Combined paravertebral and intrathecal vs thoracic epidural analgesia for post-thoracotomy pain relief.

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered the gold standard for post-thoracotomy pain relief, thoracic paravertebral block (PVB) and intrathecal opioid (ITO) administration have also been shown to be efficacious. We hypothesized that the combination of PVB and ITO provides analgesia comparable with that of TEA. METHODS: After local ethics committee approval, 84 consecutive patients undergoing open thoracic procedures were randomized to the TEA (ropivacaine 0.2%+sufentanil) or the PVB (ropivacaine 0.5%)+ITO (sufentanil+morphine) group. The primary endpoints were pain intensities at rest and during coughing/movement at 1, 2, 4, 8, 12, 24, 48, and 72 h after operation assessed by visual analogue scale (VAS) score. Data were analysed by multivariate analysis (anova; P<0.05). RESULTS: Patient and surgical characteristics were comparable between the groups. The mean and maximal VAS scores were lower in the TEA (n=43) than in the PVB+ITO group (n=37) at several time points at rest (P<0.026) and during coughing/movement (P<0.021). However, in the PVB+ITO group, the mean VAS scores never exceeded 1.9 and 3.5 at rest and during coughing/movement, respectively; and the maximal differences between the groups (TEA vs PVB+ITO) in the maximal VAS scores were only 1.2 (3.4 vs 4.6) at rest, and 1.3 (4.4 vs 5.7) during coughing/movement. CONCLUSIONS: Although VAS scores were statistically lower in the TEA compared with the PVB+ITO group at some observation points, the differences were small and of questionable clinical relevance. Thus, combined PVB and ITO can be considered a satisfactory alternative to TEA for post-thoracotomy pain relief. ClinicalTrials.gov number. NCT00493909.

Peak or plateau maximal inspiratory mouth pressure: which is best?

There is no clear evidence as to how maximal inspiratory mouth pressure (PI,max) should be measured, although plateau pressures sustained for 1 s and measured at residual volume (RV) are usually recommended. Peak and plateau PI,max were measured at RV and at functional residual capacity (FRC) in 533 healthy subjects (aged 10-90 yrs) in order to comparably test all PI,max measurements for their predictors, reproducibility and normal values. Plateau pressures accounted for 82.0-86.3%, of peak pressures. Peak and plateau pressures measured at FRC accounted for 84.3-90.5% of pressures at RV, and were highly correlated. Age was negatively predictive and weight and body mass index positively predictive of PI,max, but regression parameters were low. All PI,max measurements were comparable when calculating regression parameters, between-subject variability and reproducibility. In conclusion, peak and plateau maximal inspiratory mouth pressure are comparably useful for the assessment of inspiratory muscle strength and can be reliably measured at functional residual capacity and at residual volume. Regression equations are of low impact in predicting normal values due to the weak influence of demographic and anthropometric factors and to the high unexplained between-subject-variability. Age-related 5th percentiles can indicate the lower limit of the normal range.

Normocapnia during nIPPV in chronic hypercapnic COPD reduces subsequent spontaneous PaCO2.

Hypercapnia has been accepted during nasal intermittent positive pressure ventilation (nIPPV) and during subsequent spontaneous breathing in patients with chronic hypercapnic respiratory failure (HRF) due to COPD. We tested the hypothesis that nIPPV aimed at normalizing PaCO2 will reduce PaCO2 during subsequent spontaneous breathing. For that purpose 14 consecutive inpatients (age 61.4 +/- 9.9 years) with chronic HRF due to COPD were established on passive pressure-controlled nIPPV in a stepwise approach. Assisted ventilation with supplemental oxygen to reach normoxemia was started followed by passive ventilation with a stepwise increment in the inspiratory pressure and finally by a stepwise increase in the respiratory rate to establish normocapnia. Baseline pulmonary function parameters were: FEV1 0.97 +/- 0.43 l, PaCO2 59.5 +/- 8.4 mmHg, PaO2 49.9 +/- 7.8 mmHg, HCO3- 35.6 +/- 5.2 mmol/l, pH 7.39 +/- 0.04. Normoxemia as well as normocapnia was thus established by decreasing PaCO2 by 19.5 +/- 7.0 mmHg during nIPPV within 8.8 +/- 3.8 days (P < 0.001) (inspiratory pressure 29.8 +/- 3.8 mmHg, respiratory rate 22.9 +/- 1.9 BPM). Spontaneous PaCO2 measured 4 h after cessation of nIPPV decreased to 46.0 +/- 5.5 mmHg (P < 0.001), and HCO3- decreased to 27.2 +/- 3.0 mmol/l (P < 0.001). At 6 months of follow-up, II patients continued nIPPV with stable blood gases and with a decrease of P0.1/Plmax from 9.4 +/- 4.3% to 5.9 +/- 2.0% (P < 0.005). In conclusion, normalization of PaCO2 by passive nIPPV in patients with HRF due to COPD is possible and leads to a significant reduction of PaCO2 during subsequent spontaneous breathing and is associated with improved parameters of respiratory muscle function.

Differential effect of nicotinic agonists on the [3H]norepinephrine release from rat hippocampal slices.

The aim of this study was to investigate the mechanisms involved in the effect of nicotinic agonists on the [3H]norepinephrine ([3H]NE) release from rat hippocampal slices. The stimulatory effect of nicotine, cytisine, epibatidine and anatoxin-A was completely blocked by the nicotinic antagonist mecamylamine (10 microM). In contrast, the effect of dimethylphenylpiperazinium (DMPP) was only partially inhibited by mecamylamine but was completely blocked by the NE uptake inhibitor desipramine (DMI, 10 microM). Finally, the effect of lobeline was not affected by mecamylamine and was only partially blocked by DMI. Our data indicate that the majority of nicotinic agonists increase the release of [3H]NE exclusively via stimulation of nicotinic acetylcholine receptors (nAChRs). DMPP, in addition to the stimulation of nAChRs, also evokes a carrier-mediated release. Lobeline has no stimulatory effect on nAChRs, induces a carrier-mediated release and has a further action of unidentified mechanism. Our results suggest that special caution is required for the interpretation of data, when DMPP or lobeline are used as nicotinic agonists.

Nicotinic acetylcholine receptor antagonistic activity of monoamine uptake blockers in rat hippocampal slices.

The aim of our study was to investigate the effect of different monoamine uptake blockers on the nicotine-evoked release of [3H]noradrenaline ([3H]NA) from rat hippocampal slices. We found that desipramine (DMI), nisoxetine, cocaine, citalopram, and nomifensine inhibit the nicotine-evoked release of [3H]NA with an IC50 of 0.36, 0.59, 0.81, 0.93, and 1.84 microM, respectively. These IC50 values showed no correlation with the inhibitory effect (Ki) of monoamine uptake blockers on the neuronal NA transporter (r = 0.17, slope = 0.02), indicating that the NA uptake system is not involved in the process. In whole-cell patch clamp experiments neither drug blocked Na+ currents at 1 microM in sympathetic neurons from rat superior cervical ganglia, and only DMI produced a pronounced inhibition (52% decrease) at 10 microM. Comparison of the effect of DMI and tetrodotoxin (TTX) on the electrical stimulation- and nicotine-evoked release of [3H]NA showed that DMI, in contrast to TTX, inhibits only the nicotine-induced response, indicating that the target of DMI is not the Na+ channel. Our data suggest that monoamine uptake blockers with different chemical structure and selectivity are able to inhibit the nicotinic acetylcholine receptors in the CNS. Because these compounds are widely used in the therapy of depressed patients, our findings may have great importance in the evaluation of their clinical effects.

A possible role of nitric oxide in the regulation of dopamine transporter function in the striatum.

Brain microdialysis and high-performance liquid chromatography with electrochemical detection were used to study the effect of the nitric oxide synthase inhibitor Nomega-nitro-L-arginine methyl ester (L-NAME) on striatal dopamine (DA) release in the anesthetized rat. Systemic administration of L-NAME (10 mg/kg, i.p.) significantly decreased the resting release of DA. The peak effect (23% decrease) was reached 45 min after injection. The inactive enantiomer D-NAME (10 mg/kg, i.p.) or the vehicle (saline, 5 ml/kg i.p.) had no effect on the striatal DA level. Neither treatment altered significantly the concentration of dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA). To investigate the possible involvement of the DA uptake system L-NAME was injected also in the presence of the DA uptake inhibitor nomifensine. Local application of nomifensine (10 microM in the dialysate medium) increased the extracellular concentration of DA to about eight-fold of the basal value and stabilized it at this higher level. Under these conditions L-NAME (10 mg/kg, i.p.) was not able to alter the striatal DA level. Neither nomifensine nor L-NAME caused any change in the level of DOPAC and HVA. Our data suggest that endogenously produced nitric oxide may influence the activity of the DA transporter which effect may have special importance in the regulation of extracellular transmitter concentration in the striatum.

Analysis of deprenyl metabolites in the rat brain using HPLC-ES-MS.

Methylamphetamine and amphetamine, the two major metabolites of deprenyl in the rat brain were analyzed using HPLC method combined with electrospray-mass spectrometer. (-)-Deprenyl and (+)-deprenyl were orally administered to rats either in a single dose of 10 mg/kg, or three times a week for three weeks. The metabolites were determined in four different parts of the rat brain, such as in the frontal cortex, corpus striatum, hippocampus, and hypophysis. The ratio of methylamphetamine to amphetamine was also compared after (-)-deprenyl and (+)-deprenyl treatments.

Nicotinic acetylcholine receptor antagonist effect of fluoxetine in rat hippocampal slices.

We compared the effect of mecamylamine and fluoxetine on the hippocampal noradrenaline (NA) release evoked by nicotine in vitro. Nicotine (100 microM) increased the basal release of [3H]NA from rat hippocampal slices. This effect was blocked by the potent nicotinic antagonist mecamylamine in a dose-dependent manner (IC50 = 0.19 microM). The selective serotonin reuptake inhibitor (SSRI) fluoxetine also antagonised the response to nicotine in a dose-dependent manner with a similar strength (IC50 = 0.57 microM). Our data indicate that fluoxetine has nicotinic acetylcholine receptor antagonist effect in the central nervous system. The possible clinical significance of this finding is discussed.