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Wilson SM, Lojek ASB, Zamora-Berridi GJ, Hodgson JA. Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease. Mil Med 2021; 188:usab343. [PMID: 34463327 DOI: 10.1093/milmed/usab343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/18/2021] [Accepted: 08/05/2021] [Indexed: 11/12/2022] Open
Abstract
Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.
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Affiliation(s)
- Sara M Wilson
- Department of Anesthesiology, Walter Reed National Military Medical Center and Rotating Resident at Inova Fairfax Hospital, Bethesda, MD 20889, USA
| | - Andrei S B Lojek
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | | | - John A Hodgson
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
- National Capital Consortium Anesthesiology Residency Program, Uniformed Services University F. Edward Hebert School of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
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Horishita R, Ogata Y, Fukui R, Yamazaki R, Moriwaki K, Ueno S, Yanagihara N, Uezono Y, Yokoyama Y, Minami K, Horishita T. Local Anesthetics Inhibit Transient Receptor Potential Vanilloid Subtype 3 Channel Function in Xenopus Oocytes. Anesth Analg 2021; 132:1756-1767. [PMID: 33857022 DOI: 10.1213/ane.0000000000005546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The transient receptor potential vanilloid subtype 3 (TRPV3) channel is activated by innocuous temperature and several chemical stimuli. It is proposed to be involved in pathological pain development and is therefore considered a potential target for treating pain. Local anesthetics have been used for patients with both acute and chronic pain. Although blockage of the voltage-gated sodium channel is the primary mechanism by which local anesthetics exert their effects, they cannot be explained by this mechanism alone, especially in pathologic states such as chronic pain. Indeed, the effects of local anesthetics on multiple targets involved in the pain pathway have been reported. It has also been suggested that modulating the function of transient receptor potential (TRP) channels (eg, TRPV1 and transient receptor potential ankyrin 1 [TRPA1]) is one of the mechanisms of action of local anesthetics. However, the effects of local anesthetics on TRPV3 have not been reported. METHODS We expressed TRPV3 in Xenopus oocytes and investigated the effects of local anesthetics on 2-aminoethoxydiphenyl borate (2APB)-induced currents using 2-electrode voltage-clamp techniques. RESULTS Clinically used local anesthetics inhibited the 2APB-activated currents from the TRPV3 channel in a concentration-dependent manner at pharmacologically relevant concentrations with half maximal inhibitory concentration (IC50) values of 2.5 (lidocaine), 1.4 (mepivacaine), 0.28 (ropivacaine), and 0.17 (bupivacaine) mmol/L, respectively. Conversely, these local anesthetics also directly induced currents at higher concentrations, although these currents were quite small compared to the 2APB-induced currents. We found that the inhibition of TRPV3 by lidocaine is noncompetitive and independent of intracellular signaling cascades. 2APB-induced TRPV3 currents were reduced by extracellular N-(2,6-dimethylphenylcarbamoylmethyl) triethylammonium bromide (QX-314) but not by intracellular QX-314 nor benzocaine. Moreover, lidocaine showed a use-dependent block in TRPV3 inhibition. Finally, QX-314 appeared to slightly permeate the activated TRPV3 channel pore based on examination of oocytes coexpressing TRPV3 and a sodium channel. These results suggest that local anesthetics could inhibit TRPV3 channel function by extracellular interactions of their charged forms with the channel pore. CONCLUSIONS Local anesthetics inhibited TRPV3 2APB-induced currents at pharmacologically relevant concentrations when TRPV3 was expressed in Xenopus oocytes. These effects seem to occur via an extracellular interaction between the charged form of the anesthetic with the TRPV3 channel pore. These results help to elucidate the mechanisms of action of local anesthetics.
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Affiliation(s)
- Reiko Horishita
- From the Department of Anesthesiology, School of Medicine and
| | - Yuichi Ogata
- From the Department of Anesthesiology, School of Medicine and
| | - Ryo Fukui
- From the Department of Anesthesiology, School of Medicine and
| | - Ryo Yamazaki
- From the Department of Anesthesiology, School of Medicine and
| | | | - Susumu Ueno
- Department of Occupational Toxicology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Nobuyuki Yanagihara
- Laboratory of Pharmacology, Faculty of Food and Nutrition, Kyushu Nutrition Welfare University
| | - Yasuhito Uezono
- Department of Pain Control Research, The Jikei University School of Medicine.,Division of Supportive and Palliative Research Support, Cancer Center Hospital East
| | - Yuka Yokoyama
- Department of Molecular Pathology & Metabolic Disease, Faculty of Pharmaceutical Sciences, Tokyo University of Science
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Sohnen S, Dowling O, Shore-Lesserson L. Single dose perioperative intrathecal ketamine as an adjuvant to intrathecal bupivacaine: A systematic review and meta-analysis of adult human randomized controlled trials. J Clin Anesth 2021; 73:110331. [PMID: 33962333 DOI: 10.1016/j.jclinane.2021.110331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/25/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To identify whether adding intrathecal ketamine to intrathecal bupivacaine prolongs the time to first analgesic request in adult humans. DESIGN A meta-analysis of randomized controlled trials in humans. SETTING The majority of data was obtained in an operating room and postoperative recovery area. PATIENTS A total of 750 ASA physical status I and II patients were included in the study. Procedures performed include: cesarean section, lower abdominal surgery, lower limb surgery, and urologic surgery. INTERVENTIONS Databases including PubMed, Embase, Web of Science, and Cochrane were searched. Google Scholar was also queried. Multiple reviewers screened the papers for inclusion. MEASUREMENTS The primary outcome assessed was time to first analgesic request. Secondary outcomes included onset of sensory blockade, onset of motor blockade, duration of sensory blockade, and duration of motor blockade. Data were extracted to include means, 95% confidence intervals, tests for heterogeneity, and use of the Cochrane Collaboration guidelines to assess for publication bias. MAIN RESULTS Eleven randomized controlled trials met inclusion criteria. When comparing intrathecal bupivacaine plus ketamine to intrathecal bupivacaine alone, the time to first analgesic request was prolonged (effect size = 58.23 min (95% CI 37.36 to 79.10) p < 0.0001). Secondary outcomes showed the onset time of sensory blockade was shortened (effect size = -0.87 min (95% CI -1.361 to 0.378) p = 0.0005), the onset time of motor blockade was reduced (effect size = -0.88 min (95% CI -1.77 to 0.013) p = 0.05), the duration of sensory blockade was prolonged (effect size = 39.73 min (95% CI 15.97 to 63.50) p = 0.001), and the duration of motor blockade was prolonged (effect size = 4.02 min (95% CI 3.27 to 4.78) p < 0.0001). Studies were shown to have high heterogeneity. Egger tests for all outcomes were non-significant and funnel plots assessing publication bias were all asymmetrical. CONCLUSIONS The studies analyzed suggest there may be a benefit to using intrathecal ketamine as an adjunct to bupivacaine. Additional studies are warranted to optimize dosing, clarify the safety and efficacy of this intrathecal drug combination, and examine the various ketamine formulations as intrathecal bupivacaine adjuvants.
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Affiliation(s)
- Samantha Sohnen
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States of America.
| | - Oonagh Dowling
- Zucker School of Medicine at Hofstra/Northwell, Department of Anesthesiology, Northwell Health, New Hyde Park, NY, United States of America
| | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra/Northwell, Department of Anesthesiology, Northwell Health, New Hyde Park, NY, United States of America
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Schuitemaker J, López-Pantaleon L, Tejada Pérez P, Cubedo Culleré M, Sánchez Cohen A, Imbiscuso Esqueda A, Acosta Díez J. Variación de la baricidad en la mezcla de anestesia espinal para cesárea, ¿tiene algún efecto en la calidad anestésica? Estudio aleatorizado, doble ciego, controlado. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Neurotoxic Effects of Local Anesthetics on Developing Motor Neurons in a Rat Model. J Clin Med 2021; 10:jcm10050901. [PMID: 33668828 PMCID: PMC7956179 DOI: 10.3390/jcm10050901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/19/2021] [Accepted: 02/20/2021] [Indexed: 11/16/2022] Open
Abstract
Neurotoxic effects of local anesthetics (LAs) on developing motor neurons have not been documented. We investigated the neurotoxic effects of LAs on developing motor neurons in terms of cell viability, cytotoxicity, reactive oxygen species (ROS), and apoptosis. Embryonic spinal cord motor neurons were isolated from Sprague-Dawley rat fetuses and exposed to one of the three LAs-lidocaine, bupivacaine, or ropivacaine-at concentrations of 1, 10, 100, or 1000 µM. The exposure duration was set to 1 or 24 h. The neurotoxic effects of LAs were determined by evaluating the following: cell viability, cytotoxicity, ROS production, and apoptosis. In the 1-h exposure group, the motor neurons exposed to lidocaine and bupivacaine had reduced cell viability and increased cytotoxicity, ROS, and apoptosis in a concentration-dependent manner. Lidocaine showed the highest toxicity, followed by bupivacaine. In the 24-h exposure group, all three LAs showed significant effects (decreased cell viability and increased cytotoxicity, ROS, and apoptosis) on the motor neurons in a concentration-dependent manner. The neurotoxic effects of lidocaine were greater than those of bupivacaine and ropivacaine. Ropivacaine appeared to have the least effect on motor neurons. This study identified the neurotoxic effects of lidocaine and bupivacaine on developing spinal cord motor neurons.
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Duszynski B. Spine Intervention Society Position Statement on Best Practices for Epidural Steroid Injections in the Setting of a Preservative-Free Dexamethasone Shortage. PAIN MEDICINE 2020; 20:1277-1280. [PMID: 31034052 DOI: 10.1093/pm/pnz063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Paramasivan A, Lopez-Olivo MA, Foong TW, Tan YW, Yap APA. Intrathecal dexmedetomidine and postoperative pain: A systematic review and meta-analysis of randomized controlled trials. Eur J Pain 2020; 24:1215-1227. [PMID: 32333825 DOI: 10.1002/ejp.1575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE A systematic review and meta-analysis of randomized controlled trials (RCTs) was undertaken to evaluate the effect of intrathecal dexmedetomidine (DEX) on the duration of postoperative analgesia, postoperative pain scores and incidences of adverse effects. DATABASES AND DATA TREATMENT Database search was performed from inception until January 2019. All RCTs analysing acute postoperative pain characteristics after intrathecal DEX administration in adults undergoing spinal anaesthesia for elective surgery were included. The primary outcome was postoperative analgesic duration, defined as the time to first analgesic request. The secondary outcomes included pain scores at 6, 12 and 24 postoperative hours and rates of hypotension, bradycardia, shivering and postoperative nausea and vomiting. RESULTS Twenty-four studies comprising a total of 1,460 patients were included. Postoperative analgesic duration was prolonged with intrathecal DEX compared to placebo, with a pooled mean difference (MD) of 191.3 min (95% CI 168.8-213.8). Patients who received intrathecal DEX reported lower Visual Analogue Scale scores at 24 postoperative hours compared with those patients receiving placebo, with a MD (95% CI) of -1.05 (-1.89 to -0.20, p = 0.02). There were no differences in the incidence of adverse effects, except for a lower rate of postoperative shivering in the intrathecal DEX group (pooled relative risk 0.58, 95% CI 0.34-0.98, p = 0.04). CONCLUSIONS Compared to placebo, intrathecal DEX prolonged postoperative analgesic duration, reduced 24-hr pain intensity and reduced the incidence of shivering without an increase in other adverse effects. SIGNIFICANCE The analgesic role of intrathecal DEX is promising due to its ability to significantly increase postoperative analgesic duration when compared with placebo. Its usage can be considered for patients undergoing surgeries with significant postoperative pain, particularly those intolerant of systemic analgesia. However, the optimal dose for various surgeries as well as its long-term neurological effects warrants further studies.
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Affiliation(s)
| | | | | | - Yi W Tan
- National University Hospital, Singapore, Singapore
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Dexmedetomidine and Bupivacaine Association in Caudal Epidural Injection in Mares. J Equine Vet Sci 2020; 91:103015. [PMID: 32684274 DOI: 10.1016/j.jevs.2020.103015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 03/13/2020] [Accepted: 03/30/2020] [Indexed: 11/23/2022]
Abstract
The objective of the study was to compare the effects of caudal epidural bupivacaine and dexmedetomidine (DEX) combination, with bupivacaine or DEX plain for perineal analgesia in mares. Six healthy saddle mares weighing 330-370 kg and aged 10-15 years were used in this study. Each mare was assigned to receive three treatments: 0.04 mg/kg 0.25% bupivacaine (BP), 2 μg/kg DEX (DX), or 0.02 mg/kg bupivacaine and 1 μg/kg DEX (BPDX). The order of treatments was randomized. All drugs were injected into the caudal epidural space (Co1-Co2) through a 16-G Tuohy epidural needle. After the epidural injections, heart rate, respiratory rate, arterial blood pressures (systolic, diastolic, and mean), and rectal temperature were measured at 5, 10, 15, 30, 60, 90, and 120 minutes, and after this time, every 60 minutes until the end of the experiments. A subjective score system was used to assess analgesia, behavioral and motor blockade at the same time points. The BPDX treatment produced analgesic action with twice the duration (200 minutes) of the BP treatment (97 minutes), but with an analgesic duration shorter than the DX treatment (240 minutes) in the regions of the tail, perineum, and upper hind limbs in mares. All treatments showed mild motor blockade. No behavioral changes were observed in any of the animals. There was hemodynamic stability without significant changes in respiratory rate for all treatments. Epidural analgesia using DEX alone or the combination of DEX and bupivacaine may be an option for painful obstetric and gynecological procedures in mares.
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Safe Injectate Choice, Visualization, and Delivery for Lumbar Transforaminal Epidural Steroid Injections: Evolving Literature and Considerations. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00244-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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10
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Kaya C, Atalay YO, Meydan BC, Ustun YB, Koksal E, Caliskan S. [Evaluation of the neurotoxic effects of intrathecal administration of (S)-(+)-Ketoprofen on rat spinal cords: randomized controlled experimental study]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2019; 69:403-412. [PMID: 31371174 PMCID: PMC9391909 DOI: 10.1016/j.bjan.2019.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 03/08/2019] [Accepted: 03/17/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Intrathecal administration of non-steroidal anti-inflammatory drugs is more efficacious for post-operative pain management. Cyclooxygenase inhibiting non-steroidal anti-inflammatory drugs like (S)-(+)-Ketoprofen, may be effective at lower intrathecal doses than parenteral ones. Preclinical safety regarding possible neurotoxicity associated with the intrathecal (S)-(+)-Ketoprofen was not evaluated. Here we analysed the neurotoxicity of intrathecally administered (S)-(+)-Ketoprofen in rats. METHODS A randomized placebo-controlled experimental study was conducted. Sprague-Dawley rats (250-300g) aged 12-16 weeks were randomly divided into 2 treatments [100 and 800μg (S)-(+)-Ketoprofen] and control (sterile water) groups. Intrathecal catheters were placed via the atlantoaxial space in anesthetized rats. Pinch-toe tests, motor function evaluations and histopathological examinations of the spinal cord and nerve roots were performed at days 3, 7 and 21. Spinal cord sections were evaluated by light microscopy for the dorsal axonal funiculus vacuolation, axonal myelin loss, neuronal chromatolysis, neuritis, meningeal inflammation, adhesions, and fibrosis. RESULTS Rats in all the groups exhibited normal pinch-toe testing response (score=0) and normal gait at each observed time (motor function evaluation score=1). Neurotoxicity was higher with treatments on days 3 and 7 than that on day 21 (2, 3, 0, p=0.044; 2, 5, 0, p=0.029, respectively). On day 7, the total scores reflecting neuronal damage were higher in the 800μg group than those in the 100μg and Control Groups (5, 3, 0, p=0.048, respectively). CONCLUSION Intrathecal (S)-(+)-Ketoprofen caused dose-dependent neurohistopathological changes in rats on days 3 and 7 after injection, suggesting that (S)-(+)-Ketoprofen should not be intrathecally administered.
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Affiliation(s)
- Cengiz Kaya
- Ondokuz Mayis University, School of Medicine, Department of Anesthesiology, Kurupelit, Turquia.
| | - Yunus O Atalay
- Ondokuz Mayis University, School of Medicine, Department of Radiology, Kurupelit, Turquia
| | - Bilge C Meydan
- Ondokuz Mayis University, School of Medicine, Department of Pathology, Kurupelit, Turquia
| | - Yasemin B Ustun
- Ondokuz Mayis University, School of Medicine, Department of Anesthesiology, Kurupelit, Turquia
| | - Ersin Koksal
- Ondokuz Mayis University, School of Medicine, Department of Anesthesiology, Kurupelit, Turquia
| | - Sultan Caliskan
- Ondokuz Mayis University, School of Medicine, Department of Pathology, Kurupelit, Turquia
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Kaya C, Atalay YO, Meydan BC, Ustun YB, Koksal E, Caliskan S. Evaluation of the neurotoxic effects of intrathecal administration of (S)-(+)-Ketoprofen on rat spinal cords: randomized controlled experimental study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31371174 PMCID: PMC9391909 DOI: 10.1016/j.bjane.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background and objectives Intrathecal administration of non-steroidal anti-inflammatory drugs is more efficacious for post-operative pain management. Cyclooxygenase inhibiting non-steroidal anti-inflammatory drugs like (S)-(+)-Ketoprofen, may be effective at lower intrathecal doses than parenteral ones. Preclinical safety regarding possible neurotoxicity associated with the intrathecal (S)-(+)-Ketoprofen was not evaluated. Here we analysed the neurotoxicity of intrathecally administered (S)-(+)-Ketoprofen in rats. Methods A randomized placebo-controlled experimental study was conducted. Sprague-Dawley rats (250–300 g) aged 12–16 weeks were randomly divided into 2 treatments [100 and 800 μg (S)-(+)-Ketoprofen] and control (sterile water) groups. Intrathecal catheters were placed via the atlantoaxial space in anesthetized rats. Pinch-toe tests, motor function evaluations and histopathological examinations of the spinal cord and nerve roots were performed at days 3, 7 and 21. Spinal cord sections were evaluated by light microscopy for the dorsal axonal funiculus vacuolation, axonal myelin loss, neuronal chromatolysis, neuritis, meningeal inflammation, adhesions, and fibrosis. Results Rats in all the groups exhibited normal pinch-toe testing response (score = 0) and normal gait at each observed time (motor function evaluation score = 1). Neurotoxicity was higher with treatments on days 3 and 7 than that on day 21 (2, 3, 0, p = 0.044; 2, 5, 0, p = 0.029, respectively). On day 7, the total scores reflecting neuronal damage were higher in the 800 μg group than those in the 100 μg and Control Groups (5, 3, 0, p = 0.048, respectively). Conclusion Intrathecal (S)-(+)-Ketoprofen caused dose-dependent neurohistopathological changes in rats on days 3 and 7 after injection, suggesting that (S)-(+)-Ketoprofen should not be intrathecally administered.
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Sun X, Liu S, Liu C, Xu J, Sun J, Pan Y. An inadvertent subarachnoid injection reversed by cerebrospinal fluid lavage for the treatment of chronic low back pain: A case report. Medicine (Baltimore) 2019; 98:e14406. [PMID: 30732190 PMCID: PMC6380745 DOI: 10.1097/md.0000000000014406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE We present a case of high spinal anesthesia after inadvertent injection of local anesthetics and corticosteroids into the subarachnoid space during attempted epidural injection. Cerebrospinal fluid (CSF) lavage is a suitable method for treatment. PATIENT CONCERNS A 45-year-old woman presented with posterior thigh, leg, and ankle pain for >6 months and was treated with epidural injection. Five minutes after the third time of epidural injection, the patient complained loss of sensation and muscle strength in the lower extremities and abdominal area. DIAGNOSES A high spinal anesthesia was confirmed by the patient loss of sensation and muscle strength in the lower extremities and abdominal area. INTERVENTIONS CSF lavage was performed for treatment. OUTCOMES After CSF lavage, the patient gradually returns to normal sensory and motor functions of lower limbs. On the fourth day, the patient sensed her physical function restoring gradually and was discharged uneventfully. At 4-month follow-up, the patient could have normal activities without obvious subsequent complications and any pain. LESSONS We conclude that CSF lavage could be a helpful maneuver to clear lidocaine and betamethasone and avoid potential nerve damage caused by an unintentional intrathecal injection during an epidural injection for the treatment of chronic low back pain.
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Affiliation(s)
- Xiaodi Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shijiang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Cunming Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jie Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yinbing Pan
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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O'Reilly-Shah V, Lynde GC. Determination of ED50 and time to effectiveness for intrathecal hydromorphone in laboring patients using Dixon's up-and-down sequential allocation method. BMC Anesthesiol 2018; 18:140. [PMID: 30290794 PMCID: PMC6173834 DOI: 10.1186/s12871-018-0603-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background With the increasing occurrence of drug shortages, understanding the pharmacokinetics of alternative intrathecal opioid administration has gained importance. In particular, additional data are needed to comprehensively evaluate the analgesic properties of intrathecal hydromorphone in the laboring patient. In a phase 2 clinical trial, we set out to determine the median effective dose (ED50) and time to effectiveness for this drug in this population. Methods Using Dixon’s up-and-down sequential allocation method, twenty women presenting for labor analgesia were prospectively enrolled. A combined spinal-epidural technique was used to deliver the determined dose of intrathecal hydromorphone. Visual analog pain scores were obtained assessing peak pain scores during serial uterine contractions. Effective pain relief was defined as achieving a pain score of less than or equal to 3 out of 10. The dose was deemed to be ineffective if the patient failed to achieve this level of relief after 30 min. Results The ED50 of hydromorphone in our population was 10.9 μg (95% confidence interval 5.6–16.2 μg). Amongst patients for whom the dose was effective, the median time to pain relief was 24 min. One patient experienced both nausea and pruritus. No other complications were noted. Conclusion Due to the prolonged time to onset, hydromorphone cannot be recommended in favor of substantively better alternatives such as sufentanil and fentanyl. Trial registration Clinicaltrials.gov registration number: NCT01598506.
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Affiliation(s)
- Vikas O'Reilly-Shah
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Grant C Lynde
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
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Zhang K, Yang S, Luo C. TNF-alpha and TNF-R1 regulate bupivacaine-induced apoptosis in spinal cord dorsal root ganglion neuron. Eur J Pharmacol 2018; 833:63-68. [PMID: 29802833 DOI: 10.1016/j.ejphar.2018.05.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 02/05/2023]
Abstract
Local anesthesia has been shown to render severe spinal cord neurotoxicity. This study used an in vitro model to explore the expression and function of tumor necrosis factor (TNF) signaling pathway in bupivacaine-induced apoptotic injury in spinal cord dorsal root ganglia (DRG). DRG was prepared from adult C57BL/6 mice and incubated with 10 mM bupivacaine in vitro to induce apoptosis. QRT-PCR and western blot demonstrated that bupivacaine upregulated TNF-alpha (TNF-α) and TNF receptor 1 (TNF-R1), but left TNF receptor 2 (TNF-R2) unaffected in DRG. SiRNA-mediated TNF-α or TNF-R1 inhibition, but not TNF-R2 inhibition, rescued bupivacaine-induced DRG apoptosis. In addition, qRT-PCR and western blot demonstrated that downstream substrates of apoptotic and TNF signaling pathways, caspase-9, MAP3K and JNK, were all significantly downregulated by TNF-α or TNF-R1 inhibition, but not by TNF-R2 inhibition, in bupivacaine-injured DRG. Thus, our work suggested that TNF-α and TNF-R1 are the major contributors of TNF signaling pathway in anesthesia-induced spinal cord neurotoxicity. Targeting TNF-α / TNF-R1, not TNF-R2 signaling pathway may be the key component to rescue or prevent anesthesia-induced apoptotic injury in spinal cord neurons.
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Affiliation(s)
- Ke Zhang
- Department of Anesthesiology, The 2nd Affiliated Hospital of Chengdu Medical College, Nuclear Industry 416 Hospital, Chengdu 610051, China
| | - Shuai Yang
- Department of Anesthesiology, Affiliated Hospital and Clinical Medical College of Chengdu University, Chengdu 610081, China.
| | - Chaozhi Luo
- Department of Anesthesiology, West China School of Medicine, West China Hospital, Sichuan University, Chengdu 637400, China
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Adedayo AD, Aderinola AA, Adekilekun TA, Olaolu OO, Olanike AM, Olayemi IK. Morphine-alcohol treatment impairs cognitive functions and increases neuro-inflammatory responses in the medial prefrontal cortex of juvenile male rats. Anat Cell Biol 2018; 51:41-51. [PMID: 29644109 PMCID: PMC5890016 DOI: 10.5115/acb.2018.51.1.41] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 12/04/2017] [Accepted: 12/13/2017] [Indexed: 02/01/2023] Open
Abstract
In the developed and developing world, opioid consumption in combination with alcohol has become one of the substances abused. In this experiment, we examined the effects of alcohol, morphine, and morphine+alcohol combination on cognitive functions and neuroinflammatory responses in the medial prefrontal cortex (mPFC) of juvenile male rats. Alcohol (1.0 ml of 15% v/v ethanol twice daily, subcutaneously, 7 hours apart), morphine (0.5 ml/kg of 0.4 mg/kg morphine chlorate twice daily, subcutaneously, 7 hours apart), morphine+alcohol co-treatment (0.5 ml/kg of 0.4 mg/kg morphine chlorate+1.0 ml of 15% v/v ethanol twice daily, subcutaneously, 7 hours apart) were administered for 21 days. Treatment with morphine+alcohol significantly impairs cognition functions in the Morris water maze, passive avoidance, and novel object recognition tests, furthermore, the treatment significantly increased the quantitative count of astrocytic cells and also conferred marked neuronal cell death in the mPFC, which were studied by glial fibrillary acidic protein immunochemistry for astrocytes and Cresyl violet for Nissl's substance distribution in neurons respectively. These results suggest that alcohol, morphine, and morphine+alcohol co-treatment may trigger cognitive deficits and neuroinflammatory responses in the brain.
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Affiliation(s)
| | | | | | - Olaniyan Olayinka Olaolu
- Department of Medical Biochemistry (Chemical Pathology Unit), Osun State University (Osogbo Campus), Osogbo, Nigeria
| | | | - Ijomone Kafilat Olayemi
- Department of Anatomy, Faculty of Basic Medical Science, University of Medical Sciences, Ondo, Nigeria
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Ntshangase S, Shobo A, Kruger HG, Asperger A, Niemeyer D, Arvidsson PI, Govender T, Baijnath S. The downfall of TBA-354 - a possible explanation for its neurotoxicity via mass spectrometric imaging. Xenobiotica 2017; 48:938-944. [PMID: 28859520 DOI: 10.1080/00498254.2017.1375168] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
1. TBA-354 was a promising antitubercular compound with activity against both replicating and static Mycobacterium tuberculosis (M.tb), making it the focal point of many clinical trials conducted by the TB Alliance. However, findings from these trials have shown that TBA-354 results in mild signs of reversible neurotoxicity; this left the TB Alliance with no other choice but to stop the research. 2. In this study, mass spectrometric methods were used to evaluate the pharmacokinetics and spatial distribution of TBA-354 in the brain using a validated liquid chromatography tandem-mass spectrometry (LCMS/MS) and mass spectrometric imaging (MSI), respectively. Healthy female Sprague-Dawley rats received intraperitoneal (i.p.) doses of TBA-354 (20 mg/kg bw). 3. The concentrationtime profiles showed a gradual absorption and tissue penetration of TBA-354 reaching the Cmax at 6 h post dose, followed by a rapid elimination. MSI analysis showed a time-dependent drug distribution, with highest drug concentration mainly in the neocortical regions of the brain. 4. The distribution of TBA-354 provides a possible explanation for the motor dysfunction observed in clinical trials. These results prove the importance of MSI as a potential tool in preclinical evaluations of suspected neurotoxic compounds.
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Affiliation(s)
- Sphamandla Ntshangase
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa
| | - Adeola Shobo
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa
| | - Hendrik G Kruger
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa
| | | | | | - Per I Arvidsson
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa.,c Science for Life Laboratory, Drug Discovery & Development Platform & Division of Translational Medicine and Chemical Biology, Development of Medical Biochemistry and Biophysics, Karolinska Institutet , Stockholm , Sweden
| | - Thavendran Govender
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa
| | - Sooraj Baijnath
- a Catalysis and Peptide Research Unit, University of KwaZulu-Natal , Durban , South Africa
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Do Superior or Inferior Interlaminar Approach or Bevel Orientation Predispose to Nonepidural Needle Penetration? AJR Am J Roentgenol 2017; 209:895-903. [PMID: 28796547 DOI: 10.2214/ajr.17.18111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE There is a paucity of evidence-based literature regarding the advantages and disadvantages of the interlaminar approach and needle bevel orientation for performing a lumbar interlaminar epidural steroid injection (ESI). The purpose of this study was to determine if superior versus inferior lamina approach, needle bevel tip orientation, or both may predispose to inadvertent nonepidural penetration during lumbar interlaminar ESI. SUBJECTS AND METHODS A prospective study was performed of patients with low back pain with or without radicular pain or neurogenic claudication referred for lumbar interlaminar ESI. Two hundred eleven patients were randomized by interlaminar approach (superior vs inferior) and bevel tip orientation (cranial vs caudal). Lumbar interlaminar ESI was performed by six interventionalists of varying levels of experience using fluoroscopic guidance with curved tip epidural needles, using loss-of-resistance technique and confirmation with contrast opacification. Exact Poisson regression was used to model the study outcome. RESULTS Two hundred twenty-one lumbar interlaminar ESIs were performed on 211 patients, randomized to a superior (n = 121) or inferior lamina approach (n = 100) and to a cranial (n = 103) or caudal (n = 118) orientation of the bevel tip. Epidural needle placement was confirmed in 96.4% (n = 213) of cases. Nonepidural needle placement was most commonly associated with superior lamina approach and caudal bevel tip orientation, which was marginally significant (adjusted risk ratio, 6.88; 95% CI, 0.93-∞; p = 0.059). CONCLUSION Inadvertent nonepidural needle penetration during fluoroscopically guided lumbar interlaminar ESI appears to be affected by approach, with superior lamina approach and caudal bevel tip orientation being the least favorable technique.
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Kokki M, Pesonen M, Vehviläinen P, Litmala O, Pasanen M, Kokki H. Cytotoxicity of Oxycodone and Morphine in Human Neuroblastoma and Mouse Motoneuronal Cells: A Comparative Approach. Drugs R D 2017; 16:155-63. [PMID: 26913723 PMCID: PMC4875920 DOI: 10.1007/s40268-016-0125-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives Oxycodone is the mo
st commonly used opioid for the treatment of moderate to severe pain. The peak cerebrospinal fluid concentration after epidural oxycodone was reported to be 300-fold greater (0.025 mM) than when administered intravenously after gynecologic surgery. Additionally, those patients administered epidural oxycodone had lower pain scores, needed less rescue analgesics and had fewer adverse effects compared with intravenous administration. However, oxycodone neurotoxicity requires evaluation before intrathecal implementation for routine clinical use. Methods We used two in vitro cell culture models to compare the cytotoxicity of oxycodone with that of morphine, and to study the mechanisms underlying toxicity. Human neuroblastoma cells and mouse motoneuronal cells were treated with increasing concentrations (0.0125–2 mM) of oxycodone or morphine, and were harvested at 24, 48 or 96 h. Cell cultures were evaluated with 3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide and resazurin reduction assays. Results Both morphine and oxycodone decreased cell viability in a dose-dependent manner at concentrations between 0.5 and 2 mM. Morphine increased the number of apoptotic cells compared with oxycodone when assessed by flow cytometry, and transmission electron microscopy images revealed that exposure to both opioids evoked the appearance of numerous electron-dense, probable autophagic vacuoles in the cytoplasm of the cells. Conclusions Based on these results, it seems that the cytotoxicity of oxycodone in motoneuronal cells is similar to or less than that of morphine, and occurs only at concentrations above the peak clinical concentration in the cerebrospinal fluid after epidural administration.
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Affiliation(s)
- Merja Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland
| | - Maija Pesonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Piia Vehviläinen
- Department of Neurobiology, A.I. Virtanen Institute, University of Eastern Finland, Kuopio, Finland
| | - Outi Litmala
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland.,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Markku Pasanen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Hannu Kokki
- Anaesthesiology and Intensive Care Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland. .,Department of Anesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029 KYS, Kuopio, Finland.
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Koyyalamudi V, Sen S, Patil S, Creel JB, Cornett EM, Fox CJ, Kaye AD. Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting. Curr Pain Headache Rep 2017; 21:6. [PMID: 28210917 DOI: 10.1007/s11916-017-0604-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively. RECENT FINDINGS Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.
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Affiliation(s)
| | - Sudipta Sen
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Shilpadevi Patil
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Justin B Creel
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA
| | - Charles J Fox
- Department of Anesthesiology, LSUHSC-Shreveport, Shreveport, LA, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSUHSC-NO, New Orleans, LA, USA
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Piao LH, Fujita T, Yu T, Kumamoto E. Presynaptic facilitation by tetracaine of glutamatergic spontaneous excitatory transmission in the rat spinal substantia gelatinosa – Involvement of TRPA1 channels. Brain Res 2017; 1657:245-252. [DOI: 10.1016/j.brainres.2016.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/07/2016] [Accepted: 12/21/2016] [Indexed: 11/29/2022]
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Sondekoppam RV, Tsui BCH. Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks. Anesth Analg 2017; 124:645-660. [DOI: 10.1213/ane.0000000000001804] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cui LY, Guo NN, Li YL, Li M, Ding MX. Analgesic and physiological effect of electroacupuncture combined with epidural lidocaine in goats. Vet Anaesth Analg 2017. [PMID: 28625735 DOI: 10.1016/j.vaa.2016.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To investigate physiological and antinociceptive effects of electroacupuncture (EA) with lidocaine epidural nerve block in goats. STUDY DESIGN Prospective experimental trial. ANIMALS Forty-eight hybrid male goats weighing 27 ± 2 kg. METHODS The goats were randomly assigned to six groups: L2.2, epidural lidocaine (2.2 mg kg-1); L4.4, epidural lidocaine (4.4 mg kg-1); EA; EA-L1.1, EA with epidural lidocaine (1.1 mg kg-1); EA-L2.2, EA with epidural lidocaine (2.2 mg kg-1); and EA-L4.4, EA with epidural lidocaine (4.4 mg kg-1). EA was administered for 120 minutes. Epidural lidocaine was administered 25 minutes after EA started. Nociceptive thresholds of flank and thigh regions, abdominal muscle tone, mean arterial pressure (MAP), heart rate (HR), respiratory frequency (fR) and rectal temperature were recorded at 30, 60, 90, 120, 150 and 180 minutes. RESULTS Lidocaine dose-dependently increased nociceptive thresholds. There were no differences in nociceptive thresholds between L4.4 and EA from 30 to 120 minutes. The threshold in EA-L2.2 was lower than in EA-L4.4 from 30 to 120 minutes, but higher than in EA-L1.1 from 30 to 150 minutes or in L4.4 from 30 to 180 minutes. The abdominal muscle tone in EA-L2.2 was higher at 30 minutes, but lower at 90 and 120 minutes than at 0 minutes. There were no differences in muscle tone between L4.4 and L2.2 or EA-L4.4, and between any two of the three EA-lidocaine groups from 0 to 180 minutes. The fR and HR decreased in L4.4 at 60 and 90 minutes compared with 0 minutes. No differences in fR, HR, MAP and temperature among the groups occurred from 30 to 180 minutes. CONCLUSIONS AND CLINICAL RELEVANCE EA combined with 2.2 mg kg-1 epidural lidocaine provides better antinociceptive effect than 4.4 mg kg-1 epidural lidocaine alone in goats. EA provided antinociception and allowed a decrease in epidural lidocaine dose.
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Affiliation(s)
- Lu-Ying Cui
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, P.R. China
| | - Ni-Ni Guo
- Livestock and Poultry Breeding Center of Hubei Province, Wuhan, Hubei, P.R. China
| | - Yu-Lin Li
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, P.R. China
| | - Meng Li
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, P.R. China
| | - Ming-Xing Ding
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan, Hubei, P.R. China.
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Lynde GC. Determination of ED 50 of hydromorphone for postoperative analgesia following cesarean delivery. Int J Obstet Anesth 2016; 28:17-21. [PMID: 27641091 DOI: 10.1016/j.ijoa.2016.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 07/10/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Morphine is the most common opioid injected into the intrathecal space for postoperative analgesia following cesarean delivery, but ongoing medication shortages have resulted in limited availability. One proposed morphine alternative is hydromorphone. Studies investigating its use in post-cesarean analgesia are limited. This study was conducted to determine the median effective dose of intrathecal hydromorphone 12h postpartum. METHODS Twenty healthy women undergoing elective cesarean delivery were recruited into this study. Hydromorphone doses were determined using the up-down sequential method. The study dose of hydromorphone started at 6μg and was raised or lowered by 2μg depending on the 12-h efficacy of the preceding participant's dose. Pain scores of <3/10 were considered successful and the subsequent patient received a lower dose. Participants received 0.5% bupivacaine 12.5mg, fentanyl 25μg, and the study dose of hydromorphone as a single intrathecal injection. RESULTS Ten of 20 participants reported an effective hydromorphone dosage 12h post-injection. The median effective hydromorphone dosage was 4.6μg (95% CI 3.72 to 5.48μg) based on participants' reported visual analog pain scores of <3/10. No significant side effects or adverse outcomes were observed. CONCLUSION Intrathecal hydromorphone may be an effective alternative to morphine for post-cesarean pain management. The amount of intrathecal hydromorphone necessary to provide analgesia at 12h postoperatively may be significantly lower than doses currently in use. Further research should be performed to identify the optimal dose of intrathecal hydromorphone for post-surgical pain relief.
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Affiliation(s)
- G C Lynde
- Department of Anesthesiology, Emory University, Atlanta, GA, USA.
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Grisold W, Grisold A, Löscher WN. Neuromuscular complications in cancer. J Neurol Sci 2016; 367:184-202. [PMID: 27423586 DOI: 10.1016/j.jns.2016.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/08/2016] [Accepted: 06/01/2016] [Indexed: 12/11/2022]
Abstract
Cancer is becoming a treatable and even often curable disease. The neuromuscular system can be affected by direct tumor invasion or metastasis, neuroendocrine, metabolic, dysimmune/inflammatory, infections and toxic as well as paraneoplastic conditions. Due to the nature of cancer treatment, which frequently is based on a DNA damaging mechanism, treatment related toxic side effects are frequent and the correct identification of the causative mechanism is necessary to initiate the proper treatment. The peripheral nervous system is conventionally divided into nerve roots, the proximal nerves and plexus, the peripheral nerves (mono- and polyneuropathies), the site of neuromuscular transmission and muscle. This review is based on the anatomic distribution of the peripheral nervous system, divided into cranial nerves (CN), motor neuron (MND), nerve roots, plexus, peripheral nerve, the neuromuscular junction and muscle. The various etiologies of neuromuscular complications - neoplastic, surgical and mechanic, toxic, metabolic, endocrine, and paraneoplastic/immune - are discussed separately for each part of the peripheral nervous system.
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Affiliation(s)
- W Grisold
- Department of Neurology, Kaiser Franz Josef Hospital, Vienna, Austria.
| | - A Grisold
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - W N Löscher
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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DeRossi R, Jardim PHA, Hermeto LC, Pagliosa RC. Comparison of analgesic and systemic effects of bupivacaine, methadone, or bupivacaine/methadone administered epidurally in conscious sheep. Aust Vet J 2016; 93:164-9. [PMID: 25939263 DOI: 10.1111/avj.12313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 08/05/2014] [Accepted: 08/28/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the combination of bupivacaine and methadone administered epidurally in sheep. METHODS Six healthy female mixed-breed sheep weighing 35-46 kg and aged 12-18 months were included. Each sheep was assigned to receive three treatments: 0.5 mg/kg 0.25% bupivacaine (BP), 0.3 mg/kg 1% methadone (MT) or 0.25 mg/kg bupivacaine and 0.15 mg/kg methadone (BPMT). All drugs were injected into the lumbosacral space through an epidural catheter. Each animal received each treatment at random. Heart rate, arterial blood pressure (systolic, diastolic and mean), respiratory rate, rectal temperature, analgesia, sedation and motor block were determined before treatment and at predetermined intervals. RESULTS The duration of analgesia was 240, 220, and 180 min for BP, MT and BPMT, respectively (P < 0.05). Motor block for all agents was mild to moderate. None or the treatments significantly altered the heart rate, blood pressure or respiratory rate. CONCLUSION Our findings suggest that lumbosacral epidural administration of bupivacaine, methadone or a combination of the two drugs can provide perioperative analgesia in sheep as part of their management for surgical procedures in the flank and hindlimbs.
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Affiliation(s)
- R DeRossi
- Department of Veterinary Medicine-Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Federal University of Mato Grosso do Sul, Campo Grande, Mato Grosso do Sul, Brazil
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Peltoniemi MA, Hagelberg NM, Olkkola KT, Saari TI. Ketamine: A Review of Clinical Pharmacokinetics and Pharmacodynamics in Anesthesia and Pain Therapy. Clin Pharmacokinet 2016; 55:1059-77. [DOI: 10.1007/s40262-016-0383-6] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Zhao Y, Zhou L, Liu J, Chen Z, Yang L, Shi H. Preparation and investigation of a novel levobupivacaine in situ implant gel for prolonged local anesthetics. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2016; 45:404-408. [PMID: 26982080 DOI: 10.3109/21691401.2016.1160406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this study, levobupivacaine (LBP) was successfully incorporated into implant application based on the concept of in situ gel (PECE). The physicochemical characterization (preparation, phase transition temperature, in vitro release) were investigated. The results of viscosity measurement showed that the preparations behaved like a fluid but formed a rigid gel when exposed to increasing temperature (37 °C). In vitro release, LBP was graduated released from the gels as time lapsed, suggesting that LBP was well entrapped in PECE in situ gels. As is shown in pharmacokinetic parameters, the half-life of LBP injection (2.7 h) was shorter than that of LBP in situ gels (23.9 h), suggesting that LBP injection was taken up by other tissues more rapidly than gels. The area under the curve of LBP in situ gels was 2.18 times the size of that of LBP injection (P< 0.05). In pharmacodynamic test, even after nine hours of injection, gel group could still maintain rather good anesthesia effect and rats' stinging reaction maintained at a relatively low level, which had obvious statistical differences compared to injection group.
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Affiliation(s)
- Yanjing Zhao
- a Department of Anesthesia , Shanghai Pulmonary Hospital, Tongji University of Medicine , Shanghai , China
| | - Luocheng Zhou
- b Emergency Department , Xin Hua Hospital, Shanghai Jiao Tong University of Medicine , Shanghai , China
| | - Ji Liu
- a Department of Anesthesia , Shanghai Pulmonary Hospital, Tongji University of Medicine , Shanghai , China
| | - Zhigang Chen
- a Department of Anesthesia , Shanghai Pulmonary Hospital, Tongji University of Medicine , Shanghai , China
| | - Lei Yang
- a Department of Anesthesia , Shanghai Pulmonary Hospital, Tongji University of Medicine , Shanghai , China
| | - Hong Shi
- a Department of Anesthesia , Shanghai Pulmonary Hospital, Tongji University of Medicine , Shanghai , China
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Verlinde M, Hollmann MW, Stevens MF, Hermanns H, Werdehausen R, Lirk P. Local Anesthetic-Induced Neurotoxicity. Int J Mol Sci 2016; 17:339. [PMID: 26959012 PMCID: PMC4813201 DOI: 10.3390/ijms17030339] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/08/2016] [Accepted: 02/23/2016] [Indexed: 12/22/2022] Open
Abstract
This review summarizes current knowledge concerning incidence, risk factors, and mechanisms of perioperative nerve injury, with focus on local anesthetic-induced neurotoxicity. Perioperative nerve injury is a complex phenomenon and can be caused by a number of clinical factors. Anesthetic risk factors for perioperative nerve injury include regional block technique, patient risk factors, and local anesthetic-induced neurotoxicity. Surgery can lead to nerve damage by use of tourniquets or by direct mechanical stress on nerves, such as traction, transection, compression, contusion, ischemia, and stretching. Current literature suggests that the majority of perioperative nerve injuries are unrelated to regional anesthesia. Besides the blockade of sodium channels which is responsible for the anesthetic effect, systemic local anesthetics can have a positive influence on the inflammatory response and the hemostatic system in the perioperative period. However, next to these beneficial effects, local anesthetics exhibit time and dose-dependent toxicity to a variety of tissues, including nerves. There is equivocal experimental evidence that the toxicity varies among local anesthetics. Even though the precise order of events during local anesthetic-induced neurotoxicity is not clear, possible cellular mechanisms have been identified. These include the intrinsic caspase-pathway, PI3K-pathway, and MAPK-pathways. Further research will need to determine whether these pathways are non-specifically activated by local anesthetics, or whether there is a single common precipitating factor.
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Affiliation(s)
- Mark Verlinde
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Markus W Hollmann
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Markus F Stevens
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Henning Hermanns
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
| | - Robert Werdehausen
- Department of Anesthesiology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, Düsseldorf 40225, Germany.
| | - Philipp Lirk
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands.
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Komanski CB, Rauck RL, North JM, Hong KS, D'Angelo R, Hildebrand KR. Intrathecal Clonidine via Lumbar Puncture Decreases Blood Pressure in Patients With Poorly Controlled Hypertension. Neuromodulation 2015; 18:499-507; discussion 507. [PMID: 25944733 DOI: 10.1111/ner.12304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/28/2015] [Accepted: 02/17/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Oral clonidine is used to treat hypertension but often produces sedation and severe dry mouth; intrathecal clonidine is used to treat chronic pain but may produce hypotension. This clinical feasibility study was conducted to determine if intrathecal clonidine decreases blood pressure in patients with poorly controlled hypertension. MATERIALS AND METHODS This prospective, single-arm, open-label study was conducted in ten subjects who were taking at least three antihypertensive medications including a diuretic and had an in-office systolic blood pressure between 140 and 190 mm Hg. On the day of treatment, blood pressure was measured before and after a single lumbar intrathecal dose (150 mcg) of clonidine using an automatic oscillometric device every 10-15 min for four hours. Student's paired t-test was used for statistical comparisons. RESULTS Maximal reductions in systolic and diastolic blood pressures averaging 63 ± 20/29 ± 13 mm Hg were observed approximately two hours after clonidine administration. Decreases in systolic pressure were strongly correlated with baseline systolic pressure. Clonidine produced a significant decrease in heart rate of 11 ± 7 beats/min. No subject required intravenous fluids or vasopressor rescue therapy, or reported spinal headache. CONCLUSIONS This is the first clinical study in subjects with hypertension that demonstrates significant and profound acute reductions in blood pressure after a single dose of intrathecal clonidine. Future placebo-controlled, dose-escalating studies are warranted to assess the long-term effects of intrathecal clonidine infusion via an implantable drug pump in patients with treatment-resistant hypertension at risk of stroke or myocardial infarction.
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Affiliation(s)
- Chris B Komanski
- Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Richard L Rauck
- Carolinas Pain Institute and Center for Clinical Research, Winston-Salem, NC, USA
| | - James M North
- Carolinas Pain Institute and Center for Clinical Research, Winston-Salem, NC, USA
| | - Kyung S Hong
- Carolinas Pain Institute and Center for Clinical Research, Winston-Salem, NC, USA
| | - Robert D'Angelo
- Wake Forest University Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC, USA
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Malet A, Faure MO, Deletage N, Pereira B, Haas J, Lambert G. The Comparative Cytotoxic Effects of Different Local Anesthetics on a Human Neuroblastoma Cell Line. Anesth Analg 2015; 120:589-596. [DOI: 10.1213/ane.0000000000000562] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Efeitos neurotóxicos de levobupivacaína e fentanil sobre a medula espinhal de ratos. Braz J Anesthesiol 2015; 65:27-33. [DOI: 10.1016/j.bjan.2013.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 07/15/2013] [Indexed: 11/22/2022] Open
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Ozdogan L, Sastim H, Ornek D, Postaci A, Ayerden T, Dikmen B. Neurotoxic effects of intrathecal magnesium sulphate. Rev Bras Anestesiol 2014; 63:139-43. [PMID: 23438808 DOI: 10.1016/s0034-7094(13)70205-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/27/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the potential neurotoxic effects at the ultrastructural level of magnesium sulfate administered intrathecally as a single or multi-dose. METHODS Our study was conducted with 24 Sprague-Dawley rats that weighed 250-300 g. After a 4-hour fast, the rats were given 10 mg.kg(-1) xylazine chloride intraperitoneal and then randomly allocated into three groups. Group I (n=8) received 0.9% normal saline, Group II (n = 8) was given one intrathecal injection of 0.02 mL of 15% magnesium sulphate, and Group III (n = 8) was given 0.02 mL of 15% magnesium sulphate once a day for seven days. The injections were given within 0.40 × 50 mm from the lumbar area. After seven days, the animals were sacrificed under anesthesia with an aortic injection of 10% formaldehyde and their tissues were fixed. The medulla spinalis was then examined and histopathologically evaluated under an electron microscope. The Kruskal-Wallis test was used for statistical evaluation. A value of p < .05 was considered to be statistically significant. RESULTS Significant neurodegeneration was detected in rats given single or repeated magnesium sulphate injections compared to the control group. The histopathological evaluation score of this group was also high. CONCLUSIONS Based on electron microscopic examination, we found that intrathecal magnesium sulphate administration induced neurodegeneration.
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Affiliation(s)
- Levent Ozdogan
- Anaesthesia and Reanimation Department, Ankara Numune Training and Research Hospital, Turkey
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Ponto JA, Graham MM. Technetium Tc-99m pyrophosphate for cerebrospinal fluid leaks: Radiopharmaceutical considerations. J Am Pharm Assoc (2003) 2014; 54:45-8. [DOI: 10.1331/japha.2014.13059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Niu XY, Ding XB, Guo T, Chen MH, Fu SK, Li Q. Effects of intravenous and intrathecal dexmedetomidine in spinal anesthesia: a meta-analysis. CNS Neurosci Ther 2013; 19:897-904. [PMID: 24118775 DOI: 10.1111/cns.12172] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/03/2013] [Accepted: 08/06/2013] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To assess the effects of dexmedetomidine on the duration of sensory and motor block, postoperative analgesia, hypotension, bradycardia, and side effects in patients undergoing spinal anesthesia. METHODS Two researchers searched MEDLINE, EMBASE, and the Cochrane controlled trial register independently for randomized controlled trials comparing dexmedetomidine with a placebo without any language restrictions. RESULTS A total of 412 patients from eight trials were included in this study. The results revealed that dexmedetomidine was statistically significant in prolonging the duration of sensory block (mean difference, MD = 73.55; 95% CI, [55.69, 91.40] P < 0.00001, I(2) = 89%) and motor block (MD = 59.11; 95% CI, [29.58, 88.65] P < 0.00001, I(2) = 91%) and the time to first request for postoperative analgesia (MD = 245.77, 95% CI, [143.53, 348.00] P < 0.00001, I(2) = 98%). The occurrence of hypotension (OR = 0.60, 95% CI, [0.3-1.23], P = 0.40, I(2) = 3%) and side effects (OR = 0.9, 95% CI, [0.36-2.22], P = 0.88, I(2) = 0%) was not significantly different between dexmedetomidine and placebo. However, dexmedetomidine was associated with more frequent bradycardia requiring atropine (OR = 7.55; 95% CI, [2.76-20.63], P = 0.63, I(2) = 0%). CONCLUSIONS This meta-analysis has shown that dexmedetomidine prolonged the duration of spinal anesthesia and improved postoperative analgesia and did not increase the incidence of hypotension and adverse events, but needs more atropine to reverse bradycardia.
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Affiliation(s)
- Xiao-Yin Niu
- Department of Anesthesiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
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Abstract
Spinal cord injury results in significant mortality and morbidity, lifestyle changes, and difficult rehabilitation. Treatment of spinal cord injury is challenging because the spinal cord is both complex to treat acutely and difficult to regenerate. Nanomaterials can be used to provide effective treatments; their unique properties can facilitate drug delivery to the injury site, enact as neuroprotective agents, or provide platforms to stimulate regrowth of damaged tissues. We review recent uses of nanomaterials including nanowires, micelles, nanoparticles, liposomes, and carbon-based nanomaterials for neuroprotection in the acute phase. We also review the design and neural regenerative application of electrospun scaffolds, conduits, and self-assembling peptide scaffolds.
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Affiliation(s)
- Jacqueline Y. Tyler
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907
| | - Xiao-Ming Xu
- Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute and Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN 46202
| | - Ji-Xin Cheng
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907
- Department of Chemistry, Purdue University, West Lafayette, IN 47907
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Rafati A, Noorafshan A, Torabi N. Stereological study of the effects of morphine consumption and abstinence on the number of the neurons and oligodendrocytes in medial prefrontal cortex of rats. Anat Cell Biol 2013; 46:191-7. [PMID: 24179694 PMCID: PMC3811856 DOI: 10.5115/acb.2013.46.3.191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/26/2013] [Accepted: 06/04/2013] [Indexed: 01/25/2023] Open
Abstract
Quantitative studies to date on the effects of opioid consumption and abstinence on the nervous system using modern stereological methods have not received enough attention. In addition, they have yielded controversial results. The present study was conducted to investigate the effects of morphine, with or without abstinence, on the neurons and oligodendrocytes of the medial prefrontal cortex (MPFC) in rats using quantitative stereological methods. The male rats were divided into four groups: the first (saline [SAL]) and second (morphine [MOR]) groups were treated with saline and an escalating dose of morphine (5-20 mg/kg) for 30 days, respectively; the third (SAL+abstinence [ABS]) and fourth (MOR+ABS) groups were treated in the same manner as the previous groups plus they had a 30-day abstinence period. The results showed that the volume of the MPFC and its subdivisions decreased by approximately 15% in the MOR group compared with that in the SAL group (P<0.05). In addition, the volume decreased by approximately 24% in the MOR+ABS group compared with that in the SAL+ABS group (P<0.05). The number of neurons in the MOR and MOR+ABS groups decreased by approximately 44% and 35%, respectively, compared with that in their corresponding control groups. Moreover, the number of the oligodendrocytes in the MOR and MOR+ABS groups decreased by approximately 41% and 37%, respectively. No significant difference was noted in the number of cells in the MOR and MOR+ABS groups. In conclusion, morphine consumption leads to a permanent reduction in the number of neurons and oligodendrocytes, and no additional neuron and oligodendrocyte loss occurs after abstinence.
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Affiliation(s)
- Ali Rafati
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. ; Department of Physiology, Shiraz University of Medical Sciences, Shiraz, Iran
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Neurotoxic effects of intrathecal magnesium sulphate. Braz J Anesthesiol 2013; 63:139-43. [PMID: 24565097 DOI: 10.1016/j.bjane.2012.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 02/27/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the potential neurotoxic effects at the ultrastructural level of magnesium sulfate administered intrathecally as a single or multi-dose. METHODS Our study was conducted with 24 Sprague-Dawley rats that weighed 250-300 g. After a 4-hour fast, the rats were given 10 mg.kg(-1) xylazine chloride intraperitoneal and then randomly allocated into three groups. Group I (n = 8) received 0.9% normal saline, Group II (n = 8) was given one intrathecal injection of 0.02 mL of 15% magnesium sulphate, and Group III (n = 8) was given 0.02 mL of 15% magnesium sulphate once a day for seven days. The injections were given within 0.40x50 mm from the lumbar area. After seven days, the animals were sacrificed under anesthesia with an aortic injection of 10% formaldehyde and their tissues were fixed. The medulla spinalis was then examined and histopathologically evaluated under an electron microscope. The Kruskal-Wallis test was used for statistical evaluation. A value of p < .05 was considered to be statistically significant. RESULTS Significant neurodegeneration was detected in rats given single or repeated magnesium sulphate injections compared to the control group. The histopathological evaluation score of this group was also high. CONCLUSIONS Based on electron microscopic examination, we found that intrathecal magnesium sulphate administration induced neurodegeneration.
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Halder S, Butcher M, Allam J, Cormack C, Cox M, Dob D, Durbridge J, Norman B, Pickering E, Yentis SM. Preservative-free bicarbonate for epidural top-up. Anaesthesia 2013; 68:878-9. [DOI: 10.1111/anae.12365] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S. Halder
- Chelsea and Westminster Hospital; London; UK
| | - M. Butcher
- Chelsea and Westminster Hospital; London; UK
| | - J. Allam
- Chelsea and Westminster Hospital; London; UK
| | - C. Cormack
- Chelsea and Westminster Hospital; London; UK
| | - M. Cox
- Chelsea and Westminster Hospital; London; UK
| | - D. Dob
- Chelsea and Westminster Hospital; London; UK
| | | | - B. Norman
- Chelsea and Westminster Hospital; London; UK
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Abdallah FW, Brull R. Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. Br J Anaesth 2013; 110:915-25. [PMID: 23587874 DOI: 10.1093/bja/aet066] [Citation(s) in RCA: 192] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED Nerve blocks improve postoperative analgesia, but their benefits may be short-lived. This quantitative review examines whether perineural dexmedetomidine as a local anaesthetic (LA) adjuvant for neuraxial and peripheral nerve blocks can prolong the duration of analgesia compared with LA alone. All randomized controlled trials (RCTs) comparing the effect of dexmedetomidine as an LA adjuvant to LA alone on neuraxial and peripheral nerve blocks were reviewed. Sensory block duration, motor block duration, block onset times, analgesic consumption, time to first analgesic request, and side-effects were analysed. RESULTS were combined using random-effects modelling. A total of 516 patients were analysed from nine RCTs. Five trials investigated dexmedetomidine as part of spinal anaesthesia and four as part of a brachial plexus (BP) block. Sensory block duration was prolonged by 150 min [95% confidence interval (CI): 96, 205, P<0.00001] with intrathecal dexmedetomidine. Perineural dexmedetomidine used in BP block may prolong the mean duration of sensory block by 284 min (95% CI: 1, 566, P=0.05), but this difference did not reach statistical significance. Motor block duration and time to first analgesic request were prolonged for both intrathecal and BP block. Dexmedetomidine produced reversible bradycardia in 7% of BP block patients, but no effect on the incidence of hypotension. No patients experienced respiratory depression. Dexmedetomidine is a potential LA adjuvant that can exhibit a facilitatory effect when administered intrathecally as part of spinal anaesthesia or peripherally as part of a BP block. However, there are presently insufficient safety data to support perineural dexmedetomidine use in the clinical setting.
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Affiliation(s)
- F W Abdallah
- Department of Anesthesia and Pain Management, St Michael's Hospital, and Women's College Hospital, University of Toronto, Toronto, Canada
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Lim SM, Shin MR, Kang KH, Kang H, Nahm FS, Kim BH, Shin HY, Lim YJ, Lee SC. Evaluation of the Neurological Safety of Epidural Milnacipran in Rats. Korean J Pain 2012; 25:228-37. [PMID: 23091683 PMCID: PMC3468799 DOI: 10.3344/kjp.2012.25.4.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 07/23/2012] [Accepted: 08/03/2012] [Indexed: 11/24/2022] Open
Abstract
Background Milnacipran is a balanced serotonin norepinephrine reuptake inhibitor with minimal side effects and broad safety margin. It acts primarily on the descending inhibitory pain pathway in brain and spinal cord. In many animal studies, intrathecal administration of milnacipran is effective in neuropathic pain management. However, there is no study for the neurological safety of milnacipran when it is administered neuraxially. This study examined the neurotoxicity of epidural milnacipran by observing behavioral and sensory-motor changes with histopathological examinations of spinal cords in rats. Methods Sixty rats were divided into 3 groups, with each group receiving epidural administration of either 0.3 ml (3 mg) of milnacipran (group M, n = 20), 0.3 ml of 40% alcohol (group A, n = 20), or 0.3 ml of normal saline (group S, n = 20). Results There were no abnormal changes in the behavioral, sensory-motor, or histopathological findings in all rats of groups M and S over a 3-week observation period, whereas all rats in group A had abnormal changes. Conclusions Based on these findings, the direct epidural administration of milnacipran in rats did not present any evidence of neurotoxicity in behavioral, sensory-motor and histopathological evaluations.
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Affiliation(s)
- Seung Mo Lim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Mee Ran Shin
- Department of Prosthodontics, Dentistry, Hangang Sacred Heart Hospital, Graduated School of Clinical Dentistry, Hallym University, Seoul, Korea
| | - Kyung Ho Kang
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Baek Hui Kim
- Department of Pathology, Korea University College of Medicine, Seoul, Korea
| | - Hwa Yong Shin
- Department of Prosthodontics, Dentistry, Hangang Sacred Heart Hospital, Graduated School of Clinical Dentistry, Hallym University, Seoul, Korea
| | - Young Jin Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
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Sagadai S, Panchagnula U, Sundararajan R, Quraishi T. Residual neurological deficit after central neuraxial blocks. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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The influence of adjuvants used in regional anesthesia on lidocaine-induced neurotoxicity in vitro. Reg Anesth Pain Med 2012; 36:436-43. [PMID: 21857277 DOI: 10.1097/aap.0b013e318226ba62] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neurotoxic properties of local anesthetics can rarely lead to irreversible neuronal damage as in cauda equina syndrome. Clinically, local anesthetics are often combined with adjuvants to improve or prolong the anesthetic effect, whereas the impact of such adjuvants on lidocaine-induced apoptosis is unclear. Therefore, we investigated the influence of different adjuvants on the neurotoxicity of lidocaine. METHODS Human neuroblastoma cells and primary rat astrocytes were incubated for 24 hrs with lidocaine at a toxic concentration alone and in combination with morphine, sufentanil, clonidine, epinephrine, neostigmine, ketamine, and midazolam. Subsequently, the rates of cell death and early apoptosis were measured by flow cytometry in neuroblastoma cells, whereas astrocyte viability was analyzed by mitochondrial activity assay. In addition, isobolograms were calculated to describe the additive effects of lidocaine with ketamine or midazolam, respectively. RESULTS Coadministration of lidocaine with sufentanil, clonidine, epinephrine, and neostigmine did not alter the rates of cell death compared with cells treated with lidocaine alone. Morphine improved the viability of astrocytes only at concentrations beyond those occurring clinically. In contrast, coincubation of lidocaine with ketamine or midazolam led to significantly increased rates of cell death. The combined toxicity of ketamine and lidocaine was additive, whereas the combined toxicity of midazolam and lidocaine was subadditive. CONCLUSIONS Sufentanil, clonidine, epinephrine, and neostigmine do not influence the neurotoxicity of lidocaine in vitro. Morphine may have some cytoprotective effect at concentrations greater than those seen intrathecally in humans. In contrast, ketamine and midazolam increase the neurotoxicity of lidocaine in vitro, presumably by additive induction of mitochondrial apoptosis.
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Comparison of Analgesic Effects of Caudal Epidural 0.25% Bupivacaine with Bupivacaine Plus Morphine or Bupivacaine Plus Ketamine for Analgesia in Conscious Horses. J Equine Vet Sci 2012. [DOI: 10.1016/j.jevs.2011.08.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lee JR, Lee PB, Choe G, Lee SC, Lee HM, Kim E, Kim YC. Evaluation of the neurological safety of epidurally-administered pregabalin in rats. Korean J Anesthesiol 2012; 62:57-65. [PMID: 22323956 PMCID: PMC3272531 DOI: 10.4097/kjae.2012.62.1.57] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 06/27/2011] [Accepted: 07/11/2011] [Indexed: 11/28/2022] Open
Abstract
Background The primary site of action of pregabalin, i.e. the α-2-δ subunit of the voltage-dependent calcium channel, is located at the dorsal root ganglion and dorsal horn of the spinal cord. Therefore, the epidural administration of pregabalin could have advantages over oral administration. However, the possibility of its neurotoxicity should be excluded before any attempt at epidural administration. We evaluated the neuronal safety of epidurally-administered pregabalin by observing the sensory/motor changes and examining the histopathology of spinal cord in rats. Methods Sixty rats of 180-230 g were divided into three groups; 3 mg of pregabalin dissolved in 0.3 ml saline (group P, n = 20), 0.3 ml 40% alcohol (group A, n = 20), or 0.3 ml normal saline (group N, n = 20) was administered epidurally to the rats in each group. Pinch-toe test, motor function evaluation, and histopathologic examination of vacuolation, chromatolysis, meningeal inflammation, and neuritis were performed at the 1st, 3rd, 7th, and 21st day after each epidural administration. Results All rats enrolled in group P, like those in group N, showed neither sensory/motor dysfunction nor any histopathological abnormality over the 3-week observation period. In contrast, in group A, 80% of the rats showed abnormal response to the pinch-toe test and all rats showed decreased motor function during the entire evaluation period. In addition, all histopathologic findings of neurotoxicity were observed exclusively in group A. Conclusions The epidurally administered pregabalin (about 15 mg/kg) did not cause any neurotoxic evidence, in terms of both sensory/motor function evaluation and histopathological examination in rats.
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Affiliation(s)
- Jeong Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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The Safety of EXPAREL ® (Bupivacaine Liposome Injectable Suspension) Administered by Peripheral Nerve Block in Rabbits and Dogs. JOURNAL OF DRUG DELIVERY 2012; 2012:962101. [PMID: 22363842 PMCID: PMC3270427 DOI: 10.1155/2012/962101] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 10/04/2011] [Indexed: 11/18/2022]
Abstract
A sustained-release DepoFoam injection formulation of bupivacaine (EXPAREL, 15 mg/mL) is currently being investigated for postsurgical analgesia via peripheral nerve block (PNB). Single-dose toxicology studies of EXPAREL (9, 18, and 30 mg/kg), bupivacaine solution (Bsol, 9 mg/kg), and saline injected around the brachial plexus nerve bundle were performed in rabbits and dogs. The endpoints included clinical pathology, pharmacokinetics, and histopathology evaluation on Day 3 and Day 15 (2/sex/group/period). EXPAREL resulted in a nearly 4-fold lower Cmax versus Bsol at the same dose. EXPAREL was well tolerated at doses up to 30 mg/kg. The only EXPAREL-related effect seen was minimal to mild granulomatous inflammation of adipose tissue around nerve roots (8 of 24 rabbits and 7 of 24 dogs) in the brachial plexus sites. The results indicate that EXPAREL was well tolerated in these models and did not produce nerve damage after PNB in rabbits and dogs.
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