Early experiences of vasodilators and hypotensive anesthesia in children.

The physiological application of OHMS LAW explains the basis of hypotensive anesthesia. V = IR translates into: Pressure = Flow × Resistance or Blood pressure = Cardiac Output × Peripheral Resistance. If peripheral resistance is reduced by a vasodilator such as sodium nitroprusside (a short acting, vascular smooth muscle relaxant) or phenoxybenzamine (a long acting α adrenoreceptor antagonist), blood pressure will fall and vasoconstriction and bleeding will be reduced. A less desirable alternative to lowering blood pressure could be to reduce cardiac output by suppressing myocardial contractility using a ß(1) adrenoceptor antagonist or an inhalational agent such as isoflurane.

Non-surgical therapy for bilateral glossopharyngeal neuralgia caused by Eagle's syndrome, diagnosed by three-dimensional computed tomography: a case report.

Eagle's syndrome is an uncommon sequela of elongation of the styloid process. Symptoms include recurrent throat pain and anterolateral neck pain, with referred pain to the ear. We report a 65-year-old man who presented with bilateral glossopharyngeal neuralgia. We performed three-dimensional computed tomography which revealed that the right styloid process was 35.1 mm and the left process was 29.6 mm, leading to diagnosis of an elongated styloid process, i.e. Eagle's syndrome. Because the patient refused surgical treatment, conservative therapy was selected. Oral gabapentin, stellate ganglion block, and 8 % lidocaine spray on the tonsillar branches of the glossopharyngeal nerve resulted in complete resolution of the paroxysms of pain in approximately 3 weeks.

[Selected interventional methods for the treatment of chronic pain: Part 1: peripheral nerve block and sympathetic block]. / Ausgewählte interventionelle Verfahren zur Behandlung chronischer Schmerzen : Teil 1: periphere Nervenblockade und Sympathikusblockade.

Approximately 5-8 million people in Germany suffer from chronic pain. Some patients can obtain relief from specific interventional techniques. In detail these are blocks of the sympathetic chain and peripheral nerve blocks, regional anesthetic techniques close to the spinal cord and neuromodulation. Part 1 of this article presents peripheral nerve blocks using the example of intercostal blocks and blocks of the sympathetic chain. Peripheral nerve blocks are important for postoperative pain treatment. Only a few methods are used for chronic pain and this applies primarily to the intercostal block which is used for the treatment of pain occurring after thoracotomy, intercostal neuralgia and pain associated with infiltration of cancer. Blocks of the vegetative nervous system are accomplished on the ganglions of the head and the sympathetic chain and are therefore most commonly applied to treat headache, neuropathic and sympathetic pain in the area of abdomen and the extremities.

The reflex sympathetic dystrophy syndrome (RSDS). III. Scintigraphic studies, further evidence for the therapeutic efficacy of systemic corticosteroids, and proposed diagnostic criteria.

Sixty-four patients were evaluated prospectively for a reflex sympathetic dystrophy syndrome (RSDS), using quantitative clinical measurements, high-resolution roentgenography and scintigraphy. Five separate groups were identified by their clinical features, allowing us to distinguish patients with definite or incomplete forms of the RSDS as well as 16 patients with other disorders. Scintigraphy was found to be a useful diagnostic study that may also provide a method of predicting therapeutic response. Systemic corticosteroid therapy proved to be a highly effective mode of treatment for up to 90 percent of the patients with the RSDS.

Current therapy of hypertension. A pharmacologic approach.

Adequate treatment of hypertension requires that the physician understand the pharmacologic actions of antihypertensive agents. Although no drug is without adverse reactions, it should be possible to choose an agent or combination of agents which can effectively lower blood pressure and be tolerated by the patient. The indications, proposed mechanisms of actions and adverse effects of the following antihypertensive drugs are discussed: thiazide diuretics, spironolactone, triamterene, trimethaphan, Rauwolfia alkaloids. guanethidine, bethanidine, methyldopa, clonidine, pargyline, propranolol, hydrazaline, minoxidil, guancydine, diazoxide and sodium nitroprusside.

Adverse reactions and interactions limiting the use of antihypertensive drugs.

One major problem in the management of hypertensive patients is their lack of compliance with therapeutic regimens. Some of the problem with compliance is due to side effects of the drugs being used. Additionally, drug resistance may be related to interactions of antihypertensive drugs with other prescription and nonprescription drugs. By classifying drugs into common modes of action, common side effects can be predicted. However, each drug has its own spectrum of other side effects which can be dose-limiting. Most of the side effects are extensions of the pharmacologic actions of these drugs, and only relatively rarely is an allergic reaction a problem. Drug interactions can be important in explaining some side effects or drug resistance. A knowledge of the pharmacology of the antihypertensive drugs allows the physician to predict, in many cases, the possibility of an interaction and, indeed, can allow the use of interactions to advantage as with combinations of vasodilators and beta adrenergic blocking drugs. Until such time as the perfect antihypertensive drug is discovered, most patients can be managed satisfactorily with minimal side effects by judicious combination of available drugs and avoiding drugs which interact to cause more side effects or decrease the antihypertensive effects.

Early intervention in acute myocardial infarction: one center's perspective.

Understanding of the phenomenon of acute myocardial infarction (AMI) and definition of proper treatment have changed radically in the past decade. AMI is regarded as an evolving event with an outcome that may be modifiable. Initial attempts at intervention involved reducing myocardial oxygen requirements and salvaging ischemic tissue. Studies of beta-blockade administration, which at first was considered contraindicated, have shown that such treatment may be beneficial and may also be safe in the postinfarction period. The hypothesis that the mass of infarct sustained is important to outcome is also under study, with use of such techniques as serial plasma creatine kinase (CK) determinations and ejection fraction for assessing infarct size. Analysis of isoforms of CK is a new area of interest that may facilitate early diagnosis and define the chronologic aspects of infarcts. Myocardial reperfusion with fibrolytic agents has yielded apparent benefit, but it is an aggressive and still experimental form of intervention. Positron tomography has been used for quantitative assessment of regional metabolism and perfusion. Initial results of reperfusion with clot-selective fibrinolytic agents, expected to reduce the risk of bleeding, indicate favorable effects on the heart and no evidence of systemic bleeding.

Pharmacologic blockade of the left stellate ganglion using a drug-reservoir-pump system.

Patients suffering from the long QT syndrome (LQTS) are threatened by sudden arrhythmic cardiac death. This case report describes a new therapeutic approach to ventricular tachyarrhythmias refractory to oral pharmacological treatment (propranolol + phenytoin) using a drug-reservoir-pump system for the pharmacologic blockage of the left stellate ganglion.

alpha- and beta-adrenoceptor blockade fail to prevent high sodium diet-induced left ventricular hypertrophy.

High sodium diet (HS, 8% NaCl) induces left ventricular hypertrophy (LVH) in normotensive rats without an increase in pressure or volume load or in resting cardiac sympathetic activity. HS may affect LV adrenoceptors density or affinity or their postreceptor pathways, thereby causing LVH. We therefore assessed the effects of HS with and without blockade of alpha1- or beta-adrenoceptors by terazosin or nadolol, alone or in combination, on resting hemodynamics, LV and right ventricular (RV) weights, and LV dimensions of male WKY rats. HS increased LV weight by 14% to 17%, and the ratio of LV wall thickness to radius by 18% to 23%. Singly or in combination, the adrenoceptor antagonists did not prevent HS-induced LVH, but instead aggravated it. The increased ratio of LV wall thickness to radius and of LV to RV were attenuated by terazosin or nadolol alone. Neither the resting LV peak-systolic or end-diastolic pressures nor the right atrial pressure was changed by HS, either alone or in combination with the blockers. The failure of chronic alpha1- or beta-blockade to prevent HS-induced LVH suggests that adrenoceptor activation is not important in evoking the LVH. However, the blockers shifted the LVH from a concentric to an eccentric form, suggesting an involvement of additional trophic factors during adrenoceptor blockade.

Efficacy and toxicity of drug combinations in treatment of physostigmine toxicosis.

Atropine, in combination with 1 of 6 other drugs, was tested in mice for the ability to prevent death by an otherwise lethal dose of the cholinesterase inhibitor, physostigmine. The atropine dose (4 mg/kg, i.p.) was kept constant, while the dose of the other drug in the pair was tested in 5 geometrically spaced doses, ranging down to 1/16 of the maximum dose (which caused no gross behavioral signs). Atropine alone saved 20% of the mice. The combination of atropine and benactyzine saved 100% of the mice at all 5 doses of benactyzine; similar complete protection was afforded by the combination of atropine and the largest dose of an oxime, TMB4 (15 mg/kg). Over 80% survivals were achieved with the larger doses of atropine combinations involving hexamethonium, mecamylamine, and diazepam. No enhanced protection occurred with atropine combinations with the oxime, 2-PAM. The toxicity of the effective combinations, when used in high doses without physostigmine challenge, revealed that deaths occurred over a narrow range of doses of all combinations except atropine/diazepam. An additive toxic effect of atropine was suggested with its combinations with TMB4, mecamylamine, and diazepam, whereas no additive toxicity occurred with combinations involving hexamethonium or benactyzine (i.e., the LD50 of the combinations was about the same as for hexamethonium or benzactyzine alone). The combinations with the best therapeutic safety ratio were with diazepam (no deaths at a dose 10 times that which saved 100% of mice) and benactyzine (no deaths at a more than 50-fold dose).

Sphenopalatine ganglion block: clinical use in the pain management clinic.

Clinical experience with the sphenopalatine ganglion (SPG) block combined with a review of prior studies led to conducting a retrospective evaluation of four patients with chronic pain treated with the SPG block. The review of case reports suggests the usefulness of SPG blocks in the pain management clinic.

Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients.

OBJECTIVE: Pain-relieving effects of lidocaine/bupivicaine local anesthetic (LA) and saline (S) block of sympathetic ganglia (stellate block, 4 patients; lumbar sympathetic block, 3 patients) were compared in 7 complex regional pain syndrome (CRPS) patients on a double-blind crossover basis to evaluate the diagnostic and therapeutic value of local anesthetic sympathetic blocks. DESIGN: Patients rated their pain on a visual analog scale before and after blocks and were tested for mechanical allodynia one-half hour after blocks. Thereafter, they rated their pain intensity in diaries four times a day for 7 days. Each patient received two blocks, S and LA, and served as his own control. RESULTS: Both S and LA injections of sympathetic ganglia produced large reductions in pain intensity in 6 of 7 patients 30 minutes after block. These large reductions were accompanied by the reversal of mechanical allodynia in both S and LA. The mean difference between initial peak reduction in pain intensity produced by saline (68.7%) and active local anesthetic (74.4%) did not approach statistical significance. In striking contrast, the mean duration of pain relief was reliably longer in the case of LA (3 days, 18 hours) as compared with S ( 19.9 hours), a difference that occurred in all 7 patients. In a larger sample of 41 CRPS patients, signs of sympathetic efferent blockade, including Homer' s syndrome or skin surface temperature change, were not predictive of initial peak magnitude of pain relief from sympathetic blockade but were predictive of duration of pain reduction. CONCLUSION: The combination of these results provides evidence that duration of pain relief is affected by injection of local anesthetics into sympathetic ganglia. These results indicate that both magnitude and duration of pain reduction should be closely monitored to provide optimal efficacy in procedures that use local anesthetics to treat CRPS.

Role of autonomic nervous system for development and suppression of motion sickness in Suncus murinus.

To clarify the role of autonomic nervous function in motion sickness, the effect of agents that act on the autonomic nervous system on the motion stimuli-induced emesis was studied in two strains of Suncus murinus (Jic:SUN-Her and Jic:SUN-Ler) with congenitally different sensitivity to veratrine sulfate. We demonstrated significant differences between the two strains in sensitivity to motion stimuli. Isoproterenol (2.5 mg kg(-1), s.c.) significantly prolonged the latency to the first emetic episode induced by motion stimuli and significantly decreased the number of emetic episodes in Jic:SUN-Her suncus. Hexamethoium (2.0 mg kg(-1), s.c.) tended to shorten the latency in Jic:SUN-Ler. Acetylcholine (1.2 mg kg(-1), s.c.) enhanced the emetic response in Jic:SUN-Ler, but atropine (4.0 mg kg(-1), s.c.) suppressed motion stimuli-induced emetic response in Jic:SUN-Her. These results suggest that the predominance of parasympathetic nervous activity is relevant to the enhancement of motion stimuli-induced emetic response, whereas the predominance of sympathetic nervous activity suppresses motion stimuli-induced emetic response. Norepinephrine (0.8 mg kg(-1), s.c.) enhanced motion stimuli-induced emesis contrary to isoproterenol in Jic:SUN-Ler although both drugs are adrenergic agents. However, atropine pretreatment (4.0 mg kg(-1), s.c.) inhibits norepinephrine-induced emetic response. It was considered that norepinephrine-induced emetic response might be dependent on a secondary increase of parasympathetic nervous activity due to bororeflex. Moreover, the different emetic response in Jic:SUN-Her and Jic:SUN-Ler suncus to motion stimuli and drug administration mentioned above indicated that different participation of autonomic nervous activity and/or afferent information from the baroreceptor in the emetic response may exist between these animal groups.

Novel mechanism of action hypothesized for stellate ganglion block related to melatonin.

The mechanism of action of stellate ganglion block has generally been explained by vasodilation within its sphere of innervation. However, the success of treatment cannot always be explained by just one mechanism of action, because its clinical indications in Japan extend to many diseases, including systemic diseases. We propose a new mechanism of action for stellate ganglion block that is based on correction of melatonin rhythm disorder resulting from increased sympathetic nerve tone and does not involve vasodilation.

Differential effects of right versus left stellate ganglion block on left ventricular function in humans: an echocardiographic analysis.

STUDY OBJECTIVES: To evaluate the effects of unilateral stellate ganglion blockade on left ventricular function. DESIGN: Prospective cohort of patients with chronic regional pain syndrome type I and II of the upper extremity requiring therapeutic stellate ganglion blockade. SETTING: University-affiliated hospital. PATIENTS: Fifteen adult ASA physical status I and II patients with the diagnosis of chronic regional pain syndrome type I and II of the arm were studied. Right stellate ganglion block was performed in nine subjects and a left in six. INTERVENTIONS: Stellate ganglion block was performed with 10 mL of 1% plain Xylocaine. Transthoracic echocardiograms were performed immediately prior and 30 min following the block. MEASUREMENTS: Heart rate and blood pressure were monitored at regular intervals. Global systolic function was determined by calculating ejection fraction. Regional systolic motion was evaluated on the short axis and four-chamber views using the American Society of Echocardiography criteria. Diastolic function was assessed with pulsed-wave Doppler of the left ventricular outflow tract and the mitral valve. Data collected included isovolumic relaxation time and early and atrial velocity patterns. MAIN RESULTS: A successful stellate ganglion block was achieved in all patients. Blood pressure and heart rate were not significantly different during data collection. Patients who underwent a right stellate ganglion block showed no significant differences in systolic or diastolic function. Following a left stellate ganglion block, global and regional systolic function remained unchanged. Isovolumic relaxation time was increased but did not reach statistical significance (80 +/- 13 ms to 88 +/- 9 ms; p = 0.09). Left ventricular end-diastolic (LVEDV) and end-systolic volumes (LVESV) were significantly increased (LVEDV from 73 +/- 9 mL to 100 +/- 9 mL, p < 0.02; LVESV from 31 +/- 4 mL to 37 +/- 4 mL, p < 0.03). CONCLUSIONS: In patients without cardiovascular disease, unilateral denervation of the left ventricle after stellate ganglion block produces no clinical deleterious effects on left ventricular function.

[A comparative double-blind trial of HSR-902 and butylscopolamine bromide for relieving colic in ureteral stone patients].

The clinical efficacy and safety of HSR-902 (tiquidium bromide, Thiaton) in patients with spastic pain caused by ureteral stones were evaluated in a double blind comparative trial. A daily dose of 30 mg HSR-902 or 60 mg butylscopolamine bromide as a control drug was orally administered for 7 days. With either drug marked improvement of spastic pain was observed. The time to obtain relief from spastic pain and utility rating were significantly more excellent with HSR-902 than with butylscopolamine bromide. With all other parameters used no significant difference was observed between the two drugs. Mild adverse effects such as abdominal discomfort and constipation were observed in 2 of the 87 cases in the butylscopolamine bromide group but none of the 83 cases in the HSR-902 group. Taking efficacy and safety of the treatment into consideration, no significant difference was observed in usefulness between the two drugs, and we were able to confirm the usefulness of HSR-902 for relief from spastic pain caused by ureteral stones.

[Neurologic syndromes in myocardial infarct patients during various stages of treatment]. / Nevrologicheskie sindromy u bol'nykh infarktom miokarda na raznykh étapakh lecheniia.

The clinical picture of myocardial infarctions in complicated and manifold. A clinico-physiological analysis of neurological disorders gives ground to consider that in myocardial infarctions the process of irritation involves the peripheral vegetative apparatus and spinal segmental structures, as well as the hypothalmostem structures with the reticular formation, which in its turn is accompanied by disturbances of cortico-subcortical interrelationships. In patients with myocardial infarctions the vegetative disorders are of a regional character and may be expressed in symptomatology, characteristic of the stimulation of sympathetic ganglions on the left side, mainly in the stellate node.

[Relationship between the pathogenesis of lumbosacral radiculitis and specific treatment]. / Differentsirovannoe lechenie poiasnichno-kresttsovykh radikulitov v zavisimosti ot ikh patogeneza.

On the basis of personal experience in treating 534 patients with sacro-lumbar radiculitis the authors believe it expedient to distinguish the following clinical syndromes: lumbago, radicle neuralgia, radicle neuritis, radicle neuritis with a paralysis of the foot and the caudal syndrome. In their opinion, the main pathogenetical mechanisms of the disease, which facilitates the selection of the methods of treatment should be taken into consideration. It is stressed that a differentiated clinical approach to patients with therapeutically resistent forms of sacro-lumbar radiculitis in the majority of the cases provides good results in medicational and surgical treatment.

[Role of the nervous factor in the development of pathology of the internal organs as a result of exposing the body to extremely stressful treatment]. / Rol' nervnogo faktora v razvitii patologii vnutrennikh organov, vyzyvaemoi chrezvychainym vozdeistviem na organizm.

The paper compiles results of many years of studies performed at the Dept. of Pharmacology of the Inst. Exp. Med. of the USSR Acad. Med. Sci. and concerning neurotropic drugs for prophylaxis and pharmacological therapy of neurodystrophies underlying many a disease of internal organs. From the pharmacological standpoint, mechanisms of the neural control of trophic processes and formation of internal organs pathology are considered; significance of transmitter systems, mainly adrenergic for this control, is analysed; an important role of maintaining the tissue energy metabolism at a high level for augmentation of reparation processes, is proved; principles of prophylaxis and pharmacological therapy of internal organs diseases dependent on the neural factor, are revealed.