Bradycardia After Intravenous Ondansetron with Asystole on Rechallenge: A Case Report

Purpose:

There have been 3 published reports (4 cases) of symptomatic sinus bradycardia occurring after intravenous (IV) administration of the selective 5-hydroxytryptamine 3 (5-HT₃) receptor antagonist ondansetron. We report a fifth case in which the patient developed asystole after rechallenge with ondansetron.

Summary:

A 36-year-old pregnant patient with no cardiac history, status post cerclage for cervical insufficiency, experienced nausea in the post ambulatory care unit after administration of morphine and indomethacin for pain. After IV administration of ondansetron, the patient’s heart rate decreased to the 40s and improved spontaneously. The patient experienced a second episode of nausea, another dose of ondansetron was administered, and the patient went into asystole. Advanced cardiac life support measures were initiated and chest compressions were conducted for 3 minutes with return of spontaneous circulation. The patient was monitored overnight with no development of new cardiac arrhythmias and was discharged from the hospital in stable condition.

Conclusions:

Sinus bradycardia after IV administration of ondansetron was observed in a 36-year-old pregnant patient status post cerclage. On rechallenge, the patient went into asystole. This case report adds to the available literature regarding ondansetron-induced cardiac arrhythmias and the possibility of asystole upon rechallenge.     

Correlation between biomarkers of polycyclic aromatic hydrocarbon exposure and electrophilic tissue burden in a rat model

This study was aimed at investigating the correlation between biomarkers of exposure to polycyclic aromatic hydrocarbons and, more specifically, at examining the role of urinary 1-hydroxypyrene (1-OHP) as a reliable measure of internal dose linked to the electrophilic tissue burden (ETB), assessed as covalent binding of the ultimate carcinogen benzo(a)pyrene diolepoxide (BaPDE) with cellular proteins in target organs. The protocol included experimental verification of a previously proposed algorithm for adjustment of reference values for urinary 1-OHP with exposure to different mixtures of polycyclic aromatic hydrocarbons in a rat model. Hence, the relationships between ETB in liver, lung, and heart as well as the BaPDE–haemoglobin adducts level on the one hand, and urinary/faecal 1-OHP or urinary/faecal 3-hydroxybenzo(a)pyrene (3-OHBaP) on the other hand have been examined. Male Sprague-Dawley rats received intraperitoneally, once daily for 10 consecutive days, binary mixtures of benzo(a)pyrene (BaP) and pyrene (P) in three different exposure scenarios corresponding to BaP/P ratios of 0.2, 1 and 5, with three doses of BaP (2, 6 and 20 mg/kg) for each scenario. The ETB levels were measured as the ultimate analyte benzo(a)pyrene tetrol (BaPTeT) obtained after mild acid hydrolysis of BaPDE adducts with proteins. It was experimentally confirmed that: (1) urinary 1-OHP is a reliable biomarker linked to the ETB in tissues that are targets for carcinogenicity, such as lung, for the BaP/P ratios of 0.2 and 1 (linear regression p=0.0099 and 0.0293, respectively); (2) urinary 3-OHBaP is correlated with the BaPDE–haemoglobin adducts for all three exposure scenarios (p=0.0011 for BaP/P=0.2, p<0.0001 for BaP/P=1 and p=0.0099 for BaP/P=5). The experimental relationship between ETB and urinary 1-OHP was used to interpolate biological limit values for the urinary metabolite assuming three arbitrary critical levels of ETB. These were compared with the values calculated from the algorithm using the BaP/P ratio 1 mixture as a reference. The ratios of calculated to observed values varied from 1.0 to 1.6 for the BaP/P 0.2 mixture, and from 1.9 to 3.0 for the BaP/P 5 mixture. The results obtained in the present study indicate that the algorithm mentioned above applies well for two of the three exposure scenarios corresponding to realistic occupational BaP/P ratios of 0.2 and 1. This suggests that, using ETB as an endpoint, the proposed algorithm will reasonably predict the critical value of urinary 1-OHP for mixtures having different BaP/P ratios. Stronger linear relationships between ETB in all chosen tissues and 1-OHP or 3-OHBaP excretion were obtained with urinary metabolites than with their faecal analogues. Thus urinary 1-OHP and 3-OHBaP are more reliable biomarkers in biological monitoring strategies.     

Effects of peak concentrations on the neurotoxicity of styrene in volunteers

The manufacture of fibreglass reinforced plastic products may give rise to substantial peak exposures to styrene. Such exposure patterns need further consideration in terms of styrene neurotoxicity. The aim of this study was to evaluate the neurotoxic effects of short-term peak exposures in volunteers, at levels respecting the Quebec occupational exposure limits (8 hours time weighed average of 213 mg/m3 and 15 min average of 426 mg/ m3). The volunteers had not been previously exposed to styrene and they had no documented exposure to known neurotoxicants during the study. Twenty-four volunteers were exposed to five exposure scenarios during 6 hours: a, stable exposure to 106 mg/m3; b, variable exposure with a mean concentration of 106 mg/m3 with four 15 min peaks mounting up to 213 mg/m3; c, stable exposure to 213 mg/m3; d, variable exposure with a mean concentration of 213 mg/m3 and four peaks of 426 mg/m3 and e, two stable exposures to 5 mg/m3 (control). Before and after each exposure scenario, volunteers were submitted to a battery of sensory tests (visual and olfactory), neuropsychological tests (reaction time, attention, memory, psychomotor function), and self-evaluation questionnaires (mood and symptoms) in a test-retest design. The results show that the different exposure scenarios involving peak exposures did not influence either the performance to any test or subjective signs and symptoms. However, due caution must be exercised in extrapolation of the current results to occupational exposure since only acute exposures were tested and volunteers were at rest during exposure, which resulted in lower doses than those experienced by physically active workers.     

Active glottal closure during anoxic gasping in lambs.

The present study was aimed at assessing laryngeal dynamics and their consequences during anoxic gasping in ketamine-sedated lambs. We first verified that the glottis was closed between gasps during anoxic gasping in seven chronically instrumented lambs, aged 11-15 days. Recording of glottal constrictor muscle electrical activity, subglottal pressure and lung volume, together with endoscopic observation, confirmed the presence of active glottal closure with maintenance of a high lung volume between gasps. Secondly, we tested whether maintenance of a high lung volume between gasps improved autoresuscitation efficiency. Six sedated lambs aged 8-11 days underwent two anoxic runs, including one with an open tracheostomy to prevent maintenance of a high lung volume. Access back to air was allowed for gasping. No significant difference was found in time to eupnea resumption, hemodynamic parameters or arterial blood gases. We conclude that a high lung volume is actively maintained by glottal closure between anoxic gasps in sedated lambs. Further studies are however needed to define the importance of laryngeal dynamics during gasping.     

Reduced effects of amphetamine on prepulse inhibition of startle in gastrin-deficient mice

The present study was aimed at investigating the role of gastrin in startle, startle habituation and prepulse inhibition (PPI). There were no significant differences between gastrin knockout mice and their wildtype controls in any of these baseline parameters. The disruption of PPI by treatment with 5 mg/kg of amphetamine was absent in gastrin knockout mice. However, a higher dose of amphetamine disrupted PPI in both genotypes. Similarly, treatment with the dopamine receptor agonist, apomorphine, the N-methyl-D-aspartate receptor antagonist, MK-801, and the serotonin-1A receptor agonist, 8-hydroxy-di-propylaminotetralin (8-OH-DPAT) modulated PPI similarly in gastrin knockout mice and wildtype controls. These data suggest a role of gastrin in the brain in modulating dopamine release in areas involved in PPI.     

Treatment of resistant ascites by continuous ultrafiltration--reinfusion of ascitic fluid.

Eight patients with diuretic-resistant ascites due to cirrhosis were treated by reinfusion of concentrated ascitic fluid. In 11 procedures, with a mean duration of 21.9 hours, weight loss averaged 14.8 kg. Complications during reinfusion included septicemia in 1 procedure, left-sided heart failure in 5, pyrexia in 7 and coagulation abnormalities in 10. Ascites recurred within 2 months after reinfusion in all but one patient. Although this technique is an efficient and inexpensive method of treatment of ascites, it does not appear indicated in patients with cirrhosis and resistant ascites in view of the possibly serious complications associated with reinfusion and the poor long-term results.     

Indirect sympatholytic actions at β-adrenoceptors account for the ocular hypotensive actions of cannabinoid receptor agonists

Intraocular pressure (IOP) is the primary risk factor for glaucoma, a blinding eye disease. Cannabinoid agonists have long been known to decrease IOP, suggesting they may be useful in glaucoma treatment. However, the specific mechanism by which cannabinoids generate this ocular hypotensive effect remains unknown. The current evidence suggests the cannabinoids reduce IOP through actions at cannabinoid 1 (CB(1)) receptors within the eye, and adrenergic receptors (ARs) may also contribute to this action of cannabinoids. Considering this, the present study aimed to elucidate the mechanism behind the ocular hypotensive properties of cannabinoids through the use of mice genetically lacking either cannabinoid receptors or βARs. Cannabinoid agonists, βAR antagonists, and βAR agonists decreased IOP in wild-type mice and CB(2)(-/-) mice. In contrast, none of these compounds were found to reduce IOP in βAR(-/-) or CB(1)(-/-) mice. Desensitization of the βARs and depletion of catecholamines in wild-type mice also eliminated the ability of the cannabinoid agonist (R)-(+)-[2,3-dihydro-5-methyl-3-(4-morpholinylmethyl)pyrrolo[1,2,3-de]-1,4-benzoxazin-6-yl]-1-naphthalenylmethanone mesylate (WIN 55,212-2) to reduce IOP, strongly implicating a role for both βARs and catecholamines in the ocular hypotensive properties of cannabinoids. Finally, CB(1) receptors were shown to colocalize with tyrosine hydroxylase, a marker for adrenergic neurons. Taken together, these findings suggest that βARs are required for the ocular hypotensive properties of cannabinoids, and cannabinoids reduce IOP by acting as indirect sympatholytics and inhibiting norepinephrine release within the eye.