Boardman C. Wang

Chronic Neurological Deficits and Nesacaine-CE-An Effect of the Anesthetic, 2-Chloroprocaine, or the Antioxidant, Sodium Bisulfite?

Chronic neurological deficits have been described in patients after presumed accidental subarachnoid injection of 2-chloroprocaine-CE (Nesacaine-CE; N-CE) intended for epidural block. This study investigated the possible role of pure 2-chloroprocaine (2-CP) and sodium bisulfite, two components of Nesacaine-CE, in causing these complications when injected separately into the lumbar subarachnoid space of neurologically intact awake rabbits. Repeated 2–4-mg spinal anesthetic doses of pure 2-CP in lactated Ringers solution did not produce chronic hindlimb paralysis even though accumulated doses reached 50 mg. However, 1.2–2.4 mg of sodium bisulfite, the antioxidant in N-CE added to prolong shelf-life, resulted in irreversible hindlimb paralysis in 12 out of 14 animals. This amount of bisulfite is contained in 12–24 mg of 2% N-CE. The demonstration that persistent paralysis resulted from low dosages of sodium bisulfite contained in commercially available 2-CP requires revaluation of the suitability of this antioxidant for products prepared for intrathecal use.

Subarachnoid Injection—a Potential Complication of Retrobulbar Block

This study was undertaken to illustrate the potential for subarachnoid injection during retrobulbar block as a cause of respiratory arrest. Cadaver orbits were used to document the connection between the optic nerve sheath and the subarachnoid space. Following dissections of the orbits on one side of 24 cadavers, the optic nerve sheaths were identified and injected with 0.5 ml of water for measurement of pressure generated during injection. This was followed by intrasheath injection of equal volume of methylene blue for demonstrating the subarachnoid space surrounding the optic nerves. All injections were performed with a 1-ml syringe with a one-and-one-half-inch 22-G needle over a period of 10 s. The blue dye was found to track along the subarachnoid space of the optic nerve sheath to the chiasmatic cistern in the middle cranial fossa. Retrobulbar injections were performed on the contralateral undissected orbits and intrascleral injections were performed on undissected eyes. The size of the syringes, the gauge of the needles, and the speed of injection were uniform for all injections. The pressure generated by injection into the optic nerve sheath or intrascleral injection (approximately 138 mmHg) was three- to fourfold that produced by injection into the retrobulbar adipose tissue (approximately 35 mmHg) (P less than 0.05). The authors conclude that any resistance encountered during retrobulbar block should serve as a warning signal, mandating redirection of the needle, in order to prevent subarachnoid injection.

The antinociceptive effect of S-(+)-ibuprofen in rabbits: epidural versus intravenous administration.

This study was designed to determine whether systemic absorption plays any role in the antinociceptive effect of epidural (EP) sodium S(+)-ibuprofen (IB). One week after surgical implantation of EP catheters, six rabbits were given EP injections with either normal saline (NS) 0.4 mL or IB 10 mg in 0.4 mL NS (Group 1) on separate days. Each animal was injected with IB 10 mg intravenously (IV) on another day. Six control rabbits (Group 2) had neither surgery nor any injection. Analgesic testing was performed using electric stimulation through two electrocardiogram (ECG) skin electrodes with built-in adhesive, attached to shaved hip areas using 50 V, 1 Hz, 3 ms, before and 0.5, 1, 2, and 3 h after injection in Group 1, and in similar times in controls. The 95% confidence intervals (CI) of the mean difference between baseline and maximal nociceptive response latency of all groups were compared using analysis of covariance (ANCOVA) adjusted for baseline measurements. This comparison covered all possible pairs among all groups. Significant antinociceptive effects were seen after EP IB but not after control or IV IB. Neither motor dysfunction nor evidence of systemic toxicity or neurotoxicity was observed in any animal. (Anesth Analg 1995;80:92-6)

Antinociception without motor blockade after subarachnoid administration of S-(+)-ibuprofen in rats

This study was designed to determine whether the nonsteroidal anti-inflammatory drug (NSAID) sodium S-(+)-ibuprofen (IB), can be used intrathecally as a substitute analgesic for opiates to avoid the side effects of intrathecal narcotics. One week or more after surgical implantation of subarachnoid catheters, four groups of Sprague-Dawley rats were given 0.05 ml subarachnoid injections containing one of the following: Group A, normal saline (NS); Group B, IB 0.25 mg, 0.5 mg and 1.5 mg; Group C, morphine (M) 0.05 mg and 0.025 mg; Group D received NS or IB 1.5 mg. Animals were sacrificed for spinal cord examination one week after injection. Tail flick response latency (TFL) was determined before and 15, 30, 60, 120 and 180 minutes after each injection. TFL differences were compared. IB 1.5 mg vs NS, IB 0.5 mg vs NS, IB 0.25 mg vs M 0.05 mg, IB 0.25 mg vs M 0.025 mg, M 0.05 mg vs NS, and M 0.025 vs NS showed p < 0.05. IB 1.5 mg vs M 0.05 mg and M 0.025 mg, IB 0.5 mg vs M 0.05 mg and M 0.025 mg revealed no significant difference. No motor impairment was observed in any animal. Light microscopy of the spinal cord revealed no evidence of pathological changes in any animal (group D).

Lumbar subarachnoid catheterization in rats.

An animal model was developed for the study of subarachnoid (spinal) anesthesia and analgesia under unanesthetized, unsedated and unrestrained conditions. Sprague-Dawley rats were anesthetized with intraperitoneal ketamine (75-100 mg.kg-1). A PE10 catheter was inserted under direct vision into the lumbar subarachnoid space, through partial laminectomy of L1 or L2 with or without removal of adjacent intervertebral ligament. One week after surgery, correct position of the catheter was verified by subarachnoid injection of 0.03-0.05 ml of 1.5% lidocaine, which produced temporary hind limb paralysis in all but one animal in 28 consecutive operations. There was neither mortality nor major complication, intraoperatively or postoperatively. Only 2 animals developed minor subcutaneous would infections which responded to incision, drainage and debridement.

Lumbar subarachnoid ethylenediaminetetraacetate induces hindlimb tetanic contractions in rats : prevention by CaCl2 pretreatment ; observation of spinal nerve root degeneration

Disodium ethylenediaminetetraacetate (Na2EDTA) has replaced sodium bisulfite as the antioxidant in 2-chloroprocaine, Nesacaine CE. This study was undertaken to determine whether this new formulation has neurotoxic effects when administered in the subarachnoid space. Sprague-Dawley rats receiving subarachnoid injections of 1.5 mM or higher concentrations of Na2EDTA immediately initiated a circling behavior that was followed by the development of tetanic contractions of the hindlimbs lasting for 15-20 min. The tetanic contractions were followed by a brief period of hindlimb paralysis. Pretreatment of rats by subarachnoid injections of 1 mM CaCl2 prevented the development of tetanic contractions and paralysis of the hindlimb. Histologic examination of animals receiving Na2EDTA revealed moderate to severe focal degenerative changes in spinal nerve roots. Control rats receiving subarachnoid injections of normal saline solution did not develop tetanic contraction nor pathological changes on light microscopy. These results suggest that the preservative used in Nesacaine-MPF may be neurotoxic.

Distribution of 3H-Morphine Following Lumbar Subarachnoid Injection in Unanesthetized Rabbits

Morphine sulfate (40-100 micrograms) and 3H-morphine (125-200 pmol) were injected into the lumbar subarachnoid space of 18 unanesthetized rabbits through a surgically implanted catheter. Radioactivity remaining in the spinal cord 2, 4, 6, and 12 h later revealed recovery (mean +/- SEM) of 45 +/- 5.6% (n = 3), 30.5 +/- 14.1% (n = 4), 11.23 +/- 4.4% (n = 3), and 3.7 +/- 1.1% (n = 3), respectively, of the injected radioactivity. Tritiated morphine was found to be predominantly centered around the injection site, with limited rostral and caudal spread in the cord. No significant radioactivity was detected in plasma or cerebrospinal fluid (CSF) samples from the cisterna magna taken at 5, 15, 30, min and 1, 2, 4, 6, 12, and 24 h after receiving radioactive labeled drug (with the exception of that in one rabbit). Of the injected radioactivity, 75% was recovered in the urine in 12 h. These results suggest that the persistence of morphine in the spinal cord could account for its prolonged analgesic effect following intrathecal administration.

SUBARACHNOID INJECTION- A POTENTIAL COMPLICATION OP RETROBULBAR BLOCK

This study was undertaken to illustrate the potential for subarachnoid injection during retrobulbar block as a cause of respiratory arrest. Cadaver orbits were used to document the connection between the optic nerve sheath and the subarachnoid space. Following dissections of the orbits on one side of 24 cadavers, the optic nerve sheaths were identified and injected with 0.5 ml of water for measurement of pressure generated during injection. This was followed by intrasheath injection of equal volume of methylene blue for demonstrating the subarachnoid space surrounding the optic nerves. All injections were performed with a 1-ml syringe with a one-and-one-half-inch 22-G needle over a period of 10 s. The blue dye was found to track along the subarachnoid space of the optic nerve sheath to the chiasmatic cistern in the middle cranial fossa. Retrobulbar injections were performed on the contralateral undissected orbits and intrascleral injections were performed on undissected eyes. The size of the syringes, the gauge of the needles, and the speed of injection were uniform for all injections. The pressure generated by injection into the optic nerve sheath or intrascleral injection (approximately 138 mmHg) was three- to fourfold that produced by injection into the retrobulbar adipose tissue (approximately 35 mmHg) (P less than 0.05). The authors conclude that any resistance encountered during retrobulbar block should serve as a warning signal, mandating redirection of the needle, in order to prevent subarachnoid injection.