Plasma thromboxane B2 levels and thromboxane B2 production by platelets are increased in patients during spinal and epidural anesthesia

Concentrations of thromboxane (Tx) B2 in plasma and its production by platelets were measured in 20 spinal and 10 epidural anesthesia patients scheduled for small operations in the lower extremities. The main metabolite of prostacyclin, 6-keto-PGF1 alpha and prostaglandin (PG) E2 in plasma were also determined. Plasma TxB2 and TxB2 production by platelets increased during both spinal and epidural anesthesia. Plasma TxB2 levels also remained elevated 1 h after anesthesia. The plasma concentrations of 6-keto-PGF1 alpha and PGE2 did not change during spinal or epidural anesthesia. In in vitro studies, only low concentrations of lidocaine (0.5-1.0 micrograms/ml) and bupivacaine (0.5-3.0 micrograms/ml) increased platelet TxB2 production. In platelet rich plasma, neither lidocaine nor bupivacaine in concentrations of 0.5-3.0 micrograms/ml caused constant changes in ADP-induced platelet aggregation, but they inhibited it in toxic concentrations (12 micrograms/ml). The results suggest that the increased TxB2 plasma levels and platelet TxB2 production during regional anesthesia are not caused by local anesthetics itself but by other factors, e.g. tissue trauma. In clinically found concentrations, local anesthetics do not cause any constant changes in platelet aggregation.     

Neurotoxic effects of local anesthetics on the mouse neuroblastoma NB2a cell line

Abstract

Local anesthetics are used clinically for peripheral nerve blocks, epidural anesthesia, spinal anesthesia and pain management; large concentrations, continuous application and long exposure time can cause neurotoxicity. The mechanism of neurotoxicity caused by local anesthetics is unclear. Neurite outgrowth and apoptosis can be used to evaluate neurotoxic effects. Mouse neuroblastoma cells were induced to differentiate and generate neurites in the presence of local anesthetics. The culture medium was removed and replaced with serum-free medium plus 20 μl combinations of epidermal growth factor and fibroblast growth factor containing tetracaine, prilocaine, lidocaine or procaine at concentrations of 1, 10, 25, or 100 μl prior to neurite measurement. Cell viability, iNOS, eNOS and apoptosis were evaluated. Local anesthetics produced toxic effects by neurite inhibition at low concentrations and by apoptosis at high concentrations. There was an inverse relation between local anesthetic concentrations and cell viability. Comparison of different local anesthetics showed toxicity, as assessed by cell viability and apoptotic potency, in the following order: tetracaine > prilocaine > lidocaine > procaine. Procaine was the least neurotoxic local anesthetic and because it is short-acting, may be preferred for pain prevention during short procedures.     

Regional anesthesia for major vascular surgery.

The relative merits of general vs regional anesthesia for patients undergoing major vascular surgery has been the subject of debate over the past decade. Previous studies of regional vs general anesthesia often were deficient in experimental design and, therefore, did not produce definitive answers. Some of these deficiencies related to non-standardized, poorly conducted, and/or described general anesthetic techniques, nonstandardized methods of postoperative analgesia in the general anesthesia groups, and variations in preoperative cardiac status in the study groups. Furthermore, most studies did not conclusively demonstrate a cause and effect relationship between the proposed mechanisms of the beneficial effect of regional anesthesia and outcome. Recent studies, however, have claimed improvements in outcome following regional anesthesia in patients undergoing peripheral vascular procedures. The reported beneficial effects have included amelioration of the neuroendocrine stress response to surgery, improvement in pulmonary function, cardiovascular stability, enhancement of lower limb blood flow, reduction in the incidence of graft thrombosis, and a reduction in the thrombic response to surgery. Skeptics still question whether recent studies have the power to determine whether regional anesthesia decreases the incidence of cardiac and pulmonary complications following major vascular surgery. Furthermore, the issue of whether the beneficial effects of regional anesthesia on the incidence of graft thrombosis and the thrombotic response to surgery relating to intraoperative or postoperative regional anesthesia/analgesia, to regional anesthesia per se, or to the systemic effects of absorbed local anesthetics remains unresolved.     

A Conserved Behavioral State Barrier Impedes Transitions between Anesthetic-Induced Unconsciousness and Wakefulness: Evidence for Neural Inertia

One major unanswered question in neuroscience is how the brain transitions between conscious and unconscious states. General anesthetics offer a controllable means to study these transitions. Induction of anesthesia is commonly attributed to drug-induced global modulation of neuronal function, while emergence from anesthesia has been thought to occur passively, paralleling elimination of the anesthetic from its sites in the central nervous system (CNS). If this were true, then CNS anesthetic concentrations on induction and emergence would be indistinguishable. By generating anesthetic dose-response data in both insects and mammals, we demonstrate that the forward and reverse paths through which anesthetic-induced unconsciousness arises and dissipates are not identical. Instead they exhibit hysteresis that is not fully explained by pharmacokinetics as previously thought. Single gene mutations that affect sleep-wake states are shown to collapse or widen anesthetic hysteresis without obvious confounding effects on volatile anesthetic uptake, distribution, or metabolism. We propose a fundamental and biologically conserved concept of neural inertia, a tendency of the CNS to resist behavioral state transitions between conscious and unconscious states. We demonstrate that such a barrier separates wakeful and anesthetized states for multiple anesthetics in both flies and mice, and argue that it contributes to the hysteresis observed when the brain transitions between conscious and unconscious states.     

Effect of general anesthetics on the properties of lipid membranes of various compositions

Computer simulations of four lipid membranes of different compositions, namely neat DPPC and PSM, and equimolar DPPC-cholesterol and PSM-cholesterol mixtures, are performed in the presence and absence of the general anesthetics diethylether and sevoflurane both at 1 and 600 bar. The results are analyzed in order to identify membrane properties that are potentially related to the molecular mechanism of anesthesia, namely that change in the same way in any membrane with any anesthetics, and change oppositely with increasing pressure. We find that the lateral lipid density satisfies both criteria: it is decreased by anesthetics and increased by pressure. This anesthetic-induced swelling is attributed to only those anesthetic molecules that are located close to the boundary of the apolar phase. This lateral expansion is found to lead to increased lateral mobility of the lipids, an effect often thought to be related to general anesthesia; to an increased fraction of the free volume around the outer preferred position of anesthetics; and to the decrease of the lateral pressure in the nearby range of the ester and amide groups, a region into which anesthetic molecules already cannot penetrate. All these changes are reverted by the increase of pressure. Another important finding of this study is that cholesterol has an opposite effect on the membrane properties than anesthetics, and, correspondingly, these changes are less marked in the presence of cholesterol. Therefore, changes in the membrane that can lead to general anesthesia are expected to occur in the membrane domains of low cholesterol content.     

"Phenomenon" of vestibular compensation]

The role of spinal afferentation from the lower part of the body in establishing compensation of the consequences of the vestibular function abaissement was studied in experiments on guinea pigs. The ligation of the spinal cord at the level of thoracic segements performed under local anesthesia neither produced appreciable effect on the compensatory development at simultaneous or subsequent destruction of the labyrinth nor destroyed it in the preliminarily labyrinthectomized animals. The ligation of the spinal cord in the labyrinthectomized animals under ether or chloroform anesthesia was accompanied by a strong disorder of the compensation. The above substances also provoked analogous decompensation in the unilaterally labyrinthectomized animals with an intact spinal cord. The results obtained indicate that the reported disorder of the vestibular compensation induced by ligation of the spinal cord under ether anesthesia is consequent on an immediate effect of inhalation anesthetics on the compensatory mechanisms rather than is resultant of abolishing spinal afferentation from the lower part of the body.     

全麻药作用的脊髓机制研究

全麻药对脊髓有着广泛和复杂的作用,深入研究全麻药作用的脊髓机制,无疑有助于全麻药在临床上的合理应用和对全麻药作用机制的认识。本文综述了全麻药对脊髓内神经元、神经元间的突触传递、相关受体及离子通道的作用。     

Dupuytren's fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet

Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomy, is an outpatient operation performed with the patient under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephrine in the digits. This study is a retrospective review of operations performed by the same surgeon in the hospital (43 digits) versus the office using local anesthetics with epinephrine and no tourniquet (60 digits). Results and complications were compared and tabulated. The hospital and epinephrine groups were comparable regarding preoperative measurements. Postoperative improvement in extension at the metacarpophalangeal and proximal interphalangeal joints was similar in both the hospital and epinephrine groups. Complications, including digital nerve and artery injuries, infections, and hematomas, were similar between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of a digital artery at the proximal interphalangeal joint. Because of the similarities in results and complications, there does not seem to be an advantage to performing Dupuytren's excisions with full arm tourniquet and outpatient admission in many cases. Local anesthetics with epinephrine are safe in the treatment of Dupuytren's contracture, although both the use of digital epinephrine and the use of mechanical tourniquets carry the potential for complications. Visibility is similar to that for facial or head and neck surgery and is aided by the use of loupe magnification. The old dogma against its use in the fingers is refuted, as seen by the results in these 60 consecutive Dupuytren's fasciectomies and the results of other authors.     

Neuroaxial anesthesia in a patient with progressive systemic sclerosis : case presentation and review of the literature on systemic sclerosis

Background

Systemic sclerosis (SSc), a progressive disease characterized by excessive accumulation of connective tissue components. Although most patients have long survival, some of them progress rapidly to death. Pulmonary system involvement and pulmonary hypertension are the most frequent cause of death. When the patient with SSc is to be operated, the anesthetic procedure could be a serious problem. In this article, we report a combined spinal – epidural technique in a patient with progressive SSc and the anesthetic considerations that could be recommended for these patients.

Case presentation

A 68-year-old woman who had a history of progressive systemic sclerosis, pulmonary fibrosis, kyphoscoliosis and decreased oral apertura underwent total hip arthroplasty. This operation was performed successfully under combined spinal epidural anesthesia.

Conclusion

Systemic sclerosis is a complex disease that involves multiple organ systems. Every aspects of anesthetic care may be altered or hindered by the pathogenesis of disease. Although the choice of regional or general anesthesia is unclear, to choose combined spinal epidural anesthesia may be useful.     

Effects of spinal anesthesia on response to main pulmonary arterial distension

Nonocclusive main pulmonary arterial distension produces peripheral pulmonary hypertension. The mechanism of this response is unknown. The effects of total spinal anesthesia on the response were studied in halothane-anesthetized dogs. Before total spinal anesthesia, main pulmonary arterial balloon inflation increased pulmonary arterial pressure and resistance without affecting systemic hemodynamic variables. Both right and left pulmonary arterial pressures were monitored to exclude unilateral obstruction with main pulmonary arterial balloon inflation. Total spinal anesthesia decreased cardiac output and systemic arterial pressures. After total spinal anesthesia, main pulmonary arterial distension still increased pulmonary arterial pressure and resistance. Right atrial pacing, discontinuation of halothane anesthesia, and norepinephrine infusion during total spinal anesthesia partially reversed the hemodynamic changes caused by total spinal anesthesia. The percent increase in pulmonary vascular resistance due to main pulmonary arterial distension was similar before total spinal anesthesia and during all experimental conditions during total spinal anesthesia. The pulmonary hypertensive response is therefore not dependent on central synaptic connections.     

Inhibition of mitochondrial respiration by mepivacaine

In the last years our researches on neurotropic drugs follow our hypothesis that the strong effects on nervous system have always hidden more widespread effects on all tissues and cells. It is often required to employ local anesthetics in practising dentistry and orthodontics, particularly when children have to be treated. We have assayed in vitro one of these dental anesthetics, mepivacaine, on liver rat mitochondria: it depresses the respiration coupled to phosphorylation in mitochondria having a good respiratory control; so respiratory control too is depressed, but P/O ratio is unaffected; also respiration uncoupled by 2.4-dinitrophenol is depressed. Depressing respiration cooperates with anesthesia; unchanging P/O is good for the health of the cells and tissues treated by the mepivacaine.     

Antagonism between high pressure and anesthetics in the thermal phase-transition of dipalmitoyl phosphatidylcholine bilayer

The antagonizing action of hydrostatic pressure against anesthesia is well known. The present study was undertaken to quantitate the effects of hydrostatic pressure and anesthetics upon the phase-transition temperature of dipalmitoyl phosphatidylcholine vesicles. The drugs used to anesthetize the phospholipid vesicles included an inhalation anesthetic, halothane, a dissociable local anesthetic, lidocaine and an undissociable local anesthetic, benzyl alcohol. All anesthetics decreased the phase-transition temperature dose-dependently. In the case of lidocaine, the depression was pH dependent and only uncharged molecules were effective. The application of hydrostatic pressure increased the phase-transition temperature both in the presence and the absence of anesthetics. The temperature-pressure relationship was linear over the entire pressure range studied up to 340 bars. Through the use of Clapeyron-Clausius equation, the volume change accompanying the phase-transition of the membrane was calculated to be 27.0 cm3/mol. Although the anesthetics decreased the phase-transition temperature, the molar volume change accompanying the phase-transition was not altered. The anesthetics displaced the temperature-pressure lines parallel to each other. The mole fraction of the anesthetics in the liquid crystalline membrane, calculated from the van't Hoff equation, was independent of pressure. This implies that pressure does not displace the anesthetics from the liquid membrane, and the partition of these agents remains constant. The volume change of the anesthetized phospholipid membranes is entirely dependent upon the phase-transition and not on the space occupied by the anesthetics.     

Rhythm transformation in nerve fibers by local anesthetics: From biophysics of sodium channels to physiology of anesthesia

The review considers the basic stages in the study of rhythm transformation in the nerve fibers by local anesthetics and underlying use-dependent block of sodium channels. A potency of use-dependent local anesthetics to produce the rhythm transformation in nociceptive nerve fibers sufficient to attain local anesthesia without complete block of conduction was examined. A hypothesis was tested on attaining the conditions of local anesthesia by a decrease in discharge frequency of C-fiber nociceptors below the critical level separating the firing frequency in these sensors corresponding to their excitation with subnociceptive and nociceptive chemical stimuli. This critical level (about 2 Hz) was determined by comparison of the discharges in feline cutaneous C-fiber nociceptors during injection of chemical nociceptive and non-nociceptive stimuli. The discharge frequency in C-fiber nociceptors can be decreased in a use-dependent manner below the critical level by subcutaneous injection of lidocaine or N-propyl-ajmaline. The importance of use-dependent local anesthesia for preservation of trophic influences of the nervous system in the damaged tissue is discussed.     

Solubility, adsorption, and the thermodynamics of the cutoff effect

For many years, the expression "cutoff effect of anesthesia," has been used to denote the failure of the higher alcohols or paraffins to produce anesthesia. As such, it is used to assess the plausibility of specific models, proposed for anesthesia. However, the uses were shown, in many respects, to be problematic. This article augments the notion of the cutoff to fit for all cases in which only some of the molecules in a homologous series are anesthetics. We find that the location of the cutoff points is affected by three free energy quantities: that of the adsorption of the agent to the anesthetic "site" (f(sl,site)), that of the perturbation of the site (f(ll,site)), and that of the evaporation of the agent from its pure condensed phase (Deltamu degrees (evaporation)). This outcome indicates that the cutoff cannot be attributed to a single parameter. In addition, the analyses that attribute the cutoff to the failure of compounds to obey the much-used Meyer-Overton correlation will have to be amended. This article shows that cutoff results can be used to elucidate the structure of a site.     

Opinion: [on anesthesia for outpatient female sterilization

In actual practice, the choice of anesthesia is more likely to be decided by the personal preference of the surgeon or anesthesiologist rather than by considerations of safety. Most gynecologists in the US and Canada, working in hospitals or surgicenters, choose general anesthesia becaused skilled anesthetists are available, and it is easier for them to operate if their patients are asleep. Most anesthesiologists prefer it that way also, since their services are being fully utilized. During residency training, gynecologists need the benefit of general anesthesia to learn surgical techniques. Because they learned that way, it is the course of least resistance for them to continue to favor general anesthesia. Thus hundreds of thousands of general anesthetics are given each year to suit the convenience and skills of the gynecologist. But minilaparotomy or laparoscopy may be performed with fewer potential complications under local anesthesia, provided the patient receives proper counseling and supportive care, and provided the gynecologist's surgical technique is gentle and precise. Unfortunately, most residency programs do not provide training in such techniques, so they are learned, if at all, during practice years.     

Biochemical aspects of the action of local anesthetics

Notions on the molecular mechanisms of anesthesia are presented. The chemical characteristics are given for main representatives of certain groups of local anesthetics with peculiarities of their membrane-tropic action mentioned. The effect of local anesthetics on the synaptic transmission, membrane enzymes, ion transport through the cell membranes is considered simultaneously with the anesthesia phenomenon on the basis of the data available in literature and results of the authors' investigations.     

General Anesthetics Effects on Circadian Temporal Structure: An Update

Disruptions of circadian and biological rhythms as well as general anesthesia can induce sleep disorders, resulting in an increase in sleepiness and drowsiness and a decrease in vigilance. It has been previously shown that circadian time can influence the pharmacologic sensitivity and the duration of action of general anesthetics. Studies on interactions between general anesthesia and circadian rhythms are few, but all of them suggest an important role of general anesthetics on circadian rhythms. General anesthesia is a particular wake‐sleep state that could potentially alter circadian rhythms on the days following anesthesia. The aim of this review is to discuss the various effects of general anesthesia on animal and human circadian time structure. This topic is highly relevant to clinicians, especially those involved in that field of ambulatory practice responsible for post‐operative patient care, including patient recovery and fatigue.     

模式生物秀丽线虫与吸入麻醉药敏感性相关的基因

吸入麻醉药虽已在临床上广泛应用,然其分子作用机制和作用位点仍然不清楚。以秀丽线虫为模式生物在研究麻醉药的分子机制上有着众多优点,近年亦取得了一定的进展。以秀丽线虫作为模式生物时麻醉终点的选择主要有两种：使用大于临床浓度的吸入麻醉药,使秀丽线虫停止运动作为麻醉终点和使用接近临床浓度的吸入麻醉药,使秀丽线虫行动变得不协调和迟缓作为麻醉终点。这两种研究方法已经发现一些与吸入麻醉药敏感性相关的基因,如unc-79,unc-80,unc-9,unc-1,gas-1和unc-64等基因。这些基因主要表达于神经元,与神经突触、线粒体的功能有关。     

Electromuscular incapacitation results from stimulation of spinal reflexes

Electronic stun devices (ESD) often used in law enforcement, military action or self defense can induce total body uncoordinated muscular activity, also known as electromuscular incapacitation (EMI). During EMI the subject is unable to perform purposeful or coordinated movements. The mechanism of EMI induction has not been reported, but has been generally thought to be direct muscle and nerve excitation from the fields generated by ESDs. To determine the neuromuscular mechanisms linking ESD to induction of EMI, we investigated EMI responses using an anesthetized pig model. We found that EMI responses to ESD application can best be simulated by simultaneous stimulation of motor and sensory peripheral nerves. We also found that application of local anesthetics limited the response of ESD to local muscle stimulation and abolished the total body EMI response. Stimulation of the pure sensory peripheral nerves or nerves that are primarily motor nerves induced muscle responses that are consistent with well defined spinal reflexes. These findings suggest that the mechanism of ESD‐induced EMI is mediated by excitation of multiple simultaneous spinal reflexes. Although direct motor‐neuron stimulation in the region of ESD contact may significantly add to motor reactions from ESD stimulation, multiple spinal reflexes appear to be a major, and probably the dominant mechanism in observed motor response. Bioelectromagnetics 30:411–421, 2009. © 2009 Wiley‐Liss, Inc.     

Synergistic effect of intrathecal fentanyl and bupivacaine in spinal anesthesia for cesarean section

BACKGROUND: Potentiating the effect of intrathecal local anesthetics by addition of intrathecal opiods for intra-abdominal surgeries is known. In this study by addition of fentanyl we tried to minimize the dose of bupivacaine, thereby reducing the side effects caused by higher doses of intrathecal bupivacaine in cesarean section. METHODS: Study was performed on 120 cesarean section parturients divided into six groups, identified as B8, B10 and B 12.5 8.10 and 12.5 mg of bupivacaine mg and FB8, FB10 and FB 12.5 received a combination of 12.5 mug intrathecal fentanyl respectively. The parameters taken into consideration were visceral pain, hemodynamic stability, intraoperative sedation, intraoperative and postoperative shivering, and postoperative pain. RESULTS: Onset of sensory block to T6 occurred faster with increasing bupivacaine doses in bupivacaine only groups and bupivacaine -fentanyl combination groups. Alone lower concentrations of bupivacaine could not complete removed the visceral pain. Blood pressure declined with the increasing concentration of Bupivacaine and Fentanyl. Incidence of nausea and shivering reduces significantly whereas, the postoperative pain relief and hemodynamics increased by adding fentanyl. Pruritis, maternal respiratory depression and changes in Apgar score of babies do not occur with fentanyl. CONCLUSION: Spinal anesthesia among the neuraxial blocks in obstetric patients needs strict dose calculations because minimal dose changes, complications and side effects arise, providing impetus for this study. Here the synergistic, potentiating effect of fentanyl (an opiod) on bupivacaine (a local anesthetic) in spinal anesthesia for cesarian section is presented, fentanyl is able to reduce the dose of bupivacaine and therefore its harmful effects.