Cardiac function is controlled by the autonomic nervous system (i.e., the sympathetic and the parasympathetic nervous systems), which act via adrenoceptors and muscarinic acetylcholine receptors, respectively. At least nine adrenoceptor subtypes and five muscarinic receptor subtypes exist. In recent

Adrenergic and Muscarinic Receptors in the Human Heart

Muscarinic receptors in the mammalian heart.

Oxytocin, 5 to 10 units, is frequently given as a bolus injection following term delivery or elective termination of pregnancy. It is not general knowledge that this has any untoward effects. In the present study in young, healthy women undergoing elective termination of pregnancy, mean arterial blood pressure decreased approximately 30% and the total peripheral resistence 50%, 40 seconds after injection. However, heart rate increased 30% and stroke volume 25%, so that the cardiac output was elevated more than 50% above control. Oxytocin given as a dilute solution produced no circulatory change; hence, we suggest that this drug be administered in such fashion rather than by bolus injection.

Cardiovascular effects of oxytocin

Sufentanil, an opioid analgesic, is an analogue of fentanyl, and has been used for the induction and maintenance of anaesthesia, and for postsurgical analgesia. It has shorter distribution and elimination half-lives, and is a more potent analgesic than fentanyl. In clinical practice, however, intravenously administered sufentanil produces essentially equivalent anaesthesia to fentanyl and is a better anaesthetic than morphine or pethidine (meperidine) for major surgery. It would appear to maintain haemodynamic stability during surgery better than other opioids or inhalational anaesthetics. Postoperative respiratory depression has been reported in a few patients. For outpatient surgery, intravenous sufentanil produces equivalent anaesthesia to isoflurane or fentanyl. Recovery tends to be more rapid after sufentanil and the requirement for postoperative analgesia is less. Initial clinical trials with sufentanil administered epidurally to relieve pain during labour have produced encouraging results, but further studies are required to establish the drug's role in this indication. Epidural sufentanil produces a more rapid onset and better initial quality of analgesia than morphine, buprenorphine or hydromorphine when administered postoperatively, but the duration of analgesia is shorter. Thus, sufentanil's primary place in therapy at this time would appear to be as high dose anaesthesia for major surgery such as cardiac surgery, and as low dose supplement to balanced anaesthesia in general surgery. In addition, low doses administered epidurally seem to have a potential role for analgesia during labour or after surgery although further studies are required to clarify this situation.

Sufentanil. A review of its pharmacological properties and therapeutic use.

Heart disease is a leading cause of maternal death. The aim of this study is to review the most common causes of cardiac disease, highlight factors that should be recognized by the clinician, and address recent advances in the anaesthetic management of these patients. Incipient cardiac disease, including peripartum cardiomyopathy, myocardial infarction and aortic dissection, accounts for approximately one in six maternal deaths. The keys to successful diagnosis and management of incipient disease are: a high index of suspicion, particularly in women with known risk factors for cardiovascular disease; a low threshold for radiological investigations; early cardiology input; and invasive monitoring during labour and delivery. Echocardiography is a safe, non-invasive test, under-used in pregnancy. Management of pregnant women with pre-existing cardiac problems should be undertaken by multidisciplinary teams in tertiary centres. In women with pre-existing cardiac disease wishing to proceed to term, cardiac status must be optimized preoperatively and planned elective delivery is preferable. Vaginal delivery is preferable, and with careful incremental regional anaesthesia is safe in most women with cardiac disease. The presence of adequate systems for early detection, appropriate referral to specialist centres, and timely delivery with multidisciplinary support can minimize the serious consequences of poorly controlled heart disease in pregnancy.

Recognition and management of maternal cardiac disease in pregnancy

The article by Goroszeniuk et al. (1) prompts us to report a recent experience we had with narcotics and seizures. Our patient, a 69-yr-old, 75-kg man with three vessel coronary artery disease was scheduled for coronary artery bypass grafting. Medications included propranolol, 20 mg, four times per day. After premedication with 2 mg lorazepam and 6 mg morphine, the patient was brought to the operating room where ECG leads (chest lead V) were applied and intravenous and intraarterial cannulae placed. While the patient was breathing 100% oxygen by mask, pancuronium, 1 mg, was given, followed by sufentanil, 50 pg. The patient appeared sedated; heart rate was 86 beats1 minute and blood pressure 118/70 mm Hg. Shortly after administration of these drugs, tonic-clonic activity of the extremities started. The pupils were small and equal, with conjugate deviation to the right. Movements of the extremities spontaneously ceased in less than 30 sec. Pulse and blood pressure remained unchanged from baseline during the episode. Induction was completed with incremental doses of sufentanil to a total of 1000 pg and pancuronium, 10 mg. No further abnormal movements were observed intraor postoperatively. The patient was awake with spontaneous movement of all extremities several hours later and was extubated 10 hr postoperatively. No neurologic deficits were present. He had no memory of the event, and his postoperative course was unremarkable. Grand ma1 seizure activity has been reported after as little as 100 p g of fentanyl (2). Seizure-like movement with an absence of seizure activity on a simultaneous EEG recording during fentanyl administration has been reported (3). Sebel et al. investigated the effects of high-dose fentanyl on the EEG and found no evidence of seizure activity (4). However, high-dose fentanyl in rats can induce both clinical and EEG evidence of seizures (5). The effects of sufentanil on EEG activity has been investigated by Bovill et al., who found sharp wave activity of unclear significance with no clinical evidence of seizure activity following a dose of 15 pg/kg (6). No previous reports of seizure or seizure-like activity resulting from sufentanil have appeared to our knowledge. The etiology of the abnormal movement observed by us is unclear. It may represent seizures, myoclonic activity, or an atypical form of rigidity resulting from narcotic administration. Premedication with lorazapam did not prevent its occurrence.

Tonic-clonic activity after sufentanil.

Aortic stenosis, cesarean delivery, and epidural anesthesia.

Nitric oxide has no chronotropic effect in right atria isolated from rat heart

We designed experiments to examine the effects of insulin-dependent diabetes mellitus on the anesthetic requirements for volatile anesthetics. A standard tail-clamp technique was used to determine minimum alveolar anesthetic concentrations for halothane, enflurane, and isoflurane in spontaneously breathing rats. Three groups of animals were used: 1) diabetic rats (12 wk after induction of diabetes with streptozotocin, 50 mg/kg, single dose, intravenously), 2) insulin-treated (7 U extended insulin zinc suspension per day, subcutaneously, beginning 5 wk after streptozotocin treatment) diabetic rats, and 3) control rats. The minimum alveolar anesthetic concentration values of the control animals were 1.16 +/- 0.02 vol% for halothane, 2.25 +/- 0.05 vol% for enflurane, and 1.42 +/- 0.04 vol% for isoflurane. Minimum alveolar anesthetic concentration was reduced by 23% for halothane (0.90 +/- 0.06 vol%), by 18% for enflurane (1.85 +/- 0.07 vol%), and by 17% for isoflurane (1.18 +/- 0.04 vol%) in diabetic rats. Insulin treatment restored the anesthetic requirement to control levels for all three anesthetics. These data from the rat model indicate that uncontrolled diabetes lowers anesthetic requirements significantly.

The impact of streptozotocin-induced diabetes on the minimum alveolar anesthetic concentration (MAC) of inhaled anesthetics in the rat.

The effect of age on halothane-induced alterations of contractility in isolated rat aorta

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