published_or_final_version / abstract / toc / Anaesthesiology / Master / Master of Philosophy

Thesis (M. Phil.)--University of Hong Kong, 1998. / Includes bibliographical references (leaves 133-160).

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A maioria dos medicamentos normalmente prescritos são comercializados sob a forma racêmica, apesar de se ter conhecimento que a presença de diferentes enantiômeros em uma formulação farmacêutica pode levar a diferentes atividades farmacológicas, farmacocinéticas e perfis toxicológicos. O uso de enantiômeros puros em formulações farmacêuticas pode resultar em melhor ajuste de dose e diminuição dos efeitos adversos, fato que torna estudos a respeito de quiralidade de moléculas fundamental na área farmacêutica. Atualmente, os métodos analíticos mais empregados para a separação e determinação da pureza enantiomérica de compostos são a CLAE-FEQ e eletroforese capilar com seletores quirais. Os enantiômeros de esmolol foram separados através de CLAE-FEQ em fase reversa utilizando coluna Chiralcel-OD-RH (250 x 4,6 mm d.i.), 5 µm. A fase móvel foi composta por perclorato de potássio 100 mM, pH 2,08 : acetonitrila : dietilamina (80:20:0,2) com vazão de 0,5 mL.min-1 e detecção a 220 nm. Os enantiômeros de esmolol também foram separados através de CLAE-FEQ em fase normal utilizando coluna Chiralcel-OD (250 x 4,6 mm d.i.), 10 µm. A fase móvel foi composta por hexano : etanol : dietilamina (75:25:0,2) com vazão de 1,0 mL.min-1 e detecção a 220 nm. Ambos os métodos foram validados, sendo possível considerá-los precisos, seletivos, específicos, exatos e lineares para quantificar os enantiômeros de esmolol em medicamentos. Os testes realizados com cloridrato de sotalol por CLAE não indicaram separação enantiomérica ao serem utilizadas coluna Chiralcel OD®, Chiralcel OD-RH®, Burke e Whelk®. Os ensaios realizados por eletroforese capilar apresentaram separação parcial dos enantiômeros de sotalol e de esmolol, porém houve ausência de reprodutibilidade do método. / Most commonly prescribed drugs are marketed as racemic mixtures, even though it is well known that the presence of different enantiomers in a pharmaceutical formulation can lead to different pharmacological, pharmacokinetic and toxicological profiles. The use of pure enantiomers in pharmaceutical formulations can result in better dose adjustment and reduction of side effects, fact which makes studies on molecular chirality important to the pharmaceutical area. Currently, high performance liquid chromatography using chiral stationary phases (CSPs) and capillary electrophoresis with chiral selectors are the most commonly methods employed for the separation and determination of enantiomeric purity of compounds. The enantiomers of esmolol were separated through HPLC using a reversed phase CSP column Chiralcel-OD-RH (250 x 4,6 mm i.d.) 5 µm. The mobile phase was composed of 100 mM potassium perchlorate, pH 2,08 : acetonitrile: diethylamine (80:20:0,2) at a flow rate of 0,5 mL.min-1 and detection at 220 nm. The enantiomers of esmolol were also separated using HPLC-CSP using normal phase column Chiralcel OD (250 x 4,6 mm i.d.), 10 µm. The mobile phase consisted of hexane : ethanol : diethylamine (75:25:0,2) with a flow rate of 1,0 mL.min-1 and detection at 220 nm. Both methods were validated, and it was possible to consider them precise, selective, specific, exact and linear to quantify the enantiomers of esmolol on drugs. HPLC tests conducted with sotalol indicated no enantiomeric separation when Chiralcel OD, Chiralcel OD-RH, Burke and Whelk columns were used. Capillary electrophoresis tests showed partial separation of the enantiomers of sotalol and esmolol, but there was lack of reproducibility.

Introduction : Malgré une réanimation bien conduite, un certain nombre de patients en choc septique présentent une tachycardie persistante. Dans ce contexte, cette élévation de la fréquence cardiaque peut être le reflet d’un certain degré de dysautonomie. L’objectif de cette thèse est d’évaluer, sur un modèle expérimental de choc septique, l’impact d’un ralentissement de la fréquence cardiaque soit par un β-bloquant cardiosélectif aux effets anti inflammatoires (esmolol, travail 1) soit par l’ivabradine, un inhibiteur des canaux if sans effets anti-inflammatoires majeurs en situation aiguë, (travail 2) sur les fonctions cardiaque, vasculaire et le profil inflammatoire systémique et tissulaire. Matériels et Méthodes : Le choc septique était induit par une ligature et ponction cæcale (CLP) chez des rats Wistar. Les rats du travail 1 étaient randomisés à 4 heures de la chirurgie dans les groupes : Contrôle, Esmolol (débuté à 4 heures), Noradrénaline (débuté à 18 heures), Esmolol + Noradrénaline. Les rats du travail 2 étaient randomisés à 4 heures de la chirurgie dans les groupes Contrôle, Ivabradine (débutée à 4 heures). Un groupe Sham était réalisé dans chaque travail. Les évaluations étaient réalisées à 18 heures de la chirurgie et portaient sur la fonction cardiaque (micro PET et Millar pour le travail 1, échocardiographie pour le travail 2) in vivo, ex vivo sur la vasoréactivité (par myographie) ainsi que sur les profils inflammatoires systémique et tissulaire (cardiaque et vasculaire). Résultats : Dans les deux travaux, comparé au groupe Sham, la CLP induisait un tableau de choc septique incluant dysfonction cardiaque et hypovasoréactivité aux vasopresseurs Dans le travail 1, l’adjonction d’esmolol réduisait la fréquence cardiaque et améliorait l’inotropisme myocardique ainsi que la vasoréactivité mésentérique. Ces effets étaient associés à une réduction des cytokines inflammatoires systémiques et à une diminution de l’expression de NF-κB dans le cœur et les vaisseaux. Dans le travail 2, l’ivabradine réduisait aussi efficacement la fréquence cardiaque mais sans aucun impact sur la fonction myocardique ou la vasoréactivité. Aucun effet n’était retrouvé sur les mêmes paramètres inflammatoires. Conclusion : Dans le choc septique expérimental, l’adjonction d’un traitement β-bloquant permet une amélioration des fonctions cardiaques et vasculaires via des effets anti-inflammatoires. Néanmoins, la réduction isolée de la fréquence cardiaque semble n’apporter aucun bénéfice en termes de fonction cardiovasculaire ainsi que sur les paramètres inflammatoires. L’objectif de réduction systématique de la fréquence cardiaque n’apparaît donc pas comme un objectif intéressant dans la prise en charge du choc septique et les effets bénéfiques de l’Esmolol sont essentiellement anti-inflammatoires. / Introduction: Despite adequate initial resuscitation, some septic shock patients continue to display persistent tachycardia likely due to autonomic dysregulation. The purpose of the present study was to determine the consequences of heart rate reduction by a β-blocker (study 1) or by Ivabradine (study 2) on cardiac function, vasoreactivity and inflammatory pattern in) an experimental model of septic shock. Material and Methods: Septic shock was induced in Wistar rats by cecal ligation and puncture. In the first study, four hours after the surgery, Wistar rats were randomly allocated to the following groups: control, esmolol, norepinephrine (started at H18), and esmolol (started at H4) + norepinephrine (started at H18). In the second study, four hours after the surgery, Wistar rats were randomly allocated to the following groups: Control and Ivabradine (administered per os four hours after the surgery). A Sham- operated group was included in each study. Assessment at 18 hours included hemodynamics, in vivo cardiac function (by Micro-PET and Millar in study 1 and echocardiography in study 2) and ex vivo vasoreactivity by myography. Circulating cytokine levels were measured by ELISA while cardiac and vascular inflammatory protein expressions were assessed by Western blotting. Results: In both studies compared to sham animals, CLP animals developed hypotension, cardiac depression and vascular hyporesponsiveness to vasopressor treatment. In study 1, esmolol infusion decreased the heart rate with increased cardiac contractility and restored mesenteric vasoreactivity. These effects were associated with a decrease in systemic inflammatory cytokines as well as NF-κB activation both at the cardiac and vessel level. In study 2, compared to the CLP group, adjunction of Ivabradine also decreased the heart rate but without any impact on cardiac contractility or vasoreactivity. Adjunction of Ivabradine to CLP rats had no impact on the same tested inflammatory parameters. Conclusion: Adjunction of selective β1-blockade in experimental septic shock enhances cardiac contractility and vascular responsiveness to catecholamines whereas isolated heart rate reduction by Ivabradine does not. These protective cardiovascular effects in study 1 appear to be attributed to the anti- inflammatory effects of esmolol while in study 2, Ivabradine does not affect any of the above parameters. It is likely that heart rate reduction is not a promising target in septic shock and that the observed benefits of esmolol are mostly likely attributable to its anti-inflammatory effects.

A maioria dos medicamentos normalmente prescritos são comercializados sob a forma racêmica, apesar de se ter conhecimento que a presença de diferentes enantiômeros em uma formulação farmacêutica pode levar a diferentes atividades farmacológicas, farmacocinéticas e perfis toxicológicos. O uso de enantiômeros puros em formulações farmacêuticas pode resultar em melhor ajuste de dose e diminuição dos efeitos adversos, fato que torna estudos a respeito de quiralidade de moléculas fundamental na área farmacêutica. Atualmente, os métodos analíticos mais empregados para a separação e determinação da pureza enantiomérica de compostos são a CLAE-FEQ e eletroforese capilar com seletores quirais. Os enantiômeros de esmolol foram separados através de CLAE-FEQ em fase reversa utilizando coluna Chiralcel-OD-RH (250 x 4,6 mm d.i.), 5 µm. A fase móvel foi composta por perclorato de potássio 100 mM, pH 2,08 : acetonitrila : dietilamina (80:20:0,2) com vazão de 0,5 mL.min-1 e detecção a 220 nm. Os enantiômeros de esmolol também foram separados através de CLAE-FEQ em fase normal utilizando coluna Chiralcel-OD (250 x 4,6 mm d.i.), 10 µm. A fase móvel foi composta por hexano : etanol : dietilamina (75:25:0,2) com vazão de 1,0 mL.min-1 e detecção a 220 nm. Ambos os métodos foram validados, sendo possível considerá-los precisos, seletivos, específicos, exatos e lineares para quantificar os enantiômeros de esmolol em medicamentos. Os testes realizados com cloridrato de sotalol por CLAE não indicaram separação enantiomérica ao serem utilizadas coluna Chiralcel OD®, Chiralcel OD-RH®, Burke e Whelk®. Os ensaios realizados por eletroforese capilar apresentaram separação parcial dos enantiômeros de sotalol e de esmolol, porém houve ausência de reprodutibilidade do método. / Most commonly prescribed drugs are marketed as racemic mixtures, even though it is well known that the presence of different enantiomers in a pharmaceutical formulation can lead to different pharmacological, pharmacokinetic and toxicological profiles. The use of pure enantiomers in pharmaceutical formulations can result in better dose adjustment and reduction of side effects, fact which makes studies on molecular chirality important to the pharmaceutical area. Currently, high performance liquid chromatography using chiral stationary phases (CSPs) and capillary electrophoresis with chiral selectors are the most commonly methods employed for the separation and determination of enantiomeric purity of compounds. The enantiomers of esmolol were separated through HPLC using a reversed phase CSP column Chiralcel-OD-RH (250 x 4,6 mm i.d.) 5 µm. The mobile phase was composed of 100 mM potassium perchlorate, pH 2,08 : acetonitrile: diethylamine (80:20:0,2) at a flow rate of 0,5 mL.min-1 and detection at 220 nm. The enantiomers of esmolol were also separated using HPLC-CSP using normal phase column Chiralcel OD (250 x 4,6 mm i.d.), 10 µm. The mobile phase consisted of hexane : ethanol : diethylamine (75:25:0,2) with a flow rate of 1,0 mL.min-1 and detection at 220 nm. Both methods were validated, and it was possible to consider them precise, selective, specific, exact and linear to quantify the enantiomers of esmolol on drugs. HPLC tests conducted with sotalol indicated no enantiomeric separation when Chiralcel OD, Chiralcel OD-RH, Burke and Whelk columns were used. Capillary electrophoresis tests showed partial separation of the enantiomers of sotalol and esmolol, but there was lack of reproducibility.

Parmi les facteurs intervienant dans la régulation et le maintien du fonctionnement d'organes, le système nerveux autonome et la microcirculation jouent un rôle prépondérant. Chez les patients critiques, comme les patients en sepsis, des altérations de la balance sympatho-vagale et de la perfusion tissulaire peuvent survenir et avoir des conséquences majeures en matière de morbidité et mortalité. La mise en oeuvre de méthodes de détection précoces de ces perturbations pourrait donc contribuer à améliorer la survie des patients à risque. En effet, le suivi des paramètres hémodynamiques, comme classiquement réalisé lors de réanimation, peut s'avérer insuffisant pour détecter des altérations de perfusion tissulaire : lors de sepsis, des altérations microcirculatoires peuvent persister en dépit de la normalisation des paramètres macrocirculatoires et sont associées à un mauvais pronostic. Eu égard à la présence de dysfunctions microcirculatoires et du système nerveux autonome chez les patients critiques, ce travail de recherche s'est proposé d'évaluer l’impact de modulateurs du système sympathique sur la balance sympatho-vagale et la microcirculation. Pour ce faire, nous avons travaillé avec des modèles animaux et des animaux admis en centre hospitalier universitaire vétérinaire. Le suivi du système nerveux autonome s'est basé sur un nouvel index de mesure du tonus parasympathique (Parasympathetic Tone Activity ou PTA). En parallèle, la microcirculation a été évaluée par vidéomicroscopie (SDF, Sidestream Dark Field imaging). L'index PTA a démontré une performance correcte pour prédire les réactions hémodynamiques chez les chiens anesthésiés. Il a aussi permis de détecter une altération de la balance sympathique chez les chevaux admis pour une chirurgie de colique ainsi qu’une altération de la microcirculation en dépit des manoeuvres de réanimation. Les études précliniques sur l’impact de la perfusion d’esmolol et de dexmédétomidine dans un modèle porcin septique ont montré que, malgré leurs effets hémodynamiques potentiels, ces agents n’ont pas eu d’effet négatif sur la microcirculation. Ainsi, les résultats de ce travail suggèrent un effet bénéfique des modulateurs du système nerveux sympathique sur la microcicultion mais nécessite d'être confirmé à plus grande échelle / Among the factors involved in the regulation and maintenance of the organs’ functioning, the autonomic nervous system and the microcirculation play a preponderant role. In critical patients, such as septic patients, alterations in the sympathovagal balance and tissue perfusion may occur and have major consequences of morbidity and mortality. The implementation of early detection methods for these disturbances could therefore contribute to improve the survival of patients at risk. Indeed, the monitoring of hemodynamic parameters, as conventionally performed during resuscitation, may be insufficient to detect tissue perfusion alterations: during sepsis, microcirculatory changes may persist despite the normalization of macrocirculatory parameters and are associated with a bad prognosis. With regard to the presence of microcirculatory dysfunctions and autonomic nervous system alterations in critical patients, this research project proposed to evaluate the impact of modulators of the sympathetic system on the sympatho-vagal balance and microcirculation. In order to achieve this, we worked on animal models and animals admitted to the faculty’s veterinary hospital center. Monitoring of the autonomic nervous system was based on a new Parasympathetic Tone Activity (PTA) index. In parallel, the microcirculation was evaluated by videomicroscopy (SDF, Sidestream Dark Field imaging). The PTA index demonstrated a good performance in predicting hemodynamic reactions in anesthetized dogs. It also detected disturbances of the sympathetic balance in horses admitted for colic surgery as well as an alteration of microcirculation despite resuscitation maneuvers. Preclinical studies on the impact of esmolol and dexmedetomidine infusion in a septic swine model showed that, despite their potential hemodynamic effects, these agents did not have a negative effect on the microcirculation. Thus, these findings suggest a beneficial effect of the modulators of the sympathetic nervous system on the microcicultion, however, these resutls should be confirmed on a larger scale

Le choc septique est associé non seulement à une réponse immunitaire excessive et inappropriée contre l'infection, mais aussi à une augmentation de l'activité nerveuse sympathique, à une augmentation des catécholamines circulantes et à un dysfonctionnement autonome. Le blocage de la bêta 1-adrénergique a montré une protection cardiovasculaire et une amélioration de la survie pendant le choc septique dans les études expérimentales et cliniques, ce qui semble être dû à ses effets anti-inflammatoires. Cependant, les effets de la réduction du rythme cardiaque (HRR) d'un bloqueur des adrénorécepteurs bêta 1 sur la fonction cardiovasculaire et les voies inflammatoires restent peu clairs. En utilisant un médicament pur de réduction du rythme cardiaque, Ivabradine, dans un modèle de choc septique polymicrobien induit par CLP, nous avons constaté que la réduction de la fréquence cardiaque : 1) n'était associé à aucune amélioration des fonctions cardiaques ou vasculaires; 2) n'avait aucun impact sur les niveaux circulants de TNF-a, IL-6 ou IL-10; 3) n'a eu aucune influence sur l'expression d'iNOS et NF-κB cardiovasculaires, les rapports P-akt / akt et P-eNOS / eNOS et la dégradation d'IκBα dans ce contexte aigu. En utilisant un bloqueur bêta 1-adrénergique, Esmolol, dans un modèle de choc septique polymicrobien induit par CLP, nous avons constaté que de faibles doses d'Esmolol, ne diminuant pas la fréquence cardiaque 1) a aussi amélioré la fonction cardiaque évaluée par échocardiographie et la vasoréactivité évaluée par myographie ; 2) les bénéfices ont été associés avec la modulation des voies inflammatoire au niveau systémique et tissulaire. Ces résultats ouvrent de nouvelles perspectives dans le traitement clinique du choc septique avec des bloqueurs adrénergiques bêta 1. / Septic shock is associated with not only an excessive and an inappropriate immune response against infection, but also with increased sympathetic nerve activity, elevated circulating catecholamines and autonomic dysfunction. Beta 1-adrenergic blockade has shown to provide cardiovascular protection and survival improvement during septic shock in experimental and clinical studies, which seems due to its anti-inflammatory effects. However, the effects of heart rate reduction (HRR) of a beta 1-adrenoreceptor blocker on cardiovascular function and inflammatory pathways remain unclear. By using a pure heart rate-lowering drug, Ivabradine, in a polymicrobial septic shock model induced by CLP, we found isolated heart rate reduction 1) was not associated with any improvement in cardiac or vascular functions; 2) has no impact on circulating levels of TNF-a, IL-6 or IL-10; 3) had no influence in cardiovascular iNOS and NF-κB expression, P-akt/akt and P-eNOS/eNOS ratio and IκBα degradations in this acute setting. By using a beta 1-adrenergic blocker, Esmolol, in a polymicrobial septic shock model induced by CLP, we found that a low dose of Esmolol, which didn’t induce HRR, also 1) improved cardiac function evaluated by echocardiography and vasoreactivity tested by myograph; 2) beneficial effects were associated with the modulation of inflammatory pathways at both the systemic and the tissue levels. These results open up new perspectives in clinical treatment of septic shock with beta 1 adrenergic blockers

Aspiration of gastric content and delayed or failed intubation are the leading causes of anesthesia-related mortality and morbidity. In the recovery period, airway obstruction with subsequent hypoxia is a relatively common cause of morbidity, and is highly associated to the amount of opioids administered, especially in obese patients. The overall aim of this thesis was to study these risk factors for airway complications and postoperative hypoxia in obese patients, and to evaluate possible strategies for their prevention. In Study I, intubation times and incidence of failed intubation in obese patients were compared between direct laryngoscopy and videolaryngoscopy with the Stortz® C-MAC™. In Studies II and III, the effect of esmolol vs. remifentanil on the esophageal junction, and the possible analgesic properties of low-dose esmolol vs. placebo were evaluated using high-resolution manometry and the cold pressor test, respectively. Finally, in Study IV, the possible opioid-sparing effect of esmolol after laparoscopic gastric bypass surgery was evaluated. The use of videlaryngoscopy did not shorten intubation times, however appeared to reduce the incidence of failed intubation. Our results also show that esmolol has a favorable profile, compared to remifentanil, with regard to the protection against passive regurgitation and aspiration of gastric content. No analgesic effect of low-dose esmolol was however demonstrated. The intraoperative administration of esmolol instead of remifentanil also did not reduce the requirement of morphine for treatment of post-operative pain. The use of Stortz® C-MAC™ may be recommended for intubation of obese patients. Further studies are however required to clarify the possible role of esmolol in anesthesia.

It is a major clinical problem that survival rates after out-of-hospital cardiac arrest have not markedly improved during the last decades, despite extensive research and the introduction of new interventions. However, recent studies have demonstrated promising treatments such as targeted temperature management (TTM) and methylene blue (MB). In our first study, we investigated the effect of MB administered during experi-mental cardiopulmonary resuscitation (CPR) in the setting of postponed hypother-mia in piglets. We set out to study if MB could compensate for a delay to establish targeted TTM. The study demonstrated that MB more than compensated for 30 min delay in induction of TTM. The effect of MB added to that of TTM. The second study examined the effects of TTM and S-PBN on the endothelin system and nitric oxide synthases (NOS) after prolonged CA in a porcine CPR mod-el. The study was designed to understand the cardioprotective mechanism of S-PBN and TTM by their influence on the endothelin system and NOS regulation. We veri-fied for the first time, that these two cardioprotective postresuscitative interventions activate endothelin-1 and its receptors concomitantly with eNOS and nNOS in the myocardium. We concluded that nitric oxide and endothelin pathways are implicated in the postresuscitative cardioprotective effects of TTM. The third study compared survival and hemodynamic effects of low-dose amio-darone and vasopressin to vasopressin in a porcine hypovolemic CA model. The study was designed to evaluate whether resuscitation with amiodarone and vasopressin compared to vasopressin alone would have an impact on resuscitation success, survival, and hemodynamic parameters after hemorrhagic CA. We found that combined resuscitation with amiodarone and vasopressin after hemorrhagic circulatory arrest resulted in greater 3-hour survival, better preserved hemodynamic parameters and smaller myocardial injury compared to resuscitation with vasopressin only. In our fourth study we planned to compare hemodynamic parameters between the treatment group (milrinone, esmolol and vasopressin; MEV) and control group (vasopressin only) during resuscitation from prolonged cardiac arrest in piglets. The study was designed to demonstrate if MEV treatment improved hemodynamics or cardiac damage compared to controls. We demonstrated that MEV treatment reduced cardiac injury compared with vasopressin alone.