The negative inotropic effect of diazepam in rat right ventricular strips

Cardiovascular manifestations of sedatives and analgesics in the critical care unit

There are numerous sedatives and analgesics used in critical care medicine today; these medications are used on critically ill patients, many of whom have heart disease, including coronary artery disease or congestive heart failure. The purpose of this review is to recognize the effects of these medications on the heart. Studies that evaluated the effects of sedatives and analgesics on normal individuals or on those with heart disease were reviewed. Current choices for sustained sedation in the critically ill include the benzodiazepines, morphine, propofol, and etomidate. Each of these medications has their particular advantages and disadvantages. Benzodiazepines provide the greatest amnesia and cardiovascular safety but they can cause significant hypotension in the hemodynamically unstable patient. Morphine provides analgesia and cardioprotective activity after ischemia, although the large observational study CRUSADE showed increased mortality rate in those patients with non-ST segment elevation myocardial infarction who received morphine. Propofol is the most easily titratable drug with cardioprotective features, but its use must be accompanied with great attention to possible development of propofol infusion syndrome, which is a deadly disease, especially in patients with head injury and those with septic shock receiving vasopressors. Etomidate has a rapid onset effect and short period of action with great hemodynamic stability even in patients with shock and hypovolemia, but the incidence of adrenal insufficiency during infusion, not bolus doses, may cause deterioration in the circulatory stability. In conclusion, the sedatives and analgesics mentioned here have characteristics that give them a cardiovascular safety profile useful in critically ill patients. However, use of these drugs on an individual basis is dependent on each agent's safety and efficacy.

Preconditioning abolishion by midazolam in isolated hearts of rats

PURPOSE

To study the effects of benzodiazepine midazolam in the coronary flow (Cflo), cardiac frequency (CF) and myocardial contractility in isolated hearts of rats subjected to ischemic preconditioning (IPC).

METHODS

30 Wistar rats were used, undistinguished by gender. After anesthesia with ethyl ether, the hearts were put into perfusion (Krebs-Henseleit solution, 95% O2 and 5% CO2, 37 degrees C, 110-120mmHg), in disposable Langendorff type system. Five groups of six animals were constituted: GI- Control; GII- Ischemia; GIII- IPC; GIV- Ischemia + 100mcg of midazolam; GV- IPC + 100mcg of midazolam. After stabilization (t0), and on times t5, t10, t15, t20 and t25, CF, Cflo, systolic pressure (SP) and diastolic pressure (DP) and dP/dt were recorded. DP was maintained at 5 +/- 2 mmHg. The statistical method ANOVA and Tukey Test were employed for p < or = 0.05.

RESULTS

No significant variations have occurred between Cflo and CF. On Pd/td, differences have occurred (p<0.05) between groups I and II (respectively 94.7+/-23.0 and 62.3+/-12.1%). The preconditioning (GIII), improved significantly the results in the group II (respectively 62.3+/-12.1 and 87.1+/-12.4 %). The decrease in dP/dt in group II was not prevented by midazolam (GIV) (62.3+/-12,1 and 60.5+/-15.8 %). In group III, dP/dt was 87.1+/-12.4%, whereas in group V, only 55.5+/-17.2% (p<0.05)

CONCLUSION

Midazolam, when administered before the ischemia, was unable to prevent the ischemic deterioration of the myocardium. When administered before the preconditioning, it has abolished its protective effect.

Reversal of benzodiazepine-induced renal vasculature relaxation with flumazenil

The effects of the central-type benzodiazepine receptor antagonist flumazenil on renal vascular tone and its ability to reverse the benzodiazepine-induced vasodilation were investigated. The isolated and perfused rat kidney model was used. Flumazenil was unable to modify renal vascular resistance under basal conditions and in noradrenaline-pretreated kidneys. Relaxation induced by diazepam or clonazepam of noradrenaline-preconstricted renal vasculature was blunted by 10 microM flumazenil. These results suggest that central-type benzodiazepine receptors could be involved in benzodiazepine-induced renal vasodilation.

Negative inotropic effect of diazepam in isolated guinea pig heart

The inotropic effect of diazepam, a benzodiazepine derivative, and its mechanism of action were examined using guinea pig heart and single ventricular cell preparations. In Langendorff hearts and right ventricular free-wall preparations, diazepam (10 to 100 microM) produced a monophasic negative inotropic effect in a concentration dependent manner. Neither a central type (flumazenil 1 microM) nor a peripheral type (PK11195 10 microM) of benzodiazepine receptor antagonist antagonized the monophasic negative inotropic effects of diazepam. Diazepam (10 to 100 microM) shortened action potential duration of papillary muscle in a concentration dependent manner. In isolated single ventricular cells, diazepam (30 and 100 microM) inhibited the calcium current (I(Ca)) in a concentration dependent manner. Diazepam produced a significant decrease in I(Ca) elicited by first depolarizing pulses, however, the decrease of I(Ca) was not augmented during a train of depolarizing pulses. Thus, diazepam appears to produce a tonic block of cardiac calcium channels and the mode of inhibition is clearly different from the use-dependent block of verapamil. From these results, it was concluded that diazepam produces a monophasic negative inotropic effect that is independent of the benzodiazepine receptor, and is probably mediated through an inhibition of I(Ca) in guinea pig heart preparations.

Cardiovascular response and stress reaction to flumazenil injection in patients under infusion with midazolam

OBJECTIVES

To evaluate the cardiovascular response and acute stress reaction after arousal induced by a benzodiazepine antagonist, flumazenil, in patients sedated with midazolam.

DESIGN

Prospective study.

SETTING

Emergency center in a university hospital.

PATIENTS

A total of 12 patients were ventilated mechanically under sedation with midazolam.

INTERVENTIONS

We monitored the consciousness level, heart rate, systemic blood pressure, pulmonary artery pressure, and pulmonary artery occlusion pressure before and after a bolus injection of 0.5 mg of flumazenil. The score for the consciousness level represents the sum of the scores for eye opening and best motor response, as determined by the Glasgow Coma Scale. We measured the cardiac output, concentrations of norepinephrine, epinephrine, and 3-methoxy-4-hydroxyphenylethyleneglycol in plasma, and concentration of cortisol in serum. We calculated the left ventricular ejection fraction, cardiac index, systemic vascular resistance index, pressure-rate product, systemic oxygen delivery, and systemic oxygen consumption at 0, 10, 30, and 60 mins after injection of flumazenil.

MEASUREMENTS AND MAIN RESULTS

The serum benzodiazepine's receptor binding activity in serum was in the range from 50 to 1000 ng/mL before injection of flumazenil. Flumazenil improved the consciousness level from 6.7+/-2.0 to 8.9+/-1.6 and induced transient elevations in heart rate, blood pressure, systolic pulmonary artery pressure, and pulmonary artery occlusion pressure. Left ventricular ejection fraction, oxygen delivery index, and pressure-rate product increased significantly, from 61%+/-8%, 640+/-170 mL/min/m2, and 13,300+/-2600 mm Hg/min at 0 mins to 67% +/-5%, 710+/-220 mL/min/m2, and 16,500+/-4400 mm Hg/min at 10 mins, respectively. Concentrations of norepinephrine and epinephrine in plasma increased significantly, from 890+/-840 pg/mL and 220+/-360 pg/mL, respectively, at 0 mins to 990+/-850 pg/mL and 270+/-300 pg/mL, respectively, at 10 mins. There were no significant changes in the plasma concentration of 3-methoxy-4-hydroxyphenylethyleneglycol, the serum concentration of cortisol after the administration of flumazenil.

CONCLUSIONS

Flumazenil did not result in a significant acute stress reaction in midazolam-sedated patients, but it increased myocardial oxygen consumption by enhancing sympathetic nervous activity or antagonizing cardiovascular depression induced by midazolam.

First-degree atrioventricular block in alprazolam overdose reversed by flumazenil

This report describes a case of alprazolam overdose associated with marked first-degree atrioventricular block reversed by flumazenil. Animal and human evidence suggests activity of certain benzodiazepines at peripheral benzodiazepine receptors in the myocardium and elsewhere. Myocardial benzodiazepine receptor ligands appear to affect calcium-channel activity, which may explain the clinical findings. Benzodiazepines may behave like weak calcium-channel blockers. This case raises the possibility of a potential role for flumazenil as an adjunct in the management of calcium-channel blocker toxicity.

Diazepam potentiates the positive inotropic effect of isoprenaline in rat ventricle strips: role of cyclic AMP

The responses of the electrically driven right ventricle strip of the rat heart to isoprenaline and other cyclic AMP-related inotropic agents were recorded in the absence and in the presence of diazepam. Isoprenaline, in concentrations ranging from 10 nM to 1 microM, significantly increased, in a concentration-dependent manner, the contractile force in this preparation. Diazepam (10 microM) produced a leftward shift in the isoprenaline concentration-response curve and significantly reduced its EC50. Higher concentrations of diazepam (100 microM) produced no further shift, but reduced the maximum of the concentration-response curve of isoprenaline. Forskolin (0.5-10 microM), which directly stimulates adenyl cyclase, also produced a concentration-dependent increase in cardiac contractility. Diazepam (10 microM) displaced to the left the concentration-response curve for forskolin and reduced its EC50. The cyclic AMP analogous dibutyryl cyclic AMP (0.1-1 mM) produced concentration-dependent positive inotropic effects which were not significantly modified in the presence of diazepam (10 microM). Diazepam (10 microM) significantly enhanced the cyclic AMP production induced by isoprenaline (0.1 microM) and forskolin (10 microM) by about 136% and 35% respectively. These results indicate that diazepam potentiates the positive inotropic effect induced by beta-adrenoceptor agonists, probably by increasing cyclic AMP production induced by these agents.

Vascular and tubular actions of diazepam in isolated and perfused rat kidney

The effects of diazepam were studied in the isolated rat kidney under conditions of constant flow. Kidneys were perfused with modified Ringer-Krebs solution. Diazepam produced a raised fractional excretion of water and sodium without hemodynamic changes, suggesting a direct effect on tubular transport mechanisms. Diazepam decreased renal perfusion pressure in a concentration-dependent fashion when kidneys were pretreated with either noradrenaline or potassium chloride. Similar responses were observed when 7-chloro-5-[4-chloro-phenyl]-1, 3-dihydro-1-methyl-2H-1,4-benzodiazepin-2-one (Ro 5-4864) or clonazepam was used. These data provide evidence for a relaxant effect of benzodiazepines on preconstricted renal vasculature.