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1 Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Surgery, University of Toronto, Toronto, Ontario, Canada
2 Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
3 Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada
4 Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada
* To whom correspondence should be addressed. E-mail: pang{at}sickkids.ca.
The aim of this project was to investigate the efficacy and mechanism of action of a non-invasive remote ischemic preconditioning (IPC) technique for protection of multiple distant skeletal muscles against ischemic necrosis (infarction). It was observed in the pig that three cycles of 10 min occlusion and reperfusion in a hind-limb by tourniquet application reduced the infarction of latissimus dorsi (LD), gracilis (GC) and rectus abdominus (RA) muscle flaps by 55%, 60% and 55%, respectively, compared with their corresponding control (n=6, P < 0.01) when they were subsequently subjected to 4h of ischemia and 48h of reperfusion. This infarct protective effect of remote IPC in LD muscle flaps was abolished by an intravenous bolus injection of the non-selective opioid receptor antagonist naloxone (3 mg/kg) 10 min before remote IPC and a continuous intravenous infusion (3 mg/kg) during remote IPC and by an intravenous bolus injection of the selective 
1 opioid receptor antagonist 7-
benzylidenealtrexone maleate (3 mg/kg). However, this infarct protective effect of remote IPC was not affected by an intravenous bolus injection of the ganglionic blocker hexamethonium chloride (20 mg/kg), the non-specific adenosine receptor antagonist 8-(p-sulfophenyl) theophylline (10 mg/kg), or local intra-arterial injection of the adenosine1 receptor antagonist 8-cyclopentyl-1, 3-dipropylxanthine (3 mg/muscle flap) given 10 min before remote IPC. It was also observed that this remote IPC of skeletal muscle against infarction was associated with a slower rate of muscle ATP depletion during the 4h of sustained ischemia and a reduced muscle neutrophilic myeloperoxidase activity after 1.5h of reperfusion. These observations led us to speculate that non-invasive remote IPC by brief cycles of occlusion and reperfusion in a pig hind-limb is effective in global protection of skeletal muscle against infarction. This infarct protective effect is most likely triggered by the activation of opioid receptors in the skeletal muscle and remote IPC is associated with an energy sparing effect during sustained ischemia and attenuation of neutrophil accumulation during reperfusion.
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