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Brücken A, Coburn M, Rex S, Rossaint R, Fries M. [Current developments in xenon research. Importance for anesthesia and intensive care medicine]. Anaesthesist 2011; 59:883-95. [PMID: 20811728 DOI: 10.1007/s00101-010-1787-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The noble gas xenon exerts favorable anesthetic properties along with remarkable hemodynamic stability in healthy patients undergoing elective surgery. It represents the nearly ideal anesthetic and provides safe and well controllable anesthesia although the exact mechanism by which xenon produces anesthesia remains to be elucidated. In addition xenon offers organ protective properties for vital organs including the brain, heart and kidneys which seem to be synergistic when used in combination with therapeutic hypothermia. As the high cost of xenon will probably preclude its wider use as a routine anesthetic, data from extensive tests in large numbers of high risk patients is needed to confirm its possible superiority in this setting.
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Affiliation(s)
- A Brücken
- Klinik für Anästhesiologie, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074 Aachen.
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Delhaye O, Robin E, Bazin JE, Ripart J, Lebuffe G, Vallet B. [Benefits and indications of xenon anaesthesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:635-641. [PMID: 20667685 DOI: 10.1016/j.annfar.2010.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 04/16/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To analyze the current knowledge related to xenon anaesthesia. DATA SOURCES References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files. STUDY SELECTION All categories of articles on this topic have been selected. DATA EXTRACTION Articles have been analyzed for biophysics, pharmacology, toxicity and environmental effects, clinical effects and using prospect. DATA SYNTHESIS The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and rarity of xenon limits widespread use in clinical practice. The development of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas. CONCLUSION Reducing its cost will help xenon to find its place among anaesthetic agents and extend its use to severe patients with specific pathologies.
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Affiliation(s)
- O Delhaye
- Fédération d'anesthésie-réanimation, CHRU de Lille, rue Polonovski, Lille cedex, France
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Abstract
PURPOSE Anesthesia for pediatric patients undergoing surgery where intraoperative neurophysiological monitoring (IONM) is performed is based on an understanding of the anesthetic influence on the neural pathways involved and the physiology that supplies nutrients to the neural systems. Anesthesia in pediatric patients may be different than in adults due to the specific anesthesia considerations in children, notably the propofol infusion syndrome (PRIS) and the need to monitor immature neural pathways. This review was done to determine if the anesthesia protocols used were different than those used in adults. METHODS After reviewing the implications of anesthetic action, a survey of pediatric anesthesia practitioners in 40 North American centers was conducted to determine the anesthesia protocols used in pediatric surgery with IONM and if these were specifically modified over concerns about PRIS. RESULTS Twenty-five centers responded with 35 different protocols used by practitioners. These protocols are similar to protocols used in adult patients. Although no centers specifically avoided propofol in all patients, several strategies were used to reduce the dosage, avoid its use in selected patients, or monitor for the onset of the syndrome. CONCLUSION Anesthesia for pediatric patients undergoing surgery where IONM is being performed is consistent with the practice and principles of anesthesia for adults. Although PRIS has not caused major alterations in most patients, concern has modified the practice of some anesthesiologists.
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Sloan TB, Jäntti V. Anesthetic effects on evoked potentials. INTRAOPERATIVE MONITORING OF NEURAL FUNCTION 2008. [DOI: 10.1016/s1567-4231(07)08005-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Rajakumaraswamy N, Ma D, Hossain M, Sanders RD, Franks NP, Maze M. Neuroprotective interaction produced by xenon and dexmedetomidine on in vitro and in vivo neuronal injury models. Neurosci Lett 2006; 409:128-33. [PMID: 17052852 DOI: 10.1016/j.neulet.2006.09.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 09/02/2006] [Accepted: 09/11/2006] [Indexed: 11/17/2022]
Abstract
Xenon, an NMDA receptor antagonist and dexmedetomidine (Dex), an alpha(2)-adrenoceptor agonist, both exhibit neuroprotective effects. We investigated the nature of their interaction. In vitro: a primary co-culture of neuronal and glial cells derived from neonatal mice was exposed to oxygen and glucose deprivation (OGD) and the resulting neuronal injury was assessed by the release of lactate dehydrogenase (LDH). In vivo: Postnatal rats aged 7 days underwent right common carotid artery ligation followed by 90 min of hypoxia. The area of infarction was assessed at four days post-injury by morphological criteria. Long-term neurological function was evaluated at 30 days post-injury by testing co-ordination on rotarod. Both xenon and Dex concentration-dependently reduced LDH release with IC50 values of 42% atm (95% CI: 35-52) and 0.10 microM (95% CI: 0.08-0.16), respectively. Isobolographic analysis showed that combined effect of xenon and Dex in vitro was additive. In vivo, a combination of xenon and Dex, at doses that are individually not neuroprotective, produced significant neuroprotective effect as measured by reduction in area of infarction. The long-term neurological function data corroborated these morphological data. Our study demonstrates that the combination of xenon and Dex offers neuroprotection additively in vitro and synergistically in vivo.
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Affiliation(s)
- Nishanthan Rajakumaraswamy
- Departments of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Chelsea & Westminster Hospital, 369 Fulham Road, London SW10 9NH, United Kingdom
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Kobayashi S, Katoh T, Bito H, Sato S. Effect of xenon on catecholamine and hemodynamic responses to surgical noxious stimulation in humans. J Clin Anesth 2006; 18:343-8. [PMID: 16905079 DOI: 10.1016/j.jclinane.2005.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 12/21/2005] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE To determine the effect of xenon in combination anesthesia with sevoflurane on the catecholamine and hemodynamic responses to surgical noxious stimulation in humans. DESIGN Randomized study. SETTING A university hospital. PATIENTS This study involved 32 female ASA physical status I and II patients, age 20-58 years, scheduled for abdominal hysterectomy. INTERVENTIONS Patients were randomly divided into 4 groups: group X50-S1.5, 50% xenon and 1.5% sevoflurane; group X70-S1.5, 70% xenon and 1.5% sevoflurane; group G70-S1.5, 70% nitrous oxide and 1.5% sevoflurane; and group S2.8, 2.8% sevoflurane. No premedication was administered to the patients, and anesthesia was induced by administration of sevoflurane in oxygen and 0.10 to 0.15 mg/kg of vecuronium. After tracheal intubation, the combination of anesthetics was started, and skin incision was performed after equilibration for more than 15 minutes. MEASUREMENTS Systolic blood pressure and heart rate (HR) were recorded, and the plasma concentrations of norepinephrine, epinephrine (E), and dopamine were measured 0, 2.5, 5, 7.5, 10, 12.5, and 15 minutes after skin incision. MAIN RESULTS The maximal increase in the E concentration and the values of the area under the curve for E were significantly smaller in the X50-S1.5 and X70-S1.5 groups compared with that in the S2.8 group (P<0.05). At 1 minute after incision, the HR in X50-S1.5 was significantly lower than those in G70-S1.5 and S2.8 groups and the HR in X70-S1.5 was lower than that in S2.8 group (P<0.01). The systolic blood pressure in S2.8 group at 1 minute was significantly higher than those of other groups (P<0.01). CONCLUSION Combination anesthesia using xenon and sevoflurane suppresses the plasma E concentration and hemodynamic response after skin incision more effectively than sevoflurane anesthesia alone.
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Affiliation(s)
- Shunji Kobayashi
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Shizuoka 431-3192, Japan.
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Abstract
Of all the inert gases, only xenon has considerable anaesthetic properties under normobaric conditions. Its very low blood/gas partition coefficient makes induction of and emergence from anaesthesia more rapid compared with other inhalational anaesthetics. In experimental and clinical studies the safety and efficiency of xenon as an anaesthetic has been demonstrated. Xenon causes several physiological changes, which mediate protection of the brain or myocardium. The use of xenon might therefore be beneficial in certain clinical situations, as in patients at high risk for neurological or cardiac damage.
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Affiliation(s)
- Benedikt Preckel
- Department of Anaesthesiology, Dusseldorf University Hospital, P.O. Box 10 10 07, D-40001 Düsseldorf, Germany.
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Abstract
PURPOSE OF REVIEW Xenon anaesthesia has recently been evaluated in large-scale clinical trials that have demonstrated xenon's safe and effective clinical profile. Despite the relatively high cost of xenon anaesthesia, xenon has clear clinical advantages over other current anaesthetics. RECENT FINDINGS Xenon possesses distinct neuroprotective and cardioprotective properties in addition to a favourable pharmacokinetic profile and analgesic effects. In addition, xenon exerts preconditioning effects in the heart and may offer postoperative, as well as intraoperative, cardio and neuroprotection. SUMMARY Further clinical trials are required to evaluate the role that xenon can play in the perioperative period.
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Affiliation(s)
- Robert D Sanders
- Department of Anaesthetics and Intensive Care, Faculty of Medicine, Imperial College, London, UK
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Abstract
The 'noble' gases have been known to have anaesthetic properties for 50 years yet only recently has their application become a clinical reality. In this review we describe the preclinical and clinical studies that have led to a resurgence of interest in the use of the element xenon as an anaesthetic. Furthermore, we highlight specific areas where xenon demonstrates advantages over other anaesthetics, including safety, beneficial pharmacokinetics, cardiovascular stability, analgesia and neuroprotection.
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Affiliation(s)
- Robert D Sanders
- Department of Anaesthetics and Intensive Care, Faculty of Medicine, Imperial College London, UK
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Affiliation(s)
- R D Sanders
- Department of Anaesthetics and Intensive Care, Faculty of Medicine, Imperial College London, UK
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Kingery WS, Sawamura S, Agashe GS, Davies MF, Clark JD, Zimmer A. Enkephalin release and opioid receptor activation does not mediate the antinociceptive or sedative/hypnotic effects of nitrous oxide. Eur J Pharmacol 2001; 427:27-35. [PMID: 11553360 DOI: 10.1016/s0014-2999(01)01193-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In previous studies using Fos expression as a marker of neuronal activation, we showed that nitrous oxide (N(2)O) activates bulbospinal noradrenergic neurons in rats and that destruction of these neuronal pathways leads to loss of N(2)O antinociceptive action. Based on previous rat studies it has been proposed that these noradrenergic neurons are activated through opioid receptors through the release of endogenous opioid ligands in the periaqueductal gray. Using mice with a disrupted preproenkephalin gene (Penk2 -/-) and the opioid receptor antagonist naltrexone, we investigated the role of enkephalinergic mechanisms and opioid receptor activation in the behavioral and bulbospinal neuron responses to N(2)O in mice. The antinociceptive response to N(2)O was investigated using the tail-flick, hot-plate, and von Frey assays, the sedative/hypnotic response was measured using rotarod and loss of righting reflex, and bulbospinal neuronal activation was assessed with pontine Fos immunostaining. No differences were observed between wild-type and Penk2 -/- mice for the antinociceptive, sedative/hypnotic, and pontine neuronal activation effects of N(2)O. Similarly, naltrexone did not block N(2)O-induced antinociception, sedation, or hypnosis. We conclude that neither enkephalin nor opioid receptors participate in either the antinociceptive or the sedative/hypnotic actions of N(2)O in mice.
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Affiliation(s)
- W S Kingery
- Department of Functional Restoration, Stanford University School of Medicine, Stanford, CA, USA.
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Leclerc J, Nieuviarts R, Tavernier B, Vallet B, Scherpereel P. [Xenon anesthesia: from myth to reality]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2001; 20:70-6. [PMID: 11234584 DOI: 10.1016/s0750-7658(00)00327-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To analyze the current knowledge concerning xenon anaesthesia. DATA SOURCES References were obtained from computerized bibliographic research (Medline), recent review articles, the library of the service and personal files. STUDY SELECTION All categories of articles on this topic have been selected. DATA EXTRACTION Articles have been analysed for history, biophysics, pharmacology, toxicity and environmental effects and using prospect. DATA SYNTHESIS The noble gas xenon has anaesthetic properties that have been recognized 50 years ago. Xenon is receiving renewed interest because it has many characteristics of an ideal anaesthetic. In addition to its lack of effects on cardiovascular system, xenon has a low solubility enabling faster induction of and emergence from anaesthesia than with other inhalational agents. Nevertheless, at present, the cost and arety of xenon limit its widespread use in clinical practice. The developement of closed rebreathing system that allowed recycling of xenon and therefore reducing its waste has led to a recent interest in this gas. Reducing its cost will help xenon to find its place among anaesthetic agents. An European multicentric clinical trial under submission will contribute to the discussion of the opportunity for xenon introduction in anaesthesia.
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Affiliation(s)
- J Leclerc
- Département d'anesthésie-réanimation chirurgicale 2, CHRU, hôpital Claude Huriez, rue Michel Polonovski, 59037 Lille, France.
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Fender C, Fujinaga M, Maze M. Strain differences in the antinociceptive effect of nitrous oxide on the tail flick test in rats. Anesth Analg 2000; 90:195-9. [PMID: 10625003 DOI: 10.1097/00000539-200001000-00039] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED To study strain differences in antinociceptive effects of nitrous oxide (N2O), we examined various outbred and inbred stains of rats by using tail flick latency response. All outbred strains, i.e., Sprague-Dawley from two different breeders, Wistar, and Long-Evans, showed a similar antinociceptive response. Namely, the peak response occurred after 30 min of exposure, and tolerance to N2O developed within 60 to 90 min. Each of the four inbred stains examined, i.e., Wistar-Kyoto, Brown-Norway, Fischer, and Lewis, displayed a unique pattern of antinociceptive response to N2O. Wistar-Kyoto and Brown-Norway strains showed somewhat similar patterns as those observed in outbred strains, apart from the fact that the Wistar-Kyoto displayed a more distinct development of tolerance, whereas, the Brown-Norway strain had a lower peak effect. The Fischer strain displayed the greatest antinociceptive response to N2O, and did not develop tolerance. The Lewis strain showed no antinociceptive response to N2O. These results indicate differences in the durability and the magnitude of the antinociceptive response to N2O among various strains of rats. IMPLICATIONS Because of the variability that already exists, we recommend that animal studies examining the antinociceptive effects of nitrous oxide should be performed on inbred rat strains.
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Affiliation(s)
- C Fender
- Department of Anesthesia, Stanford University School of Medicine, California, USA
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Zacny JP, Conran A, Pardo H, Coalson DW, Black M, Klock AP, Klafta JM. Effects of naloxone on nitrous oxide actions in healthy volunteers. Pain 1999; 83:411-418. [PMID: 10568848 DOI: 10.1016/s0304-3959(99)00127-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A number of studies have examined the effects of naloxone on nitrous oxide-induced analgesia with conflicting results. In the present study the effects of a relatively high dose of naloxone was examined to determine its effects on nitrous oxide-induced analgesia, as well as on the subjective and psychomotor effects of nitrous oxide. Fourteen subjects participated in a four-session crossover trial in which they received intravenous injections of either saline or 30mg/70kg naloxone 10min into a 35min period in which they were inhaling either 100% oxygen or 30% nitrous oxide in oxygen. Ten minutes after the naloxone administration, subjects were tested on the cold pressor test. Mood and psychomotor performance were also assessed before, during and after the inhalation period. Subjects reported higher pain ratings after the naloxone injection than the saline injection, but there was no evidence of naloxone reversing the analgesic effects of nitrous oxide. Similarly while naloxone also affected mood and impaired psychomotor performance, there was no evidence of naloxone reversing the effect of nitrous oxide on these measures. The results of this study call into question the role of the opioidergic system in mediating various effects of nitrous oxide in humans.
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Affiliation(s)
- James P Zacny
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
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Nakata Y, Goto T, Ishiguro Y, Terui K, Niimi Y, Morita S. Xenon suppresses the hypnotic arousal in response to surgical stimulation. J Clin Anesth 1999; 11:305-9. [PMID: 10470632 DOI: 10.1016/s0952-8180(99)00045-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To evaluate the suppressive effects of xenon (Xe) on hypnotic arousal at skin incision. DESIGN Prospective, randomized study. SETTING Operating rooms at a university hospital. PATIENTS 35 ASA physical status I and II patients presenting for elective lower abdominal surgery. INTERVENTIONS Patients were randomly assigned to receive one of the following regimens: 1.3 minimum alveolar concentration (MAC) isoflurane, 1.3 MAC sevoflurane, 0.7 MAC Xe with 0.6 MAC sevoflurane, 1 MAC Xe with 0.3 MAC sevoflurane, or 0.7 MAC nitrous oxide (N2O) with 0.6 MAC sevoflurane (n = 7 each group). MEASUREMENTS AND MAIN RESULTS The bispectral index (BIS) was measured at baseline, during anesthesia, and after skin incision. BIS increased significantly at skin incision from the values noted during anesthesia in the sevoflurane and N2O groups, whereas it remained stable at incision in the other three groups (mean change in BIS: 0 +/- 9 for isoflurane, 15 +/- 8 for sevoflurane, 5 +/- 6 for 0.7 MAC Xe, 4 +/- 11 for 1 MAC Xe, and 9 +/- 5 for N2O). CONCLUSIONS Unlike N2O, Xe was able to suppress hypnotic arousal in response to surgical stimulation when administered with sevoflurane.
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Affiliation(s)
- Y Nakata
- Department of Anesthesia, Teikyo University School of Medicine, Ichihara Hospital, Chiba, Japan.
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Miyazaki Y, Adachi T, Utsumi J, Shichino T, Segawa H. Xenon Has Greater Inhibitory Effects on Spinal Dorsal Horn Neurons than Nitrous Oxide in Spinal Cord Transected Cats. Anesth Analg 1999. [DOI: 10.1213/00000539-199904000-00038] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Miyazaki Y, Adachi T, Utsumi J, Shichino T, Segawa H. Xenon has greater inhibitory effects on spinal dorsal horn neurons than nitrous oxide in spinal cord transected cats. Anesth Analg 1999; 88:893-7. [PMID: 10195543 DOI: 10.1097/00000539-199904000-00038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Xenon (Xe) suppresses wide dynamic range neurons in cat spinal cord to a similar extent as nitrous oxide (N2O). The antinociceptive action of N2O involves the descending inhibitory system. To clarify whether the descending inhibitory system is also involved in the antinociceptive action of Xe, we compared the effects of Xe on the spinal cord dorsal horn neurons with those of N2O in spinal cord-transected cats anesthetized with alpha-chloralose and urethane. We investigated the change of wide dynamic range neuron responses to touch and pinch by both anesthetics. Seventy percent Xe significantly suppressed both touch- and pinch-evoked responses in all 12 neurons. In contrast, 70% N2O did not show significant suppression in touch- and pinch-evoked responses. These results suggest that the antinociceptive action of Xe might not be mediated by the descending inhibitory system, but instead may be produced by the direct effect on spinal dorsal horn neurons. IMPLICATIONS Xenon (Xe) is an inert gas with anesthetic properties. We examined the antinociceptive effects of Xe and nitrous oxide (N2O) in spinal cord-transected cats. Our studies indicate that Xe has a direct antinociceptive action on the spinal cord that is greater than that of N2O.
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Affiliation(s)
- Y Miyazaki
- Department of Anesthesia, Kyoto University Hospital, Japan
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Abstract
It should be apparent from this review that far less is known about the neural basis for inhalant abuse than for other forms of drug abuse. This reflects a lack of research interest in this area (Balster, 1997). Indeed, conclusions are difficult to draw. In the case of the volatile alkyl nitrites, the most reasonable hypothesis at this time is that the cellular basis for their abuse resides in their actions on smooth muscles to produce vasodilation and relaxation, however, direct effects on the brain cannot be ruled out. Although there is some evidence that analgesic effects of nitrous oxide may involve opiate systems, even this conclusion is controversial. There is no evidence that opiate systems play a role in nitrous oxide intoxication or reinforcement. The mechanisms for these effects are unknown. They may reflect the same actions on lipid membranes or on hydrophobic sites on unspecified proteins that have been proposed as mechanisms for nitrous oxide anesthesia. In the case of the volatile solvents, fuels and anesthetics we are faced with a wide variety of specific chemicals which may produce different profiles of pharmacological effects. There is evidence that the prototypic abused solvents toluene and trichloroethane produce acute effects similar to subanesthetic concentrations of general anesthetics, as well as to the effects of classical CNS depressant drugs, such as alcohol and the barbiturates. For the anesthetics, evidence suggests that enhancement of GABAergic inhibition may be an important cellular target for their acute effects, just as it is for alcohol and other depressant drugs. For toluene, as with alcohol, recent evidence suggests a possible role for inhibition of glutamatergic neurotransmission involving NMDA receptors. Toluene has also been shown to have some dopaminergic effects which may be important to its abuse. As for the large number of other abused vapors, practically no information can be found on their cellular actions, and certainly not on actions that may be relevant to their abuse. This entire area would seem an important direction for future research.
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Affiliation(s)
- R L Balster
- Department of Pharmacology and Toxicology, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298, USA.
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