Its significance in practice. Anesthesiology 1943; 4: 150159.

Response

Klinik und Poliklinik für Anästhesiologie, und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Germany

In Response:

We appreciate Dr. Stratmann’s letter underlining potentially beneficial effects of unilateral stellate ganglion block by citing reports from the 1940s and 50s.

We are aware of reports considering blockade of the cervicothoracic sympathetic ganglion being a therapeutic or supportive option during pulmonary embolism (PE) in humans. In 1964, Nolte and Hagelsten (1) in Germany reported an improvement by bilateral stellate ganglion block during pulmonary embolism. However, even if performed bilaterally, sympathetic blockade is restricted to the level of T1 or T2. In contrast, in our experimental study in awake, chronically instrumented sheep, we investigated the effects of the complete bilateral blockade of the thoracic sympathetic nervous system.

To analyze the effects of sympathetic activation/sympathetic blockade achieved by thoracic epidural anesthesia during PE was the primary purpose of our study. Thus, we did not primarily intend to establish an animal model for the development of new therapeutic principles in the clinical setting of PE in man, and therefore completely consent to Dr. Stratmann that establishment of thoracic epidural sympathetic blockade in patients under effective anticoagulative or thrombolytic therapy is problematic. However, in patients having an epidural catheter already inserted (e.g. perioperative patients) the occurrence of PE may be effectively treated, either by using an epidural catheter at thoracic levels or by extending lumbar blockade to thoracic levels, when the catheter is implanted at lumbar segments.

Studies to evaluate the effectiveness of thoracic sympathetic blockade in the setting of PE in man have to be performed.

Nevertheless, the idea of testing stellate ganglion block animal models of PE as proposed by Dr. Stratmann seems very interesting. However, uni- or bilateral blockade of the stellate ganglion in awake, spontaneous breathing sheep would be extremely hard to perform; we feel that this is impossible in our experimental model of PE.

References

1. Nolte H, Hagelsten J. Double-sided blockade of the stellate ganglion as a therapy of choice in pulmonary embolism. Anaesthesist 1964; 13: 105.

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