Mechanisms of antinociceptive effects of ouabain in combination with neostigmine in the rat

BACKGROUND： It has been previously shown that intrathecal administration of either ouabain or neosdgmine can produce antinociceptive effects. Moreover, ouabain and neostigmine are differently associated with acetylcholine. OBJECTIVE： It has been hypothesized that intrathecal administration of ouabain, in combination with neostigmine, can produce antinociceptive synergistic effects. Atropine, as a competitive antagonist, was pre-injected to verify the mechanisms of action. DESIGN, TIME AND SETTING： This study was a randomized, controlled, animal experiment, performed at the State Key Laboratory of Oncology in Southern China between May 2006 and February 2007. MATERIALS： A total of 102 healthy, adult, Sprague Dawley rats were included. Ouabain and neostigmine （Sigma, USA）, as well as atropine （Tanabe Seiyaku, Japan）, were also used. METHODS： Varied doses of ouabain, neostigmine, and a combination of the two were intrathecally injected into rats. Six rats were allotted for each dose group. Intrathecal pretreatment with atropine was tested 10 minutes prior to intrathecal administration of neostigmine or the combination of ouabain and neostigmine. MAIN OUTCOME MEASURES： Tail-flick tests were performed to measure tail-flick latency （seconds） prior to and after administration. The response in the tail-flick test was expressed as the percentage of maximum possible effect （% MPE）, where % MPE = [tail-flick latency after administration （seconds） -mean baseline value for tail-flick latency]/[ 10 seconds - the mean baseline value for tail-flick latency （seconds）] x 100%. RESULTS： Rat spinal intrathecal administration of either ouabain or neostigmine alone produced antinociceptive effects in a dose-dependent manner. Intrathecally administration of neostigmine （0.05, 0.1, 0.3 μg ） in combination with ouabain （1 μ g ） produced enhanced antinociceptive effects, with a % MPE of 29%, 78%, and 95%, respectively （P 〈 0.05）. Intrathecally administration of 0.3μg neostigmine （% MPE： 45%）, in combination with 1 μ g ouabain （% MPE： 27%） produced potent antinociceptive effects （% MPE： 95%）. Intrathecally pre-injected atropine antagonized the antinociceptive effects of neostigmine （3 μg）, or a combination of ouabain （1 μg） and neostigmine （0.3 μg） （P 〈 0.01）. CONCLUSION： Rat spinal intrathecal administration of either ouabain or neostigmine alone produced dose-dependent andnociceptive effects. Ouabain enhanced the antinociceptive effects of neostigmine. Atropine antagonized the antinociceptive effects of neostigmine or the combination of ouabain and neostigmine. This occurs possibly due to the fact that atropine is a competitive antagonist of the muscarinic acetylcboline receptors.

A Comparative Study of Intrathecal Injection of Bupivacaine Alone or with Fentanyl, Clonidine, and Neostigmine in Lower Abdominal Surgeries

Background: Anesthesiologists are responsible for the development of pain services in the current era. Hence ideal adjuvants that can be used with bupivacaine for stable intraoperative conditions and prolonging the postoperative analgesia with fewer side effects are being investigated. Opioids, despite useful as adjuvants, are associated with undesirable side effects. Aim of the work: The study was done to compare analgesic efficacy and hemodynamic of intrathecal injection of bupivacaine alone or with fentanyl, clonidine, and neostigmine in lower abdominal surgeries, over the first 24 postoperative hours, in a randomized, double-blind, and clinical trial. Methods: 100 Patients were randomized into four equal groups, 25 patients in each group;Group B patients received 2.5 ml of 0.5% hyperbaric bupivacaine and 0.5 ml of normal saline. Group BF patients received 2.5 ml of 0.5% hyperbaric bupivacaine with (25 mics) of fentanyl. Group BC patients received 2.5 ml of 0.5% hyperbaric bupivacaine with 0.5 ml (75 mics) of clonidine. Group BN patients received 2.5 ml of 0.5% hyperbaric bupivacaine with 0.1 ml of neostigmine (50 mics) and 0.4 ml of normal saline. Intrathecal anesthesia was done with a recording of parameters intraoperative and the post-operative period. Each patient was assessed for hemodynamic parameters and effective analgesia in operation, and presence of complications (nausea, vomiting, sedation and pruritus) visual analogue pain score (VAS) postoperatively by a blinded investigator in the post-anesthesia care unit (PACU) and at 1, 2, 3, 4, 8 12, 18 and 24 h postoperatively. Results: The postoperative analgesia is more effective with group BC (the gold standard) than group B, group BF, and group BN. As regard complications during the study in all groups, complications as nausea, and vomiting were mainly with group BN;hypotension was primarily in group BC. Conclusion: Bupivacaine clonidine, bupivacaine neostigmine, and bupivacaine fentanyl intrathecal anesthesia produced a longer duration of postoperative analgesia after lower abdominal surgery in patients than bupivacaine alone. Bupivacaine clonidine mixture had the most extended period of analgesia, but with hypotension. So bupivacaine fentanyl mixture with moderate duration of analgesia and minimal side effects is most safe for a patient.

The Safe Use of Sugammadex “Rescue” after Neostigmine: 2 Case Reports

With the introduction of the rocuronium and vecuronium binding agent sugammadex into clinical practice in the United States, its use for reversal of neuromuscular blockade will likely start in some institutions as a “rescue” after failed reversal with neostigmine. However, sugammadex after neostigmine has not been extensively studied. Therefore, there is a question as to its effectiveness when used in this way especially in the airway compromised patients that the anesthesia provider will commonly face in this situation. Furthermore, there is a possibility of hemodynamic compromise. These two case reports demonstrate the safe and effective use of sugammadex after failed reversal with neostigmine.

Comparative study of single or combined epidural administration of neostigmine and morphine for postoperative analgesia

To compare the analgesic and side effects of post-operative analgesia between epidural administration ofneostigmine (NEO) and morphine (MOR) or their combination in patients undergoing abdominal surgery. Methods: One hundredand two selective patients undergoing surgery were randomly divided into five groups at the end of the surgical procedure. GroupN1 (n=11) and Group N2(n =15) were administered epidurally with NEO 1 mg and 2 mg respectively, Group M1 (n=18)and Group M2 (n=55) were administered epidurally with MOR 1 mg and 2 mg respectively, Group M1 + N1 (n=17) was administered epidurally with the combination of MOR 1 mg and NEO 1 mg. Results: Single dose epidural administration of NEO (1mg and 2 mg) or MOR (1 mg and 2 mg) showed dose-dependent analgesic effects. The analgesic duration in Group N1 (4.7 ± 2.7 h) was significantly shorter than other four groups (P<0. 01). Group M1, M2 and M1 + N1 showed better analgesic effectsthan group N1 and N2 (16.1±8.7h) , with similar analgesic durations in Group M1, M2 and M1 + N1. me percentages of excellent, good and poor effects were 0%, 54.5 % and 45.5 % respectively in Group N1. The percentages of excellent and good effects were 100% in Group M2 and M1 + N1, but 83.3% in Group N2. The time to first use analgesic medication was similar inGroup M1, M2 and M1 + N1, but longer compared with Croup N1 and N2. The incidences of nausea and vomiting closelyresem-bled one another in Croup N1, N2 and M1 + N1, which were less than those in Group M1 and M2. The incidence of urinary retention was 51.2%, 25.0% and 31.3% in Group M2, M1 and M1 + N1, respectively, but 0% in Group N1 and N2. In GroupN2 two patients opened the bowel movement and one patient developed bradycardia (58 beats/min) at 45 min after receiving NEO.Conclusion: Epidural administration of NEO produces dose-dependent prolonged analgesic effects (similar to MOR) and the combination of MOR and NEO could produce analgesia with fewer side effects than administration of equivalent analgesic doses of eachdrug separately. me epidural administration of NEO 2 mg could provide satisfactory postoperative analgesia.

Sepsis Strengthens Antagonistic Actions of Neostigmine on Flocuronium in a Rat Model of Cecal Ligation and Puncture

Background： The antagonistic actions of anticholinesterase drugs on non-depolarizing muscle relaxants are theoretically related to the activity of acetylcholinesterase （ACHE） in the neuromuscular junction （NMJ）. However, till date the changes of AChE activity in the NMJ during sepsis have not been directly investigated. We aimed to investigate the effects of sepsis on the antagonistic actions ofneostigmine on rocuronium （Roc） and the underlying changes of AChE activity in the NMJ in a rat model of cecal ligation and puncture （CLP）. Methods： A total of 28 male adult Sprague-Dawley rats were randomized to undergo a sham surgery （the sham group, n = 12） or CLP （the septic group, n = 16）. After 24 h, the time-response curves of the antagonistic actions of 0.1 or 0.5μmol/L of neostigmine on Roc （10 μmol/L）-depressed diaphragm twitch tension were measured. Meanwhile, the activity of AChE in the NMJ was detected using a modified Karnovsky and Roots method. The mRNA levels of the primary transcript and the type T transcript of AChE （AChET） in the diaphragm were determined by real-time reverse transcription-polymerase chain reaction. Results： Four of 16 rats in the septic group died within 24 h. The time-response curves of both two concentrations ofneostigmine in the septic group showed significant upward shifts from those in the sham group （P 〈 0.001 for 0.1 μmol/L; P = 0.009 for 0.5 μmol/L）. Meanwhile, the average optical density of AChE in the NMJ in the septic group was significantly lower than that in the sham group （0.517± 0.045 vs. 1.047 ±0.087, P 〈 0.001）. The AChE and AChET mRNA expression levels in the septic group were significantly lower than those in the sham group （P 0.002 for ACHE; P = 0.001 for AChEv）. Conclusions： Sepsis strengthened the antagonistic actions ofneostigmine on Roc-depressed twitch tension of the diaphragm by inhibiting the activity of AChE in the NMJ. The reduced content of AChE might be one of the possible causes of the decreased AChE activity in the NMJ.

小分子化合物Neostigmine Bromide抑制肺癌细胞增殖及其分子机制

目的研究小分子化合物Neostigmine Bromide对人肺癌细胞增殖、迁移能力的影响以及其分子机制。方法分别用0、10、20、40μmol/L浓度的Neostigmine Bromide处理A549、NCI-H460、NCI-H1299三种肺癌细胞,用CCK8检测不同浓度小分子化合物Neostigmine Bromide对肺癌细胞A549、NCI-H460、NCI-H1299增殖能力的影响。利用克隆形成实验验证化合物对肺癌细胞A549、NCI-H460增殖能力的抑制作用。应用Transwell实验检测该药物对A549和NCI-H1299细胞迁移能力的影响。Western blot技术检测化合物对NCI-H460细胞周期调控蛋白Cyclin D1和CDK4表达含量的影响。结果化合物Neostigmine Bromide通过剂量依赖的方式抑制人肺癌细胞A549、NCI-H460、NCI-H1299的增殖能力,在一定程度上抑制肺癌细胞的迁移能力,并以剂量依赖的方式下调肺癌细胞NCI-H460中Cyclin D1和CDK4的蛋白表达水平。结论 Neostigmine Bromide抑制肺癌细胞增殖和迁移能力与下调Cyclin D1和CDK4的表达水平相关。

Effect of acupoint injection of Neostigmine on gastrointestinal function after cholecystectomy

Objective： To observe the effect of acupoint injection with Neostigmine Methylsulfate at Zusanli（ST 36） on gastrointestinal function of patients after laparoscopic cholecystectomy.Methods： Totally 120 patients undergone laparoscopic cholecystectomy were randomized into an acupoint injection group, a muscular injection group, and a blank control group at 1：1：1 by random number table, 40 cases in each group. The blank control group was intervened by conventional post-operation treatment, the acupoint injection group was by acupoint injection with Neostigmine Methylsulfate 2 m L at bilateral Zusanli（ST 36） in addition to the treatment given to the blank control group, and the muscular injection group was by muscular injection with Neostigmine Methylsulfate 2 m L in addition to the treatment given to the blank control group. The two injection groups both received injection twice a day, totally for 3 d at most. The restored time of bowel sounds, initial flatulence time, defecation time and clinical efficacy were observed. Results： After treatment, there were significant differences in comparing the restored time of bowel sounds among the three groups（F=17.30, P〈0.05）, the acupoint injection group and muscular injection group were significantly different from the blank control group（P〈0.05）, and there was a significant difference between the acupoint injection group and muscular injection group（P〈0.05）; there were significant differences in comparing the initial flatulence time among the three groups（F=19.12, P〈0.05）, and the acupoint injection group was significantly different from the muscular injection group and the blank control group（P〈0.05）; there were significant differences in comparing the initial defecation time among the three groups（χ^2=21.23, P〈0.05）, while the difference between the acupoint injection group and muscular injection group was statistically insignificant（P〈0.05）. The total effective rate was 87.5% in the acupoint injection group, versus 72.5% in the muscular injection group and 60.0% in the blank control group, and there were significant differences among the three groups（P〉0.05）. Conclusion： Acupoint injection with Neostigmine Methylsulfate at Zusanli（ST 36） can shorten the restored time of bowel sounds and flatulence time in patients undergone laparoscopic cholecystectomy, and the efficacy is more significant compared to muscular injection with Neostigmine Methylsulfate.

Management of constipation in the elderly: Emerging therapeutic strategies

A number of new, novel strategies for managing constipation in the elderly have emerged over the past few years. Prucalopride is one such new agent that is highly effi cacious in managing chronic constipation. In fact, Camilleri et al in a recent study reported that the average number of bowel movements increased by at least one in nearly 47% of the patients who were administered a dose of 4 mg. Lubiprostone is another new agent recently approved by the FDA that shows efficacy in managing the symptoms of constipation. Neostigmine has also been successfully used for the management of recalcitrant constipation. Most of these studies have used subcutaneous neostigmine. Symbiotic yogurt containig components, such as Bifidobacterium and fructoligosaccharide, have also been recently shown to be highly effective in improving symptoms of constipation. Elderly patients especially those in hospices and nursing homes are often on opiods for pain management. Constipation secondary to opioid use is extremely common in nursing homes. Subcutaneous methylnaltrexone has recently been shown to be highly effective in the management of opioid-related constipation, and was recently approved by the FDA. Sacral nerve stimulation is another emerging strategy. A recent analysis by Mowatt et al supports the eff icacy of this technique. Botulinum toxin is another agent that has already been successfully used for the management of chronic, refractory constipation in children and may be very effective for elderly constipation. Further larger studies are needed to confi rm the fi ndings noted in these studies. Constipation is clearly a major issue in the elderly and these new, emerging strategies will hopefully improve the quality of life and relieve the symptoms of constipation in this population.

Analysis of incidence of residue neuromuscular blockade for rocuronium and cisatracurium

Objective:To observe the incidence of residual neuromuscular blockade at the end of operation and during tracheal extubation, and analyze the risk factors causing residual neuromuscular blockade by judging the degree of muscle relaxation according to clinical signs when after using rocuronium or cis-atracurium in general anesthesia.Methods: 500 adults were implemented with propofol-remifentanil intravenous anesthesia or sevoflurane inhalation anesthesia. Rocuronium and cis-atracurium were given, respectively. The TOFr was observed with blind method by TOF Watch SX monitor during anesthesia.Results: The mean TOFr=0.53±0.38 at the end of operation,including 275 cases of 0<TOFr<0.9 and 112 cases of TOFr=0. The mean TOFr=0.97±0.12 at extubation, including 60 cases of TOFr<0.9. The incidence of residual neuromuscular blockade at extubation showed an increasing trend with the increase of age or body mass index. The average TOFr value at extubation, which interval time over 10 min after neostigmine administration to extubation was significant higher than that of interval time less than 10 min.Conclusions:There has 12% patients with TOFr<0.9 when extubation by estimating rocuronium and cis-atracurium effect with clinical signs and experience, it has a hidden danger of residual neuromuscular blockade. The main risk factors to increasing the incidence of residual neuromuscular blockade are growing old and the short time of administrating muscle relaxants or neostigmine to extubation.

Superiority of sugammadex in preventing postoperative pulmonary complications

Background:Postoperative pulmonary complications often lead to increased mortality and financial burden.Residual paralysis plays a critical role in postoperative pulmonary complications.This meta-analysis was performed to determine whether sugammadex overmatches neostigmine in reducing postoperative pulmonary complications.Methods:PubMed,Embase,Web of Science,Medline through Ovid,Cochrane Library,Wanfang,China National Knowledge Infrastructure,and Chinese BioMedical Literature Databases were searched from their inception to 24 June,2021.Random effects models were used for all analyses.Cochrane risk of bias tool was used to assess the quality of RCTs,while Newcastle Ottawa Quality Assessment Scale was used to assess for the quality of cohort studies.Results:Seventeen studies were included in the meta-analysis.Pooled data from cohort studies showed reversing neuromuscular blocking with sugammadex had less risk of compound postoperative pulmonary complications(relative risk[RR]:0.73;95%confidence interval[CI]:0.60-0.89;P=0.002;I^(2)=81%),pneumonia(RR:0.64;95%CI:0.48-0.86;I^(2)=42%)and respiratory failure(RR:0.48;95%CI:0.41-0.56;I^(2)=0%).However,pooled data from RCTs did not show any difference between the two groups in pneumonia(RR:0.58;95%CI:0.24-1.40;I^(2)=0%)and no respiratory failure was reported in the included RCTs.The difference was not found between sugammadex and neostigmine about atelectasis in pooled data from either RCTs(RR:0.85;95%CI:0.69-1.05;I^(2)=0%)or cohort studies(RR:1.01;95%CI:0.87-1.18;I^(2)=0%).Conclusion:The evidence of superiority of sugammadex was limited by the confounding factors in cohort studies and small scale of RCTs.Whether sugammadex precedes neostigmine in preventing pulmonary complications after surgery is still unknown.Well-designed RCTs with large scale are needed.Registration:PROSPERO(https://www.crd.york.ac.uk/PROSPERO/);CRD 42020191575.