Effects of profound hypotension on cerebral blood flow during surgery for intracranial aneurysms.

The progression of changes in cerebral blood flow (CBF) and neurological status were measured in 12 patients in whom profound hypotension (mean arterial blood pressure (MABP): 30 to 40 mm Hg) was used during intracranial aneurysm surgery. Nine patients (Group I) showed autoregulation of CBF to an MABP of 40 to 50 mm Hg during surgery. None of these patients had arterial spasm preoperatively. Postoperatively, mild flow disturbances were noted at the site of retraction. Three Group I patients developed arterial spasm postoperatively, but there was no associated neurological deterioration. The remaining three patients (Group II) had impaired autoregulation during surgery, and CBF decreased by 35% to 65% at an MABP of 50 mm Hg. Two of these patients had angiography immediately before surgery, and both showed moderate to severe arterial spasm. Relatively severe flow disturbances were noted postoperatively at the site of retraction, and two patients developed ischemic deficits of late onset. Brain retractor pressure and the degree and duration of hypotension were equivalent in the two patient groups. There was no correlation between intraoperative reductions in CBF (to as low as 20 ml/100 gm/min in the unretracted hemisphere) and immediate postoperative neurological deficits. The use of halothane and mannitol and the relatively short duration of the flow reductions were suggested as factors contributing to the protection from ischemia that was observed. Arterial spasm was found to produce hemodynamic instability and reduced CBF, although neurological status was unaffected in the majority of patients. Patients with impaired autoregulation during surgery were at increased risk of delayed ischemic complications postoperatively, and showed characteristic flow disturbances at all three stages of their clinical course.

The origin of spontaneous electrical activity at the end-plate zone.

Two types of spontaneous electrical activity are present at the end-plate zone: low-voltage negative potentials that correspond to miniature end-plate potentials, and larger voltage negative-positive potentials. The electrogenic origin of the latter has been uncertain. The origin of these larger potentials was investigated in the rat phrenic nerve diaphragm preparation and in human gastrocnemius muscle just prior to intubation during administration of preoperative anesthesia. In the hemidiaphragm the larger voltage negative-positive potentials were rarely triggered by intracellular or tungsten microelectrodes. The negative-positive potentials, however, were clearly triggered by contact of the concentric needle electrode with muscle hemidiaphragm at the end-plate region. The potentials were abolished by curare. Likewise, the equivalent potentials observed at the human gastrocnemius end-plate zone were blocked by neuromuscular blocking agents. Therefore, these positive-negative discharges represent postsynaptic muscle fiber action potentials and not nerve fiber activity. They were probably presynaptically activated by mechanical irritation of the motor axon terminal and preterminal branches.

Lumbar epidural morphine as an effective analgesic following cholecystectomy.

Relief of pain with epidural morphine was evaluated in five patient subjects during two consecutive twenty-four periods after cholecystectomy. In one period, each subject received lumbar epidural morphine, first 4-6mg, and twelve hours later, 2-3 mg; in the other period, epidural placebo at the same times. Except for four hours before each injection and twenty minutes thereafter, intramuscular morphine was administered as required throughout. The experiments were double-blind. Epidural morphine, unlike epidural placebo, reduced both a visual pain analogue score (p less than 0.05) and a pain questionnaire score (p less than 0.01) twenty minutes after injection. Epidural morphine compared to placebo reduced by one-half the total amount of narcotic (epidural plus intramuscular) administered over the twenty-four hour period (p less than 0.05). Four of five subjects clearly preferred analgesia with epidural morphine over the effect of placebo plus therapeutic doses of intramuscular morphine. We conclude that epidural morphine, administered in this manner, is effective in relieving pain after cholecystectomy and that it may be preferred by patients over conventional intramuscular morphine.

Regional analgesic effect of epidural morphine in volunteers.

Limb ischaemia induced by a sub-maximum effort tourniquet technique was used to characterize the analgesic effects of lumbar epidural morphine in volunteers. As an index of pain threshold, we measured the time to perception of pain in and upper an a lower limb before and at intervals up to six hours following epidural injections of morphine 3.5 mg an 7.0 mg, and before and after subcutaneous injections of the same doses. Subcutaneous morphine had no significant effect on the times to perception of pain in either limb. Lumbar epidural morphine did not alter upper limb times, but markedly delayed the onset of pain in the lower limbs. This lower limb analgesic effect was apparent thirty minutes after injection, peaked at about ninety minutes and was still present after six hours. Serum levels of morphine were nearly identical after subcutaneous and epidural injections of the same dose. We conclude that lumbar epidural morphine produces marked analgesia for this type of experimental pain primarily by a "regional" effect rather than as a result of systemic absorption. This regional effect develops slowly and is prolonged.