Potency of mixtures of general anaesthetic agents

Binding site location on GABAA receptors determines whether mixtures of intravenous general anaesthetics interact synergistically or additively in vivo

BACKGROUND AND PURPOSE

General anaesthetics can act on synaptic GABA_A receptors by binding to one of three classes of general anaesthetic sites. Canonical drugs that bind selectively to only one class of site are etomidate, alphaxalone, and the mephobarbital derivative, R-mTFD-MPAB. We tested the hypothesis that the general anaesthetic potencies of mixtures of such site-selective agents binding to the same or to different sites would combine additively or synergistically respectively.

EXPERIMENTAL APPROACH

The potency of general anaesthetics individually or in combinations to cause loss of righting reflexes in tadpoles was determined, and the results were analysed using isobolographic methods.

KEY RESULTS

The potencies of combinations of two or three site-selective anaesthetics that all acted on a single class of site were strictly additive, regardless of which single site was involved. Combinations of two or three site-selective anaesthetics that all bound selectively to different sites always interacted synergistically. The strength of the synergy increased with the number of separate sites involved such that the percentage of each agent's EC₅₀ required to cause anaesthesia was just 35% and 14% for two or three sites respectively. Propofol, which binds non-selectively to the etomidate and R-mTFD-MPAB sites, interacted synergistically with each of these agents.

CONCLUSIONS AND IMPLICATIONS

The established pharmacology of the three anaesthetic binding sites on synaptic GABA_A receptors was sufficient to predict whether a mixture of anaesthetics interacted additively or synergistically to cause loss of righting reflexes in vivo. The principles established here have implications for clinical practice.

How has molecular pharmacology contributed to our understanding of the mechanism(s) of general anesthesia?

This review discusses the mechanism(s) of general anesthesia from a pharmacological viewpoint; in particular, the ability of drugs to produce many different effects is emphasised. The problems of experimental measurement of general anesthesia are discussed, and the possibilities for antagonism and potentiation of anesthesia considered. Physicochemical studies on anesthesia are described, as are the advancement of ideas beyond consideration of lipids and proteins as separate sites of action. The importance of studies on different areas of the brain is highlighted, and the review finishes with a survey of the effects of general anesthetics on synaptic transmission which emphasises the problems of extrapolation from in vitro to in vivo.

Evaluation of three transportable multigas anesthetic monitors: the Bruel & Kjaer Anesthetic Gas Monitor 1304, the Datex Capnomac Ultima, and the Nellcor N-2500

We compared the performance of three newly developed anesthetic agent (AA) monitors: the Bruel & Kjaer Anesthetic Agent Monitor 1304 (BK 1304), the Datex Capnomac Ultima (ULTIMA), and the Nellcor N-2500 (N-2500). The following were investigated: the linearity and accuracy in measuring AAs, oxygen, carbon dioxide, and nitrous oxide; the linearity and accuracy during warm-up time; the effect of increasing respiratory rate on the accuracy; the consequences of a difference between monitored and delivered AA and of delivering a mixture of AAs; and, finally, the effect of water vapor and alcohol. For all three monitors we found that the accuracy in determining the respiratory and anesthetic gases was sufficient for clinical use (the N-2500 does not measure oxygen). Because of the calibration mixture supplied with the device, however, the ULTIMA recorded values that were 10 to 12% (relative) less than the AA that was present. The BK 1304 had greater accuracy at higher respiratory rates than did the other two monitors, probably favoring its use in pediatric anesthesia. The N-2500 will detect which agent (isoflurane, enflurane, or halothane) is being used, alone or in a mixture. With the two other monitors the user must define which agent is given. In some situations a difference between this and the one actually delivered can theoretically lead to an overdose of AA, with the ULTIMA up to a 14.9 minimal alveolar concentration (MAC) overdose. No interference from alcohol or water vapor in the expired air was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Gas physical properties and respiratory system resistance measured by flow interruption

If the flow of gas at the airway opening of a tracheostomized dog is suddenly interrupted during expiration, the airway pressure exhibits a sudden very rapid rise, called delta Pinit, which has been shown previously to equal the resistive pressure drop across the airways in open-chest dogs, and to have a significant additional contribution from the tissues of the chest wall in intact dogs. In the present study we attempted to separate the contributions of airways and tissues to delta Pinit in intact dogs by performing flow interruptions with the lungs full of gas mixtures having different physical properties. A Moody plot (the Friction coefficient calculated using delta Pinit versus the Reynolds number) had a marked negative slope at Reynolds numbers up to 5 x 10(4), whereas the plot is predicted to have a slope close to zero at Reynolds numbers greater than 4 x 10(3) on the basis of purely fluid dynamic considerations. Assuming delta Pinit to be the result of a linear dependence of airway resistance on flow and a constant tissue resistance, we were able to account for the negative slope of the Moody plot. We also found that the values of airway and tissue resistances estimated from the data were very close to those estimated by more direct means in a previous study of delta Pinit. We conclude that it is possible to discern the separate effects of airway and tissue resistances in delta Pinit at high Reynolds numbers.

Additive and non-additive effects of mixtures of short-acting intravenous anaesthetic agents and their significance for theories of anaesthesia

1 The potency of a series of short-acting anaesthetics was established by measuring the duration of the loss of righting reflex following a single bolus injection into the tail vein of male Wistar rats. The agents were, in order of potency, etomidate, alphaxalone, methohexitone, alphadalone acetate and propanidid.2 The potency of binary mixtures of these agents was also assessed to see whether the anaesthetic effects of different agents were additive as classical theories of anaesthesia suggest. Mixtures of alphaxalone and alphadalone acetate, alphaxalone and propanidid and methohexitone and propanidid all showed simple additive effects. Mixtures of alphaxalone and etomidate and of alphaxalone and methohexitone showed a greater potency than would be expected if their effects were simply additive. Mixtures of etomidate and methohexitone were not examined.3 Mixtures of alphaxalone and either methohexitone or pentobarbitone produced a greater depression of synaptic transmission in in vitro preparations of guinea-pig olfactory cortex than would have been expected from the sum of the activities of the individual anaesthetics. Other combinations of anaesthetics did not show similar effects although the interaction between alphaxalone and etomidate was not examined.4 Neither alphaxalone nor pentobarbitone affected the membrane: buffer partition coefficient of the other for a model membrane system.5 These results are interpreted as evidence against the classical unitary hypotheses of anaesthetic action based on correlations of anaesthetic potency with lipid solubility and as supporting the view that different anaesthetics act on different structures in the neuronal membranes to produce anaesthesia.