Bupivacaine inhibits acylcarnitine exchange in cardiac mitochondria.

BACKGROUND: The authors previously reported that secondary carnitine deficiency may sensitize the heart to bupivacaine-induced arrhythmias. In this study, the authors tested whether bupivacaine inhibits carnitine metabolism in cardiac mitochondria. METHODS: Rat cardiac interfibrillar mitochondria were prepared using a differential centrifugation technique. Rates of adenosine diphosphate-stimulated (state III) and adenosine diphosphate-limited (state IV) oxygen consumption were measured using a Clark electrode, using lipid or nonlipid substrates with varying concentrations of a local anesthetic. RESULTS: State III respiration supported by the nonlipid substrate pyruvate (plus malate) is minimally affected by bupivacaine concentrations up to 2 mM. Lower concentrations of bupivacaine inhibited respiration when the available substrates were palmitoylcarnitine or acetylcarnitine; bupivacaine concentration causing 50% reduction in respiration (IC50 +/- SD) was 0.78+/-0.17 mM and 0.37+/-0.03 mM for palmitoylcarnitine and acetylcarnitine, respectively. Respiration was equally inhibited by bupivacaine when the substrates were palmitoylcarnitine alone, or palmitoyl-CoA plus carnitine. Bupivacaine (IC50 = 0.26+/-0.06 mM) and etidocaine (IC50 = 0.30+/-0.12 mM) inhibit carnitine-stimulated pyruvate oxidation similarly, whereas the lidocaine IC50 is greater by a factor of roughly 5, (IC50 = 1.4+/-0.26 mM), and ropivacaine is intermediate, IC50 = 0.5+/-0.28 mM. CONCLUSIONS: Bupivacaine inhibits mitochondrial state III respiration when acylcarnitines are the available substrate. The substrate specificity of this effect rules out bupivacaine inhibition of carnitine palmitoyl transferases I and II, carnitine acetyltransferase, and fatty acid beta-oxidation. The authors hypothesize that differential inhibition of carnitine-stimulated pyruvate oxidation by various local anesthetics supports the clinical relevance of inhibition of carnitine-acylcarnitine translocase by local anesthetics with a cardiotoxic profile.

Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats.

BACKGROUND: The authors sought to confirm a chance observation that intravenous lipid treatment increases the dose of bupivacaine required to produce asystole in rats. The authors also measured the partitioning of bupivacaine between the lipid and aqueous phases of a plasma-lipid emulsion mixture. METHODS: Anesthetized Sprague-Dawley rats were used in pretreatment (protocol 1) and resuscitation (protocol 2) experiments. In protocol 1, animals were pretreated with saline or 10%, 20%, or 30% Intralipid (n = 6 for all groups), then received 0.75% bupivacaine hydrochloride at a rate of 10 ml x kg x min(-1) to asystole. In protocol 2, mortality was compared over a range of bolus doses of bupivacaine after resuscitation with either saline or 30% Intralipid (n = 6 for all groups). The lipid:aqueous partitioning of bupivacaine in a mixture of plasma and Intralipid was measured using radiolabeled bupivacaine. RESULTS: Median doses of bupivacaine (in milligrams per kilogram) producing asystole in protocol 1 were for 17.7 for saline, 27.6 for 10% Intralipid, 49.7 for 20% Intralipid, and 82.0 for 30% Intralipid (P < 0.001 for differences between all groups). Differences in mean +/- SE concentrations of bupivacaine in plasma (in micrograms per milliliter) were significant (P < 0.05) for the difference between saline (93.3 +/- 7.6) and 30% Intralipid (212 +/- 45). In protocol 2, lipid infusion increased the dose of bupivacaine required to cause death in 50% of animals by 48%, from 12.5 to 18.5 mg/kg. The mean lipid:aqueous ratio of concentrations of bupivacaine in a plasma-Intralipid mixture was 11.9 +/- 1.77 (n = 3). CONCLUSIONS: Lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Partitioning of bupivacaine into the newly created lipid phase may partially explain this effect. These results suggest a potential application for lipid infusion in treating cardiotoxicity resulting from bupivacaine.

Malignant ventricular dysrhythmias in a patient with isovaleric acidemia receiving general and local anesthesia for suction lipectomy.

We report the occurrence of severe ventricular arrhythmias in a patient with isovaleric acidemia during general anesthesia for suction lipectomy. The timing of events and character of the ECG changes are most consistent with bupivacaine toxicity after subcutaneous injection of tumescence solution containing this local anesthetic. The patient had previously documented carnitine deficiency, a condition which, we speculate, may lower the threshold for bupivacaine induced cardiotoxicity. We review clinical considerations in isovaleric acidemia and conclude that the use of bupivacaine in these patients probably should be avoided.

Analysis of halothane effects on myocardial force-interval relationships at anesthetic concentrations depressing twitches but not tetanic contractions.

BACKGROUND: Tetanic contractions in rat myocardium depend solely on cellular Ca2+ uptake, whereas twitches depend on Ca2+ release from the sarcoplasmic reticulum. Because halothane may cause loss of sequestered Ca2+, the anesthetic was tested for its differential effects on twitch and tetanic forces. The in vitro effects of halothane on the twitch force-interval relationship were then evaluated, using a mathematical model that relates twitch contractile force to the Ca2+ content of intracellular compartments. METHODS: Isometric contractile force was measured in paced (0.4 Hz) rat atrial preparations. The sarcoplasmic reticulum was functionally eliminated using ryanodine (10(-6) M), abolishing twitches. Rapid pacing (20 Hz, 10 s) caused tetanic contractions. The effects of identical halothane exposures on twitches and tetanic contractions were compared. Ca2+ compartment model parameters were extracted from twitch force-interval data, according to a previously employed quantitative procedure. RESULTS: Halothane (0.5-1%) depressed normal twitches, but not tetanic contractions. The anesthetic decreased the amplitude of the steady-state twitch force-frequency relationship, and accelerated the course of mechanical recovery. Halothane (0.5-1%) also accelerated the decay constant for the decline in amplitude of a series of rest-potentiated contractions. The modeling showed that a 20-30% decrease in the recirculating fraction of activator Ca2+ accounts for 0.5% halothane-induced negative inotropy and acceleration of the decay constant. CONCLUSIONS: The differential effect of halothane on twitches and tetanic contractions implies that a functioning sarcoplasmic reticulum is required for halothane-induced negative inotropy. The effects of halothane on the force-interval relationship suggest that halothane reduces the sequestered pool of activator Ca2+.

A randomized, double-blind comparison of the effects of interpleural bupivacaine and saline on morphine requirements and pulmonary function after cholecystectomy.

The effect of interpleural bupivacaine and saline placebo on morphine requirements and pulmonary function after cholecystectomy was investigated. Twenty-six patients were randomly assigned on postoperative day 1 to receive either 20 ml preservative-free saline (group 1) or 20 ml 0.5% bupivacaine with epinephrine, 5 micrograms/ml (group 2) through an interpleural catheter. Adequacy of pain relief was determined by the amount of morphine used by the patient following interpleural injection. Morphine use via a patient-controlled analgesia (PCA) system was recorded for several hours before and after interpleural injection. All patients had a forced vital capacity (FVC) and FEV1 measurement immediately before and 1 h after interpleural injection. Mean hourly PCA morphine use ranged from 1.6 to 2.8 mg for the 6 h prior to interpleural treatment for groups 1 and 2. There was no difference in PCA use between the groups during this time. Group 1 patients did not reduce PCA morphine use after interpleural saline. Patients in group 2, however, significantly reduced PCA morphine use after interpleural bupivacaine. Mean PCA morphine use for group 2 was 0.38 +/- 0.15 mg/h (mean +/- SE) (81% reduction vs. control) for the first 2 h after bupivacaine (P less than 0.05). Mean PCA use in group 2 was 0.52 +/- 0.2 mg/h (73% reduction vs. control) for the third hour after bupivacaine (P less than 0.05). At the fourth and fifth hours after bupivacaine injection, mean PCA morphine use was not significantly different from that in group 1. FVC and FEV1 did not improve after interpleural saline.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of exogenous thymidine on endogenous deoxynucleotides and mutagenesis in mammalian cells.

The intracellular deoxyribonucleoside triphosphate pools in mammalian cells affect diverse biological functions including the spontaneous or induced mutability. We have isolated from murine T-lymphosarcoma S49 cells, a mutant that is unable to convert dCMP to dUMP, contains deranged intracellular dNTP pools, and exhibits a mutator phenotype. The enzymatic defect in araC-6-1 cells is a deficiency of deoxycytidylate deaminase, which accounts for the high dCTP and low TTP intracellular pools. The addition of increasing concentrations of exogenous thymidine to araC-6-1 cells alters these dNTP pools in a predictable manner: increasing the TTP and diminishing the dCTP. Concomitant with this reversal of the dCTP:TTP ratio is a marked decrease in the mutation rate followed by an increase in the mutation rates at higher exogenous thymidine concentrations. This response of the mutation rate is in contrast to that seen in the control cell line containing normal deoxycytidylate deaminase. In the latter case, increasing thymidine concentration induces an enhanced mutation rate that parallels the later phase of the thymidine-induced mutation rate in araC-6-1 cells. The deficiency of deoxycytidylate deaminase, the endogeneous dNTP pool alterations, and the mutator phenotype of araC-6-1 cells are all recessive traits in cell-cell hybrids. These observations allow one to predict whether exogenous thymidine will be mutagenic, antimutagenic, or both for a given cell line and provide a basis for understanding conflicting reports in the literature concerning the effects of the thymidine on genomic stability.

Demonstration of normal and mutant protein M1 subunits of deoxyGTP-resistant ribonucleotide reductase from mutant mouse lymphoma cells.

From a mutagenized population of mouse T-lymphoma cells (S49) in continuous culture a cell line has been isolated (Ullman, B., Gudas, L. J., Clift, S. M., Martin, D. W., Jr. (1979) Proc. Natl. Acad. Sci. U. S. A. 76, 1074-1978) with ribonucleotide reductase activity that is inhibited only 50% by concentrations of dGTP which abolish wild type enzyme activity. Ribonucleotide reductase activity from this dGuo-L cell line retains its normal sensitivity to dATP. The partial sensitivity/partial resistance of the ribonucleotide reductase suggests that the dGuo-L cell line is heterozygous for ribonucleotide reductase, possessing one normal allele and one allele which codes for a dGTP-resistant enzyme. Both homologous and heterologous mixing experiments between the separated nonidentical subunits of ribonucleotide reductase, protein M1 and protein M2, from wild type and dGuo-L cells showed that the dGTP- feedback sensitivity was governed by the source of the protein M1. A partial resolution of two dGuo-L protein M1 components was achieved by chromatography on dextran blue-Sepharose. In order to resolve the two dGuo-L protein M1 components more completely, we introduced into dGuo-L cells a second mutation which conferred resistance of the ribonucleotide reductase to dATP, while the original dGTP resistance was maintained. The chromatography of protein M1 from this latter clone, dGuo-L-Aphid-G5, on dATP-Sepharose resolved two kinetically distinct protein M1 components. The first component was sensitive to dGTP inhibition but stimulated by dATP; the second was absolutely refractory to dGTP but sensitive to dATP inhibition. This confirms the hypothesis that the dGuo-L parent is heterozygous for protein M1, containing one wild type and one mutant allele.