[Continuous lumbar epidural anesthesia: insertion a patient with unrecognized classical hemophilia A]. / Kontinuierliche lumbale Epiduralanästhesie: Anlage bei einem Patienten mit unerkannter Hämophilie A.

This report describes a case where a continuous lumbar epidural anesthesia was inserted for an operation in a patient with classical hemophilia which was unknown at the time of catheter insertion. In addition to an exact description of the intervention, the anamnesis and laboratory contraindications for epidural anesthesia are discussed. Furthermore, the necessity of preoperative investigations and their value when an epidural anesthesia is planned are also discussed.

Clonidine increases membrane-associated phospholipase A 2.

BACKGROUND AND OBJECTIVE: An anti-inflammatory effect of alpha2-adrenoreceptor agonists has been suggested. Phospholipase A2 is a key enzyme in the production of precursors of inflammatory lipid mediators. The aim of the present study was to investigate the effect of clonidine on phospholipase A2 activity in an established in vitro model. METHODS: Human being platelet membranes containing active phospholipase A2 were exposed to buffer control or to three increasing concentrations of clonidine. Phospholipase A2 was measured by a radioisotope technique. RESULTS: A massive increase in phospholipase A2 activity was measured after clonidine exposure leading to final values of 92.5 +/- 3.1 pmol mg protein(-1) min(-1) (4.5-fold higher than control values; P < or = 0.01 vs. control). After clonidine exposure the maximal reaction velocity increased, while the Michaelis-Menten constant did not change. The Lineweaver-Burk representation suggested an interaction of clonidine with the phospholipase A2-substrate complex as well as the phospholipase A2 molecule. CONCLUSION: We conclude that the putative anti-inflammatory effect of clonidine was not caused by inhibition of phospholipase A2.

Phospholipase A2-induced coagulation abnormalities after bee sting.

We will examine the correlation between various bee venom phospholipase A2 (PLA2) concentrations and several parameters of coagulation in human plasma in order to offer a rationale for requesting a particular laboratory coagulation test after bee sting(s). We will also evaluate in vitro the influence of clinically available drugs with a noncompetitive inhibitory effect on PLA2 on the anticoagulant effect of bee venom PLA2. Prothrombin index (PTi), partial thromboplastin time (PTT), antithrombin III (AT III), soluble fibrin monomers (SFM), the activity of coagulation factors I, II, V, and VIII, and thrombelastography (TEG) parameters (split point [Sp], reaction time [R], kinetic time [K], coagulation time [R + K], maximal amplitude [MA], and the growth angle [alpha]) were determined before and after addition of 1.4, 2.7, and 4.1 units (1, 2, and 3 microg protein respectively) of bee venom PLA2. Linear regression was used to determine the significance of the relationship between these coagulation parameters and bee venom PLA2 concentrations used. To study the influence of ketamine, lidocaine, magnesium, furosemide, and cromolyn on the anticoagulant effect of bee venom PLA2, PTi and factor II- and V-activities were measured before and after addition of 2.7 units of PLA2 and PLA2 plus one of the tested substances. Determinations of F II, PTi, F V, and F VIII showed a negative correlation to bee venom PLA2 concentration (r = -0.88, -0.86, -0.81, and -0.79 respectively). A positive correlation was found for PTT (r = 0.69). FII- activity and PTi correlated better with bee venom PLA2 concentration than other parameters. F I, AT III, and SFM showed no changes. Whereas Sp, R, and K were prolonged by bee venom PLA2 and a was reduced, there was no correlation to the PLA2 concentration. Addition of none of the 5 substances could correct the effects of bee venom PLA2 on the coagulation. In a patient with toxic reaction or a severe anaphylactic reaction after bee sting(s) we suggest determinations of FII and/or PTi. This will allow a quick and economical assessment of coagulation abnormalities after bee sting(s). Noncompetitive PLA2-inhibitors (ketamine, lidocaine, magnesium, furosemide, and cromolyn) are unable to correct in vitro the anticoagulant effect of bee venom PLA2. They cannot be recommended at this stage for this purpose. Further investigations with competitive PLA2-inhibitors are warranted.

L-lactate reduces in vitro the inhibition of butyrylcholinesterase (BChE) by paraoxon (E 600).

Intoxication with the organophosphorus compound paraoxon (POX), an inhibitor of serine hydrolases, is frequent. Oximes are the only enzyme reactivators clinically available. Serendipitous observation led us to the hypothesis that lactate might attenuate some of the POX effects. In vitro effects of lactate on the inhibition of butyrylcholinesterase (BChE) by POX were assessed in plasma of 12 healthy human volunteers. The determinations were repeated using different lactate and different POX concentrations. The BChE activity determinations were performed in the following settings: (i) baseline untreated plasma (BL); (ii) after addition of POX to plasma (pl+POX); (iii) after POX and plasma were incubated and then lactate was added (pl+POX/lact); (iv) after addition of lactate to plasma (pl+lact); (v) after lactate and plasma were incubated and then POX was added (pl+lact/POX); (vi) after lactate and POX were incubated and then added to plasma (lact+POX/pl). In the micro- and millimolar ranges, lactate is able to abolish in vitro the inhibition of BChE by POX in human plasma when added to plasma prior to POX or when incubated with POX prior to addition to plasma. Lactate added to plasma after POX has no protective effect. In a second set of experiments, the effect of lactate on BChE activity was determined. At high millimolar concentrations, lactate itself inhibits BChE to an extent comparable to POX. Lactate is a mixed inhibitor of BChE, being able to interfere with the enzyme-substrate complex (inhibition constant for the enzyme-inhibitor-substrate complex K'I(EIS) = 81 mM) and the enzyme (inhibition constant for the enzyme-inhibitor complex K(I) (EI) = 26 mM).

Phospholipase A2 (PLA2) activity in mini pigs after acute high dose i.v.-paraoxon (POX) intoxication.

The purpose of the present study was to establish in the mini pig model the effects of paraoxon (POX) on PLA2 activity. Six anesthetized and mechanically ventilated mini pigs were infused over 50 min with 0.3, 1, 3, 9, 27 and 81 mg POX kg(-1) BW(-1) dissolved in ethanol, respectively. The control animal received no POX but the ethanol amount corresponding to the highest POX dose. PLA2 activity measurements were carried out immediately after POX application. Data were analysed with the Mann Whitney-Wilcoxon rank order test. Statistical significance was assumed for P < or = 0.05. Exposure to POX inhibited PLA2 activity to 50.5 +/- 8.9% of baseline activity. The changes seen were not dose-dependent. The dose dependency previously demonstrated in vitro was not reproducible in vivo. This is most probably due to the massive endogenous catecholamine release leading to PLA2 activation. An additional masking effect is due to the (co)administration of drugs needed for anesthesia and cardiovascular support, especially Mg2+. These substances also influence the PLA2 activity.

Dose-dependent inhibition of phospholipase A2 by paraoxon in vitro: preliminary results.

To establish the dose dependency of phospholipase A2 (PLA2) inhibition by the organophosphorus compound (OPC) paraoxon (POX), human platelet membranes were incubated after Ca2+ removal (to inactivate the PLA2) with 0.3, 1 and 3 microg ml(-1) POX for 5, 30 and 60 min each. The PLA2 activity (pmol mg[-1] protein min[-1]) was measured after subsequent enzyme reactivation. The PLA2 activity in native platelets was considered to be 100%; all other measured values are expressed as a percentage thereof. Data were analysed with the Mann-Whitney Wilcoxon rank order test and ANOVA. Statistical significance was assumed for P < or = 0.01. Paraoxon inhibited in a dose-dependent manner the PLA2 activity. Different incubation times of the inactive PLA2 with POX did not have any additional effect on the activity reduction after activation. At the tested POX concentrations the PLA2 activity was 42 +/- 5.4%, 29 +/- 3.4% and 15 +/- 6.6%, respectively. The corresponding butyrylcholine esterase (BChE) activities were <<1% of the baseline activity. Phospholipase A2 is less sensitive to POX inhibition than BChE and, at clinically achievable POX concentrations, shows a clear dose dependency. Further work is needed to elucidate the exact mechanism and time dependency of the phenomenon.