A rare cause of status epilepticus; alpha lipoic acid intoxication, case report and review of the literature.

INTRODUCTION: Alpha lipoic acid is a powerful antioxidant widely used for the supplementary treatment of diabetic neuropathy. Intoxication with alpha lipoic acid is very rare. There is no reported dose of safety in children. CASE REPORT: A 14-month-old previously healthy girl was referred to our hospital with the diagnosis of drug intoxication. She was admitted to the emergency department with lethargy and continuing involuntary movements for several hours after she had ingested an unknown amount of alpha lipoic acid. On admission she was lethargic and had myoclonic seizures involving all extremities. She had no fever and laboratory examinations were normal except for mild metabolic acidosis. The seizures were unresponsive to bolus midazolam, phenytoin infusion and levetiracetam infusion. She was taken to the pediatric intensive care unit with the diagnosis of status epilepticus. After failure of the treatment with midazolam infusion she was intubated and thiopental sodium infusion was started. Her myoclonic seizures were controlled with thiopental sodium infusion. After 48 h intubation and mechanical ventilation thiopental sodium was gradually reduced and then stopped. Following the withdraw of thiopental sodium, she was seizure free on her discharge on the 8th day. CONCLUSION: Alpha lipoic acid and derivatives cause side effects in children like refractory convulsions. They are frequently rendered as vitamins by diabetic patients and are left at places where children can easily access them. Therefore, when faced with refractory convulsions in children who have had no disease before, intoxication by medicaments with alpha lipoic acid should be taken into consideration.

The effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia.

Potatoes contain solanaceous glycoalkaloids (SGAs), which inhibit both butyrylcholinesterase (BuChE) and acetylcholinesterase (AChE). The present study investigated the effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia. ASA I-II, adult patients, scheduled for elective surgery, were included in a randomized, blind and controlled study. Patients were randomly divided into two groups. Patients in Group P (n = 21) ate a standard portion of potatoes in their last meal prior to pre-operative fasting, while patients in Group C (n = 23) ate food not containing SGAs. Patients were premedicated with midazolam. Anesthesia was induced with thiopental and fentanyl, and maintained with sevoflurane in 50 % O2/air and fentanyl, as needed. Succinylcholine 1 mg kg(-1) was administered to facilitate endotracheal intubation. Duration of succinylcholine blockade, awakening and recovery times from anesthesia were measured. Serum BuChE levels were also measured at baseline and 4 time-points within 24 h post-consumption. Duration of succinylcholine-induced neuromuscular block, awakening and recovery time from anesthesia was significantly longer in Group P than in Group C (p < 0.05). Serum BuChE levels decreased at 6 h after consumption start in Group P. In addition, in both groups, BuChE levels markedly decreased after succinylcholine blockade, increased thereafter, but did not return to baseline within 24 h of consumption start. None of these differences observed in BuChE levels was statistically significant. This study suggests that potatoes eaten before anesthesia can prolong the duration of succinylcholine-induced neuromuscular block and delay recovery from anesthesia.

Analgesia induced by 2- or 100-Hz electroacupuncture in the rat tail-flick test depends on the activation of different descending pain inhibitory mechanisms.

UNLABELLED: We evaluated the effectiveness of intrathecal antagonists of α1- (WB4101) and α2- (idazoxan) adrenoceptors and serotonergic (methysergide), opioid (naloxone), muscarinic (atropine), GABA(A) (bicuculline) and GABA(B) (phaclofen) receptors in blocking 2- or 100-Hz electroacupuncture (EA)-induced analgesia (EAIA) in the rat tail-flick test. EA was applied bilaterally to the Zusanli and Sanyinjiao acupoints in lightly anesthetized rats. EA increased tail-flick latency, where the effect of 2-Hz EA lasted longer than that produced by 100-Hz EA. The 2-Hz EAIA was inhibited by naloxone or atropine, was less intense and shorter after WB4101 or idazoxan, and was shorter after methysergide, bicuculline, or phaclofen. The 100-Hz EAIA was less intense and shorter after naloxone and atropine, less intense and longer after phaclofen, shorter after methysergide or bicuculline, and remained unchanged after WB4101 or idazoxan. We postulate that the intensity of the effect of 2-Hz EA depends on noradrenergic descending mechanisms and involves spinal opioid and muscarinic mechanisms, whereas the duration of the effect depends on both noradrenergic and serotonergic descending mechanisms, and involves spinal GABAergic modulation. In contrast, the intensity of 100-Hz EAIA involves spinal muscarinic, opioid, and GABA(B) mechanisms, while the duration of the effects depends on spinal serotonergic, muscarinic, opioid, and GABA(A) mechanisms. PERSPECTIVE: The results of this study indicate that 2- and 100-Hz EA induce analgesia in the rat tail-flick test activating different descending mechanisms at the spinal cord level that control the intensity and duration of the effect. The adequate pharmacological manipulation of such mechanisms may improve EA effectiveness for pain management.

Status epilepticus.

Status epilepticus is a common neurological emergency in childhood and associated with significant morbidity and mortality. Status epilepticus (SE) has been defined as continuous seizure activity lasting more than 30 min or 2 or more seizures in this duration without gaining consciousness between them. However, the operational definition has brought the time down to 5 min. Management can be broadly divided into initial stabilization, seizure termination, and evaluation and treatment of the underlying cause. Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome. Seizure termination is achieved by pharmacotherapy. Benzodiazepines are the first line drugs for SE. Commonly used drugs include lorazepam, diazepam, and midazolam. In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used. Phenytoin as a second line agent is usually indicated when seizure is not controlled after one or more doses of benzodiazepines. If the seizures continue to persist, valproate, phenobarbitone or levetiracetam is indicated. Midazolam infusion is useful in refractory status epilepticus. Thiopentone, propofol or high dose phenobarbitone are considered for treatment of refractory status epilepticus. Prolonged SE is associated with higher morbidity and mortality. Long term neurological sequelae include epilepsy, behavioural problems, cognitive decline, and focal neurologic deficits.

Vagus nerve stimulation for refractory status epilepticus.

We report on the long-term follow-up of a patient with refractory non-convulsive SE who was successfully treated with VNS. A 7-year old girl with a medical history of thrombosis in the right internal cerebral vein and right thalamic bleeding 8 days after birth, developed epilepsy at the age of 13 months. At the age of 6 she presented with a refractory non-convulsive SE. A vagus nerve stimulator was placed after 11 days of thiopental-induced coma. Three days after VNS implantation, the thiopental-induced coma was successfully withdrawn and electroencephalography showed normalization one week after start of VNS. After a follow-up of 13 months she remains seizure-free and AEDs have been partially tapered. This case illustrates a potential acute abortive effect with sustained long-term seizure reduction of VNS in a 7-year old girl who presented with refractory non-convulsive SE.

Full remission of tardive dyskinesia following general anaesthesia.

A 44 year old woman with a severe drug induced tardive dyskinesia had previously been treated with a left thalamotomy and right deep brain stimulation. Thalamotomy abolished the right hemiballismus. Deep brain stimulation caused a moderate reduction of the remaining involuntary movements on the left side. After a minor orthopaedic operation under general anaesthesia, the dyskinesia disappeared completely, even with the deep brain stimulation turned off. The remission has now lasted for 41 months.

Xilazina como pré-medicação para anestesia com tiopental sódico em cães / Xylazine as a premedication for thiopental sodium anaesthesia in the dogs

A xilazina produz um bom efeito sedativo-analgésico quando associado à drogas anestésicas. O tiopental sódico é um barbitúrico de curta duração que produz sonolência, sedação e hipnose. O objetivo deste trabalho é verificar a eficiência da associação da xilazina como pré-medicação e do tiopental sódico na manutenção da anestesia, em cães. Foram usados 32 cães sem raça definida, adultos, machos e com peso entre 8 e 10 kg, que foram submetidos à procedimento operatório no esôfago cervical. A dose média de xilazina administrada foi de 3,8 mg/kg e de tiopental sódico foi de 7,7 mg/kg. Não houve necessidade de intubação endotraqueal e não ocorreu óbito relacionado com as medicações anestésicas. Concluindo, o procedimento anestésico descrito é de fácil execução, é seguro e diminui o estresse do animal.

The sodium pentothal hypnosis interview with follow-up treatment for complex regional pain syndrome.

A patient who was unresponsive to multiple conservative medical treatments for complex regional pain syndrome was assessed using a novel approach--the sodium pentothal hypnosis interview. The interview suggested that his pain was centrally generated. The patient's pain symptoms resolved with hypnotherapeutic treatment. Indications for this procedure and implications for assessment and treatment are discussed. This case raises more questions than it answers, and leaves the reader to struggle with current difficulties in diagnostic decision-making.

Sodium pentothal hypnosis: a procedure for evaluating medical patients with suspected psychiatric co-morbidity.

The cases presented here were patients referred for neurologic disability evaluations. They met the three selection criteria presented and underwent the four-phase pentothal hypnosis procedure described and at the conclusion were diagnosed as having psychiatric morbidity. We recommend that the sodium pentothal hypnosis procedure be considered for use whenever there is concern for psychiatric co-morbidity in a patient with presumed physiologic disease.

Variation of serum potassium and creatinine phosphokinase levels in suxamethonium-induced muscle relaxation.

Popular depolarising muscle relaxant, suxamethonium (succinylcholine chloride), produces fasciculation in group of muscles and 'after pain'. Mode of its action is neuromuscular blockage. It also may be associated with muscle fibre injury and altered membrane permeability. These may cause rise of serum K+ and creatinine phosphokinase (CPK) levels. But use of diazepam either during or as pretreatment may reduce the fasciculation, 'after pain' and rise of K+ and CPK levels. Present study was undertaken to show whether any correlation of the degree of fasciculation and postsuxamethonium myalgia is present or not and whether diazepam has any role in reducing muscle injury and in turn reducing the levels of serum K+ and CPK.

The effects of thiopental sodium on fentanyl-induced muscle rigidity in a human model.

STUDY OBJECTIVE: To describe a safe human model in which to study the treatment of fentanyl-induced muscle rigidity and report on the efficacy of thiopental sodium for this purpose. DESIGN: Randomized, observer-blinded comparison of regimens. SETTING: Inpatient surgery at a university-affiliated teaching hospital. PATIENTS: Thirty patients scheduled for elective surgery in whom the administration of high-dose fentanyl was felt to be appropriate and who experienced severe muscle rigidity in the chest, abdomen, and upper extremities after the fentanyl was administered. INTERVENTIONS: One arm was isolated from circulation with a blood pressure (BP) cuff inflated to 100 mmHg above systolic blood pressure (SBP), after which fentanyl 25 to 50 micrograms/kg was administered intravenously (IV) at a rate of 1 mg/min in the contralateral arm. If severe muscle rigidity became apparent in three muscle groups (the chest, abdomen, and arms), patients were either (1) observed for 3.5 minutes without further intervention, (2) given thiopental sodium 1.5 mg/kg IV, followed 120 seconds later by succinylcholine 1 mg/kg IV, or (3) given succinylcholine 1 mg/kg IV, followed 120 seconds later by thiopental sodium 1.5 mg/kg IV. MEASUREMENTS AND MAIN RESULTS: A single observer, blinded to the technique, evaluated and recorded the degree of muscle rigidity present in the chest wall, abdomen, and upper extremities (one isolated from the circulation by a tourniquet) 90 seconds and 3.5 minutes after the onset of muscle rigidity in the control group and 90 seconds after the administration of either thiopental sodium or succinylcholine in the two experimental groups. The observer was the same individual in all instances. The muscle rigidity associated with the administration of high-dose fentanyl was clinically attenuated by the administration of thiopental sodium, especially in the extremities. Succinylcholine was more effective than thiopental sodium in producing muscle flaccidity in all muscle groups not isolated by a tourniquet. In no case did the muscle rigidity compromise our ability to oxygenate the patient adequately. CONCLUSIONS: Thiopental sodium does blunt the degree of muscle rigidity induced by high-dose fentanyl, though not as effectively as does succinylcholine. One can safely isolate an extremity prior to the administration of high-dose fentanyl and a muscle relaxant, intubate the trachea, and ventilate a patient, while retaining the ability to study the effect of centrally acting drugs on fentanyl-induced rigidity in the isolated extremity.

[Effect of antihypoxic agents on the cyclic nucleotide content in different brain structures in normo-oxia and hypoxia]. / Vliianie nekotorykh antigipoksantov na soderzhanie tsiklicheskikh nukleotidov v razlichnykh strukturakh mozga v usloviiakh normo- i gipoksii.

A study was made of the effects of isothiobarbamine and guthimine (10 and 50 mg/kg, respectively) on the content of cAMP and cGMP in the brain cortex (BC) and hippocamp under normal conditions and hypoxia. Isothiobarbamine did not change the content of both cyclic nucleotides under normoxia, whereas under hypoxia it reduced the level of the cyclic nucleotides in the BC and raised it in the hippocamp. Guthimine increased their content in the BC and did not change it in the hippocamp under normoxia, whereas under hypoxia it increased the cAMP content in the hippocamp and did not change it in the BC. The cGMP content descended in both the structures under study.

Convulsive status epilepsy: is there a role for thiopentone-induced narcosis?

Convulsive status epilepsy is a medical emergency with significant mortality and morbidity. This retrospective survey reports the use of non-anaesthetic doses of thiopentone, given either by intravenous or rectal infusion. The regime was effective in controlling convulsive status without significant complications. It is suggested that this regime can be used safely when standard doses of diazepam (or clonazepam), and/or phenytoin, fail to effect immediate control of convulsive status, and before anaesthetic agents are administered.

[High doses of thiopental for therapy of post-ischaemic anoxia of the brain. A case report (author's transl)]. / Hochdosierte Thiopentalgabe zur Therapie der postischaemischen Anoxie des Gehirns.

The case of a 7-year-old child is presented, who suffered circulatory arrest during induction of anaesthesia for surgery for a posterior fossa tumour. A brain ischaemia lasting 6 minutes duration had to be assumed. After restoration of circulation, 825 mg ethiopenta were administered in order to ameliorate a possible post-ischaemic anoxia of the brain according to a protocol by Safar [18]. 11 hours after circulatory arrest the child awoke. Except for a more pronounced left sided hemiparesis and paresis of the left n. abducens no additional neurological deficit was observed compared to the neurological status before induction of anaesthesia.