Amir Baluch

The Effect of Deep-Tissue Massage Therapy on Blood Pressure and Heart Rate

AIM In the present study, we describe the effects of deep tissue massage on systolic, diastolic, and mean arterial blood pressure. MATERIALS AND METHODS The study involved 263 volunteers (12% males and 88% females), with an average age of 48.5. Overall muscle spasm/muscle strain was described as either moderate or severe for each patient. Baseline blood pressure and heart rate were measured via an automatic blood pressure cuff. Twenty-one (21) different soothing CDs played in the background as the deep tissue massage was performed over the course of the study. The massages were between 45 and 60 minutes in duration. The data were analyzed using analysis of variance with post-hoc Scheffes F-test. RESULTS Results of the present study demonstrated an average systolic pressure reduction of 10.4 mm Hg (p<0.06), a diastolic pressure reduction of 5.3 mm Hg (p<0.04), a mean arterial pressure reduction of 7.0 mm Hg (p<0.47), and an average heart rate reduction of 10.8 beats per minute (p<0.0003), respectively. CONCLUSIONS Additional scientific research in this area is warranted.

Pharmacology of cyclooxygenase-2 inhibitors and preemptive analgesia in acute pain management

Purpose of review NSAIDs have served as analgesic, antiinflammatory, and antipyretic medicines for over a century. A novel class of NSAIDs, cyclooxygenase-2 inhibitors, was introduced in 1999. All NSAIDs and aspirin inhibit active sites of cyclooxygenase-1 and cyclooxygenase-2. Recent studies have demonstrated an important role of cyclooxygenase-2 inhibitors in the management of acute pain processes. Recent findings There have been many reports related to an ‘imbalance theory’ suggesting that cyclooxygenase-2 inhibitors create an ‘imbalance’ between thromboxane and prostacyclin (reduction of prostacyclin), resulting in a prothrombic state; however, these drugs were designed to have improved gastrointestinal safety profiles by being more selective of the cyclooxygenase-2 pathway. Although balance and regulation of hemostasis is influenced in part by the balance of prostacyclin and thromboxane A2, many other substances are involved in thrombosis and include the coagulation cascade, fibrinogen and plasminogen pathways, numerous endogenous substances such as adenosine, nitric oxide, and serotonin. Summary On the basis of many human studies, one may conclude that perioperative cyclooxygenase-2 inhibitors, in standard doses, decrease opioid consumption. Future investigations that include different multimodal techniques, for example combining cyclooxygenase-2 inhibitors with regional blocks, may help elucidate and clarify the true benefits of perioperative cyclooxygenase-2 inhibitors in acute pain management strategies.

An analysis of remifentanil in the pulmonary vascular bed of the cat

In this investigation we sought to identify the role of remifentanil in the feline pulmonary vascular bed. Using adult mongrel cats in separate experiments, the effects of glibenclamide (adenosine triphosphate-sensitive K+ channel blocker), diphenhydramine (histamine H1-receptor antagonist), L-N5-(1-Iminoethyl) ornithine hydrochloride (nitric oxide synthase inhibitor), and naloxone (opioid receptor antagonist) were investigated in pulmonary arterial responses to remifentanil (opioid agonist), pinacidil (adenosine triphosphate-sensitive K+ channel activator), and bradykinin (nitric oxide synthase inducer). Under increased tone conditions in the isolated left lower lobe vascular bed of the cat, remifentanil induced a dose-dependent vasodepressor response that was not significantly altered after administration of glibenclamide and L-N5-(1-Iminoethyl) ornithine hydrochloride. Responses to remifentanil were significantly attenuated after administration of diphenhydramine and naloxone. The results suggest that remifentanil has potent vasodepressor activity in the feline pulmonary vascular bed and that these responses are mediated by histamine and opioid receptor sensitive pathways.

Pharmacology of herbals and their impact in anesthesia.

Introduction Over one half of Americans currently take dietary supplements, and up to 33% may be using herbals in place of prescription medications [1–3]. Anecdotal reports on efficacy, heavy marketing, lower costs compared with prescription medications, and accessibility are a few of the reasons for this increase in prevalence. Furthermore, many patients will not disclose their consumption of these products to their physicians. Such products do not require approval from the US Food and Drug Administration, and consequently herb–drug interactions may occur. Herbals are actually considered foods by the Food and Drug Administration, and they do not undergo any of the vigorous tests required to achieve drug status, including ensuring specific bioavailability, standardization, limitation of adulterants, and therapeutic efficacy. It is imperative that physicians, particularly the anesthesiologist, be cognizant of the potential pharmacologic effects of these herbals. In this review we discuss some of the most commonly used herbal supplements and their pharmacology.

Analysis of the effects of fentanyl in the feline pulmonary vascular bed

The objective of this study was to test the hypothesis that fentanyl induces a depressor response in the pulmonary vascular bed of the cat and to identify the receptors involved in the mediation or modulation of these effects. The authors conducted a prospective vehicle-controlled study at a university research laboratory using intact chest preparation in adult mongrel cats. In separate experiments, the effects of diphenhydramine (histamine receptor blocker), glibenclamide (ATP-sensitive K+ channel blocker), l-N5-(1-Iminoethyl) ornithine hydrochloride (l-NIO) (nitric oxide synthase inhibitor), nimesulide (selective cyclooxygenase [COX]-2 inhibitor), and naloxone (opiate receptor antagonist) were investigated on pulmonary arterial responses to fentanyl and other agonists in the pulmonary vascular bed of the cat. The systemic pressure and lobar arterial perfusion pressure were continuously monitored, electronically averaged, and recorded. In the feline pulmonary vascular bed of the isolated left lower lobe, fentanyl induced a dose-dependent vasodepressor response that was not significantly altered after administration of glibenclamide, l-NIO, and nimesulide. However, the responses to fentanyl were significantly attenuated after administration of diphenhydramine and naloxone. The results of the present study suggest that fentanyl has potent vasodepressor activity in the pulmonary vascular bed of the cat and that this response may be mediated or modulated by both histaminergic and opiate receptor sensitive pathways.

Chronic Pain and Ultrarapid Opioid Detoxification

Abstract:  Availability of opiate substances through physicians and on the street has led to a rise in dependence and in addiction resulting in countless numbers of people hooked on these drugs. Long‐term use of these agents results in reduction of endogenous supply of opiate replaced by these exogenous compounds. A technique known as Ultrarapid Detoxification (UROD) has been developed and appears more promising than conventional modalities. UROD has been modified over 3 decades resulting in a safe and an effective general anesthetic that results in hemodynamically stable withdrawal without manifestation of central nervous system hyperarousal. A cornerstone of this technique involves clonidine, which stimulates reuptake of catecholamines and allows for large doses of opioid antagonist to be delivered without significant changes in heart rate or blood pressure, displacing the opiate. Though techniques vary from center to center, safety should be paramount with the technique performed in an intensive care unit with trained professional anesthesiologists. Psychosocial issues should be evaluated by a trained addictionalist and most people will succeed from the UROD procedure without experiencing the horrible withdrawal syndrome. Patients must have realistic goals and be prepared to deal with psychosocial issues post‐procedure.

Postoperative apnea, respiratory strategies, and pathogenesis mechanisms: a review

Recovery from anesthesia is ideally routine and uneventful. After extubation, the recovering postoperative patient ought to breathe without supportive care or additional oxygenation. It has been demonstrated in previous studies that postoperative pulmonary complications are clinically relevant in terms of mortality, morbidity, and length of hospital stay. Compromised postoperative ventilation can be described as the condition in which the postoperative patient does not have satisfactory spontaneous ventilation support and adequate oxygenation. Causes of impaired ventilation, oxygenation, and airway maintenance can be mechanical, hemodynamic, and pharmacologic. This review describes prevalence and differential diagnosis, including co-morbidities of postoperative apnea. The physiological mechanisms of breathing and prolonged postoperative apnea are also reviewed; these mechanisms include influences from the brainstem, the cerebral cortex, and chemoreceptors in the carotid and aortic body. Causes of prolonged postoperative apnea and management are also discussed.

The role of cyclooxygenase in the feline pulmonary vascular bed.

Objective:There are extensive data on roles of cyclooxygenase 1 (COX 1) and cyclooxygenase 2 (COX 2) enzymes in temperature, coagulation, and inflammatory modulation. There is little known of the function of these enzymes in regulating tone in pulmonary vasculature. The purpose of this investigation was to elucidate the roles of COX 1 and 2 enzymes in the feline pulmonary vascular bed. Design:Prospective vehicle controlled study. Setting:University research laboratory. Subjects:Intact chest preparation; adult mongrel cats. Interventions:The effects of intravascular administration of U46619, angiotensin II, prostaglandin E1 (PGE1), arachidonic acid, and norepinephrine, were analyzed before and after intravascular administration of selective COX enzyme inhibitors. Measurements and Main Results:Because lobar arterial flow is constant in these experiments, changes in lobar pressure represent changes in pulmonary arterial resistance. Under constant flow conditions, lobar arterial and systemic pressures were continuously monitored, electronically averaged, and recorded. In the isolated left lower lobe of the feline lung bed, U46619, angiotensin II, arachidonic acid, and norepinephrine induced a dose-dependent vasoconstrictor response. PGE1 induced a dose-dependent vasodepressor response. After administration of the COX 1 inhibitor SC 560, the arachidonic acid-induced vasopressor responses were significantly attenuated while U46619, angiotensin II, and norepinephrine-induced vasopressor, and PGE1-induced vasodepressor responses were not significantly altered. After administration of the COX 2 inhibitor nimesulide, both the PGE 1 vasodepressor responses and arachidonic acid-induced vasopressor responses were significantly decreased while the U46619, angiotensin II, and norepinephrine-induced vasopressor responses were not significantly attenuated. Conclusions:The results of the study indicate that PGE1 has potent vasodepressor effects in the feline lung bed and this response is mediated by COX 2 pathways. The data also suggest that arachidonic acid has potent vasopressor activity in the feline pulmonary vascular bed and this response is mediated by both COX 1 and COX 2 sensitive pathways.

Minerals and Electrolytes

This chapter will review the physiology, metabolism, and clinical implications of the most common minerals and electrolytes. Emphasis will be placed on the role of the anesthesiologist in the perioperative setting.

Alternative and Herbal Pharmaceuticals

The use of alternative medicines such as minerals, vitamins, and herbal products has increased dramatically in recent years. Reasons for such an increase in prevalence include anecdotal reports on efficacy, impressive advertisement, lower cost of products compared to prescription medications, and ease of attainment of the supplements. Regardless of the reasons, it is important that physicians, particularly the pain practitioner be cognizant of the effects of these agents, whether beneficial or harmful.