Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single-event multilevel surgery

AIM

To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.

METHOD

Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).

RESULTS

There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).

INTERPRETATION

Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.

Pharmacokinetics of levobupivacaine after caudal epidural administration in infants less than 3 months of age

BACKGROUND

There are few data describing levobupivacaine pharmacokinetics in infants (<3 months) after caudal administration.

METHODS

An open-label study was undertaken to examine the pharmacokinetics of levobupivacaine 2.5 mg ml(-1), 2 mg kg(-1) in children aged less than 3 months after single-shot caudal epidural administration. Plasma concentrations were determined at intervals from 0.5 to 4 h after injection. A population pharmacokinetic analysis of levobupivacaine time-concentration profiles (84 observations) from 22 infants with mean postnatal age (PNA) 2.0 (range 0.6-2.9) months was undertaken using non-linear mixed effects models (NONMEM). Time-concentration profiles were analysed using a one-compartment model with first-order input and first-order elimination. Estimates were standardized to a 70 kg adult using allometric size models.

RESULTS

Population parameter estimates (between-subject variability) for total levobupivacaine were clearance (CLt) 12.8 [coefficient of variation (CV) 50.6%] litre h(-1) 70 kg(-1), volume of distribution (Vt) 202 (CV 31.6%) litre 70 kg(-1), absorption half-life (Tabs) 0.323 (CV 18.6%) h 70 kg(-1). Estimates for the unbound drug were clearance (CLfree) 104 (CV 43.5%) litre h(-1) 70 kg(-1), volume of distribution (Vfree) 1700 (CV 44.9%) litre 70 kg(-1), absorption half-life (Tabsfree) 0.175 (CV 83.7%) h 70 kg(-1). There was no effect attributable to PNA on CL or V. Time to peak plasma concentration (Tmax) was 0.82 (CV 18%) h. Peak plasma concentration (Cmax) was 0.69 (CV 25%) microg ml(-1) for total levobupivacaine and 0.09 (CV 37%) microg ml(-1) for unbound levobupivacaine.

CONCLUSIONS

Clearance in infants is approximately half that described in adults, suggesting immaturity of P450 CYP3A4 and CYP1A2 enzyme isoforms that metabolize levobupivacaine in infants. This lower clearance delays Tmax, which was noted to occur approximately 50 min after administration of caudal epidural levobupivacaine.

Diagnosis of left atrial myxoma following systemic embolism

Cardiac myxomas are rare and noted for their varied clinical manifestations. Consequently, the diagnosis is often unsuspected until the symptoms and signs become advanced and obvious, or when the diagnosis is made fortuitously during echocardiography. This report illustrates a case in point in which the diagnosis was made on transthoracic echocardiography and amplified using transesophageal echocardiography.

Doppler-echocardiographic assessment of Carbomedics prosthetic values in the mitral position

We prospectively studied 37 consecutive patients implanted with the Carbomedics prosthetic heart value in the mitral position (without clinical evidence of prosthetic valve dysfunction) with two-dimensional and Doppler echocardiography. The peak mitral prosthetic gradient ranged from 4.60 to 14.63 (mean 8.97 +/- 2.29) mm Hg; mean mitral prosthetic gradient ranged from 1.67 to 6.18 (mean 3.24 +/- 0.95) mm Hg; pressure half-time derived mitral valve area ranged from 1.67 to 5.30 (mean 2.70 +/- 0.80) cm2. These values compare favorably with that of another bileaflet valve (i.e., the St. Jude Medical valve). There was a wide overlap in peak and mean transmitral gradients, even with the valves of the same size, with a significant but weak inverse relationship between peak mitral gradients and valve size (p = 0.03, r = -0.36). The performance index showed a smaller range of values, again with a significant but weak inverse relationship with valve size (p = 0.001, r = -0.54). The inverse relationship between valve size and peak mitral gradient and performance index should be borne in mind when analyzing Doppler hemodynamic data.

Desulphation of dextran sulphate during kidney ultrafiltration

The renal clearance of [3H]dextran sulphate by the isolated perfused rat kidney was associated with desulphation of the molecule, as demonstrated by ion-exchange and affinity chromatography of material resident in both glomeruli and urine samples. This process also occurred in vivo. The molecular size distribution of glomerular dextran sulphate in the perfused kidney was indistinguishable from that in the perfusate, and although urinary material was smaller it remained macromolecular. Sulphatase activity was not detected in urine or in the perfusate of perfused kidneys, but was detected in glomerular and non-glomerular cortex fractions isolated by a sieving procedure. The identification of significant biochemical changes to dextran sulphate demonstrates that it does not function as an inert transport probe, and supports the concept of cellular involvement in the process of renal charge selectivity.

Anionic charge concentration of rat kidney glomeruli and glomerular basement membrane

Estimates of levels of glomerular and glomerular-basement-membrane anion charge should serve as useful quantitative markers for the integrity of the tissues in health and disease. We have developed a simple, rapid, technique to measure this charge through the use of ion exchange with radioisotopes 22Na+ and 36Cl- at low ionic strengths in phosphate buffer. When this technique is used, normal glomeruli isolated from rat have a measured net anion charge concentration of 17.4 +/- 3.7 p-equiv. per glomerulus (n = 20). Perfused rat kidneys that lose approximately half of their glomerular heparan [35S]sulphate content (owing to oxygen-radical damage) exhibited a lower anion charge, of 7.5 +/- 1.6 p-equiv. per glomerulus (n = 5). Glomerular basement membranes prepared from rat glomeruli by a sonication-centrifugation procedure in the presence of enzyme inhibitors had a charge concentration of 6.3 +/- 0.7 mu-equiv./g wet wt. of tissue (n = 4), whereas membranes prepared by sonication, centrifugation, DNAse and detergent treatment had a charge concentration of 7.1 +/- 1.6 mu-equiv./g wet wt. (n = 4). Isotope-dilution experiments with 3H2O on these detergent-prepared glomerular basement membranes demonstrated that they had a water content of approx. 93%, which would then give a net anion charge concentration of 7.6 +/- 1.7 m-equiv./l (n = 4). These values are in good agreement with those obtained by others using titration techniques [Bray and Robinson (1984) Kidney Int. 25, 527-533]. The relatively low magnitude of glomerular anion charge in normal kidneys is consistent with other recent findings that glomerular anion charge is too low to affect the glomerular transport of charged molecules in a direct, passive, biophysical manner through electrostatic interactions.

Overestimation of severity of mitral stenosis during cardiac catheterization due to a large left atrial thrombus

We report a case of mitral stenosis with a large left atrial thrombus which was obstructing pulmonary venous inflow where the conventional use of the pulmonary capillary wedge pressure as an approximation of the left atrial pressure during diagnostic cardiac catheterisation led to the over-estimation of the severity of mitral stenosis.

Charge selectivity in kidney ultrafiltration is associated with glomerular uptake of transport probes

The isolated perfused kidney exhibits substantial charge selectivity, as in vivo, in relation to fractional clearance of [3H]dextran sulfate and [3H]dextran. When cycloheximide is present in perfusate, fractional clearance of dextran sulfate is increased and proteinuria becomes significant, but glomerular filtration rate remains essentially unchanged compared with control. The possible role of cells in affecting transglomerular transport was demonstrated when isolated glomeruli from control perfused kidneys showed a very significant resident concentration of [3H]dextran sulfate and [3H]albumin, whereas there was no corresponding accumulation of [3H]dextran or [3H]inulin. Glomerular concentration of dextran sulfate and albumin was significantly reduced by cycloheximide. Kinetics of uptake and release of glomerular dextran sulfate indicated that it had a half-life of glomerular residence of approximately 2-3 min and that this half-life was considerably extended in the presence of cycloheximide. The half-life for glomerular residence of albumin was in the range of 30-40 min. The conclusion from this work is that glomerular charge selectivity for dextran sulfate could be quantitatively rationalized on the basis of transient uptake and release by glomerular cells.

Partial ischemia and proteinuria during isolated kidney perfusion is accompanied by the release of vascular [35S]heparan sulfate

The isolated kidney perfused with modified Krebs-Henseleit buffer with amino acids yields heavy proteinuria associated with reduced ATP levels characteristic of partial ischemia. These conditions are associated with a similar perfusion time dependent release of degraded vascular [35S]heparan sulfate proteoglycan into the perfusate solution which included a 60% loss of [35S]macromolecular material from the glomerulus after 2h of perfusion. Small amounts of [35S]macromolecular material were found in the urine and lymph. These results demonstrate that partial ischemia promotes a specific response in the overall renal vasculature, probably involving oxygen reactive metabolites, that results in the preferential release of heparan sulphate from the basement membrane and endothelial cells on the luminal side of the capillary wall.