Heparin-enhanced plasma phospholipase A2 activity and prostacyclin synthesis in patients undergoing cardiac surgery.

Although eicosanoid production contributes to physiological and pathophysiological consequences of cardiopulmonary bypass (CPB), the mechanisms accounting for the enhanced eicosanoid production have not been defined. Plasma phospholipase A2 (PLA2) activity, 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), and thromboxane B2 (TXB2) levels were measured at various times during cardiac surgery. Plasma PLA2 activity increased after systemic heparinization, before CPB. This was highly correlated with concurrent increases in plasma 6-keto-PGF1 alpha, TXB2 concentrations did not increase with heparin administration but did increase significantly after initiation of CPB. High plasma PLA2 activity, 6-keto-PGF1 alpha, and TXB2 concentrations were measured throughout the CPB period. Protamine, administered to neutralize the heparin, caused an acute reduction of both plasma PLA2 activity and plasma 6-keto-PGF1 alpha, but no change in plasma TXB2 concentrations. Thus the ratio of TXB2 to 6-keto-PGF1 alpha increased significantly after protamine administration. Enhanced plasma PLA2 activity was also measured in patients with lower doses of heparin used clinically for nonsurgical applications. Human plasma PLA2 was identified as group II PLA2 by its sensitivity to deoxycholate and dithiothreitol, its substrate specificity, and its elution characteristics on heparin affinity chromatography. Heparin addition to PMNs in vitro resulted in dose-dependent increases in cellular PLA2 activity and release of PLA2. The PLA2 released from the PMN had characteristics similar to those of post-heparin plasma PLA2. In conclusion, plasma PLA2 activity and 6-keto-PGF1 alpha concentrations are markedly enhanced with systemic heparinization. Part of the anticoagulant and vasodilating effects of heparin may be due to increased plasma prostacyclin (PGI2) levels. In addition the pulmonary vasoconstriction sometimes associated with protamine infusion during cardiac surgery might be due to decreased plasma PLA2 activity, with an associated increased TXB2/6-keto-PGF1 alpha ratio.

Bispectral analysis of the electroencephalogram correlates with patient movement to skin incision during propofol/nitrous oxide anesthesia.

BACKGROUND: Bispectral analysis is a signal-processing technique that determines the harmonic and phase relations among the various frequencies in the electroencephalogram. Our purpose was to compare the accuracy of a bispectral descriptor, the bispectral index, with that of three power spectral variables (95% spectral edge, median frequency, and relative delta power) in predicting patient movement in response to skin incision during propofol-nitrous oxide anesthesia. METHODS: Forty-four adult patients scheduled for elective noncranial surgery were studied. Gold cup electroencephalographic electrodes were placed on each patient in a frontoparietal montage (Fp1, Fp2, P3, and P4) referred to Cz, and the electroencephalogram was recorded continuously and processed off-line. Conventional frequency bands were used to describe power spectrum variables. Anesthesia was induced with propofol (1.5-3.0 mg-1.kg-1) and maintained with 60% nitrous oxide in oxygen and with propofol at one of three randomized infusion rates (100, 200, or 300 micrograms.kg-1.min-1). Inadequate anesthetic depth was defined as patient movement in response to a 2-cm skin incision at the planned site of surgery. Plasma propofol concentrations were measured within 2 min after skin incision. RESULTS: Complete data were available for 38 patients, of whom 17 moved in response to skin incision. Analysis of the area under the receiver operating characteristic curves showed that only for bispectral index and drug dose group was there a significant predictive relation (area > 0.5). Furthermore, the bispectrum was significantly predictive even after stratification by dose group. CONCLUSIONS: The bispectral index of the electroencephalogram is a more accurate predictor of patient movement in response to skin incision during propofol-nitrous oxide anesthesia than are standard power spectrum parameters or plasma propofol concentrations.

Bispectral analysis of the electroencephalogram during induction of anesthesia may predict hemodynamic responses to laryngoscopy and intubation.

The use of electroencephalography as a measure of adequacy of anesthesia has achieved limited success. Our purpose was to determine whether the non-linear properties of the electroencephalogram (EEG) as defined by the bispectral index was a better predictor of autonomic responses to endotracheal intubation during opioid-based anesthesia than the linear statistical properties of the EEG formulated by power spectral analysis. Thirty-nine adults scheduled for elective non-cranial surgery had a continuous EEG recorded during induction of anesthesia and endotracheal intubation. Anesthesia consisted of thiopental and nitrous oxide in oxygen, followed by 1 of 5 randomized opioid dose regimens. The EEG was continuously recorded and blood pressure was measured every minute. All electroencephalographic parameters were derived for the 3 min before and after intubation and were compared to the blood pressure and heart rate responses. Responders were defined by 2 analyses: patients who had a 20% or greater increase (1) in blood pressure or (2) in heart rate to laryngoscopy. Responders and non-responders were compared using Student's unpaired t test, and differences due to dose regimens were examined with logistic regression. Based on the criterion for blood pressure change, there were 27 responders and 12 non-responders. Heart rate changes did not differentiate between the two groups. There was a significant difference between response groups as measured by the bispectral index which distinguished responders from non-responders independently of the amount of drug given. None of the variables of power spectral analysis accurately distinguished responder from non-responder.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative determination of atracurium in human plasma using high-performance liquid chromatography.

The authors have established a new method for extraction and determination of atracurium in human plasma that employs a reversed phase high-performance liquid chromatography (HPLC). This method made use of a fluorescent spectrophotometer at an excitation wavelength of 240 nm and an emission wavelength of 310 nm. The mobile phase was made of a phosphate buffer, distilled water and acetonitrile (20V : 30V : 50V). The analytical column used was a Little Champ C(18). In a Bond Elute C(18) extraction column, which had been prewashed with a phosphate buffer and a 50% methanol solution, atracurium was extracted from acidified plasma samples using a mixture of methanol and phosphate buffer. A standard curve was prepared by the internal standard method using metocurine. A high linear correlation between atracurium concentration and the ratio of the atracurium peak height to the metocurine peak height was observed (r = 0.9994). The lowest threshold for detection of atracurium was 15 ng/ml. When the plasma concentrations of atracurium were determined in 2 clinical cases, t(1/2Alpha) was 2.10 and 1.73 min and t(1/2Beta) was 15.57 and 21.57 min, respectively. These results indicate that this method of extraction and determination is appropriate for studying the pharmacokinetics of atracurium because it allows a high reproducibility, and provides an extremely accurate, simple and quick analysis.

Pharmacokinetics and pharmacodynamics of atracurium during isoflurane anesthesia in normal and anephric patients.

We compared the pharmacokinetics and pharmacodynamics of atracurium in eight normal and eight anephric patients during isoflurane anesthesia. Plasma concentrations were measured by high performance liquid chromatography after a single injection of 0.5 mg/kg, and neuromuscular effects were evaluated by the single twitch method. With regard to pharmacokinetic or pharmacodynamic parameters, we found no statistically significant differences between normal and anephric patients. We conclude that during isoflurane anesthesia, anephric patients distribute and eliminate atracurium much as normal patients do.

Anesthetic considerations in the surgical repair of intracranial aneurysms: preanesthetic evaluation.

A preoperative evaluation for anesthesia is useful to: 1. Assess the patient's physical status and evaluate anesthetic risk 2. Judge the cardiovascular and general medical status with particular regard to hypotensive techniques 3. Estimate preoperative pulmonary reserve 4. Order appropriate premedications 5. Become aware of anatomical features relevant to the anesthetic techniques If the anesthetist has made a careful preoperative review, the patient's status is well understood and the likelihood of any complication related to anesthesia during surgery is greatly diminished.

Combination of pancuronium and metocurine: neuromuscular and hemodynamic advantages over pancuronium alone.

Combination of pancuronium and metocurine or pancuronium and d-tubocurarine produces potentiation of neuromuscular blocking effects such that administration of relatively small doses of these drugs can yield clinically effective neuromuscular blockade. The clinical characteristics of the block produced in A.S.A. class I-II patients during N2O-narcotic-thiopental anesthesia by the pancuronium-metocurine combination at the calculated ED95 (N = 8) and at twice the ED95 (N = 9) were compared with the block produced by pancuronium alone at its ED95 (N = 20) and at twice the ED95 (N = 6). Onset time (from drug injection to 95% twitch suppression) and the maximum twitch depression achieved were comparable between corresponding groups, but the 25% recovery time (from drug injection to 25% recovery of twitch height) was significantly shorter in the groups that received the pancuronium-metocurine combination. Furthermore, at twice the ED95, heart rate increased significantly more in the pancuronium group than in the pancuronium-metocurine combination group. Mean systemic blood pressure did not change significantly in either group. We conclude that patients given a combination of pancuronium and metocurine in large doses experience less hemodynamic change and more rapid recovery of neuromuscular function than do patients given equivalent doses of pancuronium alone.