Synergistic sedation with low-dose midazolam and propofol for colonoscopies.

BACKGROUND AND STUDY AIMS: Patients undergoing colonoscopy are often sedated with benzodiazepines and long-acting opiates. Since low-dose midazolam also acts synergistically with short-acting propofol, we compared this synergistic sedation with a standard combination of midazolam and the opioid nalbuphine for colonoscopies. PATIENTS AND METHODS: A total of 79 patients presenting for colonoscopies were randomly assigned to the following protocols. Patients in group I (n = 32) received a median dose of 9 mg midazolam (interquartile range [IQR] 6 to 12); 20 patients (59%) needed additional nalbuphine (median 20 mg, IQR 10 to 20). Patients in group II (n = 47) received 2 mg midazolam and repeated injections of propofol (median 100 mg, IQR 53 to 145) with a maximal bolus of 50 mg. RESULTS: Patients treated with the synergistic sedation (group II) recovered remarkably sooner after the procedure compared with those in group I, with a median time to discharge of 17 minutes vs. 93 minutes (P<0.001). Of the patients treated with analgosedation (group I), 28 % were unable to take part in a reaction time measurement and attention awareness test 1 hour after the procedure. All patients treated with the synergistic sedation were able to participate (P=0.002), and performed better. Despite a lower proportion of complete amnesia, patients treated with synergistic sedation more often rated the procedure as comfortable (81% vs. 50 %). Quality of sedation from the point of view of the endoscopist, and cardiorespiratory parameters, were similar in both groups. CONCLUSIONS: Low-dose midazolam combined with propofol is an effective and economic alternative to benzodiazepine-based analgosedation. It is associated with a high degree of patient comfort and rapid recovery times, and has a potential cost benefit concerning nursing care and bed facilities.

A determinant factor in the efficacy of GHRH administration in promoting sleep: high peak concentration versus recurrent increasing slopes.

A previous experiment indicated a greater efficacy of episodic than continuous growth hormone (GH)-releasing hormone (GHRH) administration in enhancing sleep. The greater efficacy of episodic administration could principally result from two factors, i.e. the greater peak concentration reached after episodic administration or the recurrence of increasing slopes in GHRH concentration. In order to investigate which factor essentially determines the pharmacodynamics of sleep promotion after GHRH, effects after a transient high peak in GHRH concentration were compared with those of repetitive increases in GHRH concentration. Sleep, plasma concentrations of GH, and GHRH were examined in healthy subjects after evening administration of a 'single' i.v. bolus of 50 micrograms GHRH, after five 'repetitive' boluses of 10 micrograms GHRH, and after placebo. Compared with placebo, single GHRH significantly increased time spent in stage 4 sleep (p < .01) and in stage 2 sleep, reduced time spent in wakefulness and onset latency of stage 4 sleep (p < .05, for each), while repetitive GHRH remained without effects. GH secretory activity also tended to be higher after single than repetitive GHRH. Thus, results suggest the relevance of a transiently high concentration of GHRH in blood as an essential factor in enhancing the central nervous sleep process.

Angiotensin converting enzyme inhibition by captopril influences cardiac work in healthy hearts.

Although beneficial effects of angiotensin converting enzyme (ACE) inhibition have been demonstrated in ill (ischemic, failing) hearts, it has not been proved that ACE inhibition induces changes in healthy hearts. The question is of clinical relevance, as many hypertensive patients do not display cardiac damage at the onset of treatment with ACE inhibitors, and possible changes in cardiac work might turn out more or less advantageous in the development of hypertensive heart disease. In a refined working heart preparation allowing measurement of cardiac work, including the contribution of atrial work and paracrine cardiac regulation, effects of captopril on cardiac dynamics were assessed. Coronary overflow of bradykinin, norepinephrine, and lactate was measured. Hearts were perfused for 20 min with vehicle or captopril at 3 x 10(-8), 3 x 10(-7), 3 x 10(-6), and 3 x 10(-5) mol/L. At the highest concentration, captopril increased coronary flow. Extending previous studies, the present study demonstrates that, in a concentration-dependent manner, captopril decreased oxygen consumption and maximal left ventricular pressure although the bradykinin outflow was not affected. From these influences of the drug on cardiac work and metabolism in healthy hearts, a protective influence of captopril in acute, critical situations of cardiac malnourishment or cardiac overload may be derived.

Intranasal angiotensin II directly influences central nervous regulation of blood pressure.

Intranasal administration of some peptides has been shown to directly influence central nervous functions, thus pointing to a nose-brain pathway for these substances in humans. The present study investigated whether intranasal administration of angiotensin II (ANG II) affects central nervous functions of cardiovascular control in a different way from intravenously administered ANG II. In a balanced cross-over design 12 healthy men were treated with ANG II intravenously (2.5 microg), ANG II intranasally (400 microg), and placebo. Angiotensin II, vasopressin, norepinephrine, and epinephrine plasma levels were assessed every 10 min; blood pressure, heart rate, and systemic vascular resistance were measured by a Dinamap, and by continuous, noninvasive body plethysmography. Also, feelings of activation and mood were measured. Intranasal and intravenous administration invoked equivalent increases in plasma levels of ANG II, and induced an acute rise in blood pressure of comparable size and duration. However, subsequent blood pressure profiles differed dependent on intravenous and intranasal ANG II administration; after intravenous ANG II administration blood pressure remained enhanced at an intermediate level, but it returned to normal or even decreased below normal levels after intranasal ANG II administration. Intranasal ANG II also counteracted the decrease in norepinephrine levels observed after intravenous administration of ANG II. Intranasal but not intravenous ANG II enhanced plasma concentrations of vasopressin. This diverging pattern of effects bears similarities with effects of intracerebroventricular administration of ANG II in animals, suggesting that the effects after intranasal administration reflect a direct central nervous action of ANG II.

Plasma epinephrine and norepinephrine concentrations of healthy humans associated with nighttime sleep and morning arousal.

We assessed the activity of the sympathetic nervous system during undisturbed nocturnal sleep and periods of wakefulness directly before and after sleep in healthy young men. Changes induced by periods of rapid eye movement and by morning awakening, both periods reported to demonstrate an enhanced risk for the onset of cardiovascular diseases, were of particular interest. In 13 healthy men (age, 18 to 35 years), blood for determination of epinephrine and norepinephrine was drawn every 7 minutes between 9:30 PM and 8:30 AM with the subjects resting in a strictly horizontal position. Lights were switched off at 11 PM until awakening at 7 AM. At 8:30 AM, subjects stood up and a final blood sample was drawn. Sleep was monitored somnopolygraphically, and heart rate and blood pressure were continuously measured. Average epinephrine but not norepinephrine concentrations were significantly lower during nocturnal sleep than during wakefulness before and after sleep. In parallel, heart rate and blood pressure declined significantly during sleep. During rapid eye movement sleep, both epinephrine and norepinephrine concentrations were significantly lower than during sleep stages 1 and 2 and slow-wave sleep. Whereas epinephrine concentrations gradually began to increase after morning awakening, norepinephrine levels were not significantly enhanced. However, standing up at the end of the experiment sharply increased norepinephrine concentrations by 180%, whereas epinephrine levels were less enhanced (46%) by the change of body position. This study suggests that the decrease in the activity of the sympathoadrenal branch of the sympathetic nervous system is probably due to an entrainment to the sleep-wake cycle, whereas the low activity of the noradrenergic branches depends mainly on horizontal body position during nocturnal sleep. The activities of the sympathoadrenal and noradrenergic branches of the sympathetic nervous system seem to be downregulated during rapid eye movement sleep. Awakening itself selectively enhances epinephrine levels. Subsequent orthostasis activates both the sympathoadrenal and, most prominently, the noradrenergic branches of the sympathetic nervous system.

The angiotensin converting enzyme inhibitors fosinopril and enalapril differ in their central nervous effects in humans.

BACKGROUND: Although the antihypertensive actions of different angiotensin converting enzyme (ACE) inhibitors are comparable, they may affect central nervous activity, mood and well-being differently. Thus, central nervous actions of ACE inhibitors may represent an essential factor determining compliance with antihypertensive therapy. OBJECTIVE: To compare central nervous effects of the biochemically different ACE inhibitors fosinopril and enalapril in healthy men. METHODS: In a double-blind cross-over study, auditory event-related brain potentials and heart rate variability were assessed 6 h after oral intake of placebo, enalapril (10 mg) and fosinopril (20 mg) with the doses being equipotent with regard to systemic ACE inhibition. Plasma concentrations of noradrenaline, adrenaline, vasopressin and cortisol were determined 3 and 6 h after drug intake. Central nervous effects mediated via direct systemic hypotensive actions were avoided (although not completely ruled out) by including only subjects (n = 14) who displayed no substantial drop in blood pressure following intake of the ACE inhibitors. RESULTS: Enalapril, but not fosinopril, enhanced the N1 component and the N1-P2 amplitude of the event-related brain potential (P < 0.05). In addition, enalapril enhanced plasma noradrenaline concentrations (P < 0.05). A similar effect of fosinopril failed to reach significance. There was no clear-cut effect of ACE inhibition on heart rate variability, and also plasma concentrations of adrenaline, vasopressin and cortisol remained unaffected. CONCLUSION: The results suggest an enhancing effect of enalapril on mechanisms regulating stimulus-induced cortical arousal and central nervous sympathetic outflow. The effects diverging between enalapril and fosinopril indicate that access to human brain functions differs among the various types of ACE inhibitors.

Enhanced psychophysiological signs of attention after angiotensin-converting enzyme inhibition by captopril.

Complementary to its essential role in the central nervous control of cardiovascular activity, the neuropeptide angiotensin II may regulate attentional processes. The present study evaluated central nervous, cardiovascular, and sympathetic indicators of attention after inhibition of angiotensin II synthesis by captopril (50 mg vs. placebo) in 14 men. Event-related potentials (ERPs) and stimulus-related electroencephalographic (EEG) activity were recorded while the subject performed an auditory oddball task. Captopril increased both the N1-P2 component of the ERP (p < .05) and--following the first tone of the task--the EEG desynchronization in the lower alpha frequency band (p < .05). Although blood pressure remained unchanged, heart rate was lowered (p < .05) and plasma norepinephrine concentrations increased (p < .01) after captopril. The effects suggest that inhibition of angiotensin II synthesis enhances an attentional state typically present during sensory intake.

Accelerated ST-segment reduction after thrombolytic therapy with recombinant tissue plasminogen activator (rtPA) compared to urokinase.

Effects of therapy with urokinase (UK) and with recombinant tissue plasminogen activator (rtPA) were compared in patients with acute myocardial infarction (AMI). To achieve homogenous therapeutic conditions the comparison was restricted to patients having their first AMI and to cases of clinically successful thrombolytic therapy (defined by non-invasive criteria, such as a 50% decrease in elevated ST-segment in the worst load of a 12 lead ECG within 300 min after onset of thrombolytic therapy, complete pain resolution during thrombolytic therapy, and later confirmed by angiography 10 days after AMI). Effects of UK and rtPA on continuous multilead ST-segment analysis and cardiac proteins (creatine kinase and its isoenzyme CK-MB, aspartate transaminase and hydroxybutyrate dehydrogenase) were analyzed during 24 hours following onset of therapy. Continuous ST analysis showed a faster resolution of the elevated ST-segments after thrombolytic therapy with rtPA than with UK(p < 0.01). Accelerated idioventricular rhythms (p < 0.05) occurred sooner following rtPA than UK treatment. The wash-out of creatine kinase was increased (p < 0.01) after rtPA. Although both drugs induced comparable, angiographically controlled reperfusion, the results suggest that the process of reperfusion was accelerated during thrombolysis with rtPA compared to UK. Thrombolytic therapy of AMI with rtPA may hence improve myocardial salvage.

Norepinephrine amplifies effects of vasopressin on the isolated rat heart.

We compared effects of perfusion of norepinephrine (NE, 10(-9) mol l-1 and of unchanged Krebs-Henseleit solution on the cardiac response to bolus injection of arginine vasopressin (AVP, 2 ng). 14 isolated rat working heart preparations were used in a balanced cross-over design. Coronary flow, oxygen consumption and extraction, heart rate and total flow were continuously recorded. The concentration of NE was below that exerting per se systematic influences on cardiac activity. However, NE changed the cardiac response to AVP: (1) the AVP-induced reduction in coronary flow was greater during NE (mean: 41.7%) than vehicle perfusion (30.5%, P less than 0.005. (2) The AVP-induced decrease in oxygen consumption was stronger on top of the NE (41.5%) than vehicle perfusion (33.6%, P less than 0.005). (3) Following AVP, oxygen extraction during NE was increased compared to oxygen extraction during vehicle perfusion (3.61 +/- 0.03 vs. 3.46 +/- 0.02 microliters O2 ml-1 g-1, P less than 0.005). Results support the view of a potentiating role of catecholamines for direct cardiovascular effects of AVP.

Adrenergic influences on cardiac function during ventricular fibrillation in isolated rat hearts.

Effects of norepinephrine (NE, 10(-6) M), epinephrine (E, 10(-6) M), and vehicle on coronary blood flow (CF), oxygen consumption, and lactate release were compared in 32 isolated rat hearts during 5 min of ventricular fibrillation (VF). After VF, tissue concentrations of ATP, AMP, creatinine phosphate (CP), and lactate were measured. Perfusion of treatments started 30 s after onset of VF and was maintained throughout VF. CF during VF was greater (P less than 0.005) during perfusion of E (mean +/- SE, 5.73 +/- 0.15 ml/min) than NE (5.06 +/- 0.32 ml/min) or vehicle (5.11 +/- 0.18 ml/min). Oxygen consumption during VF was higher during perfusion of E (29.5 +/- 0.9 microliters.min(-1).g wet heart wt(-1)) than vehicle (27.3 +/- 0.7 microliters.min(-1).g(-1); P less than 0.05); average oxygen consumption during NE (27.6 +/- 1.4 microliters.min(-1).g(-1)) and vehicle were comparable. After NE, but not E, tissue AMP concentrations were significantly increased, and CP concentrations were reduced compared with vehicle (P less than 0.05). Enhanced consumption of high-energy phosphates during NE suggests that there is also an enhanced demand for oxygen. However, unlike during E, during NE this demand is not met by an augmented CF. Thus, compared with E, NE treatment during VF may increase the risk of hypoxic damage.