Toxicidad sistémica secundaria a infiltración con anestésico local / Systemic toxicity secondary to local anesthetic infiltration

Introducción: Los anestésicos locales (AL) son fármacos ampliamente utilizados para procedimientos anestésicos por su perfil riesgo/beneficio favorable respecto a los anestésicos generales. No obstante, estos fármacos no están exentos de efectos adversos. Caso clínico: Hombre de 44 años sin antecedentes neurológicos que presenta un cuadro de toxicidad sistémica por AL tras la instilación de bupivacaína intratecal para ser intervenido de artroplastia de cadera. Conclusiones: Los cuadros de toxicidad sistémica por AL pueden producir sintomatología neurológica asociada o no a inestabilidad hemodinámica. Habitualmente, los síntomas neurológicos ocurren de forma precoz y deben alertar sobre la posible ocurrencia de eventos hemodinámicos ulteriores que pueden comprometer la vida del paciente. Conocer la existencia y el manejo clínico de estos cuadros de toxicidad resulta fundamental para mejorar la evolución y el pronóstico de este cuadro potencialmente mortal.(AU)

Introduction: Local anaesthetics (LA) are drugs that are widely used in anaesthetic procedures because of their favourable risk/benefit profile compared to general anaesthetics. Yet, these drugs also have some adverse effects. Case report: We report the case of a 44-year-old man with no neurological history who presented systemic toxicity due to LA after instillation of intrathecal bupivacaine for hip arthroplasty surgery. Conclusions: Systemic toxicity caused by LA can give rise to neurological symptoms that may or may not be associated with haemodynamic instability. Neurological symptoms usually occur early on and should alert to the possible occurrence of further life-threatening haemodynamic events. Being aware of the existence of these toxicities and their clinical management is essential to improve the evolution and prognosis of this potentially fatal condition.(AU)

[Systemic toxicity secondary to local anesthetic infiltration]. / Toxicidad sistémica secundaria a infiltración con anestésico local.

INTRODUCTION: Local anaesthetics (LA) are drugs that are widely used in anaesthetic procedures because of their favourable risk/benefit profile compared to general anaesthetics. Yet, these drugs also have some adverse effects. CASE REPORT: We report the case of a 44-year-old man with no neurological history who presented systemic toxicity due to LA after instillation of intrathecal bupivacaine for hip arthroplasty surgery. CONCLUSIONS: Systemic toxicity caused by LA can give rise to neurological symptoms that may or may not be associated with haemodynamic instability. Neurological symptoms usually occur early on and should alert to the possible occurrence of further life-threatening haemodynamic events. Being aware of the existence of these toxicities and their clinical management is essential to improve the evolution and prognosis of this potentially fatal condition.

TITLE: Toxicidad sistémica secundaria a infiltración con anestésico local.Introducción. Los anestésicos locales (AL) son fármacos ampliamente utilizados para procedimientos anestésicos por su perfil riesgo/beneficio favorable respecto a los anestésicos generales. No obstante, estos fármacos no están exentos de efectos adversos. Caso clínico. Hombre de 44 años sin antecedentes neurológicos que presenta un cuadro de toxicidad sistémica por AL tras la instilación de bupivacaína intratecal para ser intervenido de artroplastia de cadera. Conclusiones. Los cuadros de toxicidad sistémica por AL pueden producir sintomatología neurológica asociada o no a inestabilidad hemodinámica. Habitualmente, los síntomas neurológicos ocurren de forma precoz y deben alertar sobre la posible ocurrencia de eventos hemodinámicos ulteriores que pueden comprometer la vida del paciente. Conocer la existencia y el manejo clínico de estos cuadros de toxicidad resulta fundamental para mejorar la evolución y el pronóstico de este cuadro potencialmente mortal.

Rebound after discontinuation of teriflunomide in patients with multiple sclerosis: 2 case reports.

Teriflunomide is an oral first-line disease modifying treatment (DMT) for patients with relapsing-remitting multiple sclerosis (RRMS). It can take up to two years to achieve systemic clearance of teriflunomide to an acceptable level, but this washout period may be accelerated by administration of cholestyramine. Relapse of multiple sclerosis (MS) during washout of teriflunomide or other first-line DMT is not as common. We report two patients with RRMS who experienced a relapse after the accelerated elimination period (AEP) of teriflunomide and confirmation of negative plasmatic levels (<0.02 µg/ml). In cases of risk of MS activity, we should not wait for teriflunomide negative plasmatic levels confirmation before starting the next DMT to reduce the risk of relapse.

The GTP-binding protein RhoA localizes to the cortical granules of Strongylocentrotus purpuratas sea urchin egg and is secreted during fertilization.

The sea urchin egg has thousands of secretory vesicles known as cortical granules. Upon fertilization, these vesicles undergo a Ca2+-dependent exocytosis. G-protein-linked mechanisms may take place during the egg activation. In somatic cells from mammals, GTP-binding proteins of the Rho family regulate a number of cellular processes, including organization of the actin cytoskeleton. We report here that a crude membrane fraction from homogenates of Strongylocentrotus purpuratus sea urchin eggs, incubated with C3 (which ADP-ribosylates specifically Rho proteins) and [32P]NAD, displayed an [32P]ADP-ribosylated protein of 25 kDa that had the following characteristics: i) identical electrophoretic mobility in SDS-PAGE gels as the [32P]ADP-ribosylated Rho from sea urchin sperm; ii) identical mobility in isoelectro focusing gels as human RhoA; iii) positive cross-reactivity by immunoblotting with an antibody against mammalian RhoA. Thus, unfertilized S. purpuratus eggs contain a mammalian RhoA-like protein. Immunocytochemical analyses indicated that RhoA was localized preferentially to the cortical granules; this was confirmed by experiments of [32P]ADP-ribosylation with C3 in isolated cortical granules. Rho was secreted and retained in the fertilization membrane after insemination or activation with A23187. It was observed that the Rho protein present in the sea urchin sperm acrosome was also secreted during the exocytotic acrosome reaction. Thus, Rho could participate in those processes related to the cortical granules, i.e., in the Ca2+-regulated exocytosis or actin reorganization that accompany the egg activation.

Molecular characterisation of a fungal mono(ADP-ribosyl)transferase.

A soluble arginine-specific mono(ADP-ribosyl)transferase was detected in dormant spores of Phycomyces blakesleeanus. Soluble proteins incubated with [32P]NAD revealed, after a two dimensional electrophoretic separation, three major ADP-ribosylated substrates with molecular weights of 38, 37, and 36 kDa and pI values of 6.9, 8.1 and 4.6, respectively. The addition of MgCl2 stimulated the (ADP-ribosyl)transferase activity. This enzymatic activity was stimulated by 250 microM NO-releasing agent sodium nitroprusside and inhibited with 8 mM benzamide, 0.4 mM meta-IodoBenzylGuanidine (MIBG), and 0.5 mM novobiocin. The three ADP-ribosylation inhibitors affected the germination of Phycomyces spores. The concentrations necessary to inhibit 50% of the spore germination of Phycomyces were 0.05 mM, 0.2 mM, and 8 mM for novobiocin, MIBG, and benzamide, respectively. All the above inhibitors affected the germination process to the same extent, that is, they inhibited the tube protuberation, leaving the spores as swollen cells. These data suggest that ADP-ribosylation may be involved in the germination process of Phycomyces, particularly in germ-tube formation.

Subcellular localization of the GTP-binding protein Rho in the sea urchin sperm.

The Rho proteins are small G-proteins that belong to the Ras superfamily and play an essential role in the organization of the actin cytoskeleton. They are characteristically ADP-ribosylated by the exoenzyme C3 from Clostridium botulinum. Sea urchin sperm contain multiple small G proteins (28-24 kDa) whose identity and function are unknown. Here, we examined whether some of these proteins corresponded to the Rho subfamily. A sperm homogenate incubated with C3 and [32P]NAD revealed, by electrophoresis and autoradiography, a single radiolabeled band with a molecular mass of 25 kDa; this size was identical, under the same conditions, to that displayed by RhoA from human platelets. In flagellar fractions, the 25 kDa protein ADP-ribosylated by C3 localized in the cytosol and in the plasma membrane. In the sperm head, the 25 kDa protein was detected in a membrane preparation enriched in acrosomal and plasma membranes. Separation of these head membranes through a continuous density gradient revealed that both the 25 kDa protein [32P]ADP-ribosylated by C3 and actin had the same localization as bindin, the adhesive protein characteristic of the acrosome. An antibody against RhoB cross-reacted by immunoblotting with the 25 kDa protein and it revealed by both immunofluorescence and immunogold the presence of Rho in the acrosomal region, the middle piece of the head, and in the flagellum. Thus, the results indicate that the G-protein of 25 kDa previously detected in sea urchin sperm is Rho, likely the type B. Based on its cellular localization, Rho may participate in regulating motility and the actin polymerization that accompanies the acrosome reaction.

The GTP-binding protein G alpha s is present in dormant spores and expressed differentially during spore germination of the fungus Phycomyces blakesleeanus.

A DNA sequence homologous to a G alpha s DNA probe, and the corresponding G alpha s protein (stimulatory alpha-subunit of GTP-binding protein) were detected in Phycomyces blakesleeanus. The protein was demonstrated in membrane fractions of dormant spores of this fungus using three different experimental approaches. Photoaffinity-labelling experiments with [alpha-32P]GTP of the membrane fraction revealed two bands, of 56 and 32 kDa. The 56 kDa GTP-binding protein was detected by this method in all the stages of early development and growth investigated. Also, a spore protein of 56 kDa was ADP-ribosylated by cholera toxin, and a 56 kDa protein was detected by Western blotting with a specific antibody against mammalian G alpha s. These results indicate that G alpha s (56 kDa) is present in dormant spores of P. blakesleeanus. Using the ADP-ribosylation and Western blotting assays, G alpha s was detected during all stages of spore germination before the hyphae became highly branched, but it was not detected in the branched hyphae that formed 18 h after the initiation of spore germination. Therefore, G alpha s is expressed differentially during Phycomyces development.

The acrosome reaction in digitonin-permeabilized sea urchin sperm in the absence of the natural inducer.

In many species, the acrosome reaction of sperm is an obligatory step in fertilization. Increases in [Ca2+]i and pHi, activation of adenylyl cyclase and inositol trisphosphate generation accompany the egg jelly-induced acrosome reaction of sea urchin sperm. The signaling mechanisms involved are unknown. We used digitonin, a cholesterol-complexing compound, to selectively permeabilize the plasma membrane of sea urchin sperm suspended in a medium that mimics the cytosolic ion composition. Within 6 to 8 min, 30 to 50 microM digitonin allowed incorporation of the membrane-impermeant dye Hoechst 33258 into the sperm, staining exclusively the nucleus. No alterations in sperm morphology were caused by digitonin at the concentrations used, however, it irreversibly permeabilized the plasma membrane. Permeabilized sperm retained lactate dehydrogenase and actin. When incubated in Ca(2+)-containing permeabilization buffer (pH 7.8), sperm were capable of undergoing spontaneously the acrosome reaction; this reaction was pH dependent and displayed an absolute Ca2+ requirement. Electron microscopy indicates that the acrosome reaction undergone by permeabilized sperm resembled that induced by egg jelly. Additionally, rhodaminyl-phalloidin staining of sperm reacted under permeabilizing conditions revealed a fluorescent filament in the acrosomal tubule region, demonstrating the occurrence of actin polymerization. Thus, in permeabilized sperm the machinery necessary to perform a [Ca2+]i- and pHi-sensitive acrosome reaction is functionally preserved. Permeabilized sperm offer new avenues to study the molecular bases of the sea urchin sperm acrosome reaction.

Endogenous activity of cyclic nucleotide-dependent protein kinase in plasma membranes isolated from Strongylocentrotus purpuratus sea urchin sperm.

Activity of cyclic nucleotide-dependent protein kinase was investigated in flagellar plasma membranes of sea urchin sperm (S. purpuratus). Membranes incubated with [gamma-32P]ATP showed in the presence of 1 microM cAMP an increased phosphorylation in multiple polypeptides. Half maximal response was seen at 0.6 microM of cAMP. In contrast, higher concentrations (100 microM) of cGMP were required to cause the same amount of protein phosphorylation. 80% of the protein kinase activity stimulatable by cAMP was resistant to extraction by 10 mM EGTA and sonication but it was entirely recovered in a detergent-solubilized fraction. Membranes pretreated with 200 microM cAMP, ultracentrifuged and resuspended in buffer solution did not undergo cAMP-stimulated phosphorylation in their polypeptides. This study demonstrates that flagellar plasma membranes isolated from S. purpuratus sea urchin sperm have an endogenous cAMP-dependent protein kinase, which may be bound to the membrane via its regulatory subunit.

Determinants of the transmembrane distribution of chloride in rat lymphocytes: role of Cl(-)-HCO3- exchange.

The purpose of the present experiments was to establish the factors that determine the intracellular Cl- concentration ([Cl-]i) of lymphocytes. Coulometric and isotope equilibration determinations indicated that [Cl-]i was in the range of 70-85 mmol/l cells. Since the membrane potential (Em) of these cells approximates -55 mV, [Cl-]i is severalfold higher than the level expected at electrochemical equilibrium (approximately 16 mM). This suggests that conductive pathways contribute marginally to the distribution of Cl-. Accordingly, altering the force driving conductive Cl- fluxes by manipulating Em had little effect on [Cl-]i. The possible role of electroneutral cation-Cl- cotransport in the accumulation of intracellular Cl- was also assessed. 36Cl- uptake was largely unaffected by omission of extracellular Na+ and K+ or by addition of bumetanide, a potent cotransport inhibitor. Moreover, [Cl-]i remained unaltered for at least 1 h in cells incubated without Na+ or K+ or in the presence of loop diuretics. Thus it appears unlikely that Cl(-)-anion cotransport plays a major role in maintaining [Cl-]i. A vigorous stilbene disulfonate-sensitive anion exchanger was detected in thymocytes. This system constitutes a large fraction of the Cl- flux pathways and is possibly a major contributor to the establishment of [Cl-]i. Accordingly, modifying the force driving Cl- through the exchanger, by altering pH at constant PCO2, resulted in changes in cellular Cl- content and associated changes in cell volume. These effects were markedly reduced in the nominal absence of HCO3- or in the presence of disulfonic stilbene derivatives, suggesting that they are mediated by Cl(-)-HCO3- exchange.(ABSTRACT TRUNCATED AT 250 WORDS)

Internal pH-sensitive site couples Cl-(-)HCO3- exchange to Na+-H+ antiport in lymphocytes.

Parallel exchange of Na+-H+ and Cl-(-)HCO3- is thought to be central to the translocation of electrolytes and water during cell volume regulation and in transepithelial transport. Coupling between these transporters is thought to be indirect, through changes in the concentration of HCO3-, which result from alterations in cytosolic pH (pHi). The possibility of a more direct, HCO3-(-)independent interaction between Cl-(-)HCO3- exchange and the Na+-H+ antiport was studied in rat thymic lymphocytes. Measurements of radioactive Cl- flux and of HCO3-(-)dependent pHi changes demonstrated the presence of a Na+-independent, 4,4'diisothiocyanostilbene-2,2'-disulfonic acid-sensitive Cl-(-)HCO3- exchanger. At constant external pH, the rate of Cl-(-)HCO3- exchange was markedly accelerated by increasing pHi between 7.0 and 7.4. This activation was not related to variations in the concentration of HCO3- and is likely caused by a direct effect of intracellular H+ (OH-) on the exchanger. Osmotic shrinking of the cells induced a cytoplasmic alkalinization, due to activation of the Na+-H+ antiport. Concomitantly, the rate of anion exchange also increased. The stimulation of Cl-(-)HCO3- exchange was eliminated when the alkalinization caused by Na+-H+ exchange was precluded. These observations suggest that the exquisite pHi sensitivity of the Cl-(-)HCO3- exchange system provides a mechanism whereby the rates of cation and anion transport are closely coupled.

12-O-tetradecanoyl phorbol-13-acetate interferes with germination of Phycomyces blakesleeanus sporangiospores.

The presence of protein kinase C (PKC), a key enzyme in signal transduction, has not been investigated in fungal cells. The phorbol ester TPA, an activator of PKC, may be used as an indicator of the presence and role of PKC in Phycomyces blakesleeanus spores. Activation of spore germination by acetate was prevented by 6 nM TPA. The TPA analog 4 alpha PDD, an ineffective activator of PKC, did not affect spore germination. 3 mM dbcAMP, on the other hand, reversed the inhibition of germination caused by TPA. TPA-stimulated protein kinase activity was detected in spores. The possible relationship between PKC and the increased levels of cAMP that accompany the induction of spore germination is discussed.

Sea urchin sperm head plasma membranes: characteristics and egg jelly induced Ca2+ and Na+ uptake.

Sea urchin sperm respond to egg factors with changes in the ionic permeability of their plasma membrane. It has been previously shown that plasma membranes isolated preferentially from sea urchin sperm flagella respond to egg jelly increasing their Ca2+ and Na+ uptake (Darszon et al. (1984) Eur. J. Biochem. 144, 515-522). However, the egg jelly induced acrosome reaction occurs in the sperm head, and there is evidence for an heterogeneous distribution of plasma membrane components within the various regions of this cell. We here report a method for purifying sperm head membranes using positively charged beads according to Jacobson (1977) Biochim. Biophys. Acta 471, 331-335). Under the transmission electron microscope these membranes appeared homogeneous and apparently free of internal membranes. The yield of the preparation was 0.9% of the total protein in the sperm homogenate. The preparation contained less than 5% of the mitochondrial marker cytochrome oxidase, and 10% of the total DNA/mg protein. Surface labeling with 125I indicated a 2.5-3-fold enrichment in specific activity of the head membranes with respect to whole sperm. The SDS band pattern and the lipid composition of this preparation were different from those of isolated flagellar membranes. Phosphatidylcholine was higher in the head membranes, while phosphatidylserine and phosphatidylethanolamine were lower. The head membranes displayed a 1.7-2.3-fold higher Ca2+-ATPase activity and a 2.5-fold lower Na+/K+-ATPase activity, than the flagellar membranes. These results are consistent with a heterogeneous distribution of membrane components along the sea urchin sperm plasma membranes. Isolated head membranes sonicated in the presence of soybean phospholipid liposomes responded to egg jelly with a species-specific increase in Ca2+ and Na+ uptake. As in whole sperm, Ca2+ uptake was inhibited by the Ca2+ channel blocker nisoldipine. A close analog of this compound, [3H]nitrendipine, binds with high affinity to head membranes in a saturable, reversible manner, showing a Kd and Bmax of 31 nM and 5.3 pmol/mg protein, respectively.

Differential role of cation and anion exchange in lymphocyte pH regulation.

In lymphocytes, the Na+/H+ antiport is well suited to function in cytoplasmic pH (pHi) regulation. It is activated by departures from the physiological pHi and is thermodynamically poised to compensate for the tendency of the cells to become acidic. The driving force for H+ (equivalent) efflux is indirectly provided by the Na+ pump. Lymphocytes also possess a cation-independent anion (Cl-/HCO3-) exchange system, which, under the appropriate conditions, tends to restore pHi after an alkali load. Unlike the cation antiport, the source of energy driving the anion exchanger, i.e. the factors that determine the transmembrane Cl- distribution, is not well understood. The contribution of conductive pathways appears to be minimal, resulting in a marked difference between the membrane potential and ECl-. Instead, ECl- is very similar to EH+. Moreover, changes in the distribution of Cl- lead to alterations in the transmembrane delta pH and vice versa, suggesting a relationship between these parameters. Evidence is presented which suggests that the transmembrane distribution of HCO3-, dictated by delta pH, is a major determinant of the intracellular Cl- concentration, a process mediated by the anion exchanger. Thus, if Cl- is driven by the gradient of HCO3-, the cation-independent anion exchanger cannot play an active role in determining pHi. Instead, Cl-/HCO3- exchange may simply stabilize pHi by increasing the dynamic buffering power of the cells. Cation-independent Cl-/HCO3- exchange could be involved in pHi regulation only if coupled to a separate mechanism of intracellular Cl- accumulation, such as Na+-K+-2Cl- co-transport or an inward Cl- pump, which have not been detected in lymphoid cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Internal pH can regulate Ca2+ uptake and the acrosome reaction in sea urchin sperm.

The egg jelly-induced acrosome reaction of sea urchin sperm is accompanied by intracellular alkalinization and Ca2+ entry. We have previously shown that in the absence of egg jelly, NH4Cl, which increases intracellular pH (pHi), induces Ca2+ uptake and the acrosome reaction in sperm of the sea urchin, Strongylocentrotus purpuratus. Here we show that at a constant concentration of NH4Cl (20 mM) in seawater, sperm react less as external pH is lowered from the normal 8 to 7.25. The pH dependence of the NH4Cl response is not very sensitive to temperatures between 12 and 17 degrees C. NH4Cl (15-50 mM) stimulates Ca2+ uptake and acrosome reactions in sperm suspended in Na+-free seawater, a condition known to inhibit the inductive effect of jelly. Jelly does not further stimulate Ca2+ uptake of sperm preincubated in NH4Cl, indicating that once the permeability to Ca2+ is increased by raising the pHi, the jelly has no further effect. We have used the membrane potential-sensitive dye 3,3'-dipropylthiadicarbocyanine iodide to follow the membrane potential change that occurs when NH4Cl is added. Depolarization (25 mV) is associated with the acrosome reaction when either the natural inducer, egg jelly, or NH4Cl is added to sperm. Response to both inducers is inhibited under conditions known to abolish the acrosome reaction, i.e., low-pH seawater and nisoldipine. These results indicate that the NH4Cl-induced depolarization that accompanies the reaction is probably due to the opening of channels that allow Ca2+ to enter the cell and not to the depolarization by NH4+ ions. High-K+ seawater, which depolarizes sperm, and tetraethylammonium, a K+ channel blocker, inhibit the jelly-induced depolarization and the acrosome reaction, but do not inhibit NH4Cl-induced changes. It has already been shown that nigericin promotes Ca2+ entry and the acrosome reaction in sea urchin sperm. We found that the action of this ionophore depends on the pH of normal seawater. In the absence of external Na+ (replaced by choline), nigericin does not induce the reaction and does not stimulate Ca2+ uptake.

High pH-induced acrosome reaction and Ca2+ uptake in sea urchin sperm suspended in Na+-free seawater.

The egg jelly-induced acrosome reaction of sea urchin sperm requires the presence of Ca2+ and Na+ in seawater at its normal pH 8. Sperm suspended in seawater at pH 9 undergo the acrosome reaction in the absence of jelly. We have attempted to understand the role of external Na+ in this reaction. Sperm were suspended in Na+-free seawater and the percentage of acrosome reaction and the amount of Ca2+ uptake were determined as a function of external pH. High pH (9.0) in Na+-free medium without jelly triggered a high percentage (above 65%) of sperm acrosome reactions and a two to fourfold increase in Ca2+ uptake. Both the percentage of acrosome reactions and the amount of Ca2+ uptake were similar to those induced by either jelly or pH 9 in Na+-containing seawater. On the other hand, the absence of Na+ in seawater inhibits jelly from inducing Ca2+ uptake and acrosome reactions at pH 8.0 and even at pH 8.5. These results indicate that the Na+ requirement for the acrosome reaction induced by jelly is lost when triggering is by high pH. In contrast, Ca2+ was strictly required since sperm did not react in Ca2+-free seawater at pH 9. We also found that like the jelly-induced acrosome reaction the high-pH-induced acrosome reaction and Ca2+ uptake in complete and Na+-free seawater were inhibited by D600. This finding suggests that the same transport system for Ca2+ uptake associated with the acrosome reaction operates at both triggering conditions, i.e., jelly or pH 9. Although D600 is not now considered a specific blocker, its effect has suggested the involvement of Ca2+ channels in the acrosome reaction. This proposal is supported by our results with nisoldipine, a highly specific inhibitor of calcium channels. The drug inhibited both the sperm acrosome reaction and Ca2+ uptake induced by jelly or pH 9 in complete seawater.

The effect of neutral and charged micelles on the acid-base dissociation of the local anesthetic tetracaine.

The influence of surfactant micelles on the acid-base dissociation of the charged tertiary amino group of the local anesthetic, tetracaine, has been investigated. From measurements of tetracaine fluorescence as a function of bulk pH, apparent pK values of 6.88, 7.58 and 9.92 were found in the presence of cationic, neutral and anionic micelles, respectively, in 10 mM NaCl. These values are considerably displaced with respect to the pK in aqueous solution which is 8.26. Such large shifts can be attributed to the effect of the surface polarity and electrical potential on the dissociation behavior of the anesthetic bound to micelles. It can be expected that the acid-base dissociation of a local anesthetic adsorbed to nerve fibers will also be affected by the properties of the membrane surface. Thus, it is suggested that the influence of the interfacial region on the pK of surface-bound molecules should not be disregarded when estimating the proportion of charged and uncharged forms of local anesthetics interacting with axonal membranes.