Ultrasound-guided interscalene blocks: understanding where to inject the local anaesthetic.

Although ultrasound-guided regional anaesthesia has gained in popularity, few data exist describing the optimal location(s) to inject local anaesthetic. Our objective was to compare, for interscalene blocks, the effectiveness of an injection between the middle scalene muscle and brachial plexus sheath (peri-plexus) with an injection within the brachial plexus sheath (intra-plexus). We enrolled 170 patients undergoing shoulder surgery with general anaesthesia and interscalene block in this randomised, controlled trial. Our primary outcome variable was loss of shoulder abduction. Block quality was also measured and defined by an evaluation of onset time, sensory and motor loss and duration. There was no difference between the two groups in block onset times or block quality. After adjusting for sex, age and volume injected, intra-plexus blocks lasted a mean of 2.6 h (16%) longer (95% CI 0.25-5.01, p=0.03) than peri-plexus blocks.

Ultrasound guidance improves the success rate of a perivascular axillary plexus block.

BACKGROUND: Traditional approaches to performing brachial plexus blocks via the axillary approach have varying success rates. The main objective of this study was to evaluate if a specific technique of ultrasound guidance could improve the success of axillary blocks in comparison to a two injection transarterial technique. METHODS: Fifty-six ASA physical status I-III patients presenting for elective hand surgery were prospectively randomized to receive an axillary block performed by either a transarterial technique (Group TA) or an ultrasound-guided perivascular approach (Group US). Both groups received a total of 30 ml of 1.5% lidocaine (225 mg) with 5 microg/ml epinephrine. Patients were then evaluated for block onset in specific nerve distributions and whether or not the block acted as a surgical anesthetic. RESULTS: Group TA sustained more failures defined as conversion to general anesthesia or the inability to localize the artery [Group TA eight patients (29%) vs. Group US in which 0 patients required conversion to general anesthesia (0%) P < 0.01]. Group US demonstrated a reduction in performance times vs. Group TA (7.9 +/- 3.9 min vs. 11.1 +/- 5.7 min, P < 0.05). By 30 min post-injection, there were no significant differences between groups TA and US in terms of the proportion of patients demonstrating a complete motor or sensory loss. CONCLUSION: Ultrasonographic guidance improves the overall success rate of axillary blocks in comparison to a transarterial technique.

OMNI scale perceived exertion at ventilatory breakpoint in children: response normalized.

PURPOSE: The Children's OMNI Scale of Perceived Exertion was used to identify a response normalized rating of perceived exertion (RPE)-Overall, RPE-Legs, and RPE-Chest that corresponds to the ventilatory breakpoint (Vpt) in 8- to 12-yr-old female and male children. METHODS: Subjects were a priori stratified into two fitness groups on the basis of peak oxygen uptake (VO2 peak): average (A) (41.0-49.0 mL x kg(-1) x min(-1); N = 24) and above average (AA) (50.0-58.0 mL x kg(-1) x min(-1); N = 24). Vpt was determined by a progressive cycle ergometer protocol to VO2 peak. RESULTS: A gender effect was not observed for any descriptive or dependent variable. Mean VO2peak for the A group was 1.72 L x min(-1) and for the AA group 2.04 L x min(-1). Vpt corresponded to 64.0% VO2 peak for A and 74.0% VO2peak for AA. RPE-Overall (mean A and AA, 6.1), RPE-Legs (mean A and AA, 7.2), and RPE-Chest (mean A and AA, 4.5) did not differ between the fitness groups. CONCLUSION: Findings indicated that undifferentiated and differentiated RPE-Vpt were similar between female and male children who varied in VO2peak and Vpt. A comparatively stable RPE-Vpt for 8- to 12-yr-old children that vary in VO2peak and Vpt indicates a group normalized perceptual response.

Children's OMNI scale of perceived exertion: mixed gender and race validation.

PURPOSE: The newly developed Children's OMNI Scale of Perceived Exertion (category range: 0 to 10) was validated using separate cohorts of female and male, African American and white subjects. Each of the four cohorts contained 20 clinically normal, nonobese children, 8-12 yr of age. METHODS: A cross-sectional, perceptual estimation paradigm using a single multi-stage cycle ergometer test protocol was used. Oxygen uptake (VO2; mL x min(-1)), heart rate (HR; beats x min(-1)) and ratings of perceived exertion for the overall body (RPE-Overall), legs (RPE-Legs), and chest (RPE-Chest) were determined at the end of each continuously administered 3-min power output (PO) (i.e., 25, 50, 75, and 100 W) test stage. RESULTS: The range of responses over the four POs for all cohorts was VO2: 290.8 to 1204.0 mL x min(-1); HR: 89.2 to 164.4 beats x min(-1); and RPE-Overall, RPE-Legs, and RPE-Chest: 0.85 to 9.1. First-order correlation and linear regression analyses were performed for each cohort separately and the total sample using a repeated measures paradigm over the four POs. For all correlation/regression paradigms RPE-Overall, RPE-Legs, and RPE-Chest distributed as a positive linear function of both VO2 and HR; r = 0.85 to 0.94; P < 0.01. Differences between RPE-Overall, RPE-Legs, and RPE-Chest were examined with ANOVA for the repeated measures paradigm. RPE-Legs was higher (P < 0.01) than RPE-Chest and RPE-Overall at 25, 50, 75, and 100 W. RPE-Chest did not differ from RPE-Overall at 25 and 50 W but was lower (P < 0.01) than RPE-Overall at 75 and 100 W. CONCLUSION: The psycho-physiological responses provide validity evidence for use of the Children's OMNI Scale over a wide range of dynamic exercise intensities.

Voluntary movement strategies of individuals with unilateral peripheral vestibular hypofunction.

This study compared voluntary movement strategies of patients with unilateral peripheral vestibular hypofunction with those of age-matched healthy control subjects. All subjects performed three voluntary movement tasks with their dominant upper extremity: a forward flexion arm movement through 90 degrees, a reach to an overhead target, and a reach to a side target. Subjects performed the movement tasks sitting and standing (Body Position), and under precued and choice reaction time (RT) conditions (Task Certainty). Measures of motor planning and movement execution included RT and movement time (MT), respectively. Statistical analysis included separate Group x Task Certainty x Body Position ANOVA calculations for each task. Across tasks, results suggested no between group differences for RT. A Task Certainty main effect for the side and overhead tasks indicated that the choice RT situation resulted in longer RTs as compared to the precued RT condition. Movement time differed between the two groups. Across all three voluntary movement tasks, vestibular impaired subjects moved more slowly than control subjects. Providing vestibular subjects with a precue did not bring MT performance to the level of controls. Body position influenced MT for the side task only. Across both groups of subjects, MT for the side task was longer when performed in the standing position. The results of this study suggest that individuals with unilateral peripheral vestibular hypofunction initiate voluntary movement responses with similar timing as control subjects, but require more time to complete the movement. Vestibular rehabilitation should include goal-directed movement and should address issues of movement speed.

The effects of halothane on abnormal automaticity in canine cardiac Purkinje fibers.

UNLABELLED: Abnormal automaticity is the spontaneous beating of cardiac cells with abnormally depolarized resting membrane potentials. The effects of halothane on cardiac arrhythmias caused by abnormal automaticity are controversial, with either antiarrhythmic effects or enhancement of abnormal automaticity reported by different authors. The goal of the present investigation was to clarify the effects of halothane on abnormal automaticity induced by superfusing excised canine Purkinje fibers (PF) with barium chloride. Intracellular microelectrodes recorded action potentials from fibers superfused with buffer solution in a tissue bath. Barium chloride 0.25 mM reduced maximal diastolic potential from -82.1 +/- 5.6 mV to -67.4 +/- 9.4 mV (mean +/- SD, P < 0.05). Fibers developed abnormal automatic rhythms at a rate of 47.1 +/- 5.9 bpm. Halothane, 0.5%-4%, was added to the superfusate. Halothane reduced the rate of firing in a dose-dependent manner, so that abnormal automaticity was abolished by 4% halothane and reduced by lesser concentrations. Serendipitously, during barium superfusion, two additional fibers developed early afterdepolarizations, a cause of triggered arrhythmias in patients with long Q-T syndrome. Halothane abolished early afterdepolarizations in each. In this model of barium toxicity in excised canine PF, halothane antagonized both abnormal automaticity and early afterdepolarizations. IMPLICATIONS: Life-threatening cardiac arrhythmias may occur during anesthesia. An arrhythmia called abnormal automaticity occurs after heart attacks and can be mimicked by adding barium to small segments of heart tissue. Halothane abolished abnormal automaticity in these tissues, which suggests that it or similar agents may benefit patients prone to developing such abnormal rhythms during surgery.

Electrophysiological mechanisms for ventricular arrhythmias in patients with myocardial ischemia: anesthesiologic considerations, Pt II.

This is the second half of a two-part review article that discusses ventricular tachyarrhythmias, either induced by acute ischemia or consequent to chronic myocardial ischemia, and their anesthestic implications. The first half of the article was published in the June 1997 Issue of The Journal.

MRI of pituitary abscess: two cases and review of the literature.

Pituitary abscesses, rare lesions, may be divided into primary and secondary types. Primary pituitary abscesses occur within a previously healthy gland, while secondary abscesses arise within an existing lesion, such as an adenoma, craniopharyngioma, or Rathke's cleft cyst. Secondary abscesses share radiologic characteristics with the lesions from which they arise. There has been no review of the MRI characteristics of primary pituitary abscesses. We report two cases and review the literature. The typical primary pituitary abscess gives the same or slightly lower signal than brain on T1-weighted images, and could be mistaken for a solid mass or presumed to represent a pituitary adenoma. Contrast-enhanced images are useful, demonstrating absence of central enhancement, suggesting a fluid or necrotic center. In one of our cases, meningeal enhancement was obvious; this has not been reported previously and may be diagnostic, when associated with a rim-enhancing pituitary mass.

Presence of functional NMDA receptors in a human neuroblastoma cell line.

Data are presented that provide convincing evidence for the expression of structurally normal and functional NMDA receptors by acetylcholine-producing human LA-N-2 neuroblastoma cells in culture. Reverse transcription and polymerase chain reaction (RT-PCR), followed by cloning and DNA sequencing, revealed the presence in these cells of mRNA representing the key subunit, NMDAR1, of the receptor. This mRNA was further demonstrated by Northern analysis to be the same size as that described for human neurons. The neutral red cytotoxicity assay was utilized to examine the influence on these neuroblastoma cells of a 48-h incubation with either L-glutamic acid or the specific NMDA agonist N-phthalamoyl-L-glutamic acid (NPG). Cell cytotoxicity was shown by this assay to be increased through incubation with glutamate at 1 and 10 mM by 27 and 37%, and through incubation with NPG at 0.1 and 1 mM by 28 and 46%. A possible mechanism of these toxic effects was further evaluated using the whole-cell configuration of the patch-clamp technique and the specific NMDA agonists (+/-)1-aminocyclobutane-cis-1,3-dicarboxylic acid (ACDA) and NPG. Using this procedure, a voltage-dependent tetrodotoxin-sensitive inward sodium current was found to be increased (x 1.5) by L-glutamic acid and by both NMDA agonists in the presence of glycine. Another voltage-gated inward current, probably carried by calcium ions, was increased three- to fourfold. Hence, these glutamate activities observed in human LA-N-2 neuroblastoma cells appear to occur through the activation of functional NMDA receptors in much the same way as reported for neurons, and both glutamate and NMDA agonists can be toxic to these neuroblastoma cells. Our findings, therefore, suggest this cell line will provide a model suitable for investigating the mechanisms of NMDA-related long-term potentiation (LTP) in neurons and of the NMDA-related neurotoxic effects of glutamate in disease states that involve a reduction in cholinergic function.

Ionic signals in T47D human breast cancer cells.

Increasing evidence that ion channels play a key role in the modulation of cellular mitogenesis led us to investigate the membranes of T47D human breast cancer cells to identify the ion currents present. We report here the results of voltage-clamp studies in the whole-cell configuration on isolated, non-synchronized single cells obtained from a ductal breast carcinoma. In these studies we identified an outward rectifying potassium current and a chloride current. The potassium current activated at potentials more positive than -40 mV, reached an average value of 1.4 nA, and did not inactivate with time. This current was sensitive to block by extracellular tetraethylammonium chloride (TEA, IC50 = 1 micro M), was insensitive to charybdotoxin (CTX, IC50 = 7.8 micro M), and was not diminished by repetitive pulses separated by 1 s. Rapid voltage-dependent inactivation of the current was demonstrated by tail current analysis. The current appeared calcium-insensitive. Application of hyperpolarizing pulses did not elicit an inward potassium rectifier current. Treatment with tetrodotoxin did not reveal the presence of an inward sodium current. The potassium current was increased by the presence of aspartate in place of chloride and in the presence of the chloride channel blocker 4,4'-diisothiocyanostilbene-2,2'-disulfonic acid (DIDS). We conclude that currents present in T47D breast cancer cells include a chloride current and a voltage-gated potassium outward rectifier. We suggest that the potassium current, either alone or in conjunction with potassium currents reported in different human breast cancer cell lines by others, may play a role in the modulation of the cell cycle.

Prenatal exposure to alcohol and marijuana: effects on motor development of preschool children.

Gross motor development of preschool children prenatally exposed to alcohol and marijuana was assessed as part of a longitudinal study. Most mothers in the study were light to moderate users and discontinued or decreased use of alcohol and marijuana after the first trimester of pregnancy. The women were of lower socioeconomic status, half of the sample was African-American, and most were single. Gross motor development was evaluated with balance and ball-handling items at 3 years. Balance items included walking on a line, walking on a balance beam, standing on one foot, standing on tiptoes, and stair climbing and descent. Ball-handling items included catching, throwing, and kicking a ball. Refusal to perform items was also recorded. Prenatal alcohol and marijuana exposure did not negatively affect gross motor development. The composite score on the Stanford-Binet Intelligence Scale, age at assessment, gender, and examiner were significant predictors of gross motor performance and of refusal to participate in the balance items. The ponderal index, number of siblings, current income, examiner, current maternal use of tranquilizers, and first trimester exposure to amphetamines were also significant predictors of balance skills. Gender and number of hospitalizations predicted refusal to participate in balance items, whereas hearing and vision problems predicted refusal on ball-handling items. The components of timing, speed, and fine motor control have not been addressed in this study, and therefore it is premature to conclude that there is no impact of prenatal substance use on motor development.

Mercury suppression of a potassium current in human B lymphocytes.

Mercury is a recognized environmental toxin. Several organ systems are targeted by this substance and impairment of immune function is known to result from exposure to mercury. Using the patch clamp technique in the whole cell configuration on resting human B lymphocytes we have identified an outward potassium current and studied the effects of mercury on this current. We present data that demonstrate: (i) the absence of inward currents; (ii) a time and voltage dependent outward current with a threshold of -40 mV and reversal potential near EK+; (iii) blocking of this current by TEA (tetraethylammonium chloride) in a dose dependent manner; (iv) a slow time course for recovery from inactivation of this outwardly rectifying K+ current and, (v) the diminution and final block of this potassium current by mercury. These data supplement the findings from our laboratories that demonstrate inhibitory effects on B cell activation by mercury. We propose that the movement of potassium ions across the B cell membrane, an event presumed to be one of the first signals in the mitogenic process, is a target of mercury toxicity.

Effects of isoflurane on ouabain toxicity in canine Purkinje fibers. Comparison with halothane.

BACKGROUND: Although halothane reduces digitalis toxicity, other anesthetics, notably cyclopropane, increase toxicity. This study determined the effects of isoflurane on digitalis toxicity in isolated cardiac tissue and compared these effects with those of halothane. METHODS: Standard microelectrode techniques were used to record action potentials from excised canine Purkinje fibers. Fibers were paced at cycle lengths between 1,000 and 250 ms for 20 beats to induce delayed afterdepolarizations, which are membrane potential oscillations indicative of intracellular Na+ and Ca2+ overload, produced in these experiments by digitalis toxicity. The digitalis glycoside ouabain, 2 x 10(-7) M, was added to the Tyrode's solution superfusate to induce delayed after-depolarizations. Action potential variables and the coupling interval and amplitude of afterdepolarizations were then measured. Isoflurane (0.5%, 1%, or 2%) was added with a calibrated vaporizer (n = 8). In a second set of experiments (n = 10), isoflurane 1.25% or halothane 0.75% was added to the superfusate. After measurements had been made, the other agent was substituted. RESULTS: Ouabain produced primary and secondary delayed afterdepolarizations, which were reduced in amplitude by isoflurane in a dose-related manner (P = 0.0002). Action potential duration to 90% repolarization was shortened by ouabain (P = 0.009) and remained shortened during isoflurane administration. Action potential duration to 50% repolarization was shortened by isoflurane 2%. Halothane and isoflurane were equally effective in reducing the amplitude of delayed afterdepolarizations (both P = 0.0002). In three fibers, triggered extrasystoles appeared. Halothane and isoflurane each abolished extrasystoles. In two fibers, sustained triggered activity appeared. Isoflurane abolished the arrhythmia in each fiber. CONCLUSIONS: Isoflurane and halothane are equally effective in reducing delayed afterdepolarizations induced by ouabain toxicity.

Effect of halothane on in vivo and in vitro cardiotoxicity of an aminocardenolide.

Halothane opposes cardiotoxicity of neutral-sugar digitalis compounds in intact animals, presumably by depressing a sympathetic component of arrhythmogenesis. However, halothane also produces a dose-related reduction in arrhythmogenicity of ouabain in isolated canine Purkinje fibers, suggesting that the anesthetic may oppose direct mechanisms of cardiotoxicity as well. The present study examined in vivo and in vitro the effect of halothane on the arrhythmogenicity of ASI-222 (3-beta-O[4-amino-4-6-dideoxy-beta-D-galactopyranosyl] digitoxigen in HCl), a highly polar aminocardenolide with no sympathetic component to cardiotoxicity. For in vivo studies, ASI-222 was infused at a rate of 1 microgram/kg/min until appearance of third-degree atrioventricular (AV) block or sustained ventricular arrhythmias in 5 conscious (control) and 6 halothane-anesthetized (1.4% end-tidal) dogs. For in vitro studies, standard microelectrode techniques were used to measure action potentials (AP) in seven excised canine Purkinje fibers superfused with oxygenated Krebs-Henseleit buffer. AP were recorded during control superfusion, after induction of toxicity with 10(-7) M ASI-222, and during exposure to 0.5, 1.0, and 2.0% halothane. Purkinje fibers were paced at 500-ms cycle lengths (CL) for 20 beats, and the amplitude of delayed afterdepolarizations (DAD) were recorded. Pacing at 250 ms CL was used to trigger ectopy. In vivo studies showed no difference in the cardiotoxic dose of ASI-222 between control dogs and those anesthetized with 1.4% halothane. However, in 4 of 6 anesthetized dogs, acutely increasing the inspired halothane concentration suppressed arrhythmias once end-tidal concentration were >2.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of cadmium on potassium currents in activated B lymphocytes.

We have applied the patch clamp technique in the whole-cell configuration to study whole-cell currents in B lymphocytes under three conditions: (i) resting; (ii) interleukin-4 (IL-4)-treated; and (iii) IL-4 plus cadmium-treated murine B lymphocytes. Through these experiments we have: (i) confirmed our earlier findings and the observation of others that resting B cells express only outward currents; (ii) confirmed the presence of an inwardly rectifying K+ current elicited by treatment with the lymphokine IL-4 that was revealed in our previous study on single channel currents; (iii) demonstrated that both inward and outward rectifying K+ currents in IL-4-treated B cells are dramatically reduced by exposure to 20 microM cadmium; and (iv) determined that the activation curve of the IL-4-induced inward rectifier is shifted to more negative voltages by cadmium. We propose that one of the mechanisms by which cadmium can mediate toxicity in activated B lymphocytes is through the suppression and modulation of potassium currents, effects that may alter the timing of entry into the cell cycle.

Effects of halothane and quinidine on intracardiac conduction and QTc interval in pentobarbital-anesthetized dogs.

To confirm in vitro data that halothane and quinidine depressed cardiac conduction and prolonged action potential (AP) duration, the electrocardiogram and His bundle electrogram were recorded in dogs during basal pentobarbital anesthesia, after 1% halothane or quinidine (2.38 +/- 0.22 micrograms/mL serum concentration [mean +/- SEM]), or both. Purkinje fibers from a second dog were superfused with blood from the intact (support) dog, and APs were recorded. In the intact dogs, 1% halothane caused no changes in the electrocardiogram or His bundle electrogram. Quinidine prolonged QRS duration, QT interval, and rate-corrected QT (P < 0.05). Ventricular conduction (HS interval) slowed, and atrial effective refractory period increased (P < 0.05). Quinidine combined with halothane widened QRS, QT, and rate-corrected QT, prolonged the HS interval, and increased the vulnerability of the atrioventricular node to conduction block. Three of 20 dogs developed torsades de pointes-type ventricular tachycardia during simultaneous quinidine and halothane administration. In cross-superfused Purkinje fibers, the AP duration to 50% repolarization was shortened, and conduction time was prolonged by 1% halothane (both P < 0.05). Quinidine decreased AP amplitude, prolonged AP duration to 90% repolarization, and slowed conduction (P < 0.05). Quinidine combined with halothane decreased AP amplitude, and prolonged both AP duration to 90% repolarization and conduction (P < 0.05). When 1% halothane and therapeutic concentrations of quinidine are administered in dogs, depressed conduction and an acquired long QT syndrome with malignant ventricular arrhythmias may develop.