Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation

Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation

Thoracoscopy performed under sedation-assisted local anesthesia is associated with significant hypoventilation. Combined measurement of Spo₂ and Pcco₂ during thoracoscopy is a novel approach in the monitoring of ventilation, enhancing patient safety, and might allow to guide the administration of sedation in a better way.

Mean baseline Pcco₂ measurement was 39.1 ± 7.2 mm Hg (± SD) [range, 27.5 to 50.5 mm Hg], and peak measurement during the procedure was 52.3 ± 10.3 mm Hg (range, 37.2 to 77 mm Hg) [p < class="sc">co₂ measurement from baseline were 13.0 mm Hg and 13.2 ± 5.3 mm Hg (range, 5.5 to 27.8 mm Hg), respectively. Mean fall in Spo₂ during the procedure was 4.6 ± 3.2% (range, 1 to 14%).

(The Paratrend 7 monitoring system (PT7), which was used in our study, is a widely validated and accepted method of continuous intraarterial blood gas measurement with good accuracy and performance. Apart from our own results in patients undergoing thoracoscopic interventions with one-lung ventilation (2), this device has been validated in an experimental study (3). In the intensive care unit (4), and during cardiac surgery (5). Furthermore, this device was used by two other groups, and their results have also been published (6,7). Nevertheless, in our study, we provided ample data on the good agreement of PT7 data with laboratory blood gas analyses. In fact, whenever a laboratory blood gas analysis was performed, PT7 values were recorded simultaneously and used for bias/precision analysis. We found an overall limit of agreement for bias/precision of -3.4/15.9 mm Hg in the clinically most important range of PaO₂ values <100> a PaO₂ value of 65 mm Hg obtained by PT7 could be as low as 45.7 mm Hg or as high as 77.5 mm Hg. However, both values clearly indicate hypoxemia under an inspired oxygen fraction of 1.0 and, thus, represent a critical medical condition.)

Detection of Hypoventilation During Thoracoscopy^*

Combined Cutaneous Carbon Dioxide Tension and Oximetry Monitoring With a New Digital Sensor

1. Prashant N. Chhajed, MD, FCCP,
2. Bruno Kaegi,
3. Rajeevan Rajasekaran, and
4. Michael Tamm, MD

CHEST February 2005 vol. 127 no. 2 585-588

Substantial changes in arterial blood gases during thoracoscopic surgery

Zaugg M, Lucchinetti E, Zalunardo M, et al. Substantial changes in arterial blood gases during thoracoscopic surgery can be missed by conventional intermittent laboratory blood gas analysis. Anesth Analg. 1998;87:647-653.

Substantial and clinically relevant changes in arterial blood gases are likely to occur during thoracoscopic surgery with one-lung ventilation (OLV). We hypothesized that they may be missed when using the conventional intermittent blood gas sampling practice. Therefore, during 30 thoracoscopic procedures with OLV, the sampling intervals between consecutive intermittent laboratory blood gas analyses (BGA) were evaluated with respect to changes of PaO2, PaCO2, and pHa ([H+]) using a continuous intraarterial blood gas monitoring system.
Extreme fluctuations of PaO2 (37-625 mm Hg), PaCO2 (27-56 mm Hg), and pHa (7.24-7.51) were observed by continuous blood gas monitoring. During 63% of all sampling intervals, PaO2 decreased >20% compared with the preceding BGA value, which remained undetected by intermittent analysis. In 10 patients with a continuously measured minimal PaO2 value < or =" 60"> overestimated this minimal PaO2 by > 47%. Correspondingly, PaCO2 increases of > 10% were observed in 35% of all sampling intervals, and [H+] increases of > 10% were observed in 24% of all sampling intervals. Because these blood gas changes were not reliably detected by using noninvasive monitoring and their magnitude is not predictable during OLV, intermittent BGA with short sampling intervals is warranted. In critical cases, continuous blood gas monitoring may be helpful.
http://www.anesthesia-analgesia.org/cgi/content/abstract/87/3/647

Arterial oxygen desaturation during only one of two similar thoracoscopic procedures on the same patient

PFITZNER J. ⁽¹⁾ ; FOWLIE J. A. ⁽¹⁾ ; KISHORE M. ⁽¹⁾ ; MICHAEL A. S. ⁽¹⁾ ; LANCE D. G. ⁽¹⁾ ;

⁽¹⁾ Department of Anaesthesia and Thoracic Surgery Unit, The Queen Elizabeth Hospital, Woodville, South Australia, AUSTRALIE
Because acute hypoxia had developed during one-lung ventilation on the first occasion, serial blood gases were taken during the second. Also, whereas on the first occasion the non-ventilated lung had been left open to air when one-lung ventilation was initiated, on the second it was connected to an ambient pressure oxygen source with the object of theoretically enabling apnoeic oxygenation during lung collapse. It is argued that this fundamental difference in anaesthetic practice may have contributed to the improved oxygenation that was recorded during the second thoracoscopy.

Anaesthesia and intensive care ISSN 0310-057X CODEN AINCBS
2005, vol. 33, n^o6, pp. 805-807 [3 page(s) (article)] (16 ref.)

Venous Versus Arterial Forearm Catecholamines as an Index of Overall Sympatho-Adrenomedullary Activity

The metabolism of norepinephrine (NE) and epinephrine (EPI) in peripheral tissues limits the use of venous plasma levels of these parameters as an index of overall sympathetic or adreno-medullary activity. Therefore venous (deep antecubital vein) and arterial (brachial artery) concentrations of NE and EPI were compared in 16 hypertensive subjects. NE and EPI were determined after 30 min supine rest, and immediately before and after isometric exerise, cold provocation, head-up tilting (OST) and Stroop's colour word test (CWT). At rest venous NE exceeds arterial NE. Assuming similar fractional extractions (FE) of NE and EPI, 46±14% (mean±SD) of venous NE appeared to be produced locally. Despite this considerable local production venous and arterial levels of NE were closely correlated (r=0.92). At rest venous EPI was 42±13% lower than arterial EPI, but since the interindividual variation of the FE of EPI was relatively small and independent of arterial levels, venous and arterial levels were also closely correlated (r=0.82). All four tests caused an increase in arterial and venous NE, whereas EPI did not change. Responses of arterial and venous NE were only correlated after OST and CWT. It is concluded that at rest, but not invariably so during different forms of sympatho-adrenal activation, arterial plasma concentrations of NE and EPI can be substituted for by their respective venous equivalents. Clinical and Experimental Hypertension, Volume 11, Issue S1 1989 , pages 345 - 351

Antibody responses

Chemical sympathectomy of peripheral nerves has been demonstrated to augment antibody response following immunization with specific antigen.

Surgery: Basic Science and Clinical Evidence

By Jeffrey A. Norton, R. Randall Bollinger

Contributor Jeffrey A. Norton

Edition: illustrated

Published by Springer, 2001

ISBN 038798447X, 9780387984476

Norepinephrine response to mental challenge

DS Goldstein, G Eisenhofer, FL Sax, HR Keiser and IJ Kopin
Hypertension-Endocrine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD 20892.

We simultaneously infused tracer-labeled norepinephrine (NE) and isoproterenol (ISO) intravenously into 14 subjects to measure forearm and total body NE pharmacokinetics at rest and in response to mental challenge (video game or cognitive task). Mental challenge was associated with significantly increased heart rate (24%), systolic blood pressure (13%), cardiac output (impedance cardiography, 9%), forearm blood flow (38%), and the rate of release of endogenous NE into arterial blood (total body NE spillover, 29%), but not with changes in cardiac output (r = 0.68) and systolic blood pressure (r = 0.60), whereas those of antecubital venous NE were not. Forearm extraction of NE was related inversely to forearm blood flow both at rest (r = -0.80) and during mental challenge (r = -0.81), and total body clearance of NE was positively related to cardiac output at rest (r = 0.78) and during mental challenge (r = 0.54). The results indicate that mental challenge is associated with generally increased sympathetically-mediated NE release that determines the hemodynamic responses. Because of regional changes in sympathetic activity and blood flow during psychological stress, changes in antecubital venous NE and even arterial NE may not reflect accurately sympathetic nerve activity. Measurement of total body and regional NE pharmacokinetics avoids these difficulties.
Psychosomatic Medicine, Vol 49, Issue 6 591-605, Copyright © 1987 by American Psychosomatic Society

The integrative relationship between insulin and insulin-like growth factor 1-induced cardiovascular responses and sympathetic nervous responses

Lumbar sympathectomy caused greater increase in skeletal muscle blood flow in response to both insulin and IGF-1 when hypoglycemia occurred. But when hypoglycemia was prevented, IGF-1 induced increase in blood flow was suppressed in sympathetic denervated iliac artery. We concluded that insulin and IGF-1 have both similar and distinct effects on cardiovascular system and sympathetic nervous system. They both may act directly on vasculature to elicit vasodilation thus decrease MAP Insulin can selectively increase sympathetic nerve activity, while IGF-1 decreases sympathetic nerve activity.
Zhengbo Duanmu, Wayne State University

Vasoconstrictor responses to immersion of the hand in ice water in the sympathetically denervated forearm were abolished

Vasoconstrictor responses to immersion of the hand in ice water in the sympathetically denervated forearm were abolished; during the second minute of the cold pressor test, vascular resistance had increased by 48±20 percent in the innervated limb, whereas it had decreased by 17±5 percent in the denervated limb (P<0.02> limbs).

Figs. 1 and 2 show that L-NMMA infusion evoked a roughly 3-fold larger increase in vascular resistance in the denervated forearm than in the innervated calf. In the forearm, vascular resistance increased by 58±10 percent during L-NMMA infusion whereas in the calf, it increased only by 21±6 percent (P<0.001, forearm vs. calf). The L-NMMA induced vasoconstriction was reversed by L-arginine, but not by D-arginine, infusion (Table 1). In contrast to L-NMMA, infusion of an equipressive dose of phenylephrine increased the vascular resistance comparably in the denervated and the innervated limb (by 24±3 and 26±7 percent, respectively; P>0.5, forearm vs. calf).

Here we used subjects having undergone thoracic sympathectomy for hyperhydrosis, to probe the role of the peripheral sympathetic nervous system in the modulation of the vascular responsiveness to nitric oxide synthase inhibition. We found that sympathectomy markedly potentiated the vasoconstrictor effect of L-NMMA infusion. The L-NMMA induced vasoconstrictor effect was almost three times larger in the denervated than in the innervated limb. These findings provide the first evidence for an important interplay between the peripheral sympathetic nervous system and the L-arginine–nitric-oxide system in the regulation of the vascular tone in humans, and indicate that sympathetic innervation attenuates the vasoconstrictor effect of nitric oxide synthase inhibition.

Cardiovascular Research 1999 43(3):739-743; doi:10.1016/S0008-6363(99)00084-X
© 1999 by European Society of Cardiology

Effect of autonomic and adrenal manipulation on the serum insulin level

3. Journal of Tissue Research Vol. 4 (1) 83-88 (2004) Pilo, B. and Yadav, V.

Division of Neuroendocrinology, Department of Zoology, Faculty of Science, The Maharaja Sayajirao University of Baroda, Vadodara-390 002 India. Email: bonnypilo@satyam.net.in

Mammalian glucose homoeostasis is partially controlled by glucose sensor mechanisms in the pancreatic endocrine cells and partially through autonomic nerves. The influence of the autonomic nervous system on pancreatic insulin secretion has been studied in the present study. Vagal sectioning decreased serum insulin significantly compared to that of the sham operated rats which could be the reason for the resulting hyperglycaemic condition prevailed in these rats. Bilateral adrenalectomy and chemical sympathectomy singly increased insulin level to the same extent. Even, when vagotomy was performed together with adrenalectomy, insulin level declined but this decrease is not as significant as that in vagotomized rats. Similar result was obtained with rat treated for chemical sympathectomy and vagotomy together and this slight decrease in insulin level could favour marginal hyperglycaemia.

Insulin receptors

Glucose metabolism, however, was inhibited by chemical sympathectomy: the glucose transport rate was significantly reduced and fatty acid synthesis was nearly totally abolished. Insulin was still effective in stimulating both parameters but failed to restore normal levels. The results suggest that the sympathetic innervation of adipose tissue may exert an inhibitory effect on the number of high-affinity insulin receptors as well as on the sensitivity of the lipolysis to insulin, as both parameters were increased by sympathectomy. To explain the inhibitory effect of 6-hydroxydopamine treatment on glucose transport and fatty acid synthesis, a possible trophic effect of the sympathetic innervation is discussed as well as indirect mechanism counteracting the effects of the chemical sympathectomy.

Effects of chemical sympathectomy on insulin receptors and insulin action in isolated rat adipocytes

HG Joost and SH Quentin

Volume 229, Issue 3, pp. 839-844, 06/01/1984
Copyright © 1984 by American Society for Pharmacology and Experimental Therapeutics

incomplete sympatholysis achieved by thoracoscopic sympathicotomy

Skin temperature variations did not correlate to skin perfusion changes. Since all subjects reported dry and warm hands throughout the follow-up period, our results indicate that recording reflex responses to sympathoexcitatory stimuli does not adequately reflect clinical outcome of subtotal sympatholytic procedures performed for hyperhidrosis. Monitoring of clinical outcome should therefore include measurement of baseline sweat production and skin perfusion. However, the normalized reflex responses highlight the incomplete sympatholysis achieved by thoracoscopic sympathicotomy, which may be beneficial in some pathological conditions (such as hyperhidrosis) but detrimental in others. © 1998 John Wiley & Sons, Inc. Muscle Nerve 21: 1486-1492, 1998

---

Received: 2 November 1997; Accepted: 14 April 1998

Muscle & Nerve

Volume 21 Issue 11, Pages 1486 - 1492

Published Online: 7 Dec 1998

Copyright © 2009 Wiley Periodicals, Inc., A Wiley Company

Reflex sympathetic dystrophy syndrome and neuromediators

Concepts related to the pathophysiology of reflex sympathetic dystrophy syndrome (RSDS) are changing. Although sympathetic influences are still viewed as the most likely mechanism underlying the development and/or perpetuation of RSDS, these influences are no longer ascribed to an increase in sympathetic tone. Rather, the most likely mechanism may be increased sensitivity to catecholamines due to sympathetic denervation with an increase in the number and/or sensitivity of peripheral axonal adrenoceptors. Several other pathophysiological mechanisms have been suggested, including neurogenic inflammation with the release of neuropeptides by primary nociceptive afferents and sympathetic efferents. These neuromediators, particularly substance P, calcitonin gene-related peptide, and neuropeptide Y (NPY), may play a pivotal role in the genesis of pain in RSDS.

Thao Pham^, and Pierre Lafforgue
Joint Bone Spine
Volume 70, Issue 1, 1 February 2003, Pages 12-17

significantly more cholesterol and total lipids in the aorta after sympathectomy

While the vasomotor effect of the sympathetic nervous system (SNS) on the arterial wall is well recognized, its trophic function is not. It is the aim of these studies to demonstrate this all-important function as it relates to the vascular muscle.

Although the exact mechanism by which sympathetic nerve impulses influence the metabolism of the vessel wall is unknown, effects of sympathectomy can be demonstrated. Several lines of evidence indicate that chronic absence of sympathetic innervation in rabbits increases collagen synthesis and decreases activity of tricarboxylic acid cycle enzymes in the vascular wall. When chemically sympathectomized rabbits were fed a 1% cholesterol dietary supplement for 80 days, the aortas of these rabbits contained significantly more cholesterol and total lipids than those from fully innervated controls in spite of insignificant differences in plasma lipids.

In a subsequent series of experiments we analyzed the efficacy of the SNS in two strains of pigeons. White Carneau (WC) pigeons are known by their susceptibility to atherosclerosis of the aorta while Show Racer (SR) pigeons are not. Our results demonstrate that the abdominal aorta of WC pigeons has less sympathetic innervation and it declines faster with age than that of SR pigeons. The results of the described studies documenting the direct trophic influence of the SNS on the arterial wall are reinforced by the similarity to the vessel wall changes induced by partial sympathectomy and natural aging.

Trophic effect of the sympathetic nervous system on vascular smooth muscle

	Annals of Biomedical Engineering
	Springer Netherlands
ISSN	0090-6964 (Print) 1573-9686 (Online)
Issue	Volume 11, Number 6 / November, 1983

Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans

Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans
Heart Rhythm, Volume 2, Issue 6, Pages 602-609
J.Moak, B.Eldadah, C.Holmes, S.Pechnik, D.Goldstein

All four patients with bilateral sympathectomy had low septal myocardial 6-[¹⁸F]fluorodopamine-derived radioactivity (2,673 ± 92 nCi-kg/cc-mCi at an average of 89 minutes after injection) compared with normal volunteers (3,634 ± 311 nCi-kg/cc-mCi at 83 minutes, N = 22, P = .007) and higher radioactivity than in patients with pure autonomic failure (1,320 ± 300 nCi-kg/cc-mCi at 83 minutes, N = 7, P = .003). Patients with unilateral sympathectomy had normal 6-[¹⁸F]fluorodopamine-derived radioactivity (3,971 ± 337 nCi-kg/cc-mCi at 87 minutes).

Conclusions

Bilateral upper thoracic sympathectomy partly decreases cardiac sympathetic innervation density.

spontaneous flow oscillations occurred in the sympathectomized limbs

We measured arterial and venous plasma catecholamines and used laser-Doppler flowmetry to measure cutaneous microcirculatory flow in the sympathectomized and in the intact limbs of 3 patients who had undergone regional sympathectomies. Venous concentrations of norepinephrine, the sympathetic neurotransmitter, exceeded arterial concentrations in the intact limbs--a normal finding--but invariably were less than arterial in the sympathectomized limbs of the same patients, both during baseline conditions and during sympathetic stimulation using tilt, standing and the cold pressor test (mean arteriovenous decrement about 40%). Arterial epinephrine levels exceeded venous levels with or without sympathectomy. Skin microvascular flow rapidly decreased during the cold pressor test and the Valsalva maneuver in the intact but not in the sympathectomized limbs, and spontaneous flow oscillations occurred in the sympathectomized limbs. The results suggest that an arteriovenous increment in plasma norepinephrine reflects local release of norepinephrine from sympathetic nerve endings, whereas removal of circulating catecholamines can occur with or without sympathetic neural impulses. Laser-Doppler flowmetry can measure reflexive sympathetically mediated responses of skin microvascular flow and so can detect sympathetic denervation. Spontaneous oscillations in this flow may not depend exclusively on oscillations in the activity of the sympathetic microvascular innervation.
J Auton Nerv Syst. 1986 Apr;15(4):309-18.
http://www.ncbi.nlm.nih.gov/pubmed/3517118

Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue

Differential effects of surgical sympathectomy on rat heart concentrations of neuropeptide Y-immunoreactivity and noradrenaline.

Maccarrone C, Jarrott B.

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.
J Auton Nerv Syst. 1987 Dec;21(2-3):101-7
The aim of this study was to estimate the proportion of cardiac neuropeptide Y-immunoreactivity (NPY-ir) which is not present in sympathetic neurones innervating the rat heart. The procedure employed was to surgically sympathectomize the heart and then measure the remaining cardiac concentrations of NPY-ir and noradrenaline (NA). Unilateral (left) sympathectomy significantly reduced the levels of NPY-ir and NA in all regions of the heart (by 40-70%) except for the NPY-ir in the right atrium which was unaltered. The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy. Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue. In contrast dissimilar changes were produced in the atrium. Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%. These results indicate that approximately half the content of NPY in the right atrium is not present in sympathetic noradrenergic neurones. This pool may occur in the previously described intrinsic neurones of the right atrium.
PMID: 3450689 [PubMed - indexed for MEDLINE]

Sympathectomy-induced changes is cytokine production and immune effector function

Lacrimal Gland, Tear Film, and Dry Eye Syndromes 2: Basic Science and Clinical Relevance

By David D. Sullivan, Darlene A. Dartt, Michele A. Meneray

Edition: 2, illustrated

Published by Springer, 1998

ISBN 0306458128, 9780306458125

p.544

Cytokines, stress and depressive illness

Cytokines, signaling molecules of the immune system, have been implicated as a contributing factor for mood disorders such as depression. Several lines of evidence supporting this contention are briefly reviewed and caveats are introduced. Essentially, a relationship between cytokines and depression is based on the findings that: 1) proinflammatory cytokines (interleukin-1, interleukin-6, tumor necrosis factor-alpha) and bacterial endotoxins elicit sickness behaviors (e.g., fatigue, soporific effects) and symptoms of anxiety/depression that may be attenuated by chronic antidepressant treatment, 2) cytokines induce neuroendocrine and central neurotransmitter changes reminiscent of those implicated in depression, and these effects are exacerbated by stressors, 3) severe depressive illness is accompanied by signs of immune activation and by elevations of cytokine production or levels, and 4) immunotherapy, using interleukin-2 or interferon-alpha, promotes depressive symptoms that are attenuated by antidepressant treatment. It is argued that cytokine synthesis and release, elicited upon activation of the inflammatory response system, provoke neuroendocrine and brain neurotransmitter changes that are interpreted by the brain as being stressors, and contribute to the development of depression. Furthermore, such effects are subject to a sensitization effect so that a history of stressful experiences or cytokine activation augment the response to later challenges and hence the evolution of depression.

Anisman H, Merali Z.
Institute of Neurosciences,
Carleton University and Institute of Mental Health Research,
Royal Ottawa Hospital, University of Ottawa, Canada.
hanisman@ccs.Carleton.ca
Ann Med 2003;35(1):2-11

Cytokines, immune responses and depression

There is now evidence that major depression is accompanied by significant changes in cell-mediated and humoral immunity, and these changes may be related to the pathophysiology or pathogenesis of that illness (Connor and Leonard [1], Dantzer et al. [2], Kim et al. [3], Licinio and Wong [4]), yet data are inconsistent. Some studies have shown that major depression is associated with dysregulation of immune mediators.
However, conflicting results have also been described (Brambilla and Maggioni [12], Brambilla et al. [13], Carpenter et al. [14], Rothermundt et al. [15]). These changes have been considered in terms of the imbalance between individual pro- and anti-inflammatory cytokines and the T helper 1 (Th1) and T helper 1 (Th2) imbalance in major depression. On the other hand, an enhanced secretion of such proinflammatory cytokines would not only lead to activation of T and B lymphocytes, but also could affect the brain and elicit various symptoms of depression, such as loss of appetite, listlessness, and sleep disturbances (Maes [16]).

Hyperpigmentation after sympathectomy

Clinical and Experimental Dermatology

Volume 5 Issue 3, Pages 349 - 350
Accepted for publication 4 October 1979

Abnormal suntanning following transthoracic endoscopic sympathectomy Transthoracic endoscopic sympathectomy (TES) has become the method of choice for treating patients with palmar hypcrhidrosis. There are few complications reported with this procedure. A complication not described previously is reported here. Accepted: 25 January 1996

M. S. Whiteley, S. B. Ray-Chaudhuri, Mr R. B. Galland *

British Journal of Surgery Volume 83 Issue 12, Page 1782

A different structural appearance of the peripheral nervous system as well as a changed balance of neuropeptides in vitiliginous skin point to a critical role of the nervous system in the pathogenesis of vitiligo.
Archives of Dermatological Research
Volume 288, Number 11 / October, 1996

Pediatric Dermatology - Fulltext: Volume 22(6) November/December ...

Vitiligo and human herpesvirus 6. Is there a relationship? .... syndrome in whom the suspected etiology was a thoracoscopic sympathectomy 4 years prior. ...
pt.wkhealth.com/pt/re/pder/fulltext.00006602-200511000-00026.htm - Similar pages -
by M Smith - 2005 - Cited by 2 - Related articles - All 6 versions

The role of cervical sympathetic nervous system in secretions of stress or pineal hormone

These findings suggested that some stress stimuli are conducted via cervical sympathetic nerves to the hypothalamus, which is reduced by SGB (stellate ganglion block), and to the pineal gland at night, which causes increased melatonin and decreased serotonin levels.
The Pain Clinic, Volume 13, Number 3, 2001 , pp. 233-244(12)

Cervical sympathectomy affects adrenocorticotropic hormone and thyroid-stimulating hormone

The present results suggest that cervical sympathectomy in the rat increases ACTH secretion and decreases TSH secretion in the pituitary. These effects seem to be due to a mildly increased secretion of melatonin in the pineal body that probably in turn increases corticotropin-releasing factor (CRF) secretion and decreases thyrotropin-releasing hormone (TRH) secretion in the hypothalamus. Extrapolation of these findings to humans suggests that longterm and repeated stellate ganglion block would affect the pituitary secretions of ACTH and TSH.
http://www.springerlink.com/content/g3333g7752201496/

Received: 26 June 1995 Accepted: 1 March 1996

Journal of Anesthesia

Informed consent in Australia

Recent decisions in Australian courts affirm three important principles relating to consent to therapy. First, patients must be appropriately and adequately informed. Second, the scope and detail of the information supplied should be based on the reasonable patient's need to know rather than on the actions of the reasonable doctor. Third, the doctor must take care to ensure that the information imparted is understood by the patient. This publication reviews the basis of informed consent and traditional beneficent-style consent. The occasions when beneficence is more appropriate are outlined.

Reginald S. A. Lord 1 , 2
1 Department of Surgery, St Vincent's Hospital, University of New South Wales. Sydney. Australila
Correspondence to 2 Professor R. S. A. Lord, Level 17, St Vincent's Hospital. Victoria Street. Darlinghurst. NSW 2010. Australia.
*Presented at the 1st John Plunkett Seminar on Medical Ethics, Sydney. June 1994.

to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy

In this paper we argue that the standard focus on problems of informed consent in debates about the ethics of human experimentation is inadequate because it fails to capture a more fundamental way in which such experiments may be wrong. Taking clinical trials as our case in point, we suggest that it is the moral offence of using people as mere means which better characterizes what is wrong with violations of personal autonomy in certain kinds of clinical trials. This account also helps bring out another important way in which the autonomy of the participants in clinical trials my be violated, even in cases where they have given informed consent to their involvement. Where relevant information about the trial is framed in such a way as to induce a patient's participation by appeal to their nonrational preferences, this is also a violation of their autonomy, and one which is distinct from a failure of informed consent. The underlying wrongness of both kinds of violations, we argue, is plausibly captured by the moral offence of using people as mere means.

MEDICAL EXPERIMENTATION, INFORMED CONSENT AND USING PEOPLE
DE AN COCKING 1 JU STIN OAKLEY 1
1 Centre for Human Bioethics Monash University

Sympathectomy induces mast cell hyperplasia

Mast cell hyperplasia is found in different pathologies such as chronic inflammatory processes, fibrotic disorders, wound healing or neoplastic tissue transformation. The functional significance of the accumulation of mast cells in these processes is largely unknown. It is now established that bone marrow-derived mast cell progenitors circulate in peripheral blood and subsequently migrate into the tissue where they undergo final maturation under the influence of local microenvironmental factors. Cytokines are of particular importance for mast cell recruitment, development, and function.
http://www.ncbi.nlm.nih.gov/pubmed/11919420

Long-term superior cervical sympathectomy induces mast cell hyperplasia and increases histamine and serotonin content in the rat dura mater
Copyright © 1999 IBRO. Published by Elsevier Science Ltd.

Immune and Glial Cells Contribute to Pathological Pain States

Alterations in sympathetic fibers rapidly follow peripheral nerve injury. This occurs as sprouting of
sympathetic fibers, creating aberrant communication pathways from the new sympathetic terminals to
sensory neurons (35). Sympathetic sprouting has been documented in the region of peripheral terminal
fields of sensory neurons (262), at the site of nerve trauma (57), and within the dorsal root ganglia
(DRG) containing cell bodies of sensory neurons (248, 343). Each of these sites develops spontaneous
activity and sensitivity for catecholamines and sympathetic activation (8, 53).
The clearest evidence that immune activation participates in sympathetic sprouting comes from studies of
the DRG. DRG cells receive signals that peripheral nerve injury has occurred via retrograde axonal
transport from the trauma site. These retrogradely transported signals trigger sympathetic nerve sprouting
into DRG (205, 308). As a result of nerve damage-induced retrogradely transported signals, glial cells
within the DRG (called satellite cells) proliferate and become activated; macrophages are
recruited to the DRG as well. In turn, the activated satellite glial cells (and, presumably, the
macrophages) release proinflammatory cytokines and a variety of growth factors into the extracellular
fluid of the DRG (206, 246-248, 258, 277, 308, 358). These substances stimulate and direct the growth
of sympathetic fibers, which form basket-like terminals around the satellite cells that, in turn, surround
neuronal cell bodies.
Physiological Reviews, Vol. 82, No. 4, October 2002, pp. 981-1011; 10.1152/physrev.00011.2002.
Copyright ©2002 by the American Physiological Society

Intraneural activated T cells cause focal breakdown of the blood-nerve barrier

These findings demonstrate that activated T cells cause focal breakdown of the BNB, allowing circulating antimyelin antibody to enter the endoneurium with consequent focal demyelination.
Brain. 1995 Aug;118 ( Pt 4):857-68
Intraneural activated T cells cause focal breakdown of the blood-nerve barrier.

Spies JM, Westland KW, Bonner JG, Pollard JD.
Institute of Clinical Neurosciences, University of Sydney, NSW Australia.

Autoregulation of cerebral blood flow in orthostatic hypotension

The most common patterns of cerebral response to OH are autoregulatory failure with a flat flow-pressure relationship or intact autoregulation with an expanded autoregulated range. The least common pattern is autoregulatory failure with a steep flow-pressure relationship. Patients with patterns 1 and 2 have an enhanced capacity to cope with OH, while those with pattern 3 have reduced capacity.
Stroke. 1998 Jan;29(1):104-11. Links
Autoregulation of cerebral blood flow in orthostatic hypotension.

Novak V, Novak P, Spies JM, Low PA.

Autonomic Disorders Center, Department of Neurology, Mayo Clinic and Foundation, Rochester, Minn. 55905, USA.

Autonomic dysfunction is a common complication of peripheral neuropathies. It is often of little clinical importance, but some conditions may cause profound disturbance of autonomic function, including postural hypotension, impotence and impairment of heart rate and bladder and bowel control. Autonomic function can be evaluated by a number of investigations, some of which can be performed in a neurophysiology laboratory. Diseases that primarily affect small nerve fibres or cause acute demyelination of small myelinated fibres are most likely to cause autonomic dysfunction. Management includes treating the underlying cause and symptomatic therapy.
Autonomic neuropathy, I. Clinical features, investigation, pathophysiology, and treatment.

McDougall AJ and McLeod JG

Journal of the neurological sciences 137(2):79-88, 1996 May

sensory, limbic, and autonomic systems

The frontal lobes receive information from sensory, limbic, and autonomic systems and engage in complex cognitive functions.

The basis for prefrontal lobotomy is the apparent loss of anxiety resulting from disconnection of perceptions from normal emotional responses.
Physiology
by Roger Thies, Kirk W. Barron - 1995 - Science - 280 pages

lobotomy is often associated with hyperhidrosis

"lobotomy is often associated with hyperhidrosis. Nerves from the hypothalamus apparently pass through the pons and medulla into the cervical spinal cord, since injury to certain areas of these structures results in anhidrosis of specific regions of the body surface.
Nerves leaving the ventral ramus of the spinals nerve cord pass through the chain of sympathetic ganglia so that from thoracic roots T2 to T4 the head and neck are innervated and from T2 to T8 the upper limbs are supplied.
There is some evidence of some innervation of the face and upper extremities from T1, even though autonomic function is presumed to arise only below the first thoracic root. For example, destruction of stellate ganglia (C8-T1 or T2) produces anhidrosis of the upper body and it's extremities. Despite these generalizations, the supply of nerves to small areas such as a finger may originate from as many as seven spinal segments. It may also be very important to recognize that the anatomy of the sympathetic chain is highly varied and that many nerves may bypass the ganglia entirely, thus accounting for numerous discrepancies in the literature concerning pathways and control.
List and Peet concluded from lesions at various levels that that section of the spinal cord and specific lesions within the cord result in loss of sweating in response to heat, but not to exogenous drugs. On the other hand, destruction of peripheral nerves by interruption of the nerve trunk results in loss of sweating in response to heat and drugs within two week.
Antiperspirants and Deodorants by Karl Laden

Edition: 2, illustrated, revised

Published by CRC Press, 1999, p.31

Neuromodulation Surgery for Psychiatric Disorders

Increasingly, psychiatric changes are believed to not be attributed to a "center" of mood or behavior but, rather, are secondary to an imbalance in communication of multiple neuronal loops. However, the efficacy of DBS is typically attributed to a small generated electrical field that encompasses a very limited amount of cerebral tissue. Perhaps the stimulation generated at a certain target propagates downstream into the rest of the circuitry, gaining an amplified effect.

Currently, 6 targets for neuromodulation surgery have been published: the Cg25, the anterior internal capsule (AIC), the nucleus accumbens (NA), the ventral striatum (VS), the inferior thalamic peduncle (ITP), and the left vagus nerve. Each of these regions can be seen as nodes in the aforementioned circuitry. Putative modulation at these nodes is the basis of the current efforts investigating neuromodulation surgery for refractory psychiatric disease. The highlighted areas of Images 14, 15, 16, 17, 18, 19, 20, 21, 22, and 23 show how neuromodulation at each target may influence the aforementioned circuitry.
Brian H Kopell, MD,
Jerry L Halverson, MD
http://emedicine.medscape.com/article/1343677-overview

Patterns of reinnervation of denervated cerebral arteries

Eight weeks after ganglionectomy, these reinnervating nerve fibers formed a fairly dense plexus in a circular pattern in the circle of Willis. However, the reinnervation could not be observed in the arterial branches derived from the circle of Willis (middle cerebral artery and posterior cerebral artery) even 16 weeks after ganglionectomy. The present results clearly demonstrated the time course, distribution pattern and limitation of the reinnervation from the contralateral SCG following unilateral ganglionectomy. The fact that reinnervation could be observed only in the main cerebral arteries of the circle of Willis, in which the nerve plexus appeared to have a circular pattern, suggests a difference between the qualities of sympathetic innervation controlling the cerebral circulation in these arteries and the other arterial branches related to these differences in reinnervation capacity.

Exp Brain Res. 1991;86(1):82-9.Links

Patterns of reinnervation of denervated cerebral arteries by sympathetic nerve fibers after unilateral ganglionectomy in rats.

Handa Y, Nojyo Y, Hayashi M.

Cerebral artery mass reduced by sympathetic denervation

Bevan RD, Tsuru H, Bevan JA.

Weights of matching right and left middle or posterior cerebral arteries and their main branches from the same animal were compared 8-10 weeks after unilateral denervation by superior cervical ganglionectomy. When compared in pairs, the denervated arterial systems weighed significantly less (mean 85%) than their innervated counterparts. This suggests that the sympathetic innervation exerts a trophic influence on extracerebral arteries.

PMID: 6362090 [PubMed - indexed for Medline

Stroke. 1983 May-Jun;14(3):393-6.

the heart obeys Starling's law after chemical sympathectomy

This can be seen most dramatically in the case of premature ventricular contraction. The premature ventricular contraction causes early emptying of the left ventricle (LV) into the aorta. Since the next ventricular contraction will come at its regular time, the filling time for the LV increases, causing an increased LV end-diastolic volume. Because of the Frank-Starling law, the next ventricular contraction will be more forceful, causing the ejection of the larger than normal volume of blood, and bringing the LV end-systolic volume back to baseline.

The more the myocardium is dilated, the weaker it can pump, as it then reverts to Laplace's law.
http://en.wikipedia.org/wiki/Frank-Starling_law_of_the_heart

Response to adrenaline after sympathectomy

None of the hands in this series
exhibited significant change in flow with A1 ,ug/min. With A ,ug/min, however,
eight of the thirteen hands now had 25 % or more vasoconstriction, the mean
for the group being 30 %. With i p,g no less than eight of the ten hands tested
had more than 25 % vasoconstriction.
Thus for the two groups receiving H and i ug adrenaline marked increases
in the mean responses from 11 to 30 % and from 16 to 44 %, respectively, were
observed after sympathectomy. The ratio of postoperative to preoperative
mean responses was about the same for both doses (2-7 and 2-8). The increased
response after sympathectomy is seen (Table 2) to be due especially to changes
in hands 3, 6, 9, 11, 12 and 13, which before operation had minimal constric-
tions but responded with marked reductions in blood flow after sympathectomy.
The altered behaviour of two of these hands is portrayed in Figs. 1 and 2.
Although some of the other seven hands also showed increased vasoconstric-
tion with a given dose of adrenaline after sympathectomy this increase was
less notable.
The paired differences between the hands before and after sympathectomy
are significant at the A .g/min (t = 3-03, P < 0-02), and the i ,ug/min (t = 3-55,
P < 0-01) levels. Of the six hands manifesting notable increases in sensitivity
to adrenaline three were sympathectomized by preganglionic section and three
by ganglionectomy.
J. Physiol. (I955) I29, 53-64
EFFECT OF ADRENALINE AND NORADRENALINE ON
BLOOD VESSELS OF THE HAND BEFORE AND AFTER
SYMPATHECTOMY
BY R. S. DUFF
From the Cardiological Department, St Bartholomew's Hospital and the
Sherrington School of Physiology, St Thomas's Hospital, London

Sympathectomy and fraud

HUGE BILL FRAUD CITED AT CLINICS

March 12, 2005 - By ROBERT PEAR - National Desk - 933 Words

Twelve Blue Cross and Blue Shield plans, working with the F.B.I., said Friday that they had broken up an elaborate insurance scheme in which thousands of patients from 47 states were sent to California to undergo unnecessary surgical and diagnostic procedures, for which doctors filed more than $1 billion of fraudulent insurance claims. Insurance executives and law enforcement officials said that surgery clinics in Southern California typically paid recruiters $2,000 to $4,000 for each patient who received a medical procedure. The patients, they said, received rewards in the form of cash or discounts on cosmetic surgery.

potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak

Thorascopic manipulation of the lung and mediastinal structures may result in cardiac arrhythmias. Electrical current from the cautery may initiate atrial or ventricular tachycardia or fibrillation. Sinus tachycardia may occur secondary to CO2 retention when insufflation techniques are used. A mediastinal shift with compromise of venous return to the heart may initiate a reflex sinus tachycardia. Vagal stimulation and air or CO2 embolism with insufflation techniques may lead to bradycardia or asystole. Hypotension may result from mediastinal tamponade, air or CO2 embolization, or hemorrhage. Hypercarbia, which results from CO2 insufflation, can result in hypertension and tacjycardia. Hemorrhage from the intracostal vessels may occur at the site of trocar placement.
Exposure of the thoracic sympathetic chain requires retraction of the lung apex away from the posterior chest wall. Improper instrumentation and the frequent presence of apical blebs or adhesions may result in a parenchymal lung injury and postoperative pneumothorax or persistent air leak.

The operative procedure and the potential complications of hemorrhage, arrythmia, hypotension, pneumothorax, pain, persistent air leak, inability to complete the procedure thoracoscopically, and death are reviewed with the patient.

Haimovici's Vascular Surgery

Edition: 5, illustrated

Published by Blackwell Publishing, 2004

Death following Sympathectomy

Maura Derrane: Tragedy of the man who died of shyness
Sunday Mirror, Dec 4, 2005 by Maura Derrane

THE wife of a solicitor who died two days after undergoing an operation to stop blushing was paid nearly EUR5million in compensation during the week.

Eleanor Synnott sued the surgeon and the hospital where the operation took place. The award was one of the biggest ever paid out in Ireland.

Alan Synnott was one of the country's most successful personal injuries solicitors.
Court papers revealed that there were problems inserting the tubular device into his chest and that as a result of this his lungs were damaged and massive bleeding occurred.

Although emergency surgery was performed Alan Synott never regained consciousness and died two days later.

In 70 % compensatory sweating severe

In T2 and T3 resection, all patients experienced Compensatory Sweating and over 70% of the patients felt it was severe. Even in T2 resection, 90% of patients experienced CS and in 50% of these it was severe. High rates of CS are reported in Asian countries with hot and humid climates.

In T2 resection, recurrence rates were 15% and 19% at 1 and 2 years after surgery.It was not rare for a patient to experience recurrence more than 3 years after surgery.
Motoki Yano, MD, PhD and Yoshitaka Fujii, MD, PhD

Volume 138, Issue 1, Pages 40-45 (July 2005)

The Neuroendocrine-immune Network

Work from Livnat's laboratory, utilizing the the experimental approach following chemical sympathectomy, has documented extensive functional alterations in immune responses following denervation. In several strains of mice, sympathectomy diminished primary antibody responses by as much as 80% and 97% in spleens and lymph nodes, respectively and suppressed the secondary antibody response as well. T-cell mediated responses, such as delayed hypersensitivity to epicutaneous immunization and cytotoxic T-lymphocyte responses to alloantigens, were reduced by 50% or more in denervated mice. In contrast, proliferation, and possibly differentiation of lymphocytes (mainly B cells) in lymph nodes in the absence of immunization was markedly stimulated by sympathectomy. Furthermore natural killer cell (NK) activity in the spleen and lungs was augmented following denervation.

The Neuroendocrine-immune Network

By S. Freier

Published by CRC Press, 1990

ISBN 0849346258, 9780849346255

Sympathectomy suppresses baroreceptor function

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.

Anesth Analg. 1983 Sep;62(9):815-20
http://www.ncbi.nlm.nih.gov/pubmed/6881570?dopt=Abstract

suppression of baroreflex function can be detrimental

In this study, baroreflex control of HR was completely inhibited in 9 of 21 patients in the depressor test but in only 1 of 19 patients in the pressor test. All patients who showed complete inhibition had received bilateral T2-3 sympathectomy. Responses to decreased blood pressure are mediated by the sympathetic nervous system, whereas responses to increased blood pressure predominantly involve vagal compensation (13). Therefore, it seems that the effects of sympathetic denervation were most prominent in the depressor test after ETS.

The suppression of baroreflex function can be detrimental during anesthetic management. In particular, a poorly preserved baroreflex response to decreasing blood pressure may exaggerate hemodynamic perturbation after a sudden loss of circulating blood volume. In addition, it is possible that patients who have received ETS will show unexpected HR responses after the administration of a vasopressor or vasodilator. We conclude that baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS.
Anesth Analg 2004;98:37-39
http://www.anesthesia-analgesia.org/cgi/content/full/98/1/37

Sexual dysfunction after sympathectomy

LS, like any other surgical procedure, is not without its share of complications which include failure of adequate denervation, brief paralytic ileus, hyperhydrosis in parts of the body which remain normally innervated, sexual dysfunction, and post-sympathectomy neuralgia.

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijs/vol18n1/lumbar.xml

Pathophysiology of Diarrhea and Malabsorption

Disordered motility

• Post-vagotomy

• Post-sympathectomy

• Diabetic neuropathy

• Hyperthyroidism

• Addison’s disease (adrenal insufficiency)

• Irritable bowel syndrome

Laurence Scott Bailen, M.D.: Diarrhea and Malabsorption
http://ocw.tufts.edu/Content/48/lecturenotes/571075

Causes of Syncope:

g) *Syncope via autonomic failure:
i) Neuropathy with autonomic involvement
ii) Antihypertensives, esp. beta-blockers
iii) Surgical sympathectomy
iv) CNS autonomic failure: eg.primary autonomic failure, MSA, spinal cord lesion

Causes of *Collapse and Acute Decreased Conscious State. (* = collapse, as in sudden loss of consciousness). 1. Respiratory (O ...
www.medicine.utas.edu.au/teaching/year6/cam615_616/info/additionaltutes/additionaltutes/med.pdf

Authorised Publication of the School of Medicine
© University of Tasmania ABN 30 764 374 782

Profound Bradycardia

However, CTS (Chemical Thoracic Sympathectomy) in patients having high SDRR:SD sub [partial diffenrential] RR ratios can result in profound bradycardia.
Anesthesiology. 89(3):666-670, September 1998.
Hirose, Munetaka MD; Imai, Hiroto MD; Ohmori, Misako MD; Matsumoto, Yasunori MD; Amaya, Fumimasa MD; Hosokawa, Toyoshi
MD; Tanaka, Yoshifumi MD

The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome

British Journal of Surgery ISSN 0007-1323

1999, vol. 86, no1, pp. 45-47 (12 ref.)

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side

Several reports also demonstrate significantly lower heart rate increases during exercise in subjects who have undergone bilateral ISS [9–12] compared to pre-surgical levels. In spite of this high occurrence, recent reviews on the usual collateral effects of thoracic sympathectomy still do not include these possible cardiac consequences [6].
The aim of the present prospective study was to confirm that a significant impairment of the heart rate to workload relationship was consistently observed following unilateral and/or bilateral surgery.
Eur J Cardiothorac Surg 2001;20:1095-1100
http://ejcts.ctsnetjournals.org/cgi/content/full/20/6/1095

Palmar Hyperhidrosis worse after Sympathectomy

We describe a patient who underwent upper thoracic sympathectomy for palmar hyperhidrosis, and whose symptoms subsequently deteriorated, becoming worse than those on initial presentation.

Clinical and Experimental Dermatology

Volume 20 Issue 3, Pages 230 - 233

Published Online: 27 Apr 2006

Accepted for publication 6 January 1995

THE SYMPATHETIC NERVOUS SYSTEM AS A HOMEOSTATIC MECHANISM

The responses of intact rats to cold-exposure (4°C) include vasoconstriction, piloerection, shivering, adrenocorticotrophin (ACTH) hypersecretion and increased mobilization of free fatty acids and glucose. Adrenal demedullation prevents the increased mobilization of glucose and decreases survival time. Chemical sympathectomy blocks all of the responses except ACTH hypersecretion. Such animals lose body heat rapidly and die in a few hours. Total adrenalectomy has a similar effect. The damaging actions of chemical sympathectomy are reversed by administration of catecholamines while those of total adrenalectomy are reversed by cortisone. Thus, the sympathetic nervous system appears to be essential for existence at low environmental temperature.

http://jpet.aspetjournals.org/cgi/content/abstract/157/1/103