In Reply:--Hong's suggestion that the use of contrast media would have avoided the complication reported is dismissed for the following reasons:
1. The event occurred near the end of the procedure, when fluoroscopy would not be used.
2. Injections of neurolytic agent in contrast material may show intravascular and intramedial injections during the event, thereby not preventing it.
The patient's allergic response to contrast media was generalized urticaria, respiratory distress, and hypotension. Although the risk of reaction to contrast media can be decreased by using nonionic media, as well as steroids and histamine blockers, such precautions do not eliminate contrast media reactions. Because the computed tomography (CT) study did not suggest anatomic distortion of the area of injection, we did not believe there was a need to risk the use of contrast media, which, again, would not have avoided or prevented the events noted in this case. The autopsy confirmed the CT findings: There was no tumor invasion near or into the affected vessels.
Before the autopsy, our clinical assessment was that intravascular injection of alcohol caused the events. We believed that this produced celiac/mesenteric vascular thrombosis, leading to the bowel infarction and pain. It was difficult to understand how the injection of a small amount (1 ml) of alcohol would have produced it. The postmortem examination resolved this dilemma with the finding of aortic dissection, which could explain the clinical events. We do not attribute the pain, which occurred at the time of the dissection, to intravascular alcohol. We cannot explain the generalized body pain but report it because it was a significant event.
It is doubtful that use of celiac block will cease despite "effective use of oral opioids and the availability of epidural/spinal infusion techniques." Our patient represents a failure of oral and parenteral opioid analgesia. The cost/benefit of epidural/spinal infusion techniques and low risk/high response of celiac block for pain control in terminal cancer patients will maintain celiac blocks as an analgesic modality. It is the specific technique of transaortic approach to celiac plexus block that eventually may be placed out of favor.
Ronald Kaplan, MD, Associate Professor of Anesthesiology, Albert Einstein College of Medicine, Attending Anesthesiologist, Montefiore Medical Center, Bronx, New York 10467