Characterization of parasympatholytic chronotropic responses following intravenous administration of atropine to clinically normal dogs.

OBJECTIVE: To determine heart rate (HR) and heart rate variability (HRV) after IV administration of 3 doses of atropine to clinically normal, large-breed adult dogs. ANIMALS: 6 mixed-breed dogs, weighing between 23 and 50 kg. PROCEDURE: Continuous ECG were recorded prior to and following IV administration of saline (0.9% NaCl) solution and 0.02, 0.04, and 0.06 mg of atropine/kg of body weight. Heart rate and HRV within sympathetic and parasympathetic domains were determined, using customized software, and responses to treatments were compared. Each dog received all treatments with > or = 2 days between treatments. RESULTS: HR increased and HRV within the parasympathetic domain decreased after all atropine treatments, compared with pretreatment values. Heart rate was significantly higher after administration of 0.06 mg of atropine/kg than after 0.02 mg/kg but was not different from HR after administration of 0.04 mg/kg. Five of 6 dogs given the 0.04 or 0.06 mg/kg dose attained HR > 135 beats/min, but only 1 of 6 dogs given the 0.02 mg/kg dose attained a HR > 135 beats/min. Heart rate variability within the parasympathetic domain decreased significantly from pretreatment values after all atropine treatments. Atropine doses of 0.04 and 0.06 mg/kg induced significantly lower HRV than did the 0.02 mg/kg dose, but HRV after the higher doses were not different from each other. HRV within the sympathetic domain after any treatment did not change from pretreatment values. CONCLUSIONS AND CLINICAL RELEVANCE: IV administration of 0.04 or 0.06 mg of atropine/kg increased HR and induced complete parasympathetic blockade in clinically normal, large-breed adult dogs.

Effect of autonomic blockade on power spectrum of heart rate variability during exercise.

To validate power spectral analysis of heart rate variability (HRV) as an autonomic indicator during exercise, ten males performed four identical progressive cycling tests during infusions of saline, esmolol (beta 1-blocker), glycopyrrolate (muscarinic blocker), or both drugs. Power spectra were constructed from the recorded electrocardiogram by Fourier algorithm and integrated for low-frequency power (LF) and high-frequency power (HF). Four different LF bands (0.004-0.1, 0.004-0.15, 0.05-0.1, and 0.05-0.15 Hz) and two different HF bands (0.1-1.0 and 0.15-1.0 Hz) were evaluated. The parasympathetic index, HF, decreased exponentially with workload and was attenuated by glycopyrrolate and combined treatments with both HF frequency bands measured. Whereas some sympathetic indexes (LF/total power and LF/HF) did reflect expected increases in sympathetic nerve activity associated with progressive increases in work intensity, none of the measured increases responded appropriately to autonomic blockade. It is concluded that HRV is a valid technique for noninvasive measurement of parasympathetic tone during exercise, but its validity as a measure of sympathetic tone during exercise is equivocal.

Predicting cardiac autonomic neuropathy in type I (insulin-dependent) diabetes mellitus.

A total of 24 subjects with type I insulin-dependent diabetes mellitus were studied. Cardiac parasympathetic function was measured by supine heart rate variability (HRV) in the respiratory frequency 0.10-0.50 Hz and the sympathetic index was measured as the ratio of HRV between 0.055 and 0.098 Hz to that between 0.004 and 0.5 Hz. Factors assessing diabetic control and complications, and factors unrelated to diabetes but possibly influencing HRV, were recorded. Association with depressed HRV was assessed with correlation, and prediction of depressed HRV was determined with multiple regression. Factors associated with depressed HRV but not independently predictive were renal dysfunction and elevated thyroid stimulating hormone. Elevated glycosylated haemoglobin was not significantly correlated with depressed HRV. Four factors (presence of diabetic retinopathy, male gender, duration of diabetes and increasing age) were significant in the regression and sufficed to predict 81% of the sample variance. The relative weights (beta) were -0.65, 0.40, -0.40 and 0.26, respectively. Supine sympathetic index was not sufficient to demonstrate sympathetic dysfunction. It is proposed that the regression model may be used to identify patients likely to have cardiac parasympathetic autonomic dysfunction.

Optimal frequency ranges for extracting information on autonomic activity from the heart rate spectrogram.

Heart rate variability spectrum analysis provides useful quantitative indices of neural control of the SA node. This method is attractive both for its simplicity and the lack of invasive instrumentation, particularly for human investigation. The differing spectral characteristics of parasympathetic and sympathetic control of heart rate allows separate measurement. However, there are widely varying opinions as to the appropriate frequency bands to represent these two inputs. We compared the heart rate variability spectra of 16 humans in supine and upright positions. Adequate measures of parasympathetic or sympathetic activity change should correlate respectively inversely or directly with heart rate change. Frequently used spectral measures of sympathetic activation did not correlate with heart rate changes. With optimization of frequency bands, we found that restricting the sympathetic band to frequencies below 0.1 Hz and above 0.05 Hz (0.055 to either 0.086-0.098 Hz), and dividing by total spectral amplitude 0.004-0.5 Hz (to account for parasympathetic fluctuations within the sympathetic band) produced the best results. The parasympathetic band was best from 0.1 Hz to a frequency greater than that of the respiratory sinus arrhythmia. The optimization method detailed here is easily applied to circumstances other than active orthostasis, and should provide a means of empirically determining useful frequency limits.

Up-and-down regulation of skeletal muscle acetylcholine receptors. Effects on neuromuscular blockers.

Multiple factors alter the interaction of muscle relaxants with the NMJ. This review has focused on the aberrant responses caused principally by alterations in AChRs (table 1). Many pathologic states increase (up-regulate) AChR number. These include upper and lower motor neuron lesions, muscle trauma, burns, and immobilization. Pre- or postjunctional inhibition of neurotransmission by drugs or toxins also up-regulate AChRs. These include alpha- and beta-BT, NDMR, anticonvulsants, and clostridial toxins. We speculate that other bacterial toxins also up-regulate AChR. With proliferation of AChRs, agonist drug dose-response curves are shifted to the left. The exaggerated release of potassium when depolarization occurs with the use of agonists such as SCh and decamethonium can be attributed to the increased number of AChR. Thus, SCh should be avoided in patients who are in the susceptible phase (see section V). In the presence of increased AChR, the requirement for NDMR is markedly increased. Thus, the response to NDMR may be used as an indirect estimator of increased sensitivity to SCh (table 1). The most extensively studied pathologic state in which there is a decrease in AChRs is myasthenia gravis; there is immunologically mediated destruction and/or functional blockade of AChRs. The pathophysiologic and pharmacologic changes in LEMS are quite distinct from those of myasthenia gravis. Decreased AChRs in myasthenia gravis result in resistance to agonists and increased sensitivity to competitive antagonists. In conditioning exercise, the perturbed muscles show sensitivity to NDMR that may be due to decreased AChRs. Chronic elevations of ACh observed with organophosphorus poisoning or chronic use of reversible cholinesterase inhibitors results in down-regulation of AChRs. In this condition, SCh should be avoided because its metabolic breakdown would be impaired; the requirement for NDMR may be decreased. All of the varied responses to SCh and NDMR, which are associated with concomitant changes in AChRs, are analogous to drug-receptor interactions observed in other biologic systems.

Cardiovascular function during induced hypotension by fenoldopam or sodium nitroprusside in anesthetized dogs.

Fenoldopam, a selective dopamine1 receptor agonist, has been recommended for induced hypotension because it effectively lowers arterial blood pressure and improves renal perfusion. We examined cardiovascular functions during hypotension induced by fenoldopam or sodium nitroprusside. In eight halothane-anesthetized dogs, the left ventricle (LV) was instrumented with pressure and ultrasonic dimension transducers for the assessment of LV contractility using the analysis of the pressure-diameter relationship. Blood flow distribution was measured by radioactive microspheres. Doses of fenoldopam and nitroprusside were titrated to reduce mean arterial blood pressure to 60 mm Hg. After 40 min of hypotension, fenoldopam and nitroprusside caused similar increases in heart rate (17% +/- 4% vs 19% +/- 10%, respectively) and decreases in systemic vascular resistance (-24% +/- 5% vs -27% +/- 4%). Hypotension induced by fenoldopam was associated with higher LV end-diastolic pressure (4.4 +/- 0.6 vs 2.5 +/- 1.1 mm Hg) and end-systolic meridional wall stress (33.0 +/- 4.3 vs 17.8 +/- 2.1 g/cm2) when compared with nitroprusside. There were no significant changes in cardiac output and cardiac contractility as expressed by the slope (Ees) of the LV end-systolic pressure-diameter relationship, velocity of shortening of the diameter, and percentage of wall thickening of the LV. In contrast to nitroprusside, which decreased renal blood flow from 197 +/- 19 to 163 +/- 15 mL/min, renal blood flow increased during fenoldopam-induced hypotension from 187 +/- 20 to 239 +/- 18 mL/min. The increase in renal perfusion was similar in upper, middle, and lower regions of the kidney; however, it was more in the medulla compared with the cortex (37% +/- 17% vs 25% +/- 7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Nalbuphine antagonism of fentanyl-induced ventilatory depression: a randomized trial.

The authors anesthetized 18 patients with good pulmonary and ventricular function for coronary artery bypass grafting with high doses of fentanyl. When the patients were arousable and their vital signs stable in the intensive care unit, the authors administered nalbuphine or placebo (randomly and double-blinded) until extubation criteria were met, and subsequently gave nalbuphine for analgesia. In one of ten placebo patients, tracheal extubation was accomplished without nalbuphine. This patient then retained CO2 and required nalbuphine; the other nine placebo patients could not be extubated after placebo trials and were given nalbuphine. In all other patients in both groups, tracheal extubation was successful following nalbuphine (median dose 60 micrograms/kg, range 30-180 micrograms/kg). One patient became renarcotized 4 h after tracheal extubation without an increase in plasma fentanyl concentration; he received an additional dose of nalbuphine and recovered without further incident. Nine patients required treatment with vasoactive agents or beta-blockers for hypertension or tachycardia associated with the administration of nalbuphine. Eight of 18 patients were not satisfied with nalbuphine analgesia, and required morphine for relief of their pain. Recurrent elevations of fentanyl concentrations in plasma were observed and appeared to be related to increasing motor activity. Nalbuphine is an effective opioid antagonist after fentanyl anesthesia, but its use is associated with side effects, and analgesia for the post-sternotomy patient may be unsatisfactory unless the dose is carefully titrated to the minimum required to antagonize respiratory depression.

Alternative work scheduling for professional social workers.

The authors present some practical evidence that the changing nature of today's work force requires innovative alternatives to traditional scheduling based on the 9 to 5, five-day workweek. They support alternative work scheduling (AWS) as an updated and promising approach. Described is their experience with a two-year AWS pilot project in the Social Work Service of an urban medical center, with their focus upon the processes of negotiating, programming, and implementing the concepts of "flex-time," "compressed workweek," and "job sharing." Informal assessment indicates strongly positive responses from the participating social workers, other members of the health care team, and the consumers of the services.