26 A Method for Continuous Blood Sampling During Flotation REST John Turner, Jr., Harmony Shroeder and Thomas Fine Flotation Restricted Environmental Stimulation Therapy (flotation REST) is a deep relaxation modality in which an individual lies supinely in a thermoneutral buoyant fluid with minimal photic, auditory and tactile stimulation (Lilly, 1977). Blood levels of several hormones, including aldosterone, renin activity, ACTH, LH, and cortisol, have been measured in association with flotation REST (henceforth, REST) and significant changes in the levels of several of these hormones have been reported (Turner & Fine 1983, 1991; Turner et al, 1989; MoGrady et al, 1987). Thes icross-session changes in plasma levels of hormones. Although pre- to post-session decreases in plasma cortisol have been observed (Turner & Fine, 1983) in sessions as brief as 35 minutes, the characteristics and Patterns of hormonal change during a REST session are unknown, One of the difficulties faced in considering blood sampling during 4 REST session is the possible disruption of the REST experience in objaining in-scssion samples. In the present repeated-measures study, technique is demonstrated which uses an intravenous fine t0 permit studies have examined pre- to post-session and262 John Turner, Jr. et al continuous blood sampling during the REST experience. Subject condition during REST was assessed via rating of physical and mental comfort and measurement of plasma corti Method Subjects Subjects were four healthy male medical student volunteers aged 22-30. ‘The study was performed during summer vacation, and no major stresses were reported, Each subject experienced six sessions, 60 minutes each, Session 1 was baseline blood sampling in a Non-RES! (waterbed) environment. The session consisted of reclining on waterbed in a warm (85°F), dimly lit room. Sessions 2-5 were RES! without blood sampling, and in the first three of these sessions th. subject floated with the intravenous (i.v.) setup attached (no needle) Session 6 was continuous sampling in the REST environment. Procedure All blood sampling was done between 1100 and 1600 in consideration of diurnal cortisol release patterns (Weitzman et al., 1971), Samples were taken via intravenous catheter using a 20 ga., 2.8 cm needle (Gelco Corp.) placed in the dorsal vein of the lower forewrnt All ix, operations were performed by a trained phlebotomist with extensive iv. experience. The line was inserted into the forearm alte the subject was in the REST chamber and extended his arm outsis through a portal (see Figure 26-1). After iv. placement, the subjevt drew his hand inside the chamber and rested it on a plastic foam slat» 16x 16 x 2.cm,, which provided buoyancy to keep the iv. site out of th fluid. 26. Continuous Blood Sampling 263 Figure 26-1. Diagram of subject in REST with intravenous monitoring system: a) subject with arm through portal 0 receive iv. line, b) subject and i.v. system as it appears during collection. Using a peristaltic pump, 70-90 ml of blood was withdrawn at a rate of 1.4 ml/minutes for 40-60 minutes. The blood was collected into heparinized tubes in 3 ml fractions. Silastic® tubing (16 ga.) was used throughout the collection system (see Figure 26-2), Total tubing length of the system from i.v. site to fraction tube was 1.9 m. Clotting within the system was prevented by continuous infusion of 51 mg heparin per minute in isotonic saline. The heparin line was inserted into the iv. tubing approximately 1.0 cm distal to the iv. site. Blood sample fractions were centrifuged at 3000 X ¢, for 20 minutes and plasma was decanted and frozen until assayed for cortisol. Plasma cortisol levels were determined by RIA kit (ICN Biomedical, Inc., Carson, California)264 John Turner, Jr. et al y ti Figure 26-2. Diagram of continous blood collection system. Each subject filled out a mental-physical comfort rating sci immediately after each session. Comfort was rated on a scale of 0 to It! with 10 being consistent comfort and 0 being consistent discomfort. subjects also gave a subjective report of each session's experience Results Difficulties in blood collection were encountered initially due to clottin: of blood in the iv. system proximal to the heparin infusion site, an collection was not possible beyond 25 minutes. By soaking the hut sx needle in heparin solution (100 mg/ml) and drying off the outside 0 the barrel prior to insertion, this problem was corrected. All samplivs periods were at least 40 minutes, aad four were 60 minutes. There wer no differences in ratings of mental or physical comfort among. tH sessions (see Table 26-1) 26, Continuous Blood Sampling 265 Table 26-1 Condition Mental Comfort® Physical Comfort* —— Non-REST 1S 212 19 +08 with Blood Sampling? REST with 83211 88205 Mock Blood Sampling’ REST alone 85206 9.0 + 10 REST with 82206 87409 Blood Sampling Comfort is rated on a scale of 010 10, with 10 being eonsisent comfort and @ being consistent discomfort (n=4). Consisted of reclining on a waterbed in 2 warm (85° F.), dimly lit room. Consisted of sampling procedure and paraphernalia without venipuneture, ‘was no infection and no unusual bruising, swelling or tissue discoloration associated with the iv. use, and no clotting failure was observed. Subjective reports regarding the REST experience were Consistently positive, despite one subject’s expression of anxiety about being in REST, prior to the initial experience. Three subjects stated that they had no reservations about having an iv. line. One subject Expressed mild concern, All subjects said that they felt much more Comfortable knowing that an experienced phlebotomist was doing the by. work266 John Turner, Jr. etal Plasma cortisol levels varied across fractions, and patterns varied among subjects. No consistent chanige was observed within given session, and there were no consistent differences between patterns in Session 1 and Sessions 6, although the average levels of cortisol were higher in Session 1 than in Session 6. Representattive cortisol data are shown in Figure 26-3. Sonate REST route wee | / (E&e Figure 26-3. Plasma cortisol levels during a REST session and a Now REST (waterbed) session: a) data from a singe subject (DD. data averaged for all subjects 26. Continuoos Blood Sampling 267 Discussion The results of this study demonstrate that blood may be collected continuously from subjects for up to 60 minutes during a REST ‘experience, Heparinization of the iv. needle and hub and continuous heparin infusion into the iv. line distal 40 the iv. placement site are necessary in this procedure to prevent clotting, On the basis of the rating scales and subjective reports it appears that continuous blood withdrawal does not alter the subjects’ perception of the REST experience. The cortisol data appear to be consistent with the subjective-rating data. Previous studies have shown that repeated, brief REST is deeply relaxing (A. Barabasz, M. Barabasz, Dyer & Rather, 1990; Turner & Fine, 1983; Suedfeld, Ballard, & Murphy, 1983) and is associated with decreased plasma cortisol (Turner & Fine, 1983, 1991; Turner et al., 1989). Since cortisol levels in the present study were lower in Session 6 than in baseline Session 1, it appears that in terms of the overall study, the presence of the iv. line did not compromise the relaxation-REST cesponse. On the other hand, the pre- to post- cortisol decrease (approximately 20%) in REST reported elsewhere (Turner & Fine, 1983) was not consistently observed in the present study. Two of the subjects showed a small decrease (<12%) in cortisol Goring the monitored REST session, while one other subject showed no change and the fourth showed a slight increase, The reason for this discrepancy is unknown. It may reflect a less relaxing experience in Session 6 associated with the presence of the iw. line. This is, however, not consistent with the rating and report data. One possible explanation may be found in comparing the starting values in the two studies. The subjects in the present study showed beginning cortisol levels which averaged 40% lower than the starting values of the previous study and were even lower than the post session values of that study. ‘Thus, it is possible that the cortisol values in the present study were already near minimum by Session 6 and could not decfine further. The results of this study are valuable and encouraging in providing a hitherto unavailable opportunity for continuous monitoring of blood- born substinces dutuy, the REST experience