Mechanical and electrical equipment interference provokes a misleading Neurally Adjusted Ventilatory Assist (NAVA) EAdi signal.

BACKGROUND: Neurally Adjusted Ventilatory Assist (NAVA) offers synchronized proportional pressure in accordance with the electrical activity of the diaphragm (EAdi). NAVA relies on the EAdi to trigger the respiratory cycle and then adjusts the ventilatory assist to the neural drive. The technique necessitates a catheter with bipolar microelectrodes positioned near the crural diaphragm where this signal can be captured. Capturing a reliable EAdi signal is a condition sine qua non for using NAVA as a mode of ventilation. The displayed signal represents the sum of the electrical activity of the muscle action potential of the diaphragm and is expressed in microvolts. METHODS: A technical note illustrated by a case series in the intensive care unit (ICU) of a tertiary referral hospital with experience using NAVA. RESULTS: Here, we report on three separate cases in which the use of an intra-aortic balloon catheter, a pacemaker and a heating device all resulted in a distortion of the EAdi signal, despite good positioning of the catheter. In a fourth case, we observed internal interference from leaking cardiac electrical activity due to the malpositioning of the EAdi catheter in a patient with atrial fibrillation. CONCLUSION: We illustrate that the detection and therefore interpretation of the EAdi signal during NAVA can be influenced by mechanical and electrical interference by other equipment used in the ICU or from endogenous leaking cardiac activity.

EEG in the FEAB model: measurement of electroencephalographical burst suppression and seizure liability in safety pharmacology.

INTRODUCTION: The purpose of this study was to explore the integration of electroencephalographical (EEG) measurements into the fentanyl/etomidate-anaesthetised Beagle (FEAB) model in order to detect burst suppression and/or seizure development caused by compounds, prior to new molecular entity (NME) declaration. Detecting such unfavourable side effects prevents their being found in conscious animals at a later stage of safety evaluation. In addition, this has the advantage of performing safety studies on the three vital organ systems (cardiovascular system, respiratory system and central nervous system) within one and the same animal model. METHODS: Dogs were anaesthetized and instrumented according to the FEAB model requirements, and in addition three needle electrodes were placed on the cranium and a one lead EEG signal was measured. The raw signal was analysed by the Narcotrend® (MonitorTechnik, Bad Bramstedt, Germany) for depth of anaesthesia registration, visually analysed for burst suppression ratio calculation after different anaesthetics (pentobarbital and etomidate), and spiking and seizure activity were quantified after intravenous administration of different proconvulsant agents: pentylenetetrazole (PTZ), bicuculline (BCC), bupropion (BUP) and pilocarpine (PIL). RESULTS: High doses of pentobarbital (60 mg/kg over 10 min) and etomidate (6 mg/kg over 10 min) induced dose-dependent burst suppression of 98 ± 2% and 61 ± 16%, respectively. Infusions of PTZ (1.5mg/kg/min), BCC (0.0625 mg/kg/min), BUP (0.5mg/kg/min) and PIL (5mg/kg/min) induced dose-dependent spiking and seizures: the thresholds were 34 ± 2, 0.15 ± 0.03, 10.0 ± 1 and 144 ± 9 mg/kg, respectively. In PTZ-treated dogs, spiking and seizures could be abolished with diazepam (2mg/kg i.v.) or with propofol (4 mg/kg i.v.). DISCUSSION: The present study showed that a one lead EEG can be used reliably in the FEAB model to estimate the depth of anaesthesia, and to detect burst suppression and seizure risk in safety pharmacology studies.

The Electro-Mechanical window: a risk marker for Torsade de Pointes in a canine model of drug induced arrhythmias.

BACKGROUND AND PURPOSE: In cardiovascular pharmacology, electrical and mechanical events can be distinguished, and the phrase 'electro-mechanical window' (EMw) describes the temporal difference between these events. We studied whether changes in EMw have potential predictive value for the occurrence of arrhythmias in fentanyl/etomidate-anaesthetized beagle (FEAB) dogs. EXPERIMENTAL APPROACH: The EMw was calculated as differences between the QT interval and QLVP(end) in FEAB dogs during atrial pacing, treatment with isoprenaline or atropine, body temperature changes and induction of Torsade de Pointes (TdP) in an LQT1 model. KEY RESULTS: The electrical systole (QT interval) was shorter than the duration of the mechanical event (QLVP(end) ), providing a positive EMw. Atrial pacing, atropine or body temperature changes had no major effects on EMw, despite large changes in QT duration. However, ß-adrenoceptor stimulation (with isoprenaline) decreased the EMw (from 90 to 5 ms) and in combination with HMR1556, a blocker of the slowly activating potassium current (I(Ks) ), induced a large negative EMw (-109ms) and TdP. Prevention of TdP by atenolol or verapamil was associated with a less negative EMw (-23 to -16ms). Mexiletine, a poorly effective long QT treatment, did not affect the EMw or prevent TdP induction. CONCLUSIONS AND IMPLICATIONS: The EMw is a marker, other than QT prolongation, of TdP risk in the FEAB model. Therefore, we suggest examining the EMw as a risk marker in cardiovascular safety studies and as a potential biomarker to improve clinical management of long QT syndrome patients, especially in patients with borderline QT prolongation.

A profile of European ICU nursing.

OBJECTIVE: To evaluate major similarities and major differences between Western European countries in intensive care unit (ICU) nurse staffing, education, training, responsibilities, and initiative. DESIGN: A questionnaire was sent to Western European doctor members of the European Society of Intensive Care Medicine, to be passed on to the nurse-in-charge of their ICU. RESULTS: 156 completed questionnaires were analyzed: 49% were from university hospitals, 26% from university-affiliated hospitals, and 25% from community hospitals; 42% of the hospitals had more than 700 beds, 67% of the ICUs had between 6 and 12 beds, and 54% were mixed medical-surgical units. Among British units, 79% had more than three full-time nursing equivalents (FTE) per ICU bed, while in Sweden 75% of units had less than two FTE/ICU bed. University hospitals had more nursing staff per bed than community hospitals. As regards training, 33% of nurses followed a training course before starting work on the ICU and 64% after starting on the unit, and 85% had easy access to continuing education, particularly in the university hospitals. In an emergency, more than 70% of nurses regularly initiated oxygen administration, mask ventilation, or cardiac massage. In Sweden 100% of nurses and in Switzerland 91% of nurses regularly inserted peripheral intravenous catheters, but only 7% of German nurses did. No German nurses and only 12% of British nurses regularly performed arterial puncture, but in Sweden 75% of nurses regularly did. CONCLUSION: Even though the number of participants were limited, our questionnaire revealed variations in nurse staffing patterns among European countries and in their systems of training and education. Nurse autonomy also varies widely between countries.

Combined thromboxane A2 synthase inhibition and prostaglandin endoperoxide receptor antagonism limits myocardial infarct size after mechanical coronary occlusion and reperfusion at doses enhancing coronary thrombolysis by streptokinase.

OBJECTIVES: We sought to examine to what extent a combination of strong thromboxane A2 synthase inhibition and moderate endoperoxide receptor blockade enhances streptokinase-induced coronary thrombolysis and provides anti-ischemic activity independent from its thrombolytic activity. METHODS: Coronary thrombi, induced by crush injury and stenosis of the coronary artery, were lysed with streptokinase, 10,000 IU/kg body weight over 90 min, in anesthetized dogs receiving solvent (n = 11), ridogrel, 0.31 mg/kg intravenously, for thromboxane A2 synthase inhibition (n = 7) or ridogrel, 5 mg/kg, for additional prostaglandin endoperoxide receptor antagonism in addition to thromboxane A2 synthase inhibition (n = 7) 10 min before the administration of streptokinase. RESULTS: Thrombolytic efficacy was greatest in animals receiving both dual-acting ridogrel, 5 mg/kg intravenously, and streptokinase as evidenced by the highest incidence of high grade coronary reperfusion (solvent 3 of 11; ridogrel, 0.31 mg/kg, 5 of 7; ridogrel, 5 mg/kg, 7 of 7; p < 0.05 vs. solvent) within the shortest delay (solvent 210 min; ridogrel, 0.31 mg/kg, 85 min; ridogrel, 5 mg/kg, 37 min; p < 0.05 vs. solvent and ridogrel, 0.31 mg/kg) and the lowest incidence of reocclusion (solvent 5 of 7; ridogrel, 0.31 mg/kg, 2 of 7; ridogrel, 5 mg/kg, 1 of 7; p < 0.05 versus solvent). Myocardial infarct size after coronary artery ligation (90 min) and subsequent reperfusion (150 min) in anesthetized dogs was 49.3 +/- 4.3% versus 29 +/- 3.9% (p < 0.05 vs. solvent) of the area of the left ventricle at risk in dogs receiving solvent (n = 9) or ridogrel, 5 mg/kg intravenously (n = 10), respectively, despite similar hemodynamic characteristics, collateral blood flow and area at risk in both groups. CONCLUSIONS: Combined thromboxane A2 synthase inhibition and endoperoxide receptor antagonism 1) upgrades thrombolysis with streptokinase in canine coronary arteries, 2) limits myocardial infarct size after nonthrombotic coronary occlusion and reperfusion, and 3) may preserve ventricular function compromised by coronary occlusion through dual manipulation of the arachidonic acid cascade in blood and myocardial tissue, respectively.

Thromboxane A2/prostaglandin endoperoxide (TXA2/PG-END) receptor binding properties in human platelets of ridogrel, a combined TXA2 synthase inhibitor--TXA2/PG-END receptor antagonist.

Ridogrel, a potent thromboxane A2 (TXA2) synthase inhibitor, also has thromboxane A2 prostaglandin endoperoxide (TXA2/PG-END) receptor antagonistic properties as documented in functional studies of human platelets. In the present study, the binding affinities of the TXA2 synthase inhibitors, ridogrel, dazoxiben, dazmegrel and pirmagrel, and the TXA2/PG-END receptor antagonists, GR32191, L670596, SQ29548, ICI159995, AH69212 and sulotroban, for the TXA2/PG-END receptor labelled with [3H]SQ29548 on intact human platelets were assessed. The potencies of the TXA2/PG-END receptor antagonists to inhibit specific [3H]SQ29548 binding to intact human platelets ranged between 1.2 nM and 6,200 nM and corresponded to the ability of the drugs to suppress human platelet aggregation induced by TXA2/PG-END receptor stimulation with U46619 and collagen. The TXA2 synthase inhibitors dazoxiben, dazmegrel and pirmagrel could not inhibit specific [3H]SQ29548 binding to intact human platelets, tested up to 10(-5) M, nor suppress human platelet aggregation, indicating lack of any receptor antagonistic properties. Ridogrel, however, directly bound to the TXA2/PG-END receptor with micromolar affinity (IC50 = 5.2 microM) and inhibited U46619-27, or collagen-induced platelet aggregation, with ED50-values of 27 microM and 4.7 microM respectively. The present study thus demonstrates that antagonism by ridogrel of TXA2/PG-END receptor activation on platelets as defined in functional tests, coincides with inhibition of specific ligand binding to the receptors.

5-Hydroxytryptamine and arachidonic acid metabolites modulate extensive platelet activation induced by collagen in cats in vivo.

1. The pathways contributing to the platelet adhesion/aggregation reaction elicited by collagen microfibrils, administered to cats in vivo, were analysed. 2. The intra-aortic infusion of collagen (100 micrograms kg-1 in 1 min) caused an extensive activation of platelets, as evidenced by the time-dependent drop of free platelet numbers in whole blood, and the increases of 5-hydroxyindoles (5-HI), 5-hydroxytryptamine (5-HT) and thromboxane B2 (TXB2) levels in plasma, prepared from effluent venous blood sampled from the inferior caval vein. 3. 5-HT2 receptor blockade with ketanserin (0.63 mg kg-1 i.v., 10 min) and cyclo-oxygenase inhibition with aspirin (10 mg kg-1 i.v., 10 min) slightly attenuated the peak reduction of free platelets in whole blood in response to collagen without affecting changes in plasma 5-HI. Aspirin, but not ketanserin, reduced the collagen-induced changes in plasma TXB2, prostaglandin E2 (PGE2) and 6K-PGF1 alpha. 4. Dual TXA2 synthetase inhibition/TXA2-prostaglandin endoperoxide receptor antagonism with ridogrel (5 mg kg-1 i.v., 10 min) halved the drop in free platelets, reduced the release of platelet 5-HI, inhibited the increase in plasma TXB2 and elevated that of 6K-PGF1 alpha and PGE2 in response to collagen. 5. Combined treatment with ketanserin and aspirin reduced the collagen-induced drop of free platelets and the release of platelet 5-HI to a similar extent as ridogrel alone; plasma prostanoids were affected as with aspirin alone. 6. Combined administration of ketanserin and ridogrel virtually eliminated the collagen-induced platelet adhesion/aggregation response and release of 5-HI; prostanoids were affected as with ridogrel alone. 6. Combined administration of ketanserin and ridogrel virtually eliminated the collagen-induced platelet adhesion/aggregation response and release of 5-HI; prostanoids were affected as with ridogrel alone. 7. The results indicate that the interplay between 5-HT and arachidonic acid metabolites is causally involved in the platelet reaction to activation induced by collagen in cats in vivo.

The role of endogenously formed diacylglycerol in the propagation and termination of platelet activation. A biochemical and functional analysis using the novel diacylglycerol kinase inhibitor, R 59 949.

The putative roles for the second messenger, diacylglycerol, were investigated in intact platelets using a novel diacylglycerol kinase inhibitor, R 59 949, or (3-[2-[4-[bis(4-fluorophenyl)methylene]-1-piperidinyl]ethyl]-2,3- dihydro-2-thioxo-4(1H)-quinazolinone). The compound inhibited the diacylglycerol kinase in a concentration-dependent manner (10(-8) to 10(-5) M) in isolated platelet membranes and in intact platelets. When platelets were stimulated with vasopressin in the presence of the compound, protein kinase C activity was markedly increased; the formation of inositol phosphates, the increase in intracellular Ca2+ and shape-change reaction were antagonized while the vasopressin-induced polyphosphoinositide synthesis was amplified, and this in a distinct inositolphospholipid pool. In the presence of R 59 949, vasopressin- as well as collagen-induced release reaction and aggregation was strongly increased, independently of the formation of arachidonate metabolites. It is concluded that diacylglycerol formed after receptor activation, likely by activating the protein kinase C, plays an important role in the propagation of platelet functional responses in casu aggregation and secretion and controls the termination of the primary receptor coupled responses.

Ketoconazole inhibits the biosynthesis of leukotrienes in vitro and in vivo.

Ketoconazole inhibits in vitro (IC50:2.6 X 10(-5) M) the formation of 5-HETE and LTB4 by isolated, carrageenin-elicited rat peritoneal PMN leukocytes, challenged with the Ca2+-ionophore A23187 in the presence of [14C]-arachidonic acid ([14C]-AA). The relative potency of various compounds tested in this respect is NDGA greater than nafazatrom greater than phenidone greater than ketoconazole greater than BW 755C. In contrast to the other compounds studies, ketoconazole in vitro, up to 1 X 10(-4) M, has no effect on the fatty acid cyclo-oxygenase or the 12-lipoxygenase-mediated metabolism of [14C]-AA by isolated human platelets; however, it stimulates the 15-lipoxygenase activity in phenylhydrazine-induced rabbit reticulocytes. After oral administration (10-40 mg/kg, -2 hr), ketoconazole inhibits in a dose-dependent way, the leukotriene-mediated anaphylactic bronchoconstriction in guinea pigs. This study demonstrates that ketoconazole is a comparatively specific and orally active inhibitor of the 5-lipoxygenase activity bearing on the production of leukotrienes derived from arachidonic acid.

Thromboxane A2-induced vascular endothelial cell damage and respiratory smooth muscle cell contraction: inhibition by flunarizine, a Ca2+-overload blocker.

The fast intravenous injection of arachidonic acid (AA) in mice produces, in a dose-related way, mortality due to respiratory distress. Upon electron microscopical examination an extensive oedematous damage of the capillary endothelium was found; thrombotic platelet obstructions were present in a minority of pulmonary capillaries only. Protection against this toxic AA-effect is obtained with inhibitors of fatty acid cyclo-oxygenase and of thromboxane (TXA2) synthetase, suggesting involvement of TXA2 as a causative mediator. The Ca2+-entry blockers flunarizine, niludipine and nimodipine, not affecting TXA2 synthesis by murine platelets, also provide protection, but not the antiplatelet drugs ticlopidine, dipyridamole or suloctidil; thrombocytopenia induced by busulphan does not affect the AA-induced mortality nor the protection obtained with flunarizine. Platelet-independent bronchoconstriction induced by AA in guinea-pigs is also inhibited by flunarizine. This study suggests that the AA-induced mortality test reflects pulmonary conversion of AA to TXA2 producing endothelial cell damage and respiratory smooth muscle cell contraction rather than a thrombotic phenomenon. The protective effect of flunarizine against TXA2 induced changes in vivo may contribute to its effectiveness in particular hypoxic conditions associated with liberation of AA.

Platelet-vessel wall interactions in hemostasis: implication of 5-hydroxytryptamine.

5-Hydroxytryptamine (5-HT) is implicated in the platelet-vessel wall interactions during hemostasis. Indeed, the tail bleeding time and the initial blood loss in rats are significantly increased by platelet amine depletion with reserpine/parachlorophenylalanine, by the specific 5-HT2 receptor antagonists ketanserin, R 55 667 and R 56 433 and by the ergot derivatives metergoline and methysergide. In the dose range affecting hemostasis, the serotonergic receptor antagonists also inhibit the 5-HT-amplified aggregation of ADP-sensitized platelets in rat whole blood. Bleeding times are also prolonged by alpha 1-adrenergic receptor antagonism with prazosin or phentolamine, by specific thromboxane A2-synthetase inhibition with R 59 655 or dazoxiben, and by anticoagulant treatment. The latter three mechanisms of action are not explanatory for the effect of the tested serotonergic antagonists, since bleeding times are prolonged by specific 5-HT2 receptor antagonists without an effect on alpha-adrenergic receptors, on platelet prostaglandin biosynthesis or on coagulation and fibrinolysis. The present study shows the interplay between the platelet-derived mediators 5-HT and TXA2 at the level of the platelet or the blood vessel to be of major importance in the platelet-vessel wall interactions during hemostasis.

Platelet activation by endogenous 5-hydroxytryptamine and histamine released by mast cell degranulation with compound 48/80 in the rat.

The intravenous injection of the mast cell degranulator C 48/80 (1 mg/kg) in rats did not produce thrombocytopenia nor circulating platelet aggregates but sensitized the platelets to aggregate upon turbulence challenge. Such turbulence-induced platelet aggregation was not accompanied by formation of thromboxane B2. Electron microscopy revealed absence of platelet degranulation. Turbulence-induced platelet aggregation was completely prevented by pre-treatment of the rats with cyproheptadine, dipyridamole and VK 774, partially with ketanserin (5HT2-receptor antagonist), but not with methysergide (antiserotonergic drug), pyrilamine (antihistaminic drug), suprofen, aspirin (cyclo-oxygenase inhibitors), phentolamine, propranolol, flunarizine, lidoflazine, oxycoumarin or Trasylol. Combined treatment with the anti-histaminic drug pyrilamine and the 5HT2-receptor antagonist ketanserin resulted in a dose-related inhibition for ketanserin of the turbulence-induced platelet aggregation. These experiments point to an interaction between histamine and 5-hydroxytryptamine in the platelet activation by mast cell released mediators.

Enhanced platelet turnover and prostaglandin production in spontaneously hypertensive rats.

The anti-hypertensive effect of ketanserin, a selective 5-HT2 antagonist, both in experimental and human pathology (1,2) could implicate the blood platelets as a source for peripherally available 5-hydroxytryptamine (5-HT), acting to increase peripheral vascular resistance (3). Therefore we examined various blood platelet parameters in spontaneously hypertensive rats in comparison with normotensive Wistar rats.