Effects of Systemic Local Anesthetics on Perioperative Ischemia Reperfusion May Be Beneficial To the Editor: We read with interest the article by Hahnenkamp et al. (1). The authors describe beneficial effects of local anesthetics, including 1) attenuating the perioperative stress response, 2) decreasing the in- cidence of vascular graft occlusion and thromboembolic complica- tions, 3) inhibitory effects on platelet aggregation, and 4) antiinflam- matory effects. As indicated by the authors, these events and their manipulation are important for patient outcome, with further stud- ies required to clarify the systemic effects of local anesthetics in the perioperative period (1). Ischemia reperfusion is an important event in the perioperative period, with such injury consequent to surgeries such as aortic (2), cardiac (3), orthopedic, and plastic surgery (4). Local anesthetics in vitro are beneficial in animal models of ischemia reperfusion (5,6). Potential therapeutic mechanisms include antiinflammatory (7) and antioxidant actions (8). The role of local anesthetics and ischemia reperfusion in the perioperative period has not been studied. Stud- ies of the effects of systemic local anesthetics in the perioperative period should also examine this possible beneficial effect. The au- thors did not discuss this important perioperative event and the likely benefit of local anesthetics. Dominic Harmon, MMedSci, FCARCSI Wei Lan, MB Department of Anaesthesia and Intensive Care Medicine Cork University Hospital Cork, Ireland References 1. Hahnenkamp K, Theilmeier G, Van Aken HK, et al. The effects of local anesthetics on perioperative coagulation, inflammation, and microcirculation. Anesth Analg 2002;94: 1441–7. 2. Barry MC, Wang JH, Redmond HP, et al. Plasma factors augment neutrophil and endothelial activation during aortic surgery. Eur J Vasc Endovasc Surg 1997;13:381–7. 3. Hearse DJ, Bolli R. Reperfusion induced injury: manifestations, mechanisms, and clinical relevance. Cardiovasc Res 1992;26:101– 8. 4. Wakai A, Wang JH, Winter DC, et al. Tourniquet-induced systemic inflammatory response in extremity surgery. J Trauma 2001;51:922– 6. 5. Edel D, Lipfert P, Preckel B, et al. Lidocaine reduces ischaemic but not reperfusion injury in isolated rat heart. Br J Anesth 2001;86:846 –52. 6. Tomori H, Shiraishi M, Koga H, et al. Protective effects of lidocaine in hepatic ischemia/reperfusion injury in vitro. Transplant Proc 1998;30:3740 –2. 7. Hollmann MW, Durieux ME. Local anesthetics and the inflammatory response: a new therapeutic indication. Anesthesiology 2000;93:858 –75. 8. Kang MY, Tsuchiya M, Packer L, et al. In vitro study on antioxidant potential of various drugs used in the perioperative period. Acta Anaesthesiol Scand 1998;42:4 –12. DOI: 10.1213/01.ANE.0000039465.58263.CD In Response: We thank Drs. Harmon and Lan for their interest in our review and for their thoughts concerning the effects of local anesthetics besides their ability to block Na + channels. We had to restrict our manu- script on local anesthetic effects on perioperative coagulation, in- flammation, and microcirculation (1) because of the restricted infor- mation and therefore were not able to cover influences of local anesthetic on all perioperative aspects. We agree completely that the role of local anesthetics in ische- mia reperfusion is unclear and has not yet been elucidated in detail. Some studies report local anesthetic effects on myocardial infarction and reperfusion of the ischemic heart. Although the discussion is still controversial (2), experiments of myocardial ischemia in a porcine (3) and a dog model (4) have shown that lidocaine preserved the ischemic myocardium and was able to reduce infarct size. This effect may be a result of antiinflamma- tory effects of lidocaine in areas of myocardial infarction or stunned myocardium. We thank Drs. Harmon and Lan for their most interesting comment on our review and fully support their view that these effects of systemic local anesthetics on perioperative ischemia reperfusion should be studied in more detail, especially as local anesthetics are probably the most commonly used compounds in anesthesia. They are safe, have an infrequent rate of side effects, and are easy to use. K. Hahnenkamp C. W. Hoenemann Department of Anaesthesiology and Intensive Care University Hospital Muenster Mu ¨ nster, Germany References 1. Hahnenkamp K, Theilmeier G, Van Aken HK, Hoenemann CW. The effects of local anesthetics on perioperative coagulation, inflammation, and microcirculation. Anesth Analg 2002;94:1441–7. 2. de Lorgeril M, Rousseau G, Basmadjian A, Latour JG. Lignocaine in experimental myocardial infarction: failure to prevent neutrophil accumulation and ventricular fibrillation and to reduce infarct size. Cardiovasc Res 1988;22:439 – 46. 3. Lee R, Nitta T, Schmid RA, et al. Retrograde infusion of lidocaine or l-arginine before reperfusion reduces myocardial infarct size. Ann Thorac Surg 1998;65:1353–9. 4. Lesnefsky EJ, VanBenthuysen KM, McMurtry IF, et al. Lidocaine reduces canine infarct size and decreases release of a lipid peroxidation product. J Cardiovasc Pharmacol 1989;13:859 –901. A Misleading Conclusion and Abstract To the Editor: I was concerned to read the discrepancy between the actual results obtained and the conclusion reached by Kopacz et al. (1) in their paper published in your journal. In their Results section, the authors reported, “There were no differences in plasma concentrations of local anesthetic in patients who received plain levobupivacaine compared with patients in the epinephrine-containing groups. . ..” In accordance, they stated that “statistical significance was not reached for any of these measures” at the beginning of their Dis- cussion. However, they then proceeded to conclude, “The addition of epinephrine decreases plasma local anesthetic levels . . ..” My greatest concern is the statement in their Abstract that “peak serum levobupivacaine levels were reduced. . ..” As many readers, espe- cially those searching for information on Medline, read only the abstracts, may I suggest that the authors should perhaps issue an erratum to the conclusion that they actually reported in the Abstract to read: “Peak serum levobupivacaine levels were not significantly reduced. . ..” to concur with the findings in their Results. Bee Beng Lee, FANZCA, FHKCA, FHKAM Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital Shatin Hong Kong, China Dr. Kopacz does not wish to respond. Reference 1. Kopacz DJ, Helman JD, Nussbaum CE, et al. A comparison of epidural levobupiva- caine 0.5% with or without epinephrine for lumbar spine surgery. Anesth Analg 2001;93:755– 60. DOI: 10.1213/01.ANE.0000039469.58263.F2 Combined Spinal and Epidural Anesthesia for Cesarean Section in a Patient with Hypertrophic Obstructive Cardiomyopathy To the Editor: The administration of general anesthesia has been recommended in the management of anesthesia for cesarean section in patients with hypertrophic obstructive cardiomyopathy (HOCM) (1). We present, to our knowledge, the first case of combined spinal and epidural anesthesia for cesarean section in a patient with HOCM. A 35-yr-old primigravida with HOCM underwent elective ce- sarean section at 32 weeks’ gestation. The patient was monitored with the use of radial and pulmonary artery catheters. Spinal ANESTH ANALG LETTERS TO THE EDITOR 629 2003;96:626 –33