Anesthesia for outpatient female sterilization

This issue of the Bulletin deals with the principles of anesthesia for outpatient female sterilization with emphasis on techniques for laparoscopy and minilaparotomy. General anesthesia techniques provide analgesia, amnesia, and muscle relaxation and are particularly useful for managing the anxious patient. Disadvantages include increased expense, need for specialized equipment, and highly trained personnel, and delayed recovery. Complications, though relatively rare, can be life-threatening and include aspiration of stomach contents, hypoxia, hypercarbia, hypotension, hypertension, cardiac arrhythmias, cardiorespiratory arrest, and death. There is no single preferred technique of general anesthesia, athough most anesthetists employ methods that allow rapid recovery of faculties, enabling the patient to be discharged soon after surgery. To accomplish this end, light anesthesia with sodium thiopental induction and nitrous oxide maintenance is often used. Short duration muscle relaxation with an agent such as succinylcholine supplements this technique. Other techniques include light anesthesia with inhalational anesthetic agents and the use of intravenous ketamine. Local anesthesia augmented by systemic and/or inhalational analgesia is supplanting general anesthesia techniques for laparoscopy in many locales. This approach is also particularly well-suited for minilaparotomy in developing countries, where it has achieved its greatest popularity. The local technique carries with it reduced morbidity and mortality but may not entirely relieve discomfort. The primary danger of local anesthesia is respiratory depression due to excessive narcosis and sedation. The operator must be alert to the action of the drugs and should always use the minimal effective dose. Although toxicity due to overdosage with local anesthetic drugs is occasionally experienced, allergic reactions to the amide-linkage drugs such as lidocaine or bupivacaine are exceedingly rare. For outpatient laparoscopy or minilaparotomy, local anesthesia with proper preoperative counselling and premedication should provide adequate relief of pain and is the method of choice, unless the patient cannot be examined awake or is totally uncooperative. The decision to utilize either general or local anesthesia should be made by the patient after thorough counselling by the surgical team. In many cases, the circumstances of the surgical environment will dictate the choice, but patient comfort and safety should always be the goal.     

四种麻醉药物对食蟹猴麻醉效果分析和选择应用

目的分析比对速眠新、氯胺酮、异氟烷和利多卡因4种不同麻醉药对食蟹猴的麻醉效果。方法总结实际工作中分别使用四种不同麻醉药物对食蟹猴作用的麻醉特点。结果速眠新、氯胺酮、异氟烷均能获得较好的麻醉效果,能满足不同手术、采样需要;局麻药利多卡因对食蟹猴麻醉的实际应用不理想。结论食蟹猴的手术及其他侵犯性操作等都应该考虑生物安全和动物福利要求,实行麻醉,但应根据食蟹猴实验内容要求和不同麻醉药特点选择合适的麻醉方法,确保人员和动物安全,实验结果不受影响。     

Efficacy of pentavalent antimony, amphotericin B, and miltefosine in Leishmania amazonensis-infected macrophages under normoxic and hypoxic conditions

Recently, our group demonstrated that mouse lesions infected with Leishmania amazonensis are hypoxic. Evidence indicates the negative impact of hypoxia on the efficacy of a variety of chemotherapeutic agents against tumors, fungi, bacteria, and malaria parasites. In the present study, comparison of the effect of antileishmanial drugs on L. amazonensis-infected macrophages under normoxic and hypoxic conditions was performed. We compared the effect of 5% oxygen tension with a tension of 21% oxygen on peritoneal murine macrophage cultures infected with the parasite and treated with glucantime, amphotericin B, or miltefosine. Analysis of the infection index (percentage of infected macrophages x number of amastigotes per macrophage), dose-dependent efficacy of drugs, and IC(50) values demonstrated that hypoxia conferred a small, but significant, resistance to all 3 antileishmanial drugs. The present finding suggests that in vitro assays under hypoxia should not be neglected in drug studies.     

SYSTEMIC TOXIC REACTIONS TO LOCAL ANESTHETICS

The topical use of anesthetic agents involves an element of risk. Systemic toxic reactions are rare, but they do occur and may result in death. When a reaction occurs from a topical application, it usually progresses rapidly to respiratory and cardiovascular collapse, and thus therapy must be instituted with more haste to avoid deaths. Fatal systemic toxic reactions from topically administered anesthetic drugs are, in effect, usually not due to well informed use of the drug but to misuse owing to less than complete understanding of absorption.Emphasis is placed on the causes, prophylaxis and treatment of severe systemic toxic reactions which follow the topical application of local anesthetic drugs. If systemic toxic reactions resulting from a safe dose of a local anesthetic agent are correctly treated, there will usually follow an uneventful recovery rather than a catastrophe.     

Modulation of respiration during brain hypoxia

This review is a summary of the effects of brain hypoxia on respiration with a particular emphasis on those studies relevant to understanding the cellular basis of these effects. Special attention is given to mechanisms that may be responsible for the respiratory depression that appears to be the primary sequela of brain hypoxia in animal models. Although a variety of potential mechanisms for hypoxic respiratory depression are considered, emphasis is placed on changes in the neuromodulator constituency of the respiratory neuron microenvironment during hypoxia as the primary cause of this phenomenon. Hypoxia is accompanied by a net increase in neuronal inhibition due to both decreased excitatory and increased inhibitory neuromodulator levels. A survey of hypoxia-tolerant cellular systems and organisms suggests that hypoxic respiratory depression may be a manifestation of the depression of cellular metabolism, which appears to be a major adaptation to limited oxygen availability in these systems.     

Reduced bone marrow pO2 following treatment with radioprotective drugs

The sensitizer adduct technique [( 3H]misonidazole binding) was used to assess the extent of murine bone marrow hypoxia following treatment with a variety of radioprotectors. The binding rates previously determined in vivo were compared to those obtained by incubating marrow cells in atmospheres of varying oxygen content. Parallel experiments demonstrated that the oxygen dependence of [3H]misonidazole binding (Km approximately 0.15% oxygen) was similar to the oxygen dependence of marrow radiosensitivity (Km approximately 0.2% oxygen). Maximally radioprotective doses of several drugs have been shown to increase the binding of [3H]misonidazole significantly in vivo. A comparison to the in vitro binding rates suggests that the average oxygen concentration in the marrow at times associated with radioprotection was on the order of 0.5 to 0.8% oxygen. The relative importance of marrow hypoxia to the overall radioprotective effects of different drugs may vary considerably. However, these results have demonstrated that certain radioprotective drugs can induce marrow hypoxia and this reduced pO2 may contribute to the efficacy of these agents.     

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.     

Le bloc paracervical en obstétrique

Local anesthesia can be very useful in the first stage of labour when a general anesthetic cannot be given during this stage, and it is associated with reduced respiratory depression in the fetus. Paracervical block anesthesia is one such method of local anesthesia. Its successful use depends upon a proper technique, knowledge of the indications and contraindications, appropriate equipment and use of a long-acting anesthetic agent of low toxicity. A series of 90 cases of paracervical block are described in which the success rate was 90 to 95%.     

As the anesthesiologist sees the sunset

Age need no longer be a barrier to operation in view of the expanding knowledge of the care of surgical patients. Blood volumes and blood components can be maintained with replacement therapy. Nutritional and vitamin requirements are better understood and carbohydrates, proteins and vitamins must be given in sufficient quantities to prevent further debilitation during the critical period following operation. It has been suggested that the usual pharmacological effects of drugs may not be applicable to elderly patients. The choice of anesthetic agent based on pharmacological effects on younger persons does not necessarily apply to the aged.     

Reversal of ketamine/xylazine anesthesia in the rabbit with yohimbine

Ketamine and xylazine used in combination have been shown to be effective, easily administered, cost efficient agents for surgical anesthesia in the rabbit. The effect of xylazine on the central nervous system has been shown to be mediated through alpha-2 adrenergic receptors. Yohimbine, an alpha-2 adrenergic antagonist has been shown to reverse xylazine induced depression and partially antagonize ketamine in other species. We evaluated the antagonistic effect of yohimbine on ketamine/xylazine anesthesia in the rabbit. Six New Zealand White rabbits were anesthetized with intramuscular ketamine (50 mg/kg) and xylazine (10 mg/kg) to establish baseline parameters including respiratory rate, heart rate, and palpebral, pedal and postural reflex activity. Fourteen days later each rabbit was subjected to the same anesthetic regimen followed 30 minutes later by the intravenous administration of yohimbine (0.2 mg/kg). The duration of anesthesia estimated by the time elapsed between the loss and return of the palpebral reflex was reduced in the yohimbine treated trial (means = 29.7 +/- 1.9 minutes) compared to the control trial (means = 67.0 +/- 13.5 minutes). The palpebral reflex returned within 5 minutes following yohimbine treatment. Our results indicated that yohimbine is an effective antagonist of ketamine/xylazine anesthesia in the rabbit. Yohimbine decreases anesthetic duration after intravenous administration and also may aid in the control of undesirable anesthetic effects and overdosage.     

Do inhalation general anesthetic drugs induce the neuronal release of endogenous opioid peptides?

The antagonism of some effects of inhalation general anesthetic agents by naloxone suggests that there may be an opioid component to anesthetic action. There is evidence that this opioid action component is due to neuronal release of endogenous opioid peptides. The strongest evidence is provided by studies that monitor changes in the concentration of opioid peptides in the perfused brain following inhalation of the anesthetic. Indirect or circumstantial evidence also comes from studies of anesthetic effects on regional brain levels of opioid peptides, antagonism of selected anesthetic effects by antisera to opioid peptides and anesthetic-induced changes radioligand binding to opioid receptors. It is likely that some inhalation general anesthetics (e.g., nitrous oxide) can induce neuronal release of opioid peptides and that this may contribute to certain components of general anesthesia (e.g., analgesia). More definitive studies utilizing in vivo microdialysis or autoradiography in selected areas of the brain during induction and successive states of general anesthesia have yet to be conducted.     

Response of wild subantarctic fur seal (Arctocephalus tropicalis) females to ketamine and tiletamine-zolazepam anesthesia

This study is the first to compare the anesthetic effects of two cyclohexamines on free-ranging subantarctic fur seal (Arctocephalus tropicalis) females. From April to July 1999, 107 females were immobilized for tooth extraction and blood sampling, using either ketamine (Ketalar, n = 58) alone or tiletamine-zolazepam (Zoletil 100, n = 49) mixture. Animals were injected intramuscularly at mean doses of 2.1 mg/kg for ketamine and 1.1 mg/kg for tiletamine-zolazepam mixture. Individual response to both drugs was highly variable. The dosage required to achieve a satisfactory level of anesthesia was smaller for subantarctic fur seals than for most other species of seals and was less for animals in better body condition. Few side effects were observed during the trials, aside from mild tremors caused by ketamine, and respiratory depression or prolonged apnea caused by tiletamine-zolazepam. We recommend use of ketamine, especially by those with little experience in anesthesia of fur seals. However, precautionary measures should be taken, such as using low doses for animals in good body condition and being prepared for anesthetic emergencies to avoid any casualties.     

Reversal of aplastic anaemia secondary to systemic lupus erythematosus by high-dose intravenous cyclophosphamide

Aplastic anaemia is rare as a primary feature of systemic lupus erythematosus and is more commonly a complication of treatment with cytotoxic drugs. Three years after starting treatment for systemic lupus erythematosus a 22-year-old woman developed bone-marrow depression. Azathioprine was thought to be responsible and was withdrawn. The aplastic anaemia worsened despite treatment with prednisolone. In view of clinical and serological evidence of lupus disease activity the patient was given high-dose intravenous cyclophosphamide and the aplastic anaemia responded in a sustained manner.In such cases of continued disease activity high-dose immunosuppressive agents may prove effective.     

Chemotherapy and the Immune Response in Protozoal Infections1

Available evidence indicates that many of the antiprotozoal drugs currently in use significantly modify the immune response of the host. The effect depends on both the drug and the host. Some drugs enhance the immune response, some are immuno-suppressants, and others enhance some types of immune mechanisms while suppressing others. Future efforts in the development of antiprotozoal drugs should consider their effects on both the parasite and the immune response of the host. Also in the chemotherapy of protozoal infections consideration should be given to the combined usage of immunoenhancing agents and antiprotozoal drugs.     

Morphological alterations in cultured neuromuscular tissue induced by two anesthetic agents

A diversity of pathogenic effects was observed in two complementary culture systems following their exposure to the anesthetic agents. Thiopental sodium and ketamine hydrochloride. The cytotoxic effects of both agents in these two culture types were reversible and dose-related. In organotypic spinal cord slice cultures, thiopental sodium caused general toxicity but no demyelination, while ketamine hydrochloride induced, to a varied extent, damage of the myelin sheath and degeneration of mitochondria into multilamellar bodies. In autologous nerve-muscle co-cultures both anaesthetic agents caused the arrest of muscle contractions. However, when added to skeletal muscle cultures, the drugs differed in their effect. Thiopental sodium did not inhibit spontaneous muscle contractions indicating, as in the case of Tubocurarine, a direct effect of the drug on the neuromuscular junction. Ketamine hydrochloride, in contrast, arrested spontaneous muscle contractions, implying that it did not directly affect the neuromuscular synapse.Special is one dedicated to Dr. Paola S. Timiras.     

The Effect of Anesthetic Agents on Zinc Metabolism in the Rat Liver

The administration of nembutal and chloral hydrate anesthetic agents in the rat produces an increase in the uptake of zinc, as Zn-65, in the liver. Associated with this is the appearance of a low-molecular-weight Zn-binding protein in the soluble cytosol fraction. This protein is comparable to that induced by the stress of severe exercise, by burn injury, and by Zn injection, and is probably Zn metallothionein. This is an example of the induction of a Zn binding protein in the liver by a drug, and confirms that anesthesia significantly effects Zn metabolism in the liver. Consequently this effect of anesthetic agents should be taken into account in the investigation of the regulation of Zn metabolism.     

Effects of mitomycin C and porfiromycin on exponentially growing and plateau phase cultures

Abstract. Laboratory studies and clinical trials are exploring the use of hypoxia-directed cytotoxic agents as adjuncts to radiotherapy. Because hypoxia and the microenviron-mental inadequacies associated with hypoxia in solid tumours inhibit cell proliferation, an essential requirement for the successful use of hypoxia-directed drugs in cancer therapy is that these drugs be toxic to quiescent tumour cells, as well as tumour cells progressing rapidly through the cell cycle. The experiments reported here compared the cytotoxicities of mitomycin C and porfiromycin to exponentially growing and plateau phase cultures of EMT6 mouse mammary tumour cells. The proliferative status of the cultures did not influence the cytotoxicity of mitomycin C under either aerobic or hypoxic conditions, or the cytotoxicity of porfiromycin in air. Exponentially growing cultures were slightly more sensitive than plateau phase cultures to porfiromycin in hypoxia, but the difference between the sensitivities of proliferating and quiescent cells was much smaller than the difference between aerobic and hypoxic cells. No evidence for repair of potentially lethal damage was found after treatment with porfiromycin in air or in hypoxia; this is in agreement with previous findings for mitomycin C. Mitomycin C and porfiromycin therefore exhibit the toxicity to quiescent cells needed for effective use as hypoxia-directed drugs for the treatment of solid tumours.     

The effects of pentobarbital, fentanyl-droperidol, ketamine-xylazine and ketamine-diazepam on arterial blood pH, blood gases, mean arterial blood pressure and heart rate in adult male rats

Although anesthetics are known to cause respiratory and cardiovascular depression in humans, these adverse effects rarely have been investigated in laboratory rodents. This study evaluated the effects of four different injectable drugs, pentobarbital, fentanyl-droperidol (Innovar-Vet), ketamine-xylazine and ketamine-diazepam on the respiratory and cardiovascular systems of rats. Results showed marked acidosis, hypercarbia and hypoxia with high doses of Innovar-Vet, moderate respiratory depression with all dosages of pentobarbital and minimal respiratory depression with ketamine-xylazine and ketamine-diazepam. Innovar-Vet, ketamine-xylazine and pentobarbital caused profound hypotension, particularly at high dosages, while ketamine-diazepam caused the least depression in mean arterial blood pressure of all drugs evaluated. None of the drugs studied produced significant alterations in heart rate. Throughout all dosages investigated, the ketamine-diazepam combination showed the least overall effects on ventilation and perfusion of the four parenteral drug combinations studied.     

Controlled Comparison of the Efficacy of Fourteen Preparations in the Relief of Postoperative Pain

Thirteen analgesic drugs, four of them at two dose levels, four analgesics in combination with antagonist or neuroleptic agents, and saline have been evaluated simultaneously in the relief of postoperative pain. The method of assessment was designed to favour drugs which provided freedom from pain with minimum depression of consciousness. Only levorphanol 2 mg proved significantly superior to pethidine 100 mg, which was used as the standard reference drug. Oxycodone 10 mg, pentazocine 20 mg, and the morphine 10 mg and cyclizine 50 mg combination were the most successful of the remaining drugs. None of the drug combinations was significantly better than the analgesic drug given alone.