Management and complications of complete heart block in pregnancy.

Although rare, increasing numbers of women with pacemakers are becoming pregnant. We describe the complications of a woman with arrhythmia and a pacemaker for complete heart block experienced before, during, between and after her pregnancies. We illustrate the benefits of multidisciplinary care, good communication and regular assessment in a stable, but complex woman.

Minimum local analgesic dose of intrathecal bupivacaine in labor and the effect of intrathecal fentanyl.

BACKGROUND: Combining bupivacaine with fentanyl for intrathecal analgesia in labor is well recognized, but dosages commonly used are arbitrarily chosen and may be excessive. This study aimed to determine the median effective dose (ED50) of intrathecal bupivacaine, defined as the minimum local analgesic dose (MLAD), and then use this to assess the effect of different doses of fentanyl. METHODS: In this double-blind, randomized, prospective study, 124 parturients receiving combined spinal epidural analgesia at 2-6-cm cervical dilatation were allocated to one of four groups to receive bupivacaine alone or with 5, 15, or 25 microg fentanyl, using the technique of up-down sequential allocation. Analgesic effectiveness was assessed using 100-mm visual analog pain scores, with less than or equal to 10 mm within 15 min defined as effective. MLAD was calculated using the formula of Dixon and Massey. Pruritus and duration of spinal analgesia were also recorded. RESULTS: Minimum local analgesic dose of intrathecal bupivacaine was 1.99 mg (95% confidence interval, 1.71, 2.27). There were similar significant reductions in MLAD (P < 0.001) for all bupivacaine-fentanyl groups compared with bupivacaine control. There was a dose-dependent increase in both pruritus and duration of spinal analgesia with increasing fentanyl (P < 0.0001). CONCLUSION: Under the conditions of this study, the addition of intrathecal fentanyl 5 microg offers a similar significant bupivacaine dose-sparing effect as 15 and 25 microg. Analgesia in the first stage of labor can be achieved using lower doses of fentanyl, resulting in less pruritus but with a shortening of duration of action.

The effect of rate of stimulation on force of contraction in a partially paralyzed rat phrenic nerve hemidiaphragm preparation.

This study was performed to determine whether presynaptic receptor blockade could be differentiated from postsynaptic blockade by examining the effect of increasing rates of indirect stimulation on twitch height depression (THD) on partially paralyzed in vitro rat diaphragm preparations. We calculated the T200/T1 ratio (force of the 200th stimuli divided by the force of the first stimuli) at rates of 0.2 Hz, 0.5 Hz, 1 Hz, and 2 Hz using a drug concentration which provided approximately 20% THD during stimulation at 0.1 Hz. Markedly different T200/T1 ratios were demonstrated when hexamethonium, a drug with predominantly presynaptic effects, was compared with alpha bungarotoxin, a drug with predominantly postsynaptic effects. These results were then compared with those from vecuronium, rocuronium, mivacurium, and tubocurarine. Both hexamethonium and rocuronium caused a marked decrease in T200/T1 ratio at higher rates of stimulation; alpha bungarotoxin caused a slight increase in T200/T1 ratio at higher rates of stimulation. The T200/T1 ratios produced by vecuronium, mivacurium, and tubocurarine lay intermediate between hexamethonium and alpha bungarotoxin. Significant differences in T200/T1 ratios were found when alpha bungarotoxin was compared with all other drugs at 2 Hz. Hexamethonium and rocuronium produced significant differences in T200/T1 ratio from those of all the other drugs at 1 Hz and 2 Hz. There were significant differences in the T200/T1 ratio found after hexamethonium and rocuronium compared to alpha bungarotoxin at 0.5 Hz. No significant differences at any rate of stimulation were found between hexamethonium and rocuronium. No difference was observed in the effect of vecuronium, mivacurium, and tubocurarine. We conclude that, if the observed effect is the result of hexamethonium acting predominantly at presynaptic sites and alpha bungarotoxin acting predominantly at postsynaptic sites, the relative contribution of small doses of nondepolarizing drugs at each site can be differentiated by determining the T200/T1 ratio at rates of 1 Hz or 2 Hz. Our results are consistent with the suggestion that small doses of rocuronium have marked presynaptic activity, but that vecuronium, mivacurium, and tubocurarine have both pre- and postsynaptic effects.

Tracheal intubation conditions after one minute: rocuronium and vecuronium, alone and in combination.

Rocuronium is a recently introduced nondepolarising neuromuscular blocking agent with a rapid onset and intermediate duration of action. Experimental observations have suggested that during onset it acts synergistically with other nondepolarising agents, but that at a steady state the combined action is additive. In order to investigate whether synergism during onset produces a clinical benefit we performed the following study of tracheal intubation conditions. Consenting patients presenting for elective surgery which required tracheal intubation were randomly allocated to receive a standard anaesthetic and either a twice ED95 dose of rocuronium, or vecuronium, or an equipotent mixture of both drugs. Tracheal intubation conditions were assessed after 60 s and scored as excellent, good, poor or impossible. The conditions produced in the rocuronium and the mixture groups were similar and both were significantly better than those of vecuronium. Excellent intubation conditions were achieved in 57% of the rocuronium group, 70% of the mixture group and 27% of the vecuronium group. We conclude that a mixture of rocuronium and vecuronium acts synergistically during the early part of their action and a mixture containing one ED95 of both agents provides comparable conditions for tracheal intubation as an equipotent dose of rocuronium.

Is rocuronium an exception to the relation between onset and offset? A comparison with pipecuronium.

A general relation between the rate of onset and rate of recovery from non-depolarizing blockade has been demonstrated, with recovery consistently about ten times slower than onset. This observation has led to the suggestion that non-depolarizing agents share a common mechanism of action. Rocuronium, a recently introduced steroidal non-depolarizing agent, is claimed to have a very rapid onset but an intermediate duration and appears to test this hypothesis. To investigate this paradox we have calculated the rates of onset and recovery of rocuronium using the isolated human forearm and compared them with those of pipecuronium. The mean ratio of recovery time/onset time for rocuronium was 31.3, which is significantly greater than that for pipecuronium, 11.6 (P < 0.01). Whilst pipecuronium conforms to the same general relation between onset and offset described previously for other non-depolarizing agents, rocuronium appears to have a disproportionately rapid rate of onset for its rate of recovery. This suggests that onset, recovery, or both onset and recovery, from rocuronium blockade occur in a different manner to that of other non-depolarizing agents.

Elevated nitric oxide production in rheumatoid arthritis. Detection using the fasting urinary nitrate:creatinine ratio.

OBJECTIVE: To develop a simple method for assessing endogenous nitric oxide (NO) production applicable to routine clinical practice in rheumatology. METHODS: NO production was assessed in patients with rheumatoid arthritis (RA) as serum nitrate levels and as the urinary nitrate:creatinine ratio in morning samples of urine following an overnight fast. The influence of dietary intake of nitrate on these measurements was investigated in healthy volunteers. The clinical value of the urinary nitrate:creatinine ratio was validated in patients with infectious gastroenteritis, in whom its production is known to be increased. RESULTS: Urinary nitrate:creatinine ratios were significantly elevated in patients with RA (average 3-fold elevation over controls; P < 0.005) or infectious gastroenteritis (average 10-fold elevation, P < 0.001). Serum nitrate was significantly elevated only in patients with infectious gastroenteritis (P < 0.001). Dietary intake of nitrate had no significant influence on the fasting morning urinary nitrate:creatinine ratio in the healthy volunteers, showing that this parameter is a useful indicator of endogenous NO production.

The influence of cold on the recovery of three neuromuscular blocking agents in man.

The Arrhenius hypothesis suggests that change in temperature has a less marked effect on the rate of physical processes than on biological reactions. We have investigated the process underlying recovery from neuromuscular block in man by studying the effect of cooling on the rate of recovery from depolarising and non-depolarising block. Vecuronium, rocuronium and decamethonium (C10) neuromuscular block were investigated using the isolated forearm technique on awake human volunteers. In these experiments, one arm was cooled whilst the other was used as control. Moderate hypothermia decreased the rate of recovery from all three agents, but this was significantly less marked with the depolarising drug. The mean Q10 (the anticipated change in rate of a reaction across of 10 degrees C temperature gradient) of the rate of recovery for vecuronium was 3.21, rocuronium 2.86 and decamethonium 1.29. This suggests a different process in the recovery of these two types of drug. According to the Arrhenius hypothesis this would suggest that the recovery from non-depolarising drugs is likely to involve a biochemical mechanism and that recovery from decamethonium is controlled by a physical process.

Interaction of decamethonium with hexamethonium or vecuronium in the rat: an isobolographic analysis.

We used isobolographic analysis to investigate the interaction of decamethonium with either hexamethonium or vecuronium in the rat phrenic nerve hemidiaphragm preparation. EC50 values of decamethonium, hexamethonium, and vecuronium were (mean +/- SEM) 47.36 +/- 9.58 microM, 4.27 +/- 0.53 mM, and 5.19 +/- 1.17 microM, respectively. Combinations of drugs in concentrations corresponding to the 1:2, 1:1, and 2:1 ratios of their EC50 values were used to determine three points of each isobole. Decamethonium and hexamethonium showed antagonism: significant deviations from the line of additivity were found at EC50 ratios of 2:1 and 1:1 (P < 0.01 and P < 0.05, respectively) indicating that hexamethonium is a potent antagonist of decamethonium. For decamethonium and vecuronium none of the three points on the isobole was significantly different from the corresponding point on the line of additivity. Hexamethonium is known to be a weak antagonist at the postsynaptic nicotinic acetylcholine receptor but a potent antagonist at the presynaptic nicotinic receptor. Vecuronium is a more potent antagonist at the postsynaptic nicotinic receptor but a much weaker antagonist at the presynaptic site. It was postulated that in the rat the primary site of action of decamethonium is at the presynaptic nerve terminal. Our findings suggest that presynaptic rather than postsynaptic potency of a nondepolarizing drug determines ability to antagonize the effect of a depolarizing drug in the rat.