Thirty patients undergoing total hip replacement were randomly allocated to one of two groups. One group (n = 14) received extradural anaesthesia with 0.5% bupivacaine with adrenaline continued into the postoperative period (24 h) for pain relief. The other group (n = 16) received general anaesthesia with controlled ventilation, using nitrous oxide in oxygen and fentanyl i.v. Following surgery they received a narcotic analgesic i.m. on demand. Analysis of fibrinolysis inhibition activity and plasminogen activators revealed a significantly better fibrinolytic function in patients given continuous extradural anaesthesia than in those who received general anaesthesia followed by narcotics in the period after operation. Furthermore, the capacity for activation of factor VIII was significantly lower after operation in the former group.

Catechol-O-methyltransferase (COMT) metabolizes catecholamines such as dopamines, noradrenaline and adrenaline. It exists as common high and low activity alleles in the population (determined by a valine 158 methionine polymorphisms), and high red blood cell activity of COMT has previously been associated with schizophrenia. To examine the relationship between COMT and schizophrenia genetically, the transmission disequilibrium test was performed on 22 multiply affected Caucasian and Japanese families genotyped for val158met and a second, silent, polymorphism (C256G), using PCR based assays. The high activity val158 allele was transmitted from parents to the affected individuals more frequently than the low activity met158 allele, although this was not statistically significant. Combining this data with a previous study using Chinese family trios with schizophrenia (Li et al., 1996) gave a highly significant result (p = 0.0015). The G256 allele was also transmitted preferentially to the affected offspring, and this was statistically significant when schizophrenia, schizoaffective disorder and unspecified functional psychosis were included in the definition of the affected phenotype (p = 0.03). Overall, these findings may indicate an effect of COMT alleles on susceptibility to schizophrenia, or reflect linkage disequilibrium with a different causative polymorphism in the vicinity. Other reported associations of COMT with obsessive compulsive and rapid cycling bipolar disorder indicate that the COMT gene may have complex and pleiotropic effects on susceptibility and symptomatology of neuropsychiatric disorders.

Angioedema without urticaria is a clinical syndrome characterised by self-limiting local swellings involving the deeper cutaneous and mucosa tissue layers. Most occurrences of angioedema respond to treatment with a histamine H1 receptor blocker (antihistamine) because they are an allergic or parallergic reaction. A small number of cases do not respond to antihistamine treatment. Such cases tend to occur in patients with deficiency or dysfunction of the inhibitor of the first component of the complement (C1-INH), but more rarely can occur in patients with other conditions and as an adverse drug reaction. Angioedema is well documented in patients taking ACE inhibitors. Considering that 35 to 40 million patients are treated worldwide with ACE inhibitors, this drug class could account for several hundred deaths per year from laryngeal oedema. ACE inhibitors certainly do not mediate angioedema through an allergic or idiosyncratic reaction. For this reason the relationship with this drug is often missed and consequently quite underestimated. Rare instances of angioedema have also been reported with angiotensin II receptor antagonists. This adverse effect seems to occur less frequently with angiotensin II receptor antagonists than with ACE inhibitors. However, we do not know whether this adverse effect has the same mechanism with the 2 classes of medications. Some cases of severe angioedema have been recently reported after treatment with fibrinolytic agents. Scattered reports suggest the possibility of angioedema associated with the use of estrogens, antihypertensive drugs other than ACE inhibitors, and psychotropic drugs. Angioedema can also occur with nonsteroidal anti-inflammatory drugs. Prevention of angioedema relies first on the patient history. Estrogen and ACE inhibitors should be avoided in a patient with congenital or acquired C1-INH deficiency. In the case of ACE inhibitors, the appearance of angioedema following long term treatment does not lessen the probability that such an agent could be the cause. The most important action to take in a patient with suspected drug-induced angioedema is to discontinue the pharmacological agent. Epinephrine (adrenaline), diphenydramine and intravenous methylprednisolone have been proposed for the medical management of airway obstruction, but so far no controlled studies have demonstrated their efficacy. If the acute airway obstruction leads to life-threatening respiratory compromise an emergency cricothyroidotomy must be performed.

During contractile activity, skeletal muscles undergo a net loss of cytoplasmic K(+) to the interstitial space. During intense exercise, plasma K(+) in human arterial blood may reach 8 mm, and interstitial K(+) 10-12 mm. This leads to depolarization, loss of excitability and contractile force. However, little is known about the effects of these physiological increases in extracellular K(+) ([K(+)](o)) on contractile endurance. Soleus muscles from 4-week-old rats were mounted on transducers for isometric contractions in Krebs-Ringer bicarbonate buffer containing 4-10 mm K(+), and endurance assessed by recording the rate of force decline during continuous stimulation at 60 Hz. Increasing [K(+)](o) from 4 to 8 or 10 mm and equilibrating the muscles for 40 or 20 min augmented the rate of force decline 2.4-fold and 7.2-fold, respectively (P < 0.001). The marked loss of endurance elicited by exposure to 8 or 10 mm K(+) was alleviated or significantly reduced by stimulating the Na(+),K(+)-pumps by intracellular Na(+) loading, the beta(2)-agonist salbutamol, adrenaline, calcitonin gene related peptide, insulin or repeated excitation. In conclusion, excitation-induced increase in [K(+)](o) is an important cause of high-frequency fatigue, and the Na(+),K(+)-pumps are essential for the maintenance of contractile force in the physiological range of [K(+)](o). Recordings of contractile force during continuous stimulation at 8-10 mm K(+) may be used to analyse the effects of agents or conditions influencing the excitability of working isolated muscles.

Effects of beta-adrenoceptor stimulation on intracellular Ca2+ transients and tension were explored in rat ventricular muscles injected with aequorin. Adrenaline (0.05-5.0 microM) and isoproterenol (0.05-1.0 microM) increased the peak of twitch tension and accelerated relaxation. The former effect depended on Ca2+ concentration in Tyrode's solution ([Ca2+]o) and the stage of the experiment. Low concentrations of these drugs added to normal Tyrode's solution containing 2 mM [Ca2+]o did not potentiate twitch tension in the early stage of the experiments. These drugs increased the peak of the aequorin light signal and slightly accelerated the falling phase of the light especially the tail. Effects of dibutyryl-cyclic AMP (DB-cAMP)(0.1-5.0 mM) and 3-isobutyl-1-methylxanthine (IBMX) (0.01-0.5 mM) were qualitatively similar to those of adrenaline and isoproterenol. Isoproterenol applied at the peak of Na-deficient contracture decreased tension without significantly changing the light signal; similar results were obtained in the presence of ryanodine (1 microM). The results were interpreted as follows: The increase of intracellular cAMP induced by beta-adrenoceptor stimulation facilitated Ca2+ uptake by sarcoplasmic reticulum (SR) and decreased Ca2+ sensitivity of contractile elements. Faster relaxation induced by cAMP was considered to be due to the decrease of Ca2+ sensitivity of contractile elements and faster Ca2+ uptake by SR. The slightly faster falling phase of light transient might be due to the faster Ca2+ uptake by SR, which predominates over the slower fall of [Ca2+]i induced by the decreased Ca2+ sensitivity of the contractile element.

Adrenaline resulted in a reversible 4-fold increase in the amount of pyruvate dehydrogenase in its active non-phosphorylated form in the perfused rat heart within 1 min. The increase was less in extent in hearts from starved or diabetic rats or in hearts from control rats oxidizing acetate, unless pyruvate was added to the perfusion medium. Increases could also be induced by other inotropic agents, supporting the hypothesis that increases in cytoplasmic Ca2+ can be relayed into mitochondria and influence oxidative metabolism.

Imidazolines bind with high affinity not only to alpha-adrenoceptors but also to specific imidazoline binding sites (IBS) labelled by either [3H]clonidine or [3H]idazoxan and termed I1- and I2-IBS, respectively. Since bovine adrenal chromaffin cells lack alpha 2-adrenoceptors, we investigated the pharmacological characteristics of [3H]clonidine binding sites in the bovine adrenal medulla. The binding of [3H]clonidine was rapid, reversible, partly specific (as defined by naphazoline 0.1 mmol/l; 55% specific binding at [3H]clonidine 10 nmol/l), saturable and of high affinity. The specific binding of [3H]clonidine to bovine adrenal medullary membranes was concentration-dependently inhibited by various imidazolines, guanidines and an oxazoline derivative but not, or with negligible affinity, by rauwolscine and (-)-adrenaline. In most cases, the competition curves were best fitted to a two-site model. The rank order of affinity for the high affinity site (in a few cases the single detectable site) was as follows: naphazoline>> or = BDF 7579 (4-chloro-2-isoindolinyl guanidine)>> or = clonidine>> or = cirazoline>> or = BDF 6143 (4-chloro-2-(2-imidazoline-2-ylamino)-isoindoline hydrochloride)>> BDF 7572 (4,7-chloro-2-(2-imidazolin-2-ylamino)-isoindoline)>> moxonidine = rilmenidine>> BDF 6100 (2-(2-imidazoline-2-ylamino)-isoindoline) = idazoxan>> phentolamine>> aganodine = guanabenz>> amiloride>> histamine. This rank order is compatible with the pharmacological properties of the I1-IBS. The non-hydrolysable GTP-analogue Gpp(NH)p (5'guanylylimidodiphosphate; 100 mumol/l) inhibited specific [3H]clonidine binding by about 50%. Equilibrium [3H]clonidine binding was also significantly reduced by K+ and Mg2+.(ABSTRACT TRUNCATED AT 250 WORDS)

Several lines of evidence suggest that the endogenous opioid peptides endorphins may play a role in the defensive response of the organism to stress. The present paper summarizes these findings as well as evidence linking endorphins to the anterior pituitary polypeptide hormone adrenocorticotropin (ACTH). Evidence is presented that endorphins may function as trophic hormones in peripheral target organs such as the adrenal medulla and the pancreas. As such they may be part of the physiological mechanisms that mediate adrenaline and glucagon release in response to stress. Endorphins (enkephalins) are also suggested to play a role in the control of the pituitary gland during stress. In such capacity they may act as hormone-releasing or inhibiting factors. Finally, endorphins appear to play a role in the behavioral concomitants of stress. In such capacity endorphins are suggested to function as modulators of neural systems that mediate the elaboration and expression of the reactive/affective components of stress. Speculations on the mode of interaction between endorphins and ACTH in the global response to stress are discussed.

1. Evidence is presented that the increase in clearing-factor lipase activity that occurs when adipose tissue from starved rats is incubated in a defined medium in vitro is due to an increase in the total enzyme content of the system. It is shown that the clearing-factor lipase activity rises to reach a plateau level where, it is suggested, rates of enzyme synthesis and of enzyme destruction become balanced. 2. The presence of heparin in the incubation medium results in the extraction of part of the clearing-factor lipase originally present in the adipose tissue and this could provide the stimulus for the increase in total enzyme content. 3. Glucose is required in the incubation medium at a very low concentration. It can be replaced by fructose, but not by pyruvic acid, lactic acid, glyceric acid or dihydroxyacetone. 4. Adrenaline and corticotrophin inhibit the increase in enzyme activity when they are present in the incubation medium. 5. The high clearing-factor lipase activity associated with adipose tissue of fed rats is decreased by 50% within 3hr. of the injection of puromycin.

Isolated preparations of the rabbit vas deferens were incubated with (--)-(3)H-nor- adrenaline. A preferential release of (3)H-noradrenaline was demonstrated after electrical stimulation of the intramural nerves in those tissues labelled with 10 ng/ml (3)H-noradrenaline. There was no preferential release of (3)H-noradrenaline when the vasa were initially labelled with 100 ng/ml (3)H-noradrenaline. It is concluded that low concentrations of (3)H-noradrenaline do not mix homogeneously with the total tissue store but enter a small easily releasable store.

1. The beta-adrenoceptor (beta-AR) subtypes mediating relaxation of the rabbit, rat and canine detrusors were subjected to functional investigation using selective beta-AR agonists and antagonists. 2. In all three species, isoprenaline, noradrenaline and adrenaline each produced a concentration-dependent relaxation of the detrusor. The rank order for their relaxing potency was isoprenaline>adrenaline)noradrenaline in rabbits and rats, but isoprenaline>noradrenaline)adrenaline in dogs. 3. Dobutamine did not produce relaxation of the detrusors at concentrations that are selective for beta1-AR. The selective beta2-AR agonist, procaterol, had a more potent relaxing effect on rabbit and rat detrusors than on the canine detrusor. CGP-12177A, a selective beta3-AR agonist, was more effective in the rabbit than in the other two species. On the other hand, the relaxing effect of another beta3-AR agonist, CL316243, was more pronounced in dogs and rats than in rabbits. 4. CGP-20712A (10(-9) to 10(-7) M), a selective beta1-AR antagonist, caused a slight rightward shift of the concentration-relaxation response curve for isoprenaline in the canine detrusor (pA2 9.41), but not in the rabbit and rat detrusors. ICI-118,551, a selective beta2-AR antagonist, antagonized the isoprenaline-induced relaxation in rabbits (pA2 9.45) and rats (pA2 9.05), but not in dogs. Bupranolol, a non-selective beta-AR antagonist, caused a rightward shift of the concentration-relaxation curve for isoprenaline in the rabbit (pA2 9.32) and rat (pA2 8.98). However, higher concentrations (3 x 10(-8) to 10(-5) M) were needed to induce a rightward shift of the curve for isoprenaline in the dog (pA2 8.19) than in the other two species. 5. We have confirmed that the distribution of beta-AR subtypes in the detrusor muscle varies significantly from species to species and we provide here the first evidence of the presence of beta3-AR in the detrusor. It is suggested that the relaxation induced by adrenoceptor agonists in urinary bladder smooth muscle may be mediated mainly via beta2-AR in rabbits, via both beta2- and beta3-AR in rats, but mainly via beta3-AR in dogs.

1. Two-dimensional electrophoresis has been used to study the extent of phosphorylation of the P light chain of myosin and troponin I in the rabbit beating heart. 2. A procedure has been developed that eliminates endogenous protein phosphatase activity during homogenization and sample preparation for electrophoresis. 3. Evidence has been obtained for two unphosphorylated forms of the P light chain in myosin from the ventricle of the rabbit, guinea pig and cow. 4. In vivo and in the rabbit perfused beating heart about 25% of the P light-chain fraction is in the phosphorylated form. 5. Intervention with adrenaline produced a slight increase in the extent of phosphorylation that reached a maximum after the peak in inotropic response. A similar increase was obtained with ischaemia in the absence of adrenaline. 6. The changes in phosphorylation of the major forms of troponin I identified by electrophoresis occurred after the peak of response to adrenaline and were compatible with previous results.

BACKGROUND

One of the controversies in preventive medicine is, whether a general reduction in sodium intake can decrease the blood pressure of a population and thereby reduce cardiovascular mortality and morbidity. In recent years the debate has been extended by studies indicating that reducing sodium intake has effects on the hormone and lipid profile.

OBJECTIVE

To estimate the effects of low sodium versus high sodium intake on systolic and diastolic blood pressure (SBP and DBP), plasma or serum levels of renin, aldosterone, catecholamines, cholesterol and triglycerides.

METHODS

"MEDLINE" and reference lists of relevant articles were searched from 1966 through December 2001.

METHODS

Studies randomising persons to low sodium and high sodium diets were included if they evaluated at least one of the above outcome parameters.

METHODS

Two authors independently extracted the data, which were analysed by means of Review Manager 4.1.

RESULTS

In 57 trials of mainly Caucasians with normal blood pressure, low sodium intake reduced SBP by -1.27 mm Hg (CI: -1.76; -0.77)(p<0.0001) and DBP by -0.54 mm Hg (CI: -0.94; -0.14) (p = 0.009) as compared to high sodium intake. In 58 trials of mainly Caucasians with elevated blood pressure, low sodium intake reduced SBP by -4.18 mm Hg (CI: -5.08; - 3.27) (p < 0.0001) and DBP by -1.98 mm Hg (CI: -2.46; -1.32) (p < 0.0001) as compared to high sodium intake. The median duration of the intervention was 8 days in the normal blood pressure trials (range 4-1100) and 28 days in the elevated blood pressure trials (range 4-365). Multiple regression analyses showed no independent effect of duration on the effect size. In 8 trials of blacks with normal or elevated blood pressure, low sodium intake reduced SBP by -6.44 mm Hg (CI: -9.13; -3.74) (p < 0.0001) and DBP by -1.98 mm Hg (CI: -4.75; 0.78) (p = 0.16) as compared to high sodium intake. The magnitude of blood pressure reduction was also greater in a single trial in Japanese patients. There was also a significant increase in plasma or serum renin, 304% (p < 0.0001), aldosterone, 322%, (p < 0.0001), noradrenaline, 30% (p < 0.0001), cholesterol, 5.4% (p < 0.0001) and LDL cholesterol, 4.6% (p < 0.004), and a borderline increase in adrenaline, 12% (p = 0.04) and triglyceride, 5.9% (p = 0.03) with low sodium intake as compared with high sodium intake.

CONCLUSIONS

The magnitude of the effect in Caucasians with normal blood pressure does not warrant a general recommendation to reduce sodium intake. Reduced sodium intake in Caucasians with elevated blood pressure has a useful effect to reduce blood pressure in the short-term. The results suggest that the effect of low versus high sodium intake on blood pressure was greater in Black and Asian patients than in Caucasians. However, the number of studies in black (8) and Asian patients (1) was insufficient for different recommendations. Additional long-term trials of the effect of reduced dietary sodium intake on blood pressure, metabolic variables, morbidity and mortality are required to establish whether this is a useful prophylactic or treatment strategy.

Plasma adrenaline-blood glucose interrelationships in insulin-induced hypoglycaemia in man have been studied using a sensitive double-isotope derivative method for adrenaline estimation. Plasma adrenaline reached a peak of 1.24 ng/ml at 45 minutes after insulin while blood glucose reached a nadir of 22 mg/100 ml at 30 minutes. There was a strong correlation both between the rise in adrenaline and the degree of hypoglycaemia and between the rise in adrenaline and the post-hypoglycaemic rise in glucose. Plasma noradrenaline rose from 0.29 to 0.59 ng/ml, the rise correlating with the rise in adrenaline. Changes in pulse rate preceded and were unrelated to changes in plasma catecholamines. Fuel mobilisation in response to adrenaline infusion (6 mug/min. for 20 min.) in normoglycaemic man was also studied. Plasma adrenaline concentration rose from a mean of 0.02 ng/ml to 0.71 ng/ml while plasma noradrenaline concentration was unchanged. Blood glucose rose from 71 to 98 mg/100 ml while plasma insulin decreased from 11 to 8 muU/ml. Blood lactate rose by 0.85 mM while pyruvate concentration remained unchanged. Blood glycerol concentration rose twofold and ketone body concentration threefold but there was little change in the concentrations of the glucogenic amino acids, alanine, glutamate and glutamine. Both the 3-hydroxybutyrate/acetoacetate ratio and the lactate/pyruvate ratio rose implying a more reduced intracellular state due presumably to increased hepatic fatty acid oxidation. It is concluded that adrenaline enhances the recycling of lactate and spares glucose through the mobilitsation of lipids but that amino acids are little affected.

The influence of postoperative pain on muscle function, and the possible effect of local anesthetics on the normal muscle function are discussed. The integrated EMG (IEMG) during maximum voluntary contraction of the quadriceps muscle was registered in ten patients the day after undergoing reconstruction of the anterior cruciate ligament. Recordings were taken before, 5, 12, and 20 min to 25 min after epidural injection of 20 ml of 0.25% lidocaine with adrenaline (2.5 micrograms/ml). As pain gradually subsided, IEMG increased a mean of 2,728% 20 min to 25 min after injection (range 425% to 10,068%), compared to initial recordings before anesthesia. This indicates that pain relief plays a significant role in the ability to normally activate the quadriceps muscle after open knee surgery. Neither the Hoffman (H-)reflex, nor maximum voluntary isokinetic muscle torque was appreciably affected by epidural injection of dilute local anesthetics, as tested on two healthy volunteers. Infiltrations of local anesthetics into the distal part of the quadriceps muscle did not affect maximum voluntary isokinetic knee extension torque. From the experiments performed we conclude that it is possible to selectively block pain by injections of local anesthetics into the epidural space, without interfering with normal muscle function. It might thus be possible to prevent some of the postoperative muscle atrophy by using a continuous epidural analgesia for two to three days following surgery, and starting an early active physical therapy program.

BACKGROUND

Severe injury activates the sympathoadrenal, hemostatic and inflammatory systems, but a maladapted response may contribute to a poor outcome. Soluble CD40L is a platelet-derived mediator that links inflammation, hemostasis and vascular dysfunction.

OBJECTIVE

To investigate the association between the sCD40L level and tissue injury, shock, coagulopathy and mortality in trauma patients.

METHODS

A prospective, observational study of 80 trauma patients admitted to a Level I Trauma Center. Data on demography, biochemistry, Injury Severity Score (ISS) and 30-day mortality were recorded and admission plasma/serum analyzed for sCD40L and biomarkers reflecting sympathoadrenal activation (adrenaline, noradrenaline), tissue/endothelial cell/glycocalyx damage (histone-complexed DNA fragments [hcDNA], Annexin V, thrombomodulin and syndecan-1), coagulation activation/inhibition (PF1.2, TAT-complex, antithrombin, protein C, activated protein C, sEPCR, TFPI, von Willebrand factor [VWF], fibrinogen and factor [F] XIII), fibrinolysis (D-dimer, tissue plasminogen activator [tPA] and plasminogen activator inhibitor-1 [PAI-1]) and inflammation (interleukin-6 [IL-6] and sC5b-9). We compared patients stratified by median sCD40L level and investigated predictive values of sCD40L for mortality.

RESULTS

High circulating sCD40L was associated with enhanced tissue and endothelial damage (ISS, hcDNA, Annexin V, syndecan-1 and sTM), shock (pH, standard base excess), sympathoadrenal activation (adrenaline) and coagulopathy evidenced by reduced thrombin generation (PF1.2), hyperfibrinolysis (D-dimer), increased activated partial thromboplastin time (APTT) and inflammation (IL-6) (all P < 0.05). A higher ISS (P = 0.017), adrenaline (P = 0.049) and platelet count (P = 0.012) and lower pH (P =0.002) were associated with higher sCD40L by multivariate linear regression analysis. High circulating sCD40L (odds ratio [OR] 1.84 [95% CI 1.05-3.23], P = 0.034), high age (P = 0.002) and low Glasgow Coma Score (GCS) pre-hospital (P = 0.002) were independent predictors of increased mortality.

CONCLUSIONS

High early sCD40L levels in trauma patients reflect tissue injury, shock, coagulopathy and sympathoadrenal activation and predict mortality. As sCD40L has pro-inflammatory activity and activates the endothelium, sCD40L may be involved in trauma-induced endothelial damage and coagulopathy.

The cytoplasmic Ca2+ concentration ([Ca2+]i) was continuously monitored in single glucagon-producing alpha 2-cells isolated from the mouse pancreas and later identified by immunostaining. Up to 60% of the alpha 2-cells exhibited spontaneous [Ca2+]i oscillations (frequency 0.1-0.3/min) in a medium containing 3 mM glucose. In originating from a basal level of 60-100 nM, reaching peak values of 300-400 nM and promptly disappearing after blocking voltage-dependent Ca2+ channels with methoxyverapamil, the oscillations resembled those in insulin-releasing beta-cells stimulated by glucose. The oscillatory activity was suppressed when combining elevation of glucose to 20 mM with the addition of 2-2000 ng/ml insulin. Whereas 10 mM of L-arginine or l-glycine transformed the oscillations into sustained elevation of [Ca2+]i, there was no response to 1 mM tolbutamide or 0.1-1 mM gamma-aminobutyric acid. The observations that alpha 2-cells differ from islet cells secreting insulin and somatostatin in responding to adrenaline with mobilisation of intracellular calcium can be used for their rapid identification. It is suggested that the oscillations reflect periodic entry of Ca2+ due to variations of the membrane potential.

We have assessed the ability of amiodarone and the new amiodarone-like antiarrhythmic agent, SR 33589 (N,N-dibutyl-3-[4-((2-butyl-5-methylsulphonamido)benzofuran-3-yl-c arbonyl) phenoxy]propylamine), to inhibit the effects of adrenoceptor stimulation in anaesthetized and conscious dogs. In anaesthetized, atropinized dogs, adrenoceptor stimulation was achieved (i) by i.v. administration of adrenaline and measurement of increased blood pressure (ii) by i.v. administration of isoprenaline and measurement of increased heart rate and decreased blood pressure. In conscious dogs, adrenoceptor stimulation was achieved by i.v. administration of isoprenaline and measurement of increased heart rate. In anaesthetized, atropinized dogs, both amiodarone and SR 33589 inhibited to similar extents, alpha-adrenoceptor stimulation (as indicated by attenuation of adrenaline-induced increases in blood pressure). The beta 1-adrenoceptor inhibitory activity of SR 33589 (as demonstrated by blockade of isoprenaline-induced increases in heart rate) was significant, but less marked than amiodarone (heart rate elevation reduced by 39%, P < 0.001 with 10 mg/kg SR 33589 and by 52%, P < 0.01 with 10 mg/kg amiodarone). In contrast, its beta 2-adrenoceptor antagonistic activity (as demonstrated by blockade of isoprenaline-induced reduction in blood pressure) was more marked (mean blood pressure decrease reduced by 69%, P < 0.01 with 10 mg/kg SR 33589 and by 31%, P < 0.05 with 10 mg/kg amiodarone). In conscious dogs, both SR 33589 and amiodarone (12.5, 25 and 50 mg/kg p.o.) inhibited isoprenaline-induced increases in heart rate by approximately the same amount for varying durations depending on the dose.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE

Previous investigators have demonstrated amelioration of lipid-soluble drug toxidromes with infusion of lipid emulsions. Clomipramine is a lipid-soluble tricyclic antidepressant with significant cardiovascular depressant activity in human overdose. We compare resuscitation with Intralipid versus sodium bicarbonate in a rabbit model of clomipramine toxicity.

METHODS

Thirty sedated and mechanically ventilated New Zealand White rabbits were infused with clomipramine at 320 mg/kg per hour. At target mean arterial pressure of 50% initial mean arterial pressure, animals were rescued with 0.9% NaCl 12 mL/kg, 8.4% sodium bicarbonate 3 mL/kg, or 20% Intralipid 12 mL/kg. Pulse rate, mean arterial pressure, and QRS duration were sampled at 2.5-minute intervals to 15 minutes. In the second phase of the experiment, 8 sedated and mechanically ventilated rabbits were infused with clomipramine at 240 mg/kg per hour to a mean arterial pressure of 25 mm Hg. Animals received either 2 mL/kg 8.4% sodium bicarbonate or 8 mL/kg 20% Intralipid as rescue therapy. External cardiac compression and intravenous adrenaline were administered in the event of cardiovascular collapse.

RESULTS

Mean difference in mean arterial pressure between Intralipid- and saline solution-treated groups was 21.1 mm Hg (95% confidence interval [CI] 13.5 to 28.7 mm Hg) and 19.5 mm Hg (95% CI 10.5 to 28.9 mm Hg) at 5 and 15 minutes, respectively. Mean difference in mean arterial pressure between Intralipid- and bicarbonate-treated groups was 19.4 mm Hg (95% CI 18.8 to 27.0 mm Hg) and 11.5 mm Hg (95% CI 2.5 to 20.5 mm Hg) at 5 and 15 minutes. The rate of change in mean arterial pressure was greatest in the Intralipid-treated group at 3 minutes (6.2 mm Hg/min [95% CI 3.8 to 8.6 mm Hg/min] Intralipid versus -0.25 mm Hg/min [95% CI -1.9 to 1.4 mm Hg/min] saline solution) and 5 minutes (4.4 mm Hg/min [95% CI 3.0 to 5.9 mm Hg/min] Intralipid versus 0.06 mm Hg/min [95% CI -0.9 to 1.1 mm Hg/min] saline solution). In the second phase of the experiment spontaneous circulation was maintained in all Intralipid-treated rabbits (n=4). All animals in the bicarbonate-treated group developed pulseless electrical activity and proved refractory to resuscitation at 10 minutes (n=4, P=.023).

CONCLUSIONS

In this rabbit model, Intralipid infusion resulted in more rapid and complete reversal of clomipramine-induced hypotension compared with sodium bicarbonate. Additionally, Intralipid infusion prevented cardiovascular collapse in a model of severe clomipramine toxicity.

The cardiovascular, biochemical and hormonal responses to a standard test meal have been investigated in patients with chronic autonomic failure and normal subjects. In autonomic failure there was a rapid (within 15 min), substantial and prolonged fall in blood pressure after the meal. A marked fall in blood pressure also occurred after a liquid meal of similar composition and caloric content, with no change in blood pressure in age-matched subjects with normal autonomic function. In autonomic failure after the test meal the blood pressure reached its nadir (45% fall) after 60 min, and had not returned to pre-meal levels after 3 h. There were no changes in cutaneous and forearm blood flow. In the normal subjects there were no changes in blood pressure after the meal; forearm blood flow fell and cardiac output increased. In autonomic failure there were no changes in plasma noradrenaline levels, unlike the normal subjects. Plasma adrenaline levels were unchanged in both groups. There was a similar rise in levels of plasma renin activity in both groups. The haematocrit and plasma osmolality did not change in either group. Changes in plasma glucose and plasma insulin levels were similar in both groups. The responses of 3 pancreatic gut peptides, neurotensin, pancreatic polypeptide and enteroglucagon, were greater in autonomic failure. Basal levels and responses of vasoactive intestinal polypeptide, cholecystokinin-8 and somatostatin were similar in both groups. The motilin response was greater in normal subjects. We conclude that in patients with autonomic failure there was a rapid, substantial and prolonged fall in blood pressure after a meal. This reduction in blood pressure was not counteracted by an increase in sympathetic nervous activity and other compensatory changes, as occur normally. It was unlikely that osmotic effects of the meal or gut secretions resulted in a significant loss of intravascular fluid into the gut. The fall in blood pressure probably results from vasodilatation within the splanchnic circulation, to which pancreatic and gastrointestinal hormones with vasodilatory actions may contribute.

BACKGROUND

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.

OBJECTIVE

To assess the benefits and harms of adrenaline in the treatment of anaphylaxis.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://www.clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/ and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion.

RESULTS

We found no studies that satisfied the inclusion criteria.

CONCLUSIONS

On the basis of this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular injection should still be regarded as first-line treatment for the management of anaphylaxis.

Ropivacaine, a new long acting amide type local anaesthetic, was compared with bupivacaine in a randomized double-blind study. One hundred and ten patients undergoing extradural anaesthesia received a test dose of 3 ml of 1% lignocaine with adrenaline which was followed by 15 ml of one of five solutions: 0.5, 0.75 or 1.0% ropivacaine or 0.5 or 0.75% bupivacaine. There was little difference between the groups with respect to speed of onset or sensory block. The duration of analgesia was increased by increasing the concentration of both drugs, but this had minimal effect on onset time or extent of block. When the same concentration of each drug was administered, there were inconsistent differences in duration of sensory block, none of which was statistically significant. Increasing concentration of both drugs resulted in greater degree and longer duration of motor block. Ropivacaine produced a slower onset, shorter duration and less intense motor block than the same concentration of bupivacaine. The cardiovascular changes were similar in all groups.