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Ševc J, Mochnacký F, Košuth J, Alexovič Matiašová A, Slovinská L, Blaško J, Bukhun I, Holota R, Tomori Z, Daxnerová Z. Comparative model of minimal spinal cord injury reveals a rather anti-inflammatory response in the lesion site as well as increased proliferation in the central canal lining in the neonates compared to the adult rats. Dev Neurobiol 2024; 84:169-190. [PMID: 38812372 DOI: 10.1002/dneu.22942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/30/2024] [Accepted: 05/04/2024] [Indexed: 05/31/2024]
Abstract
Spinal cord injury (SCI) resulting from trauma decreases the quality of human life. Numerous clues indicate that the limited endogenous regenerative potential is a result of the interplay between the inhibitory nature of mature nervous tissue and the inflammatory actions of immune and glial cells. Knowledge gained from comparing regeneration in adult and juvenile animals could draw attention to factors that should be removed or added for effective therapy in adults. Therefore, we generated a minimal SCI (mSCI) model with a comparable impact on the spinal cord of Wistar rats during adulthood, preadolescence, and the neonatal period. The mechanism of injury is based on unilateral incision with a 20 ga needle tip according to stereotaxic coordinates into the dorsal horn of the L4 lumbar spinal segment. The incision should harm a similar amount of gray matter on a coronal section in each group of experimental animals. According to our results, the impact causes mild injury with minimal adverse effects on the neurological functions of animals but still has a remarkable effect on nervous tissue and its cellular and humoral components. Testing the mSCI model in adults, preadolescents, and neonates revealed a rather anti-inflammatory response of immune cells and astrocytes at the lesion site, as well as increased proliferation in the central canal lining in neonates compared with adult animals. Our results indicate that developing nervous tissue could possess superior reparative potential and confirm the importance of comparative studies to advance in the field of neuroregeneration.
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Affiliation(s)
- Juraj Ševc
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Filip Mochnacký
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Ján Košuth
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Anna Alexovič Matiašová
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Lucia Slovinská
- Faculty of Medicine, Associated Tissue Bank, P. J. Šafárik University in Košice and L. Pasteur University Hospital, Košice, Slovak Republic
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, Košice, Slovak Republic
| | - Juraj Blaško
- Institute of Neurobiology, Biomedical Research Center, Slovak Academy of Sciences, Košice, Slovak Republic
| | - Ivan Bukhun
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Radovan Holota
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
| | - Zoltán Tomori
- Institute of Experimental Physics, Slovak Academy of Sciences, Košice, Slovak Republic
| | - Zuzana Daxnerová
- Faculty of Science, Institute of Biology and Ecology, P. J. Šafárik University in Košice, Košice, Slovak Republic
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Xia Y, Yang Z, Li J, Liu P, Song H, Sun N, Li L, Zhang W. Urethrocutaneous fistula and glans dehiscence formation of hypospadias surgery in patients receiving caudal block vs. non-caudal block: A meta-analysis. J Pediatr Urol 2024; 20:227-236. [PMID: 38000951 DOI: 10.1016/j.jpurol.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND This meta-analysis aimed to evaluate the difference in postoperative complications as urethrocutaneous fistula or glans dehiscence, in children undergoing primary hypospadias repair with caudal block (CB) versus non-caudal block (NCB). METHODS Data were obtained from MEDLINE, Embase, Web of Science, and the Cochrane Library. Comparative studies of CB versus NCB were identified, with reports of complications published or presented until October 2022. Subgroup analyses were performed based on study type, meatal location (distal only), type of NCB, surgeon and technique, and concentration and dose of anesthetics. RESULTS Compared to the reference group of NCB, CB was not significantly associated with the development of complications following primary hypospadias repair (OR 1.40, 95 % CI 0.88-2.23). After adjusting for confounding factors, such as type of study(OR 1.51, 95%CI: 0.29-7.91), type of NCB[PB (OR 1.82, 95 % CI: 0.87-3.84), GA (OR 1.26, 95 % CI: 0.39-4.04)], meatal location (distal only) (OR 1.22, 95 % CI: 0.61-2.43), surgeon and technique (OR 1.37, 95 % CI: 0.59-3.14) and concentration and dose of anesthetics(OR 2.74, 95 % CI: 0.82-9.20), subgroup analyses revealed no significant association between CB and NCB (P > 0.05). DISCUSSION Previous studies have found a correlation between CB and increased incidence of postoperative complications (urethrocutaneous fistula or glans dehiscence) of hypospadias, but different literature have suggested that surgical technique, surgical duration and the severity of hypospadias, rather than CB, are closely related to the occurrence of complications. In order to reduce confounding factors, subgroup analyses were conducted. The results showed that no correlation could be found in postoperative complications and CB. CONCLUSIONS This meta-analysis compared the incidence of urethrocutaneous fistula or glans dehiscence in the CB and NCB groups for primary hypospadias repair in children, indicating that no clear correlation could be found in postoperative complications and CB. Subgroup analyses on study type, type of NCB, meatal location (distal only), surgeon and technique, and regional anesthetic concentration and dose supported this conclusion.
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Affiliation(s)
- Yujie Xia
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China.
| | - Zhenzhen Yang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China.
| | - Jiayi Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China.
| | - Pei Liu
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China
| | - Honcheng Song
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China
| | - Ning Sun
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China
| | - Lijing Li
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China.
| | - Weiping Zhang
- Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health (NCCH), Beijing, 100045, China.
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Wu L, Wei S, Pei D, Yao Y, Xiang Z, Yu E, Chen Z, Du Z, Qu S. Activation of the Akt Attenuates Ropivacaine-Induced Myelination Impairment in Spinal Cord and Sensory Dysfunction in Neonatal Rats. Mol Neurobiol 2023; 60:7009-7020. [PMID: 37523045 DOI: 10.1007/s12035-023-03498-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
Prolonged exposure to local anesthetics (LAs) or intrathecal administration of high doses of LAs can cause spinal cord damage. Intraspinal administration of LAs is increasingly being used in children and neonates. Therefore, it is important to study LA-related spinal cord damage and the underlying mechanism in developmental models. First, neonatal Sprague-Dawley rats received three intrathecal injections of 0.5% ropivacaine, 1% ropivacaine, 2% ropivacaine or saline (90-min interval) on postnatal day 7. Electron microscopy, luxol fast blue staining and behavioral tests were performed to evaluate the spinal neurotoxicity caused by ropivacaine at different concentrations. Western blot analysis and immunostaining was performed to detect the expression changes of p-Akt, Akt, myelin gene regulatory factor (MYRF) and myelin basic protein (MBP) in the spinal cord treated with different concentrations of ropivacaine. Our results showed that 1% or 2% ropivacaine impaired myelination in the spinal cord and induced sensory dysfunction, but 0.5% ropivacaine did not. Moreover, 1% or 2% ropivacaine decreased the expression of p-Akt, MYRF and MBP in the spinal cord. Then, in order to further explore the role of these proteins in this model, the Akt-specific activator (SC79) was intraperitoneally injected 30 min before 2% ropivacaine treatment. Interestingly, SC79-mediated activation of Akt partly rescued ropivacaine-induced myelination impairments and sensory dysfunction. Overall, the results showed that ropivacaine caused spinal neurotoxicity in a dose-dependent manner in neonatal rats and that activation of the Akt partly rescued ropivacaine-induced these changes. These data provide insight into the neurotoxicity to the developing spinal cord caused by LAs.
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Affiliation(s)
- Lei Wu
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Siwei Wei
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Dongjie Pei
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Yiyi Yao
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Zhen Xiang
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Eryou Yu
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Zheng Chen
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China
| | - Zhen Du
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China.
| | - Shuangquan Qu
- Department of Anesthesiology, Hunan Children's Hospital, No.86 Ziyuan Rd, Changsha, 410007, Hunan, China.
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Mistry MM, Endlich Y. Incidents relating to paediatric regional anaesthesia in the first 8000 cases reported to webAIRS. Anaesth Intensive Care 2023; 51:408-421. [PMID: 37786341 DOI: 10.1177/0310057x231198255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Regional anaesthesia is an essential tool in the armamentarium for paediatric anaesthesia. While largely safe and effective, a range of serious yet preventable adverse events can occur. Incidence and risk factors have been described, but few detailed case series exist relating to paediatric regional anaesthesia. Across Australia and New Zealand, a web-based anaesthesia incident reporting system enables voluntary reporting of detailed anaesthesia-related events in adults and children. From this database, all reports involving paediatric regional anaesthesia (age less than 17 years) were retrieved. Perioperative events and their outcomes were reviewed and analysed. When offered, the reported contributing or alleviating factors relating to the case and its management were noted. This paper provides a summary of these reports alongside an evidence review to support safe practice. Of 8000 reported incidents, 26 related to paediatric regional anaesthesia were identified. There were no deaths or reports of permanent harm. Nine reports of local anaesthetic systemic toxicity were included, seven equipment and technical issues, six errors in which regional anaesthesia made an indirect contribution and four logistical and communication issues. Most incidents involved single-shot techniques or a neuraxial approach. Common themes included variable local anaesthetic dosing, cognitive overload, inadequate preparation and communication breakdown. Neonates, infants and medically complex children were disproportionately represented, highlighting their inherent risk profile. A range of preventable incidents are reported relating to patient, systems and human factors, demonstrating several areas for improvement. Risk stratification, application of existing dosing and administration guidelines, and effective teamwork and communication are encouraged to ensure safe regional anaesthesia in the paediatric population.
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Affiliation(s)
- Manisha M Mistry
- Department of Paediatric Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Yasmin Endlich
- Department of Anaesthesia and Acute Pain Medicine, Royal Adelaide Hospital, Adelaide, Australia
- Department of Paediatric Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia
- Faculty of Anaesthesia, University of Adelaide, Adelaide, Australia
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Gutiérrez-Riveroll KI, Dosta-Herrera JJ, Mejía-Picazo HJ, Lozada-Rosete KG, SPérez-Penilla MA. [Ultrasound-guided caudal block with ropivacaine in infraumbilical surgeries in pediatric patients]. REVISTA MEDICA DEL INSTITUTO MEXICANO DEL SEGURO SOCIAL 2023; 61:S445-S452. [PMID: 37934911 PMCID: PMC10746332 DOI: 10.5281/zenodo.8319756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/13/2023] [Indexed: 11/09/2023]
Abstract
Background The use of local anesthetics as part of multimodal analgesia is an attractive concept in pediatric patients, since the evaluation and management of pain is a challenge in children under 7 years of age. Despite having guidelines and multiple studies on volume calculation, no safe and effective recommendation has been issued. Objective To demonstrate that ultrasound-guided caudal block with a dose of 0.75 mL/kg of 0.2% ropivacaine has the same analgesic effect as a dose of 1.2 mL/kg. Material and methods Randomized, prospective, longitudinal, comparative equivalence clinical trial. One hundred patients 0-7 years of age scheduled for elective or emergency infraumbilical surgery were enrolled between April 2021 and January 2022. Children were randomized 1:1 to be assigned to ultrasound-guided caudal block. Results 100 patients divided into two groups with 0.2% ropivacaine volumes (0.75 mL vs. 1.2 mL). Both groups demonstrated the trans-anesthetic and post-anesthetic sedoanalgesia variables without significant differences for both groups on the FLACC pain scale after surgery and in recovery (p > 0.5), in the pain reassessment on the FLACC scale in the office called chronic pain (p > 0.5) in both groups. No complications were reported in the follow-up consultations and no arrhythmias were reported in both groups during surgery. Conclusions the results of both groups did not show differences between a volume of 0.75 mL and 1.2 mL, the administration of 0.2% ropivacaine is favored with the use of ultrasound, which allows effective administration of lower doses of local anesthetic with reduced risk of complications. It is necessary to carry out studies in other types of surgery to compare the use of less volume of local anesthetic compared to the Melman formula used in this study.
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Affiliation(s)
- Karla Itzel Gutiérrez-Riveroll
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Departamento de Anestesia Pediátrica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Juan José Dosta-Herrera
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Jefatura del Servicio de Anestesia. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Héctor Jorge Mejía-Picazo
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Departamento de Anestesia Pediátrica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Karla Guadalupe Lozada-Rosete
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Departamento de Anestesia Pediátrica. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
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Wingert TEA, Hekmat D, Ayad I. Regional Anesthesia for Neonates. Neoreviews 2023; 24:e626-e641. [PMID: 37777613 DOI: 10.1542/neo.24-10-e626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
Pain management in neonates and infants has many unique and important facets, particularly in former preterm infants. Untreated pain and surgical stress in neonates are associated with myriad negative sequelae, including deleterious inflammatory, autonomic, hormonal, metabolic, and neurologic effects. Meanwhile, opioid side effects are also very impactful and affect multiple systems and pathways, particularly in the neonatal and infant population. Regional anesthesia presents a unique opportunity to provide highly effective analgesia; prevent deleterious signaling cascade pathways within the endocrine, immune, and nervous systems from occurring; and create conditions to facilitate reduced reliance on opioids and other analgesics. In some cases, clinicians can completely avoid general anesthesia and systemic anesthetics. This review will discuss some of the unique aspects of pain management in neonates and infants and provide an overview of the different regional anesthetic options available, namely, spinal anesthesia, epidural anesthesia, and peripheral nerve blocks.
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Affiliation(s)
- Theodora E A Wingert
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Diana Hekmat
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Ihab Ayad
- Department of Anesthesiology and Perioperative Medicine, University of California at Los Angeles, Los Angeles, CA
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Oumer KE, Aychew H, Daniel T, Mekete G, Belete KG, Negash TT. Incidence and associated factors of post-dural puncture headache among orthopaedic patients after spinal anesthesia: a prospective cohort study. Ann Med Surg (Lond) 2023; 85:4703-4708. [PMID: 37811087 PMCID: PMC10552984 DOI: 10.1097/ms9.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/02/2023] [Indexed: 10/10/2023] Open
Abstract
Background Post-dural puncture headache (PDPH) is one of a complication of spinal anaesthesia, influenced mostly by various factors including the patient's age, spinal needle size and design and sex. This headache can be severe and debilitating, preventing ambulation and limiting daily living activities. Objective This study assessed the incidence and associated factors of PDPH among patients who received spinal anaesthesia for orthopaedic procedures at the Debre Tabor Comprehensive Specialized Hospital from June to August 2022. Methods Prospective cohort study design was employed using Consecutive sampling method among patients who received spinal anaesthesia for orthopaedics procedure at Debre Tabor Comprehensive Specialized Hospital from June to August 2022. Data were collected by face to face interview and direct observation based on questionnaire. The data were entered to epidata 4.6 and analyzed by SPSS version 20 software. A total 95 patients aged 16-75 was participated in study. Those independent variable that were significant on binary logistic regression at P less than 0.2, were analyzed on multivariate regression, and considered significant association with PDPH at P value less than 0.05. Result Ninety-five study participants were included in our study of which 19 (20%) had developed PDPH. Among patients who develop PDPH; 9.5% of the patients reported moderate pain while 10.5% experience mild PDPH and 80% of patient has no pain. The BMI and age were found to have significant association with PDPH [(P value 0.018, adjusted odds ratio 8.738, 95% CI, 1.461-52.269) and (P value 0.011, adjusted odds ratio 12.146, 95% CI, 1.753-84.170)], respectively) to PDPH. Conclusion and recommendation The incidence of PDPH was found to be higher in Debre Tabor Comprehensive Specialized Hospital. The hospital management and the anaesthetists should minimize the magnitude of by strictly following different preventive strategies.
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Affiliation(s)
- Keder Essa Oumer
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor
| | - Habtamu Aychew
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor
| | - Tenbite Daniel
- Department of Anesthesia, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getachew Mekete
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor
| | - Kumlachew Geta Belete
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor
| | - Tadese Tamire Negash
- Department of Anesthesia, College of Health Sciences, Debre Tabor University, Debre Tabor
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Yaksh TL, Santos GGD, Borges Paes Lemes J, Malange K. Neuraxial drug delivery in pain management: An overview of past, present, and future. Best Pract Res Clin Anaesthesiol 2023; 37:243-265. [PMID: 37321769 DOI: 10.1016/j.bpa.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Activation of neuraxial nociceptive linkages leads to a high level of encoding of the message that is transmitted to the brain and that can initiate a pain state with its attendant emotive covariates. As we review here, the encoding of this message is subject to a profound regulation by pharmacological targeting of dorsal root ganglion and dorsal horn systems. Though first shown with the robust and selective modulation by spinal opiates, subsequent work has revealed the pharmacological and biological complexity of these neuraxial systems and points to several regulatory targets. Novel therapeutic delivery platforms, such as viral transfection, antisense and targeted neurotoxins, point to disease-modifying approaches that can selectively address the acute and chronic pain phenotype. Further developments are called for in delivery devices to enhance local distribution and to minimize concentration gradients, as frequently occurs with the poorly mixed intrathecal space. The field has advanced remarkably since the mid-1970s, but these advances must always address the issues of safety and tolerability of neuraxial therapy.
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Affiliation(s)
- Tony L Yaksh
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA.
| | | | | | - Kaue Malange
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA
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Visoiu M. Evolving approaches in neonatal postoperative pain management. Semin Pediatr Surg 2022; 31:151203. [PMID: 36038217 DOI: 10.1016/j.sempedsurg.2022.151203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.
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Affiliation(s)
- Mihaela Visoiu
- Associate Professor of Anesthesiology and Perioperative Medicine, Department of Anesthesiology and Perioperative Medicine; UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA, United States of America.
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Gawe ZA, Isa HM, Almashaur MM, Haider F, Almulla K. The Effect of Caudal Anesthesia Block on Perioperative Pain Control and Reduction of the Anesthetic Agent in Pediatric Infraumbilical Surgery: A Prospective Randomized Trial Study. Anesth Essays Res 2022; 16:301-306. [PMID: 36620118 PMCID: PMC9813991 DOI: 10.4103/aer.aer_64_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/14/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022] Open
Abstract
Background Caudal epidural block (CEB) is a commonly performed neuraxial block to provide effective pain relief and analgesia in pediatric patients undergoing infraumbilical surgery. Aims This study aimed to compare the effectiveness of adding CEB to general anesthesia (GA) in terms of intra- and postoperative pain management. Design Prospective, randomized case-controlled trial study. Setting Operation theater, and postoperative recovery rooms at Salmaniya Medical Complex, Bahrain. Materials and Methods A total of 74 patients aged 2 months to 6 years with American Society of Anesthesiologists physical status classification I were recruited over a 6-month period between December 2019 and May 2020. Patients were allocated into two groups (Group A, with CEB) or (Group B, without CEB). Both groups were compared based on hemodynamic stability, pain scores, level of sedation, analgesia need, and parental satisfaction. Statistical Analysis Data were analyzed using SPSS program. Categorical and numerical variables of both the groups were compared. Results Patients with CEB had better hemodynamic stability during the surgical procedure based on heart rate (P = 0.039). Pain intensity scores were less in patients with CEB than those without (P < 0.001). Fentanyl consumption was lower in Group A compared to Group B at the end of surgery (P = 0.002). They were also ambulated earlier and discharged sooner than those without CEB. Parental satisfaction was 92.1% in Group A compared to 63.9% in Group B (P = 0.012). Conclusions Adding CEB to GA for intraoperative and perioperative pain control in pediatric patients undergoing infraumbilical surgery makes it more effective, safe, and with better parental satisfaction.
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Affiliation(s)
- Zeana Amer Gawe
- Department of Anesthesia, Salmaniya Medical Complex, Government Hospital in Bahrain, Manama, Bahrain
| | - Hasan Mohamed Isa
- Department of Pediatric, Salmaniya Medical Complex, Arabian Gulf University, Manama, Bahrain
| | | | - Fayza Haider
- Department of Surgery, Salmaniya Medical Complex, Arabian Gulf University, Manama, Bahrain
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Diaz R, Gouvêa G, Spiller CS, Chevi D, Carneiro FC, Alheira A, Pureza AL, Steinbrück K, Fernandes R, Neves DB, Enne M. Thoracic epidural analgesia and immediate extubation for less than 10 kg infants undergoing living donor liver transplantation: A report of two successful cases. Pediatr Transplant 2022; 26:e14242. [PMID: 35122453 DOI: 10.1111/petr.14242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 10/28/2021] [Accepted: 01/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perioperative pain management in small infants weighing <10 kg undergoing liver transplantation is challenging. The use of TEA in this setting has not been reported, as well as its potential role to facilitate IE, ie, in the OR. METHODS We describe here the use of TEA in two small infants who had IE after a LDLT procedure. RESULTS TEA was successfully performed and IE was achieved in both cases. Postoperative analgesia assessment in the OR was satisfactory according to the FLACC pain scale, with scores of 2 and 3 for each patient, respectively. There were no major complications in the postoperative period, and the two children were discharged home uneventfully. CONCLUSIONS The use of TEA and its influence on IE rate and other perioperative outcomes should be more explored in small infants undergoing LDLT.
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Affiliation(s)
- Rodrigo Diaz
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Anesthesia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Glauber Gouvêa
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Anesthesia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Camila Santos Spiller
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Anesthesia, Americas Medical City, Rio de Janeiro, Brazil
| | - Débora Chevi
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Anesthesia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Fernanda Cavalcanti Carneiro
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Anesthesia, Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Alice Alheira
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil
| | - Ana Luiza Pureza
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil
| | - Klaus Steinbrück
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Surgery, Hospital Federal de Bonsucesso (HFB), Rio de Janeiro, Brazil
| | - Reinaldo Fernandes
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Surgery, Universidade Federal Fluminense (UFF), Niteroi, Brazil
| | - Douglas Bastos Neves
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Surgery, Hospital Federal dos Servidores do Estado (HFSE), Rio de Janeiro, Brazil
| | - Marcelo Enne
- Liver Transplantation Unit, Complexo Hospitalar de Niterói (CHN), Niteroi, Brazil.,Department of Surgery, Hospital Federal de Ipanema (HFI), Rio de Janeiro, Brazil
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12
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Walker SM, Malkmus S, Eddinger K, Steinauer J, Roberts AJ, Shubayev VI, Grafe MR, Powell SB, Yaksh TL. Evaluation of neurotoxicity and long-term function and behavior following intrathecal 1 % 2-chloroprocaine in juvenile rats. Neurotoxicology 2021; 88:155-167. [PMID: 34801587 DOI: 10.1016/j.neuro.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/08/2021] [Accepted: 11/16/2021] [Indexed: 01/20/2023]
Abstract
Spinally-administered local anesthetics provide effective perioperative anesthesia and/or analgesia for children of all ages. New preparations and drugs require preclinical safety testing in developmental models. We evaluated age-dependent efficacy and safety following 1 % preservative-free 2-chloroprocaine (2-CP) in juvenile Sprague-Dawley rats. Percutaneous lumbar intrathecal 2-CP was administered at postnatal day (P)7, 14 or 21. Mechanical withdrawal threshold pre- and post-injection evaluated the degree and duration of sensory block, compared to intrathecal saline and naive controls. Tissue analyses one- or seven-days following injection included histopathology of spinal cord, cauda equina and brain sections, and quantification of neuronal apoptosis and glial reactivity in lumbar spinal cord. Following intrathecal 2-CP or saline at P7, outcomes assessed between P30 and P72 included: spinal reflex sensitivity (hindlimb thermal latency, mechanical threshold); social approach (novel rat versus object); locomotor activity and anxiety (open field with brightly-lit center); exploratory behavior (rearings, holepoking); sensorimotor gating (acoustic startle, prepulse inhibition); and learning (Morris Water Maze). Maximum tolerated doses of intrathecal 2-CP varied with age (1.0 μL/g at P7, 0.75 μL/g at P14, 0.5 μL/g at P21) and produced motor and sensory block for 10-15 min. Tissue analyses found no significant differences across intrathecal 2-CP, saline or naïve groups. Adult behavioral measures showed expected sex-dependent differences, that did not differ between 2-CP and saline groups. Single maximum tolerated in vivo doses of intrathecal 2-CP produced reversible spinal anesthesia in juvenile rodents without detectable evidence of developmental neurotoxicity. Current results cannot be extrapolated to repeated dosing or prolonged infusion.
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Affiliation(s)
- Suellen M Walker
- Department of Anesthesiology, University of California San Diego, CA, USA; Developmental Neurosciences Department, UCL Great Ormond Street Institute of Child Health and Department of Anaesthesia and Pain Medicine, Great Ormond St Hospital Foundation Trust, London, United Kingdom.
| | - Shelle Malkmus
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Kelly Eddinger
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Joanne Steinauer
- Department of Anesthesiology, University of California San Diego, CA, USA
| | - Amanda J Roberts
- Animal Models Core, Scripps Research Institute, La Jolla, CA, USA
| | - Veronica I Shubayev
- Department of Anesthesiology, University of California San Diego, CA, USA; Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Marjorie R Grafe
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Susan B Powell
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA; Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Tony L Yaksh
- Department of Anesthesiology, University of California San Diego, CA, USA
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Gibbs A, Kim SS, Heydinger G, Veneziano G, Tobias J. Postoperative Analgesia in Neonates and Infants Using Epidural Chloroprocaine and Clonidine. J Pain Res 2020; 13:2749-2755. [PMID: 33154665 PMCID: PMC7608143 DOI: 10.2147/jpr.s281484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/07/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In neonates and infants, epidural analgesia has gained popularity as a means of providing postoperative analgesia, limiting opioid-related adverse effects and improving the postoperative course. In addition to a local anesthetic agent, adjunctive agents may be added to further augment analgesia. Clonidine is an α2-adrenergic agonist that is frequently added to single-shot caudal analgesia, but there are limited data regarding its use in a continuous epidural infusion, especially in patients ≤12 months of age. METHODS We retrospectively reviewed the hospital records of neonates and infants who received postoperative epidural infusions with 2-chloroprocaine, and clonidine was identified over a 4-year period. RESULTS The study cohort included 52 neonates and infants ranging in age from 0 to 12 months and in weight from 2.1 to 10.1 kilograms. The catheters were dosed with either 1.5% 2-chloroprocaine (n=47) or 3% 2-chloroprocaine (n=5) with clonidine (median concentration 0.2 µg/mL) infused at a median rate of 0.72 mL/kg/hour. Pain scores were uniformly ≤3 at all evaluation points during the first 72 postoperative hours with a limited need for supplemental systemic opioids. No serious adverse effects were noted. CONCLUSION With the recognized limitations of a retrospective study, these preliminary data demonstrate the safety of adding clonidine to an epidural infusion of 2-chloroprocaine in neonates and infants less than 12 months of age. Future studies are needed to determine its analgesic efficacy compared to 2-chloroprocaine alone and the optimal clonidine concentration for postoperative epidural infusions.
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Affiliation(s)
- Anna Gibbs
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Stephani S Kim
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Giorgio Veneziano
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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14
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Yaksh TL. Frontiers in Pain Research: A Scope of Its Focus and Content. FRONTIERS IN PAIN RESEARCH 2020; 1:601528. [PMID: 35295691 PMCID: PMC8915630 DOI: 10.3389/fpain.2020.601528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
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15
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Forman N, Sinskey J, Shalabi A. A Review of Middle Aortic Syndromes in Pediatric Patients. J Cardiothorac Vasc Anesth 2020; 34:1042-1050. [DOI: 10.1053/j.jvca.2019.07.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/04/2023]
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16
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Joksimovic SL, Joksimovic SM, Manzella FM, Asnake B, Orestes P, Raol YH, Krishnan K, Covey DF, Jevtovic-Todorovic V, Todorovic SM. Novel neuroactive steroid with hypnotic and T-type calcium channel blocking properties exerts effective analgesia in a rodent model of post-surgical pain. Br J Pharmacol 2020; 177:1735-1753. [PMID: 31732978 DOI: 10.1111/bph.14930] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/30/2019] [Accepted: 11/02/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Neuroactive steroid (3β,5β,17β)-3-hydroxyandrostane-17-carbonitrile (3β-OH) is a novel hypnotic and voltage-dependent blocker of T-type calcium channels. Here, we examine its potential analgesic effects and adjuvant anaesthetic properties using a post-surgical pain model in rodents. EXPERIMENTAL APPROACH Analgesic properties of 3β-OH were investigated in thermal and mechanical nociceptive tests in sham or surgically incised rats and mice, with drug injected either systemically (intraperitoneal) or locally via intrathecal or intraplantar routes. Hypnotic properties of 3β-OH and its use as an adjuvant anaesthetic in combination with isoflurane were investigated using behavioural experiments and in vivo EEG recordings in adolescent rats. KEY RESULTS A combination of 1% isoflurane with 3β-OH (60 mg·kg-1 , i.p.) induced suppression of cortical EEG and stronger thermal and mechanical anti-hyperalgesia during 3 days post-surgery, when compared to isoflurane alone and isoflurane with morphine. 3β-OH exerted prominent enantioselective thermal and mechanical antinociception in healthy rats and reduced T-channel-dependent excitability of primary sensory neurons. Intrathecal injection of 3β-OH alleviated mechanical hyperalgesia, while repeated intraplantar application alleviated both thermal and mechanical hyperalgesia in the rats after incision. Using mouse genetics, we found that CaV 3.2 T-calcium channels are important for anti-hyperalgesic effect of 3β-OH and are contributing to its hypnotic effect. CONCLUSION AND IMPLICATIONS Our study identifies 3β-OH as a novel analgesic for surgical procedures. 3β-OH can be used to reduce T-channel-dependent excitability of peripheral sensory neurons as an adjuvant for induction and maintenance of general anaesthesia while improving analgesia and lowering the amount of volatile anaesthetic needed for surgery.
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Affiliation(s)
- Sonja Lj Joksimovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA.,Pharmacology Graduate Program, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Srdjan M Joksimovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA
| | - Francesca M Manzella
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA.,Neuroscience Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
| | - Betelehem Asnake
- Department of Anesthesiology and Pain Medicine, University of California, Davis, CA, USA
| | - Peihan Orestes
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA
| | - Yogendra H Raol
- Department of Pediatrics, Division of Neurology, Translational Epilepsy Research Program, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathiresan Krishnan
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA
| | - Douglas F Covey
- Department of Developmental Biology, Washington University School of Medicine, St. Louis, MO, USA.,Taylor Family Institute for Innovative Psychiatric Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA
| | - Slobodan M Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, Co, USA.,Neuroscience Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO, USA
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Selection of Reliable Reference Genes for Analysis of Gene Expression in Spinal Cord during Rat Postnatal Development and after Injury. Brain Sci 2019; 10:brainsci10010006. [PMID: 31861889 PMCID: PMC7017034 DOI: 10.3390/brainsci10010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/11/2019] [Accepted: 12/18/2019] [Indexed: 11/17/2022] Open
Abstract
In order to obtain unbiased results of target gene expression, selection of the most appropriate reference gene (RG) remains a key precondition. However, an experimental study focused on the validation of stably expressed RGs in the rat spinal cord (SC) during development or after spinal cord injury (SCI) is missing. In our study, we tested the stability of the expression of nine selected RGs in rat SC tissue during normal development (postnatal days 1-43, adulthood) and after minimal (mSCI) and contusion (cSCI) spinal cord injury. The following RGs were tested: common housekeeping genes of basal cell metabolism (Gapdh, Hprt1, Mapk6) and protein translation (Rpl29, Eef1a1, Eif2b2), as well as newly designed RGs (Gpatch1, Gorasp1, Cds2) selected according to the RefGenes tool of GeneVestigator. The stability of RGs was assessed by geNorm, NormFinder, and BestKeeper. All three applets favored Gapdh and Eef1a1 as the most stable genes in SC during development. In both models of SCI, Eif2b2 displayed the highest stability of expression, followed by Gapdh and Gorasp1/Hprt1 in cSCI, and Gapdh and Eef1a1 in the mSCI experiments. To verify our results, selected RGs were employed for normalization of the expression of genes with a clear biological context in the SC-Gfap and Slc1a3/Glast during postnatal development and Aif1/Iba1 and Cd68/Ed1 after SCI.
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18
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Seering MS, Bayman EO, Wong CA, Ranganath YS, Marian AA. Comparison of the effect of three different adjuvants on the analgesic duration of single injection interscalene brachial plexus block: a prospective, randomized, triple blinded clinical trial. Reg Anesth Pain Med 2019; 44:rapm-2018-100201. [PMID: 31308262 DOI: 10.1136/rapm-2018-100201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of regional anesthesia can result in faster recovery and better patient satisfaction. Addition of perineural adjuncts to local anesthetics may improve the duration of analgesia, but there is a paucity of data comparing them in a single randomized trial. We compared the effects of three adjuncts clonidine, dexamethasone, and buprenorphine, on the duration of analgesia of interscalene brachial plexus block. METHODS 160 patients, undergoing elective shoulder surgery, were randomized to four groups to receive an interscalene block with one of the following solutions: ropivacaine alone, ropivacaine with clonidine 75 µg, ropivacaine with dexamethasone 8 mg, or ropivacaine with buprenorphine 300 µg. The primary outcome variable was the duration of analgesia; secondary outcome measures were time to onset of the block, and the duration of sensory and motor blocks. RESULTS There was no statistically significant difference in the total analgesia time among the four groups; p=0.11. The pairwise comparison in analgesic time and 99% CI were: control versus clonidine (-1.94 hours (-7.33 to 3.12)), control versus dexamethasone (-4.16 hours (-9.50 to 0.58)) and control versus buprenorphine (-1.1 hours (-5.34 to 3.23)). There was no differences in block set-up time, or total sensory and motor block duration among the groups. CONCLUSION There was no significant improvement in the duration of analgesia with addition of any of the three adjuncts to interscalene blocks. However, there was a larger than expected variability in patient response, hence the study may have been underpowered for the primary outcome.
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Affiliation(s)
- Melinda S Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emine O Bayman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Anil A Marian
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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19
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Priming of Adult Incision Response by Early-Life Injury: Neonatal Microglial Inhibition Has Persistent But Sexually Dimorphic Effects in Adult Rats. J Neurosci 2019; 39:3081-3093. [PMID: 30796159 PMCID: PMC6468109 DOI: 10.1523/jneurosci.1786-18.2019] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 01/12/2019] [Accepted: 01/15/2019] [Indexed: 02/06/2023] Open
Abstract
Neonatal hindpaw incision primes developing spinal nociceptive circuitry, resulting in enhanced hyperalgesia following reinjury in adulthood. Spinal microglia contribute to this persistent effect, and microglial inhibition at the time of adult reincision blocks the enhanced hyperalgesia. Here, we pharmacologically inhibited microglial function with systemic minocycline or intrathecal SB203580 at the time of neonatal incision and evaluated sex-dependent differences following adult reincision. Incision in adult male and female rats induced equivalent hyperalgesia and spinal dorsal horn expression of genes associated with microglial proliferation (Emr1) and transformation to a reactive phenotype (Irf8). In control adults with prior neonatal incision, the enhanced degree and duration of incision-induced hyperalgesia and spinal microglial responses to reincision were equivalent in males and females. However, microglial inhibition at the time of the neonatal incision revealed sex-dependent effects: the persistent mechanical and thermal hyperalgesia following reincision in adulthood was prevented in males but unaffected in females. Similarly, reincision induced Emr1 and Irf8 gene expression was downregulated in males, but not in females, following neonatal incision with minocycline. To evaluate the distribution of reincision hyperalgesia, prior neonatal incision was performed at different body sites. Hyperalgesia was maximal when the same paw was reincised, and was increased following prior incision at ipsilateral, but not contralateral, sites, supporting a segmentally restricted spinal mechanism. These data highlight the contribution of spinal microglial mechanisms to persistent effects of early-life injury in males, and sex-dependent differences in the ability of microglial inhibition to prevent the transition to a persistent pain state span developmental stages.SIGNIFICANCE STATEMENT Following the same surgery, some patients develop persistent pain. Contributory mechanisms are not fully understood, but early-life experience and sex/gender may influence the transition to chronic pain. Surgery and painful procedural interventions in vulnerable preterm neonates are associated with long-term alterations in somatosensory function and pain that differ in males and females. Surgical injury in neonatal rodents primes the developing nociceptive system and enhances reinjury response in adulthood. Neuroimmune interactions are critical mediators of persistent pain, but sex-dependent differences in spinal neuroglial signaling influence the efficacy of microglial inhibitors following adult injury. Neonatal microglial inhibition has beneficial long-term effects on reinjury response in adult males only, emphasizing the importance of evaluating sex-dependent differences at all ages in preclinical studies.
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20
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Joksimovic SL, Joksimovic SM, Tesic V, García-Caballero A, Feseha S, Zamponi GW, Jevtovic-Todorovic V, Todorovic SM. Selective inhibition of Ca V3.2 channels reverses hyperexcitability of peripheral nociceptors and alleviates postsurgical pain. Sci Signal 2018; 11:eaao4425. [PMID: 30154101 PMCID: PMC6193449 DOI: 10.1126/scisignal.aao4425] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Pain-sensing sensory neurons of the dorsal root ganglion (DRG) can become sensitized or hyperexcitable in response to surgically induced peripheral tissue injury. We investigated the potential role and molecular mechanisms of nociceptive ion channel dysregulation in acute pain conditions such as those resulting from skin and soft tissue incision. We used selective pharmacology, electrophysiology, and mouse genetics to link increased current densities arising from the CaV3.2 isoform of T-type calcium channels (T-channels) to nociceptive sensitization using a clinically relevant rodent model of skin and deep tissue incision. Furthermore, knockdown of the CaV3.2-targeting deubiquitinating enzyme USP5 or disruption of USP5 binding to CaV3.2 channels in peripheral nociceptors resulted in a robust antihyperalgesic effect in vivo and substantial T-current reduction in vitro. Our study provides mechanistic insight into the role of plasticity in CaV3.2 channel activity after surgical incision and identifies potential targets for perioperative pain that may greatly decrease the need for narcotics and potential for drug abuse.
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Affiliation(s)
- Sonja L Joksimovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
- Pharmacology Graduate Program, School of Pharmacy, University of Belgrade, 11000 Belgrade, Serbia
| | - Srdjan M Joksimovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Vesna Tesic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Agustin García-Caballero
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Alberta T2N 4N1 Canada
| | - Simon Feseha
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Gerald W Zamponi
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Alberta T2N 4N1 Canada
| | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Slobodan M Todorovic
- Department of Anesthesiology, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA.
- Neuroscience Graduate Program, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA
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21
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Ahmad N, Greenaway S. Anaesthesia for inguinal hernia repair in the newborn or ex-premature infant. BJA Educ 2018; 18:211-217. [PMID: 33456835 DOI: 10.1016/j.bjae.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- N Ahmad
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,University College London Institute of Child Health, London, UK
| | - S Greenaway
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Barts Health NHS Trust, London, UK
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22
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Is spinal anaesthesia in young infants really safer and better than general anaesthesia? Curr Opin Anaesthesiol 2018; 31:302-307. [DOI: 10.1097/aco.0000000000000578] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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Dhar D, Poree LR, Yaksh TL. Evolution of the Spinal Delivery of Opiate Analgesics. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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24
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Emami A, Tepper J, Short B, Yaksh TL, Bendele AM, Ramani T, Cisternas AF, Chang JH, Mellon RD. Toxicology Evaluation of Drugs Administered via Uncommon Routes: Intranasal, Intraocular, Intrathecal/Intraspinal, and Intra-Articular. Int J Toxicol 2017; 37:4-27. [PMID: 29264927 DOI: 10.1177/1091581817741840] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
As the need for nasal, ocular, spinal, and articular therapeutic compounds increases, toxicology assessments of drugs administered via these routes play an important role in human safety. This symposium outlined the local and systemic evaluation to support safety during the development of these drugs in nonclinical models with some case studies. Discussions included selection of appropriate species for the intended route; conducting nonclinical studies that closely mimic the intended use with adequate duration; functional assessment, if deemed necessary; evaluation of local tissues with special histological staining procedure; and evaluations of safety margins based on local and systemic toxicity.
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Affiliation(s)
- Armaghan Emami
- 1 US Food and Drug Administration, Silver Spring, MD, USA
| | - Jeff Tepper
- 2 Tepper Nonclinical Consulting, San Carlos, CA, USA
| | - Brian Short
- 3 Brian Short Consulting, LLC, Trabuco Canyon, CA, USA
| | - Tony L Yaksh
- 4 Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | | | | | | | - Jay H Chang
- 1 US Food and Drug Administration, Silver Spring, MD, USA
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Jayaram K, Durga P. Regional anesthesia for thoracotomy pain in newborns and infants- a systematic review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2017.10.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Frawley G, Huque MH. Infant spinal anesthesia: Do girls need a larger dose of local anesthetic? Paediatr Anaesth 2017; 27:1037-1042. [PMID: 28815798 DOI: 10.1111/pan.13219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gender differences in absorption, distribution, and metabolism of a number of anesthetic agents have been identified in adults. Clinically, adult studies suggest women demonstrate slower onset of opioid analgesic effects, lower spinal and epidural dose requirements, and greater sensitivity to neuromuscular blocking agents. Sex-related differences in the pharmacokinetics and pharmacodynamics of local anesthetics in neonates and infants, however, have not been well documented. As a result, it is not known whether modification of the dose of local anesthetic for awake spinal anesthesia in infants is required. AIMS Our aim was to determine whether the ED50 and ED95 of local anesthetics used for infant spinal anesthesia are different between sexes. METHODS This was a retrospective analysis of data previously collected during dose-response studies of levobupivacaine and ropivacaine spinal anesthetics. The doses were reanalyzed using generalized linear regression analysis to determine whether there is a discernible difference in dose requirements between male and female infants. RESULTS One hundred and twenty infant spinal anesthetics were reviewed. For levobupivacaine, the ED50 (95% CI) was 0.69 (0.49-0.88) mg vs 0.49 (0.33-0.65), whereas the ED95(95% CI) was 1.07 (0.73-1.41) vs 0.93 (0.64-1.22) for girls and boys, respectively. For ropivacaine spinal anesthesia, the ED50 (95% CI) was 0.64 (0.35-0.92) mg vs 0.30 (-0.32-0.92), whereas the ED95 (95% CI) was 1.30 (0.73-1.87) vs 1.66 (0.55-2.76) for girls and boys, respectively. CONCLUSION There is no evidence that sex differences occur at the ED50 dose range or at the clinically relevant ED95 dose. Modification of spinal anesthetic dose is not required for infant girls.
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Affiliation(s)
- Geoff Frawley
- Department of Paediatric Anaesthesia and Pain Management, Royal Childrens Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia.,Critical Care and Neurosciences Theme, Murdoch Childrens Research institute, Parkville, VIC, Australia
| | - Md Hamidul Huque
- Clinical Epidemiology and Biostatistical Unit, Murdoch Childrens Research Institute, Parkville, VIC, Australia
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The European society of regional anesthesia and pain therapy and the American society of regional anesthesia and pain medicine joint committee practice advisory on controversial topics in pediatric regional anesthesia I and II. Curr Opin Anaesthesiol 2017; 30:613-620. [DOI: 10.1097/aco.0000000000000508] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lim WY, Wijeratne SA, Lim EHL. Awake caudal anaesthesia in neonates/young infants for improved patient safety. BMJ Case Rep 2017; 2017:bcr-2016-218500. [PMID: 28551594 PMCID: PMC5612206 DOI: 10.1136/bcr-2016-218500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2017] [Indexed: 11/04/2022] Open
Abstract
Caudal epidural block in a conscious infant is a recognised technique that allows the avoidance of general anaesthesia and risks associated with it. It is also technically easier to perform reliably compared with an awake subarachnoid block in skilled hands.1 While local anaesthetic systemic toxicity is a rare complication of caudal anaesthesia, this case illustrates the potential for caudal anaesthesia done awake in enhancing patient safety through early recognition of local anaesthetic systemic toxicity.
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Affiliation(s)
- Wan Yen Lim
- Anaesthesiology, Singapore General Hospital, Singapore, Singapore
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Butkevich IP, Mikhailenko VA, Vershinina EA, Aloisi AM, Barr GA. Long-Term Effects of Chronic Buspirone during Adolescence Reduce the Adverse Influences of Neonatal Inflammatory Pain and Stress on Adaptive Behavior in Adult Male Rats. Front Behav Neurosci 2017; 11:11. [PMID: 28184190 PMCID: PMC5266710 DOI: 10.3389/fnbeh.2017.00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 01/12/2017] [Indexed: 01/07/2023] Open
Abstract
Neonatal pain and stress induce long-term changes in pain sensitivity and behavior. Previously we found alterations in pain sensitivity in adolescent rats exposed to early-life adverse events. We tested whether these alterations have long-lasting effects and if those effects can be improved by the 5-hydroxytryptamine 1A (5-HT1A) receptor agonist buspirone injected chronically during the adolescent period. This study investigates: (1) effects of inflammatory pain (the injection of formalin into the pad of a hind paw) or stress (short maternal deprivation-isolation, MI), or their combination in 1-2-day-old rats on the adult basal pain, formalin-induced pain, anxiety and depression; (2) effects of adolescent buspirone in adult rats that experienced similar early-life insults. Changes in nociceptive thresholds were evaluated using the hot plate (HP) and formalin tests; levels of anxiety and depression were assessed with the elevated plus maze and forced swim tests respectively. Both neonatal painful and stressful treatments induced long-term alterations in the forced swim test. Other changes in adult behavioral responses were dependent on the type of neonatal treatment. There was a notable lack of long-term effects of the combination of early inflammatory pain and stress of MI on the pain responses, anxiety levels or on the effects of adolescent buspirone. This study provides the first evidence that chronic injection of buspirone in adolescent rats alters antinociceptive and anxiolytic effects limited to adult rats that showed behavioral alterations induced by early-life adverse treatments. These data highlight the role of 5-HT1A receptors in long-term effects of neonatal inflammatory pain and stress of short MI on adaptive behavior and possibility of correction of the pain and psychoemotional behavior that were altered by adverse pain/stress intervention using buspirone during critical adolescent period.
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Affiliation(s)
- Irina P. Butkevich
- Laboratory of Ontogenesis of the Nervous System, I.P. Pavlov Institute of Physiology, Russian Academy of SciencesSt. Petersburg, Russia
| | - Viktor A. Mikhailenko
- Laboratory of Ontogenesis of the Nervous System, I.P. Pavlov Institute of Physiology, Russian Academy of SciencesSt. Petersburg, Russia
| | - Elena A. Vershinina
- Department of Information Technologies and Mathematical Modeling, I.P. Pavlov Institute of Physiology, Russian Academy of SciencesSt. Petersburg, Russia
| | - Anna M. Aloisi
- Department of Medicine, Surgery and Neuroscience, University of SienaSiena, Italy
| | - Gordon A. Barr
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of PennsylvaniaPhiladelphia, PA, USA
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Yaksh TL, Fisher CJ, Hockman TM, Wiese AJ. Current and Future Issues in the Development of Spinal Agents for the Management of Pain. Curr Neuropharmacol 2017; 15:232-259. [PMID: 26861470 PMCID: PMC5412694 DOI: 10.2174/1570159x14666160307145542] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 12/02/2015] [Accepted: 02/05/2016] [Indexed: 11/22/2022] Open
Abstract
Targeting analgesic drugs for spinal delivery reflects the fact that while the conscious experience of pain is mediated supraspinally, input initiated by high intensity stimuli, tissue injury and/or nerve injury is encoded at the level of the spinal dorsal horn and this output informs the brain as to the peripheral environment. This encoding process is subject to strong upregulation resulting in hyperesthetic states and downregulation reducing the ongoing processing of nociceptive stimuli reversing the hyperesthesia and pain processing. The present review addresses the biology of spinal nociceptive processing as relevant to the effects of intrathecally-delivered drugs in altering pain processing following acute stimulation, tissue inflammation/injury and nerve injury. The review covers i) the major classes of spinal agents currently employed as intrathecal analgesics (opioid agonists, alpha 2 agonists; sodium channel blockers; calcium channel blockers; NMDA blockers; GABA A/B agonists; COX inhibitors; ii) ongoing developments in the pharmacology of spinal therapeutics focusing on less studied agents/targets (cholinesterase inhibition; Adenosine agonists; iii) novel intrathecal targeting methodologies including gene-based approaches (viral vectors, plasmids, interfering RNAs); antisense, and toxins (botulinum toxins; resniferatoxin, substance P Saporin); and iv) issues relevant to intrathecal drug delivery (neuraxial drug distribution), infusate delivery profile, drug dosing, formulation and principals involved in the preclinical evaluation of intrathecal drug safety.
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Affiliation(s)
- Tony L. Yaksh
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Casey J. Fisher
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Tyler M. Hockman
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
| | - Ashley J. Wiese
- University of California, San Diego, Anesthesia Research Lab 0818, 9500 Gilman Dr. LaJolla, CA 92093, USA
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Zhang Y, Lin H, Yi WB. Evaluation of the effects of ketamine on spinal anesthesia with levobupivacaine or ropivacaine. Exp Ther Med 2016; 12:2290-2296. [PMID: 27698726 DOI: 10.3892/etm.2016.3587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 04/21/2016] [Indexed: 02/07/2023] Open
Abstract
Spinal anesthesia or regional anesthesia is a potent anesthetic procedure. Additional modalities have been sought to increase the duration of block in spinal anesthesia. Ketamine is an N-methyl-D-aspartate (NMDA) receptor blocker that has an anesthetic effect when injected intrathecally and has a synergic effect with bupivacaine. Ketamine also has potent analgesic properties. The present study investigated the effect of intrathecally administered ketamine on spinal anesthesia with levobupivacaine or ropivacaine. Sprague-Dawley rats at post-natal day 21 were exposed to spinal anesthesia with 0.5% levobupivacaine or 0.5% ropivacaine. Separate groups of rats were treated with intrathecal ketamine at a 5 or 10 mg/kg bodyweight dose along with ropivacaine or levobupivacaine. The thermal and mechanical withdrawal latencies of the animals were determined using hot plate and von Frey filaments, respectively. A rotarod apparatus was employed to assess the capacity of the rats to rotate the spindle at 24 h following anesthesia. The gait of the rat pups was also assessed. Intrathecal administration of ketamine resulted in dense blocks and extended the duration of spinal blocks as evidenced by thermal latencies and responses to von Frey filaments. The latency to fall was shorter in rats exposed to ketamine along with ropivacaine or levobupivacaine spinal anesthesia. The gait parameters were also more disturbed upon ketamine administration. In conclusion, ketamine administration with ropivacaine or levobupivacaine increased the intensity and duration of spinal blockade, thereby increasing the anesthetic effects.
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Affiliation(s)
- Yan Zhang
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
| | - Hong Lin
- Department of Anesthesiology, Qianfoshan Hospital of Shandong, Taian, Shandong 271000, P.R. China
| | - Wen-Bo Yi
- Department of Anesthesiology, Qilu Hospital of Shandong University, Jinan, Shandong 250012, P.R. China
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Brooks MR, Golianu B. Perioperative management in children with chronic pain. Paediatr Anaesth 2016; 26:794-806. [PMID: 27370517 DOI: 10.1111/pan.12948] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 12/28/2022]
Abstract
Children with chronic pain often undergo surgery and effective perioperative management of their pain can be challenging. Identification of the pediatric chronic pain patient preoperatively and development of a perioperative pain plan may help ensure a safer and more comfortable perioperative course. Successful management usually requires multiple different classes of analgesics, regional anesthesia, and adjunctive nonpharmacological therapies. Neuropathic and oncological pain can be especially difficult to treat and usually requires an individualized approach.
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Affiliation(s)
- Meredith R Brooks
- Department of Anesthesiology, Cook Children's Hospital, Fort Worth, TX, USA
| | - Brenda Golianu
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Meenakshi Karuppiah NP, Shetty SR, Patla KP. Comparison between two doses of dexmedetomidine added to bupivacaine for caudal analgesia in paediatric infraumbilical surgeries. Indian J Anaesth 2016; 60:409-14. [PMID: 27330203 PMCID: PMC4910481 DOI: 10.4103/0019-5049.183394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background and Aims: Caudal block (CB) with adjuvants is routinely used in children for anaesthesia. We evaluated the efficacy of the α2 adrenergic agonist, dexmedetomidine at two different doses as an adjuvant to bupivacaine in CB. Methods: This study was conducted on ninety children. Control group BD0 received 0.25% bupivacaine 1 ml/kg, whereas, the study groups BD1 and BD2 received 1 μg/kg and 2 μg/kg dexmedetomidine, respectively, with 0.25% bupivacaine 1 ml/kg as a single shot CB. Adequacy of the block, haemodynamic changes, duration of analgesia and side effects were compared. Analysis of Variance was used for between-group comparisons of numerical variables. Student's t-test and Mann–Whitney U-test were used for quantitative data. Results: The demography was comparable. Anal sphincter 5 min after administration of the CB was relaxed in 89.3%, 82.1% and 75% of cases in BD0, BD1 and BD2 groups, respectively. The sphincter was relaxed at the end of surgery in all the cases. Comparable haemodynamics was noted with significantly prolonged duration of analgesia in the groups BD1 (964.2 ± 309 min) and BD2 (1152.6 ± 380.4 min) compared to control (444.6 ± 179.4 min). While no complications were encountered in groups BD0 and BD1, bradycardia was observed in four cases of BD2 group with accompanied hypotension in one of them. Conclusion: Dexmedetomidine as an adjuvant to bupivacaine improves the quality of CB, provides good operating conditions and increases the duration of post-operative analgesia. We conclude that 1 μg/kg is as effective as 2 μg/kg of dexmedetomidine and with a better safety profile.
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Affiliation(s)
| | - Sumalatha R Shetty
- Department of Anaesthesiology and Critical Care, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
| | - Krishna Prasad Patla
- Department of Anaesthesiology and Critical Care, K.S. Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
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Abstract
PURPOSE OF REVIEW This article summarizes recent data related to the safety and efficacy of postoperative analgesia in children that influence clinical practice recommendations. RECENT FINDINGS Postoperative pain continues to be experienced by hospitalized children and following discharge after short stay or ambulatory surgery. Updated recommendations for post-tonsillectomy analgesia exclude codeine and suggest regular administration of paracetamol and NSAID, but evidence for the most appropriate dose and type of opioid for rescue analgesia is limited. The incidence of opioid-related respiratory depression/oversedation in hospitalized children ranges from 0.11 to 0.41%, with recent large series identifying high-risk groups and contributory factors that can be targeted to minimize the risk of serious or permanent harm. Data demonstrating feasibility and safety of regional analgesic techniques is increasing, but additional and procedure-specific evidence would improve technique selection and inform discussions of efficacy and safety with patients and families/carers. Persistent postsurgical pain is increasingly recognized following major surgery in adolescents. Evaluation of potential predictive factors in clinical studies and investigation of underlying mechanisms in laboratory studies can identify targets for both pharmacological and nonpharmacological interventions. SUMMARY Recommendations for postoperative pain in children continue to evolve, with data incorporated from randomized controlled trials, case series and large audits. Management of pain following surgery in children needs to not only encompass efficacy and safety in the immediate perioperative period, but also consider pain following discharge after ambulatory surgery and the potential risk of persistent postsurgical pain following major surgery.
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Ayob F, Arnold R. Do caudal blocks cause complications following hypospadias surgery in children? Anaesthesia 2016; 71:759-63. [PMID: 27156640 DOI: 10.1111/anae.13490] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Ayob
- Department of Anaesthesia, University Hospital Lewisham, London, UK
| | - R Arnold
- Department of Anaesthesia, University Hospital Lewisham, London, UK.
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Turner MA. Clinical trials of medicines in neonates: the influence of ethical and practical issues on design and conduct. Br J Clin Pharmacol 2015; 79:370-8. [PMID: 25041601 DOI: 10.1111/bcp.12467] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 06/24/2014] [Indexed: 01/03/2023] Open
Abstract
In the past, there has been a perception that ethical and practical problems limit the opportunities for research in neonates. This perception is no longer appropriate. It is now clear that research about the medicines used in neonates is an ethical requirement. It is possible to conduct high quality research in neonates if the research team adapt to the characteristics of this population. Good practice involves respecting the specific needs of newborn babies and their families by adopting relevant approaches to study design, recruitment, pharmacokinetic studies and safety assessment. Neonatal units have a unique culture that requires careful development in a research setting. Clinical investigators need to recognize the clinical and ethical imperative to conduct rigorous research. Industry needs to engage with neonatal networks early in the process of drug development, preferably before contacting regulatory agencies. Follow-up over 3-5 years is essential for the evaluation of medicines in neonates and explicit funding for this is required for the assessment of the benefit and risk of treatments given to sick newborn babies. The views of parents must be central to the development of studies and the research agenda. Ethical and practical problems are no longer barriers to research in neonates. The current challenges are to disseminate good practice and maximize capacity in order to meet the need for research among newborn babies.
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Affiliation(s)
- Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Xu KX, Tao J, Zhang N, Wang JZ. Neuroprotective properties of vitamin C on equipotent anesthetic concentrations of desflurane, isoflurane, or sevoflurane in high fat diet fed neonatal mice. Int J Clin Exp Med 2015; 8:10444-58. [PMID: 26379835 PMCID: PMC4565218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/08/2015] [Indexed: 06/05/2023]
Abstract
Obesity has been reported to be one of the significant contributors to various chronic disease conditions. Childhood obesity has been on an alarming increase over recent years leading to various health complications. Millions of children undergo surgery each year as a part of medical care on various health grounds. In the present study, influence of vitamin C on the effect of obesity and over-weight under anaesthetic exposure was analysed. Separate groups of neonatal mice (C57BL/6) were fed on high-fat diet to induce obesity. The mice were administered with vitamin C at 30 and 60 mg/kg b.wt post natal day 1 (P1) to P21. P7 mice were exposed to equipotent doses of isoflurane or sevoflurane or desflurane. Neuroapoptosis was assessed by measuring activated caspase-3 and TUNEL assay. Plasma S100β levels were detected by ELISA. The mice were assessed for their general behaviour. Morris water maze test was performed to assess the spatial working memory. Anesthesia exposure caused severe neuroapoptosis and also raised the levels of plasma S100β. Neuroapotosis, working memory and learning impairments observed following anesthetics were comparatively more profound on high fat diet fed mice. Desflurane exposure resulted in higher apoptotic counts, learning and memory deficits than equipotent dose of isoflurane and sevoflurane. Vitamin C supplementation offered significant protection against anesthetic induced neurotoxicity and behavioural alterations. Vitamin C administration resulted in marked reduction in neurotoxicity induced by anesthesia and as well improved learning and memory of both normal and high fat diet fed mice.
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Affiliation(s)
- Kai-Xiang Xu
- Department of Neurosurgery, 208 Hospital of PLAChangchun 130062, China
| | - Jun Tao
- Department of Spinal Branch, Wendeng Osteopath HospitalWeihai 230038, China
| | - Nan Zhang
- Department of Obstetrics and Gynecology, Renji HospitalShanghai 200127, China
| | - Jian-Zhong Wang
- Department of Neurosurgery, 208 Hospital of PLAChangchun 130062, China
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Morton NS. Anaesthesia and the developing nervous system: advice for clinicians and families. BJA Educ 2015. [DOI: 10.1093/bjaceaccp/mku020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Eizaga Rebollar R, García Palacios MV, Morales Guerrero J, Torres Morera LM. [Central blockades in Pediatrics: A review of current literature]. ACTA ACUST UNITED AC 2015; 63:91-100. [PMID: 25866132 DOI: 10.1016/j.redar.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 02/28/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
Pediatric neuraxial anesthesia is an effective tool that can be used as a supplement or alternative to general anesthesia. However, there have always been doubts about its usefulness and risk-benefit ratio. The purpose of this review is to describe the current role of central blockades in pediatric patients, upgrade practical and safety aspects, and review the latest technological advances applied to this procedure.
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Affiliation(s)
- R Eizaga Rebollar
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España.
| | - M V García Palacios
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario Puerta del Mar, Cádiz, España
| | - J Morales Guerrero
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
| | - L M Torres Morera
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
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Abstract
Ongoing advances in the perioperative management of the newborn have undoubtedly decreased the incidence of morbidity and mortality of this vulnerable patient group. The introduction of new surgical techniques and more comprehensive understanding of the effects of varied anesthetic drugs and techniques on the surgical newborn present many challenges for pediatric surgeons and anesthesiologists. Thorough preoperative evaluation and open communication between members of the health care team are important. A basic understanding of age-dependent variables and the interaction of anesthetic and surgical procedures is essential in minimizing perioperative morbidity and mortality.
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Affiliation(s)
- Mary Ellen McCann
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children׳s Hospital, 300 Longwood Ave, Boston, MA 02115; Department of Anaesthesia, Harvard Medical School, Boston, MA.
| | - Sulpicio G Soriano
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children׳s Hospital, 300 Longwood Ave, Boston, MA 02115; Department of Anaesthesia, Harvard Medical School, Boston, MA
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41
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Suresh S, Schaldenbrand K, Wallis B, De Oliveira G. Regional anaesthesia to improve pain outcomes in paediatric surgical patients: a qualitative systematic review of randomized controlled trials. Br J Anaesth 2014; 113:375-390. [DOI: 10.1093/bja/aeu156] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
Pain is a common presenting and often persistent symptom for children with rheumatological disease. Pain is not clearly related to disease severity in children with inflammatory juvenile idiopathic arthritis, and presentations of non-inflammatory musculoskeletal pain are common but there is limited evidence to guide management. Pain assessment must extend beyond measures of pain severity to more fully evaluate characteristics of pain, functional impact and psychosocial effects and family interactions. Evaluation of mechanisms of joint pain in adults has identified potential treatment targets, but additional studies are required as the acute and long-term impacts of pain and injury change during postnatal development. Genotyping, sensory evaluation and neuroimaging may better characterize chronic musculoskeletal pain, identify high-risk groups and/or provide additional outcome measures to monitor disease and treatment progress. An integrated approach to management is required to effectively select and target interventions, reduce pain and disability and improve long-term outcome.
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Does the addition of tramadol and ketamine to ropivacaine prolong the axillary brachial plexus block? BIOMED RESEARCH INTERNATIONAL 2014; 2014:686287. [PMID: 24883319 PMCID: PMC4032708 DOI: 10.1155/2014/686287] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/25/2014] [Accepted: 04/07/2014] [Indexed: 02/06/2023]
Abstract
Background and Objectives. A prospective, randomized, controlled, double-blind clinical trial to assess the effect of tramadol and ketamine, 50 mg, added to ropivacaine in brachial plexus anesthesia. Methods. Thirty-six ASA physical statuses I and II patients, between 18 and 60 years of age, scheduled for forearm and hand surgery under axillary brachial plexus block, were allocated to 3 groups. Group R received 0.375% ropivacaine in 40 mL, group RT received 0.375% ropivacaine in 40 mL with 50 mg tramadol, and group RK received 0.375% ropivacaine in 40 mL with 50 mg ketamine for axillary brachial plexus block. The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events (nausea, vomiting, and feeling uncomfortable) were recorded. Results. The onset time of sensorial block was the fastest in ropivacaine + tramadol group. Duration of sensorial and motor block was the shortest in the ropivacaine + tramadol group. Duration of analgesia was significantly longer in ropivacaine + tramadol group. Conclusion. We conclude that when added to brachial plexus analgesia at a dose of 50 mg, tramadol extends the onset and duration time of the block and improves the quality of postoperative analgesia without any side effects.
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Pohanka M. Inhibitors of acetylcholinesterase and butyrylcholinesterase meet immunity. Int J Mol Sci 2014; 15:9809-25. [PMID: 24893223 PMCID: PMC4100123 DOI: 10.3390/ijms15069809] [Citation(s) in RCA: 142] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 03/06/2014] [Accepted: 03/11/2014] [Indexed: 12/22/2022] Open
Abstract
Acetylcholinesterase (AChE) inhibitors are widely used for the symptomatic treatment of Alzheimer’s disease and other dementias. More recent use is for myasthenia gravis. Many of these inhibitors interact with the second known cholinesterase, butyrylcholinesterase (BChE). Further, evidence shows that acetylcholine plays a role in suppression of cytokine release through a “cholinergic anti-inflammatory pathway” which raises questions about the role of these inhibitors in the immune system. This review covers research and discussion of the role of the inhibitors in modulating the immune response using as examples the commonly available drugs, donepezil, galantamine, huperzine, neostigmine and pyridostigmine. Major attention is given to the cholinergic anti-inflammatory pathway, a well-described link between the central nervous system and terminal effector cells in the immune system.
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Affiliation(s)
- Miroslav Pohanka
- Faculty of Military Health Sciences, University of Defence, Trebesska 1575, Hradec Kralove CZ-50001, Czech Republic.
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45
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Pickard A, Davies P, Birnie K, Beringer R. Systematic review and meta-analysis of the effect of intraoperative α₂-adrenergic agonists on postoperative behaviour in children. Br J Anaesth 2014; 112:982-90. [PMID: 24727829 DOI: 10.1093/bja/aeu093] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Undergoing general anaesthesia is distressing for children, with up to two-thirds demonstrating abnormal behaviours after their procedure, such as emergence delirium (ED) and post-hospitalization behaviour change. The aim of this systematic review was to determine the effect of intraoperative i.v. α₂-adrenergic agonists on postoperative behaviour in children. We included published full-text reports of randomized controlled trials involving children who received i.v. clonidine or dexmedetomidine after induction of general anaesthesia, who were assessed for postoperative behavioural disturbance. After screening of references identified by the search strategy, a data collection form was developed and piloted. Data extraction was performed by one reviewer and checked by a second. Twelve randomized trials met the inclusion criteria. Ten studies (n=669) reported dichotomous data that were included in the pooled analysis of α₂-adrenergic agonists vs placebo. There was strong evidence that i.v. α₂-adrenergic agonists reduced postoperative ED (overall summary odds ratio 0.28, 95% confidence interval 0.19-0.40, P<0.001). No studies examined post-hospitalization negative behaviour changes. There was evidence that α₂-adrenergic agonists prolonged time in the recovery room. No adverse haemodynamic events were reported in any arm of any study. This meta-analysis provides evidence that intraoperative i.v. α₂-adrenergic agonists reduce the incidence of emergency delirium in children. The prolongation of time in recovery is unlikely to be clinically relevant. The absence of data regarding the effect on post-hospitalization behavioural changes provides an opportunity for future research.
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Affiliation(s)
- A Pickard
- Department of Anaesthesia, Bristol Royal Children's Hospital, Bristol, UK
| | - P Davies
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - K Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - R Beringer
- Department of Anaesthesia, Bristol Royal Children's Hospital, Bristol, UK
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Yaksh TL, Hobo S, Peters C, Osborn KG, Richter PJ, Rossi SS, Grafe MR, Eisenach JC. Preclinical toxicity screening of intrathecal oxytocin in rats and dogs. Anesthesiology 2014; 120:951-61. [PMID: 24492326 PMCID: PMC5392224 DOI: 10.1097/aln.0000000000000148] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anatomic, physiologic, and behavioral studies in animals suggest that spinally released oxytocin should produce analgesia in humans and may also protect from chronic pain after injury. In this article, the authors report preclinical toxicity screening of oxytocin for intrathecal delivery. METHODS Intrathecal oxytocin, 11 μg (6 U) or vehicle, was injected intrathecally in 24 rats, followed by frequent behavioral assessment and histologic examination of spinal contents 2 or 14 days after injection. In three dogs, a range of intrathecal oxytocin doses (18 to 550 μg in 0.5 ml) was injected followed by physiologic, biochemical, and behavioral assessments. Ten dogs were then randomized to receive five daily injections of intrathecal oxytocin, 550 μg in 0.5 ml, or vehicle with similar assessments and, necropsy and histologic analysis were conducted 2 days later. RESULTS In rats, intrathecal oxytocin resulted in transient scratching and itching behaviors, without other differences from vehicle. There was no behavioral, gross anatomic, or histologic evidence of neurotoxicity. Dose ranging in dogs suggested mild effects on motor tone, blood pressure, and heart rate at the 550 μg dose. Repeated boluses in dogs did not produce behavioral, biochemical, neurological, gross anatomic, or histologic evidence of neurotoxicity. CONCLUSIONS Substances, including natural neurotransmitters, may be toxic when administered in pharmacologic doses in the spinal cord. This preclinical toxicity screen in two species suggests that bolus injections of oxytocin in concentrations up to 1,100 μg/ml are unlikely to cause neurotoxicity. The authors also support cautious clinical application of intrathecal oxytocin under regulatory supervision.
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Affiliation(s)
- Tony L. Yaksh
- Department of Anesthesiology, University of California, San Diego (UCSD), CA
| | - Shotaro Hobo
- Department of Anesthesiology, Wake Forest School of Medicine (WFSM), Winston-Salem, NC
| | - Christopher Peters
- Department of Anesthesiology, Wake Forest School of Medicine, WFSM, Winston-Salem, NC
| | - Kent G. Osborn
- Diagnostic Laboratory, Animal Care Program, University of California, San Diego,(UCSD), CA
| | - Philip J. Richter
- Animal Care Program, Department of Pathology, University of California, San Diego,(UCSD), CA
| | - Steven S. Rossi
- Project Scientist, Anesthesiology Research laboratory, (UCSD), CA
| | - Marjorie R. Grafe
- Department of Pathology Medical Director, Neuropathology Oregon Health Sciences University, Portland, OR
| | - James C. Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, WFSM, Winston-Salem, NC
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Abstract
Effective management of procedural and postoperative pain in neonates is required to minimize acute physiological and behavioral distress and may also improve acute and long-term outcomes. Painful stimuli activate nociceptive pathways, from the periphery to the cortex, in neonates and behavioral responses form the basis for validated pain assessment tools. However, there is an increasing awareness of the need to not only reduce acute behavioral responses to pain in neonates, but also to protect the developing nervous system from persistent sensitization of pain pathways and potential damaging effects of altered neural activity on central nervous system development. Analgesic requirements are influenced by age-related changes in both pharmacokinetic and pharmacodynamic response, and increasing data are available to guide safe and effective dosing with opioids and paracetamol. Regional analgesic techniques provide effective perioperative analgesia, but higher complication rates in neonates emphasize the importance of monitoring and choice of the most appropriate drug and dose. There have been significant improvements in the understanding and management of neonatal pain, but additional research evidence will further reduce the need to extrapolate data from older age groups. Translation into improved clinical care will continue to depend on an integrated approach to implementation that encompasses assessment and titration against individual response, education and training, and audit and feedback.
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Affiliation(s)
- Suellen M Walker
- Correspondence Suellen Walker, Portex Unit: Pain Research; 6th Floor Cardiac Wing, UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK,
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Abstract
Even after a vast safety record, the role of spinal anesthesia (SA) as a primary anesthetic technique in children remains contentious and is mainly limited to specialized pediatric centers. It is usually practiced on moribund former preterm infants (<60 weeks post-conception) to reduce the incidence of post-operative apnea when compared to general anesthesia (GA). However, there is ample literature to suggest its safety and efficacy for suitable procedures in older children as well. SA in children has many advantages as in adults with an added advantage of minimal cardio-respiratory disturbance. Recently, several reports from animal studies have raised serious concerns regarding the harmful effects of GA on young developing brain. This may further increase the utility of SA in children as it provides all components of balanced anesthesia technique. Also, SA can be an economical option for countries with finite resources. Limited duration of surgical anesthesia in children is one of the major deterrents for its widespread use in them. To overcome this, several additives like epinephrine, clonidine, fentanyl, morphine, neostigmine etc. have been used and found to be effective even in neonates. But, the developing spinal cord may also be vulnerable to drug-related toxicity, though this has not been systematically evaluated in children. So, adjuvants and drugs with widest therapeutic index should be preferred in children. Despite its widespread use, incidence of side-effects is low and permanent neurological sequalae have not been reported with SA. Literature yields encouraging results regarding its safety and efficacy. Technical skills and constant vigilance of experienced anesthesia providers is indispensable to achieve good results with this technique.
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Affiliation(s)
- Anju Gupta
- Department of Anesthesiology and Intensive Care, Delhi State Cancer Hospital, Dilshad Garden, New Delhi, India
| | - Usha Saha
- LHMC and Associated Hospitals, New Delhi, India
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Wiese AJ, Rathbun M, Butt MT, Malkmus SA, Richter PJ, Osborn KG, Xu Q, Veesart SL, Steinauer JJ, Higgins D, Lappi DA, Russell B, Yaksh TL. Intrathecal substance P-saporin in the dog: distribution, safety, and spinal neurokinin-1 receptor ablation. Anesthesiology 2013; 119:1163-77. [PMID: 24051388 DOI: 10.1097/aln.0b013e3182a95164] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neurokinin-1 receptors (NK1-rs) located on superficial dorsal horn neurons are essential for integration of nociceptive input. Intrathecal injection of substance P-saporin (SP-SAP) leads to local loss of spinal NK1-r (+) neurons suggesting its potential as a therapeutic agent for chronic pain. The authors determined, in a canine model, effects of lumbar intrathecal SP-SAP. METHODS Distribution of SP-SAP and Saporin was determined in plasma, lumbar cerebrospinal fluid, and tissue. Safety of intrathecal SP-SAP was determined in four groups (six dogs each) administered 0 (0.9% saline), 1.5, 15, or 150 µg SP-SAP through lumbar intrathecal catheters. Behavioral, physiologic, and biochemical variables were assessed. Spinal tissues were collected at 7 and approximately 90 days, or earlier if significant morbidity developed, and analyzed for NK1-r (+) neuron loss and histopathology. RESULTS SP-SAP and Saporin were detectable in lumbar cerebrospinal fluid for up to 4 and 24 h, respectively. Animals receiving intrathecal saline, 1.5, or 15 µg of SP-SAP showed no persistent neurologic deficits. Three animals receiving 150 µg of SP-SAP developed pelvic limb paraparesis and were euthanized prematurely. Immunohistochemistry and in situ hybridization cell counts confirmed a significant reduction in NK1-r (+) in superficial dorsal horn neurons from lumbar spinal cord after intrathecal administration of 15 and 150 µg of SP-SAP. A significant loss of NK1-r neurons in the lumbar ventral horn occurred only with 150-µg SP-SAP. CONCLUSION Intrathecal 15-µg SP-SAP reduced dorsal, but not ventral, NK1-r (+) neurons at the spinal level of delivery with minimal side effects, whereas 150-µg SP-SAP resulted in motor neuron toxicity.
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Affiliation(s)
- Ashley J Wiese
- * Research Fellow, † Staff Research Associate, # Postdoctoral Fellow, §§ Professor of Anesthesiology and Pharmacology, Department of Anesthesiology, University of California, San Diego, California. ‡ President, Tox Path Specialists, LLC, Frederick, Maryland. § Director, Campus Veterinary Medicine, ‖ Associate Director, Diagnostic Laboratory, Office of Animal Research, University of California. ** Vice President, †† President/CSO, ‡‡ Research Scientist, Advanced Targeting Systems, San Diego, California
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Evaluation of spinal toxicity and long-term spinal reflex function after intrathecal levobupivaciane in the neonatal rat. Anesthesiology 2013; 119:142-55. [PMID: 23514721 DOI: 10.1097/aln.0b013e31828fc7e7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuraxial anesthesia is utilized in children of all ages. Local anesthetics produce dose-dependent toxicity in certain adult models, but the developing spinal cord may also be susceptible to drug-induced apoptosis. In postnatal rodents, we examined the effects of intrathecal levobupivacaine on neuropathology and long-term sensorimotor outcomes. METHODS Postnatal day 3 (P3) or P7 rat pups received intrathecal levobupivacaine 2.5 mg/kg (0.5%) or saline. Mechanical withdrawal thresholds and motor block were assessed. Spinal cord tissue analysis included apoptosis counts (activated caspase-3, Fluoro-Jade C) at 24 h, glial reactivity at 7 days, and histopathology in cord and cauda equina at 24 h and 7 days. Long-term spinal function in young adults (P35) was assessed by hind limb withdrawal thresholds, electromyography responses to suprathreshold stimuli, and gait analysis. RESULTS Intrathecal levobupivacaine produced spinal anesthesia at P3 and P7. No increase in apoptosis or histopathological change was seen in the cord or cauda equina. In the P3 saline group, activated caspase-3 (mean±SEM per lumbar cord section 6.1±0.3) and Fluoro-Jade C (12.1±1.2) counts were higher than at P7, but were not altered by levobupivacaine (P=0.62 and P=0.11, two-tailed Mann-Whitney test). At P35, mechanical withdrawal thresholds, thermal withdrawal latency, and electromyographic reflex responses did not differ across P3 or P7 levobupivacaine or saline groups (one way ANOVA with Bonferroni comparisons). Intrathecal bupivacaine at P3 did not alter gait. CONCLUSION Single dose intrathecal levobupivacaine 0.5% did not increase apoptosis or produce spinal toxicity in neonatal rat pups. This study provides preclinical safety data relevant to neonatal use of neuraxial local anesthesia.
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