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Bupivacaine Inhibits Baroreflex Control of Heart Rate in Conscious 197 Anesthesiology 2000; 92:197–207 © 2000 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Bupivacaine Inhibits Baroreflex Control of Heart Rate in Conscious Rats Kyoung S. K. Chang, M.D., Ph.D.,* Don R. Morrow, B.S.,† Kazuyo Kuzume, M.D.,‡ Michael C. Andresen, Ph.D.§ Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/92/1/197/399010/0000542-200001000-00032.pdf by guest on 26 September 2021 Background: Because exposure to intravenously adminis- 0.633 6 0.204 vs. 0.277 6 0.282; nitroprusside, 0.653 6 0.142 vs. tered bupivacaine may alter cardiovascular reflexes, the au- 0.320 6 0.299 ms/mmHg, P < 0.05). In contrast, bupivacaine did thors examined bupivacaine actions on baroreflex control of not alter baroreflex sensitivity in the presence of methyl atropine. heart rate in conscious rats. Conclusions: Bupivacaine, in clinically relevant concentrations, Methods: Baroreflex sensitivity (pulse interval vs. systolic inhibits baroreflex control of heart rate in conscious rats. This blood pressure in ms/mmHg) was determined before, and 1.5 inhibition appears to involve primarily vagal components of the and 15.0 min after rapid intravenous administration of bupiv- baroreflex–heart rate pathways. (Key words: Autonomic nervous acaine (0.5, 1.0, and 2.0 mg/kg) using heart rate changes evoked system; baroreceptors; hypertension; local anesthetics.) by intravenously administered phenylephrine or nitroprusside. The actions on the sympathetic and parasympathetic auto- nomic divisions of the baroreflex were tested in the presence of BUPIVACAINE is a potent, long-acting local anesthetic a muscarinic antagonist methyl atropine and a b-adrenergic agent. An infrequent but serious complication arises if bu- antagonist atenolol. pivacaine accidentally enters into the general circulation.1 Results: Within seconds of injection of bupivacaine, mean Sudden cardiovascular collapse (ventricular tachycardia, arterial pressure increased and heart rate decreased in a dose- ventricular fibrillation, cardiac asystole, or complete heart dependent manner. Baroreflex sensitivity was unaltered after administration of 0.5 mg/kg bupivacaine. In addition, 1 mg/kg block) can occur immediately after accidental intravenous 1 bupivacaine at 1.5 min depressed phenylephrine-evoked reflex injection of bupivacaine. Despite the well-established pe- bradycardia (0.776 6 0.325 vs. 0.543 6 0.282 ms/mmHg, P < ripheral cardiovascular toxic effects of bupivacaine on the 0.05) but had no effect on nitroprusside-induced tachycardia. heart and blood vessels,2 relatively little is known about its Bupivacaine (2 mg/kg), however, depressed reflex bradycardia effects on neural regulatory mechanisms. Some evidence and tachycardia (phenylephrine, 0.751 6 0.318 vs. 0.451 6 0.265; nitroprusside, 0.839 6 0.256 vs. 0.564 6 0.19 ms/mmHg, seems to support that bupivacaine actions alter neural 3–6 P < 0.05). Baroreflex sensitivity returned to prebupivacaine control of blood pressure and heart rate. Bupivacaine, levels by 15 min. Bupivacaine (2 mg/kg), in the presence of when administered intravenously in subconvulsive or con- atenolol, depressed baroreflex sensitivity (phenylephrine, vulsive doses, produced hypertension, tachycardia, and ar- rhythmias in humans3 and in awake or lightly anesthetized 4–6 * Associate Professor, Department of Anesthesiology, Oregon Health animals. Direct central injection of bupivacaine into the Sciences University and Veterans Affairs Medical Center. lateral cerebral ventricle of the cat evoked hypertension † Research Assistant, Department of Anesthesiology, Oregon Health and ventricular arrhythmias.7 Recently, we demonstrated Sciences University. that bupivacaine, in clinically relevant concentrations, de- ‡ Visiting Research Fellow, Department of Pediatrics, Ehime University. presses baroreceptor sensory discharge.8 Thus, baroreflex § Professor, Department of Physiology and Pharmacology, Oregon impairment may precede or accompany direct cardiotoxic Health Sciences University. effects of bupivacaine and contribute to cardiac arrhyth- Received from the Departments of Anesthesiology and Physiology mias. In pentobarbital-anesthetized animals, bupivacaine and Pharmacology, Oregon Health Sciences University and Veterans depressed baroreflex control of heart rate.9 Pentobarbital Affairs Medical Center, Portland, Oregon; and the Department of Pe- 10,11 diatrics, Ehime University, Ehime, Japan. Submitted for publication itself depresses baroreflex control of heart rate but also March 25, 1999. Accepted for publication July 28, 1999. Supported in modifies the actions of bupivacaine. For example, bupiva- part by grants from the American Heart Association, Oregon Affiliate, caine-induced hypertension or arrhythmias are observed Portland, Oregon; and grant no. HL-58760 from the National Institutes infrequently during pentobarbital-induced anesthesia.12,13 of Health, Bethesda, Maryland. Presented in part at the annual meeting Our current studies were undertaken (1) to determine of the Federation of American Societies for Experimental Biology, Anaheim, California, April 28, 1994. whether bupivacaine impairs baroreflex control of heart Address reprint requests to Dr. Chang: Department of Anesthesiology, rate in conscious, unanesthetized animals; and (2) if so, Oregon Health Sciences University, 3181 S. W. Sam Jackson Park Road, to identify which components of the autonomic nervous Portland, Oregon 97201. Address electronic mail to: [email protected] system (sympathetic or parasympathetic) are responsi- Anesthesiology, V 92, No 1, Jan 2000 198 CHANG ET AL. ble for the baroreflex change. We found that clinically between systolic blood pressure and succeeding pulse relevant doses of bupivacaine produce hypertension and intervals. The slope or gain of the baroreflex was esti- bradycardia and impair baroreflex control of heart rate in mated from this linear fit to heart rate changes in re- a dose-dependent manner, primarily by affecting cardiac sponse to ramp changes in systolic blood pressure.14,15 vagal component. In all cases, the control correlation coefficient (r) ex- ceeded on average 0.87, and in those during maximal Materials and Methods depression with bupivacaine r exceeded on average 0.6, Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/92/1/197/399010/0000542-200001000-00032.pdf by guest on 26 September 2021 with P , 0.0001. This method has the advantage of Preparation for Study of Conscious Rats assessing the baroreflex in a short period, a necessity as The study protocol was approved by the Oregon the effects on blood pressure of a bolus intravenous Health Sciences University Animal Care and Use Com- injection of bupivacaine were short-lived (,5 min for 2 mittee. Experiments were performed in male Sprague- mg/kg). Phenylephrine was infused intravenously (50 Dawley rats (weight, 300–350 g; Simonsen, Gilroy, CA). mg z kg21 z min21 for 15 s) to obtain a pressor–brady- For induction of anesthesia, rats were placed in a clear cardic response and sodium nitroprusside (20 mg z kg21 z 2 plastic box filled with 5% isoflurane–02 for 10 min. After min 1 for 45 s) to test the depressor–tachycardic re- loss of consciousness, an endotracheal tube (14-gauge sponse. Peak increases or decreases of MAP of 50–60 intravenous catheter; Critikon, Tampa, FL) was placed mmHg were obtained. All reflex changes were al- and adequate anesthesia maintained with isoflurane most completely eliminated by ganglionic blockade with (2.0–2.5%) and oxygen. Ventilation was controlled. A chlorisondamine (10 mg/kg given intravenously; peak femoral artery was cannulated with polyethylene tube heart rate before chlorisondamine, 2125 6 37 [phenyl- (PE50; Becton Dickinson, Sparks, MD) to monitor blood ephrine, n 5 5] and 1160 6 45 [nitroprusside, n 5 3]; pressure, and each femoral vein was cannulated (with after chlorisondamine, 118 6 17 [phenylephrine] PE10; Becton Dickinson), one for injection of bupiva- and 121 6 4 [nitroprusside]). The total volumes (45– caine and the other for vasoactive drug infusion to test 135 ml) and rate of infusion (3 ml/s) were kept minimal, the baroreflex. These catheters were filled with heparin- and administration of saline in these ranges had no effect ized saline and led subcutaneously to the scruff of the on blood pressure or heart rate. neck and externalized through a small incision. Three Baroreflex sensitivity was determined before and 1.5 stainless wire electrodes were placed under the skin of and 15.0 min after intravenous bolus injection of bupiv- left and right front legs and left hind leg for electrocar- acaine (0.5, 1.0, and 2.0 mg/kg). Because acute tolerance diographic monitoring. After cannulation, animals were developed with multiple injections of bupivacaine, each extubated when the spontaneous respiration resumed. rat received only a single dose of bupivacaine on a given Rats were treated prophylactically with 30,000 U peni- test day. Each rat was tested first with either pressor cillin given intramuscularly and allowed to recover for 2 (phenylephrine) or depressor (nitroprusside) drug. The days. order of vasoactive drug delivery was random. On the Monitoring Hemodynamic Parameters subsequent day, the baroreflex test was repeated with On the day of the experiment, each rat was placed in the vasoactive challenge not tested the previous day. a rat restrainer. The arterial catheter was connected to a To partition the autonomic basis of the observed pressure transducer (Baxter, Round Lake, IL) to monitor changes in heart rate during exposure
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