The EEG, evoked potentials, and single-unit activity during ketamine anesthesia in cats

Gamma-burst cortical activity in awake behaving macaques

Electrophysiological recordings during ketamine anesthesia have revealed a slow alternating pattern of high- and low-frequency activity (a "gamma-burst" pattern) that develops along with the onset of general anesthesia. We examine the role of NMDA receptor antagonism in generating the gamma-burst pattern and the link between gamma-bursts and dissociative anesthesia by comparing the effects of ketamine with those of the highly selective NMDA receptor antagonist CGS 19755 on multi-site intracranial electrophysiology and behavior in rhesus macaques. The data show NMDA antagonism alone drives gamma-burst activity, and that it can do so without causing anesthesia. This supports the expanding consensus that ketamine's anesthetic properties are mediated by mechanisms other than NMDA receptor inhibition.

Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial

BACKGROUND

The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy.

OBJECTIVES

The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery.

METHODS

Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events.

RESULTS

Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively.

CONCLUSIONS

Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Ketamine: Pro or antiepileptic agent? A systematic review

Purpose

of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice.

Recent findings

Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent.

Summary

Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.

Investigation of the effect and availability of ketamine on electroencephalography in cats with temporal lobe epilepsy

In recent years, electroencephalography (EEG) in veterinary medicine has become important not only in the diagnosis of epilepsy, but also in determining the epileptogenic focus. In cats, sedation and immobilization, usually with medetomidine or dexmedetomidine, are necessary to place the electrodes and to obtain stable scalp EEG recordings. In this study, we hypothesized that, for cats with temporal lobe epilepsy (TLE), ketamine, a sedative/anesthetic and N-methyl-D-aspartate (NMDA) antagonist that activates the limbic system and is also used to treat refractory status epilepticus in dogs, would induce sufficient sedation and immobilization for EEG, as well as induce interictal epileptiform discharges (IEDs) that are more pronounced than those induced with medetomidine. We obtained EEG recordings from TLE cats and healthy cats administered either ketamine or medetomidine alone (study 1) or ketamine after medetomidine sedation (study 2). In study 1, the frequency of IEDs showed no statistically significant difference between ketamine and medetomidine in both TLE and healthy cats. Seizures were observed in 75% (9/12) cats of the TLE group with ketamine alone. When ketamine was administered after sedation with medetomidine (study 2), 3/18 cats in the TLE group developed generalized tonic-clonic seizure and 1/18 cats showed subclinical seizure activity. However, no seizures were observed in all healthy cats in both study 1 and study 2. Slow wave activity at 2-4 Hz was observed in many individuals after ketamine administration regardless studies and groups, and quantitative analysis in study 2 showed a trend toward increased delta band activities in both groups. While there was no significant difference in the count of IEDs between medetomidine and ketamine, ketamine caused seizures in cats with TLE similar to their habitual seizure type and with a higher seizure frequency. Our results suggest that ketamine may activate epileptiform discharges during EEG recordings. However, caution should be used for cats with TLE.

Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children

Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.

Asleep DBS under ketamine sedation: Proof of concept

BACKGROUND

Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring.

OBJECTIVE

This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients.

METHODS

Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA).

RESULTS

All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing.

CONCLUSIONS

This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.

Comparison of anaesthetic- and seizure-induced states of unconsciousness: a narrative review

In order to understand general anaesthesia and certain seizures, a fundamental understanding of the neurobiology of unconsciousness is needed. This review article explores similarities in neuronal and network changes during general anaesthesia and seizure-induced unconsciousness. Both seizures and anaesthetics cause disruption in similar anatomical structures that presumably lead to impaired consciousness. Despite differences in behaviour and mechanisms, both of these conditions are associated with disruption of the functionality of subcortical structures that mediate neuronal activity in the frontoparietal cortex. These areas are all likely to be involved in maintaining normal consciousness. An assessment of the similarities in the brain network disruptions with certain seizures and general anaesthesia might provide fresh insights into the mechanisms of the alterations of consciousness seen in these particular unconscious states, allowing for innovative therapies for seizures and the development of anaesthetic approaches targeting specific networks.

The changes of cerebral hemodynamics during ketamine induced anesthesia in a rat model

Current electroencephalogram (EEG) based-consciousness monitoring technique is vulnerable to specific clinical conditions (eg, epilepsy and dementia). However, hemodynamics is the most fundamental and well-preserved parameter to evaluate, even under severe clinical situations. In this study, we applied near-infrared spectroscopy (NIRS) system to monitor hemodynamic change during ketamine-induced anesthesia to find its correlation with the level of consciousness. Oxy-hemoglobin (OHb) and deoxy-hemoglobin concentration levels were continuously acquired throughout the experiment, and the reflectance ratio between 730 and 850 nm was calculated to quantify the hemodynamic changes. The results showed double peaks of OHb concentration change during ketamine anesthesia, which seems to be closely related to the consciousness state of the rat. This finding suggests the possibility of NIRS based-hemodynamic monitoring as a supplementary parameter for consciousness monitoring, compensating drawbacks of EEG signal based monitoring.

Electroencephalogram signatures of ketamine anesthesia-induced unconsciousness

OBJECTIVES

Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist commonly administered as a general anesthetic. However, neural circuit mechanisms to explain ketamine anesthesia-induced unconsciousness in humans are yet to be clearly defined. Disruption of frontal-parietal network connectivity has been proposed as a mechanism to explain this brain state. However, this mechanism was recently demonstrated at subanesthetic doses of ketamine in awake-patients. Therefore, we investigated whether there is an electroencephalogram (EEG) signature specific for ketamine anesthesia-induced unconsciousness.

METHODS

We retrospectively studied the EEG in 12 patients who received ketamine for the induction of general anesthesia. We analyzed the EEG dynamics using power spectral and coherence methods.

RESULTS

Following the administration of a bolus dose of ketamine to induce unconsciousness, we observed a "gamma burst" EEG pattern that consisted of alternating slow-delta (0.1-4Hz) and gamma (∼27-40Hz) oscillations. This pattern was also associated with increased theta oscillations (∼4-8Hz) and decreased alpha/beta oscillations (∼10-24Hz).

CONCLUSIONS

Ketamine anesthesia-induced unconsciousness is associated with a gamma burst EEG pattern.

SIGNIFICANCE

The EEG signature of ketamine anesthesia-induced unconsciousness may offer new insights into NMDA circuit mechanisms for unconsciousness.

Supply-demand mismatch transients in susceptible peri-infarct hot zones explain the origins of spreading injury depolarizations

Peri-infarct depolarizations (PIDs) are seemingly spontaneous spreading depression-like waves that negatively impact tissue outcome in both experimental and human stroke. Factors triggering PIDs are unknown. Here, we show that somatosensory activation of peri-infarct cortex triggers PIDs when the activated cortex is within a critical range of ischemia. We show that the mechanism involves increased oxygen utilization within the activated cortex, worsening the supply-demand mismatch. We support the concept by clinical data showing that mismatch predisposes stroke patients to PIDs as well. Conversely, transient worsening of mismatch by episodic hypoxemia or hypotension also reproducibly triggers PIDs. Therefore, PIDs are triggered upon supply-demand mismatch transients in metastable peri-infarct hot zones due to increased demand or reduced supply. Based on the data, we propose that minimizing sensory stimulation and hypoxic or hypotensive transients in stroke and brain injury would reduce PID incidence and their adverse impact on outcome.

VIDEO ABSTRACT

Magnetoencephalography of epilepsy with a microfabricated atomic magnetrode

Magnetoencephalography has long held the promise of providing a noninvasive tool for localizing epileptic seizures in humans because of its high spatial resolution compared with the scalp EEG. Yet, this promise has been elusive, not because of a lack of sensitivity or spatial resolution but because the large size and immobility of present cryogenic (superconducting) technology prevent long-term telemetry required to capture these very infrequent epileptiform events. To circumvent this limitation, we used Micro-Electro-Mechanical Systems technology to construct a noncryogenic (room temperature) microfabricated atomic magnetometer ("magnetrode") based on laser spectroscopy of rubidium vapor and similar in size and flexibility to scalp EEG electrodes. We tested the magnetrode by measuring the magnetic signature of epileptiform discharges in a rat model of epilepsy. We were able to measure neuronal currents of single epileptic discharges and more subtle spontaneous brain activity with a high signal-to-noise ratio approaching that of present superconducting sensors. These measurements are a promising step toward the goal of high-resolution noninvasive telemetry of epileptic events in humans with seizure disorders.

Treatment of status epilepticus with ketamine, are we there yet?

Status epilepticus (SE), a neurological emergency both in adults and in children, could lead to brain damage and even death if untreated. Generalized convulsive SE (GCSE) is the most common and severe form, an example of which is that induced by organophosphorus nerve agents. First- and second-line pharmacotherapies are relatively consensual, but if seizures are still not controlled, there is currently no definitive data to guide the optimal choice of therapy. The medical community seems largely reluctant to use ketamine, a noncompetitive antagonist of the N-methyl-d-aspartate glutamate receptor. However, a review of the literature clearly shows that ketamine possesses, in preclinical studies, antiepileptic properties and provides neuroprotection. Clinical evidences are scarcer and more difficult to analyze, owing to a use in situations of polytherapy. In absence of existing or planned randomized clinical trials, the medical community should make up its mind from well-conducted preclinical studies performed on appropriate models. Although potentially active, ketamine has no real place for the treatment of isolated seizures, better accepted drugs being used. Its best usage should be during GCSE, but not waiting for SE to become totally refractory. Concerns about possible developmental neurotoxicity might limit its pediatric use for refractory SE.

The effect of ketamine on nerve conduction in isolated sciatic nerves of the toad

The actions of 100-2500 mug ketamine hydrochloride per ml Ringer solution were examined on the various components of the compound nerve volley of isolated sciatic-tibial nerves of toads. The smaller diameter fibres were blocked first and fibres of progressively larger diameter were blocked with increasing ketamine concentration. A progressive reducton in conduction velocities and amplitude, as well as increasing thresholds, accompanied increased drug contact and concentration. A preliminary trial on human volunteers revealed an apparent loss of pain and thermal sensations following subcutaneous injection.

The NMDA receptor complex as a therapeutic target in epilepsy: a review

A substantial amount of research has shown that N-methyl-D-aspartate receptors (NMDARs) may play a key role in the pathophysiology of several neurological diseases, including epilepsy. Animal models of epilepsy and clinical studies demonstrate that NMDAR activity and expression can be altered in association with epilepsy and particularly in some specific seizure types. NMDAR antagonists have been shown to have antiepileptic effects in both clinical and preclinical studies. There is some evidence that conventional antiepileptic drugs may also affect NMDAR function. In this review, we describe the evidence for the involvement of NMDARs in the pathophysiology of epilepsy and provide an overview of NMDAR antagonists that have been investigated in clinical trials and animal models of epilepsy.

A Comparison of Sleeplike Slow Oscillations in the Hippocampus Under Ketamine and Urethane Anesthesia

During sleep and anesthesia, a slow (≤1 Hz) synchronized rhythmic fluctuation of the network activity in the neocortex (nCTX) is prominent. This rhythm, called the slow oscillation (SO), corresponds to sequences of neuronal activity and inactivity (UP and DOWN states) in local and extended networks. Recently, this network pattern has also been described in the hippocampus (HPC) and, interestingly, it shows a dynamic correlation with ongoing SO in the nCTX. However, because of its transient nature during both sleep and urethane anesthesia, studying the SO in the HPC is difficult. Ketamine anesthesia is known to induce a uniform and continuous SO state in the nCTX, but its effects on HPC activity and HPC–nCTX interplay are unknown. Using multisite local field potential recordings, we investigated the effects of ketamine anesthesia on HPC activity and its relation to concurrent nCTX activity. We directly compared the spectral content and spatial distribution of laminar potentials and current source density (CSD) under ketamine to urethane anesthesia. Ketamine evoked stable bouts of SO in the HPC that had a peak frequency of 1.77 ± 0.08 Hz, slightly higher than that of urethane: 1.17 ± 0.07 Hz. Laminar voltage and CSD profiles of SO were highly correlated across ketamine and urethane anesthesia, although a higher degree of HPC–nCTX coherence at SO frequencies appeared under ketamine as opposed to urethane. In addition, activity in the gamma bandwidth (30–40 Hz) made up 4.7% of the power spectrum under ketamine, but accounted for only 2.0% of the power spectrum in urethane. Although some differences exist, the SO under ketamine anesthesia appears highly similar to that under urethane.

Fast propagating waves within the rodent auditory cortex

Central processing of acoustic signals is assumed to take place in a stereotypical spatial and temporal pattern involving different fields of auditory cortex. So far, cortical propagating waves representing such patterns have mainly been demonstrated by optical imaging, repeatedly in the visual and somatosensory cortex. In this study, the surface of rat auditory cortex was mapped by recording local field potentials (LFPs) in response to a broadband acoustic stimulus. From the peak amplitudes of LFPs, cortical activation maps were constructed over 4 cortical auditory fields. Whereas response onset had same latencies across primary auditory field (A1), anterior auditory field (AAF), and ventral auditory field and longer latencies in posterior auditory field, activation maps revealed a reproducible wavelike pattern of activity propagating for ∼45 ms poststimulus through all cortical fields. The movement observed started with 2 waves within the primary auditory fields A1 and AAF moving from ventral to dorsal followed by a motion from rostral to caudal, passing continuously through higher-order fields. The pattern of propagating waves was well reproducible and showed only minor changes if different anesthetics were used. The results question the classical "hierarchical" model of cortical areas and demonstrate that the different fields process incoming information as a functional unit.

[Anesthesia for procedures other than neurosurgery in the adult with epilepsy]

Epilepsy is a common disease affecting between 1% and 2% of the general population. The incidence increases with age. Given the complicated etiology and pathogenesis of this disease, epileptic patients of all ages may require anesthesia. The perioperative care of these patients involves a number of special considerations, although the main issues to deal with are pharmacologic. This review gives an overview of the etiopathogenesis and pathophysiology of epilepsy and describes the general characteristics of antiepileptic drug therapy. The anesthetic implications of chronic treatment with antiepileptic agents and the interactions between these drugs and common anesthetics are discussed in more detail.

Clinical and EEG phenotypes of epilepsy in the baboon (Papio hamadryas spp.)

Spontaneous seizures have been reported in several baboon subspecies housed at the Southwest Foundation for Biomedical Research (SFBR), including Papio hamadryas anubis as well as cynocephalus/anubis and other hybrids. This study classified clinical and electroencephalographic (EEG) phenotypes in these subspecies based upon interictal and ictal findings, as well as photosensitivity, by scalp EEG. One hundred baboons underwent 1-h EEG studies with photic stimulation (PS), 49 with previously witnessed seizures and 51 without. The animals were classified according to these electroclinical phenotypes: presence or absence of interictal epileptic discharges (IEDs), seizures and photoparoxysmal or photoconvulsive responses. Effects of age, gender, and species on EEG phenotypes were also examined. Six discrete electroclinical phenotypes were identified. Generalized IEDs of 2-3, 4-6, and/or 6-7Hz were identified in 67 baboons. Epileptic seizures were recorded in 40 animals, including myoclonic and generalized tonic-clonic seizures. Thirty-three animals were photosensitive. Although the prevalence of IEDs and seizures were similar in seizure and asymptomatic animals, photosensitivity was more prevalent in the seizure animals (p=0.001). P.h. anubis/cynocephalus hybrids were more likely to be photosensitive than P.h. anubis (p=0.004). The reliable characterization of distinct epileptic phenotypes in this pedigreed colony is critical to the success of future genetic analyses to identify genetic factors underlying their epilepsy.

Spatiotemporal effects of microstimulation in rat neocortex: a parametric study using multielectrode recordings

Using microstimulation to imprint meaningful activity patterns into intrinsically highly interconnected neuronal substrates is hampered by activation of fibers of passage leading to a spatiotemporal "blur" of activity. The focus of the present study was to characterize the shape of this blur in the neocortex to arrive at an estimate of the resolution with which signals can be transmitted by multielectrode stimulation. The horizontal spread of significant unit activity evoked by near-threshold focal electrical stimulation (charge transfer 0.8-4.8 nC) and multielectrode recording in the face representation of the primary somatosensory cortex of ketamine anesthetized rats was determined to be about 1,350 microm. The evoked activity inside this range consisted in a sequence of fast excitatory response followed by an inhibition lasting >100 ms. These 2 responses could not be separated by varying the intensity of stimulation while a slow excitatory rebound after the inhibitory response was restricted to higher stimulus intensities (>2.4 nC). Stimulation frequencies of 20 and 40 Hz evoked repetitive excitatory response standing out against a continuous background of inhibition. At 5- and 10-Hz stimulation, the inhibitory response showed a complex interaction pattern attributed to highly sublinear superposition of individual inhibitory responses. The present data help to elucidate the neuronal underpinnings of behavioral effects of microstimulation. Furthermore, they provide essential information to determine spatiotemporal constraints for purposeful multielectrode stimulation in the neocortex.

High-dose ketamine hydrochloride maintains somatosensory and magnetic motor evoked potentials in primates

Monitoring the descending neural motor volleys (MEPs), in comparison to muscle action potentials, allows sensitive motor assessment under anesthesia irrespective of the use of muscular blockade and status of skeletal musculature. Ketamine hydrochloride (KH) had preserved muscle MEPs on a pre-established primate model. The present work examines the effect of incremental hypnotic KH dosages thoracic neural on somatosensory (SEP) and MEPs recorded epidurally in response to transcranial magnetic stimulation (TMS). Through a small thoracic T11-T12 laminotomy, an insulated double bipolar electrode was inserted epidurally and cephalad in seven cynomolgus monkeys. Thoracic spinal TMS-MEPs, and SEPs, were tested against graded increase of KH doses (0.01, 0.018, 0.032, 0.056, 0.1, and 0.18 mg kg(-1) min(-1) i.v. infusion). The direct (D-) and indirect (I-) epidural MEP peaks were well-defined under sole KH infusion. The waveforms were consistent at various dosages. At the highest cumulative dose (0.18 mg kg(-1) min(-1), total 6.5 mg kg(-1) over 150 min), I5 was host and I3 and I4 latencies were delayed. The scalp and spinal SEP showed no significant change. Recording of both neural D- and I- MEPs and SEPs is feasible under high sole i.v. KH. It is the first agent to maintain up to four later I1 peaks. The reproducibility of both modalities is unquestionable under KH-based deep anesthesia. This reflects the maintenance of state of neural excitability under KH.

[Epileptogenic drugs in anesthesia]

Most anaesthetics and analgesics have both pro- and anticonvulsant activity. The data in the literature should be analysed with respect to the patient population, the recording of epileptic activity and the method of EEG analysis. Among inhaled anaesthetics, isoflurane has strong anticonvulsant properties. In some circumstances, sevoflurane may induce an epileptic activity. With the exception of ketamine and etomidate, all intravenous hypnotics may be used for anesthesia of the epileptic patient. Midazolam is a potent anticonvulsant. Among narcotics, fentanyl and alfentanil may induce clinical or electroencephalographic seizures. Considering the large number of patients treated with these agents without any neurological adverse effect, the clinical relevance of these data is unclear. Neuromuscular blocking agents do not possess pro- or anticonvulsant properties.

Excitatory actions of propofol and ketamine in the snail Lymnaea stagnalis

This study compares the actions of the intravenous anaesthetics propofol and ketamine on animal behaviour and neuronal activity in the snail Lymnaea stagnalis, particularly in relation to excitatory effects observed clinically. When injected into the whole animal, neither agent induced total anaesthesia. Rather, behavioural activity was enhanced by propofol (10(-5) M) and ketamine (10(-7) M), indicating excitatory effects. When superfused over the isolated central nervous system (CNS), differential effects were produced in two identified neurons, right pedal dorsal 1 (RPeD1) and visceral dorsal 4 (VD4). Resting membrane properties were largely unaffected. However, spike after hyperpolarisation was significantly reduced in RPeD1, but not VD4, with some evidence of increased excitability. In addition, an intrinsic bursting property (post-stimulus burst) in VD4 was altered by propofol (10(-7) M). The results suggest significant excitatory components in the actions of some intravenous anaesthetics, as well as a potential role in modifying excitation and bursting mechanisms in the CNS.

The Epidural and Intrathecal Administration of Ketamine

An overview of the spinal administration of ketamine is presented. Ketamine acts as a noncompetitive antagonist of the NMDA receptor Ca(++ channel pore. This effect provides interesting possibilities in pain therapy. However, there are still contrasting results that seem to be due to a lack of comparative controlled studies. The presence of systemic and neurotoxic effects presently limits clinical use).

Midazolam attenuates ketamine-induced abnormal perception and thought process but not mood changes

PURPOSE

To determine the effects of midazolam, 30 ngxmL(-1), on altered perception, mood, and cognition induced by ketamine.

METHODS

After ketamine was administered to achieve target concentrations of 50, 100, or 150 ngxmL in 11 volunteers, perception, mood, and thought process were assessed by a visual analog scale. Mini-Mental State examination (MMSE) assessed cognition. Boluses of midazolam, 30, 14.5, and 12 microgxkg(-1), were injected every 30 min to maintain the plasma concentration at 30 ngxmL(-1), which was reached 30 min after each injection.

RESULTS

Ketamine produced changes in perception about the body (P < 0.01, 0.001, and 0.0001 at 30, 60, and 90 min), surroundings (P < 0.01 and 0.0001 at 60 and 90 min), time (P < 0.002 and 0.0001 at 60 and 90 min), reality (P < 0.001 and 0.0001 at 60 and 90 min), sounds (P < 0.002 at 90 min), and meaning (P < 0.05 at 90 min). Subjects felt less energetic and clearheaded (P < 0.02 and 0.05) during ketamine, midazolam, and their co-administration. Ketamine impaired thought process (P < 0.003 and 0.0001 at 60 and 90 min). Ketamine and midazolam decreased mean total MMSE and recall scores (P < 0.001 for both). Co-administration reduced the number of subjects with perceptual (body, P < 0.01 and 0.001 at 30 and 60 min) and thought process abnormalities. Within the range of observation, co-administration did not affect the changes in mood or recall.

CONCLUSION

Midazolam attenuates ketamine-induced changes in perception and thought process.

Metabolic mapping of the rat brain after subanesthetic doses of ketamine: potential relevance to schizophrenia

Subanesthetic doses of ketamine have been shown to exacerbate symptoms in schizophrenia and to induce positive, negative, and cognitive schizophrenic-like symptoms in normal subjects. The present investigation sought to define brain regions affected by subanesthetic doses of ketamine, using high resolution autoradiographic analysis of 14C-2-deoxyglucose (2-DG) uptake and immunocytochemical staining for Fos-like immunoreactivity (Fos-LI). Both functional mapping approaches were used because distinct and complementary information is often obtained with these two mapping methods. Ketamine, at a subanesthetic dose of 35 mg/kg, substantially increased 2-DG uptake in certain limbic cortical regions, including medial prefrontal, ventrolateral orbital, cingulate, and retrosplenial cortices. In the hippocampal formation, the subanesthetic dose of ketamine induced prominent increases in 2-DG uptake in the dentate gyrus, CA-3 stratum radiatum, stratum lacunosum moleculare, and presubiculum. Increased 2-DG uptake in response to 35 mg/kg ketamine was also observed in select thalamic nuclei and basolateral amygdala. Ketamine induced Fos-LI in the same limbic cortical regions that exhibited increased 2-DG uptake in response to the subanesthetic dose of the drug. However, no Fos was induced in some brain regions that showed increased 2-DG uptake, such as the hippocampal formation, anterioventral thalamic nucleus, and basolateral amygdala. Conversely, ketamine induced Fos in the paraventricular nucleus of the hypothalamus and central amygdala, although no effect of the drug on 2-DG uptake was apparent in these regions. In contrast to the increase in 2-DG uptake observed in select brain regions after the subanesthetic dose, an anesthetic dose of ketamine (100 mg/kg) produced a global suppression of 2-DG uptake. By contrast, a robust induction of Fos-LI was observed after the anesthetic dose of ketamine that was neuroanatomically identical to that produced by the subanesthetic dose. Results of the present investigation show that anesthetic and subanesthetic doses of ketamine have pronounced effects on regional brain 2-DG uptake and induction of Fos-LI. The alterations in regional brain metabolism induced by the subanesthetic dose may be relevant to effects of ketamine to induce schizophrenic-like symptoms.

Anaesthetic management in maple syrup urine disease

Two children with maple syrup urine disease undergoing emergency and elective surgery are reported. The administration of ketamine to a 12-month-old boy without neurological problems and propofol infusion to a 5-year-old girl with a history of convulsions, was uneventful. We believe that a full knowledge of the pathophysiology of maple syrup urine disease and potential peri-operative problems associated with the disease are essential, so that patients are not subjected to unnecessary risks.

Effects of salicylate on neural activity in cat primary auditory cortex

The effect of systemically applied salicylate on single-unit firing activity in primary auditory cortex was investigated in six cats. A dose of 200 mg/kg sodium salicylate was administered intraperitoneally, and recordings from the same units were performed prior to application and continuously up to, on average. 6 h after administration. Local field potentials were used to track the threshold shifts and general input-output (I/O) behavior following salicylate administration. All animals showed 20-30 dB of threshold shift about 2 h after administration and showed no recovery during the following 4 h. I/O curves were invariably of the recruitment type. Significant changes were found in spontaneous firing rates for two groups of unit separately. Low-spontaneous rate units (initial firing rate < 1 spike/s) showed an increase in spontaneous rate and high-spontaneous rate units (initial firing rate > 1 spike/s) showed a decrease in spontaneous firing rate. There were no significant changes in modal and mean values for interspike-interval (ISI) histograms. The duration-to-rebound peak in the autocorrelation function for spontaneous firings was prolonged significantly after salicylate administration. Peak cross-correlation coefficients for the firing patterns of simultaneously recorded cells showed no significant change but the correlogram's central peak was significantly narrower after salicylate application. The percentage of firings occurring in bursts showed no significant change after administration of salicylate. The best modulation frequency in response to stimulation with periodic click trains decreased after administration. Both the changes in the spontaneous autocorrelogram and in the temporal modulation transfer function suggest a prolongation in the duration of the Ca(2+)-activated K+ conductance of the cortical pyramidal cells following salicylate. This suggests that salicylates affect both the auditory periphery and the auditory cortex.

Possible participation of NMDA and glycine receptors but not GABAA receptors in enflurane-induced opisthotonus in mice

1. We previously reported that volatile anaesthetics produce incidences of a transient opisthotonus in mice, a sign of CNS stimulation. This study was performed to investigate mechanisms by which enflurane-induced opisthotonus (EIO) occurs. 2. The effects of pretreatment of N-methyl-D-aspartate (NMDA) antagonists dizocilpine (MK-801; DIZ) and ketamine (KET), GABAA antagonists picrotoxin (PIC), pentylenetetrazol (PTZ) and glycine antagonist strychnine (STR) on the incidence of EIO were determined. Prior to exposure to 2.0% enflurane in air, male ddN mice were given intraperitoneal injections of 0.2 mL saline (control), 0.5-5.0 mg/kg DIZ, 20-80 mg/kg KET, 2.9 mg/kg PIC, 40.0 mg/kg PTZ and 0.75 mg/kg STR. After the injection, the behavioural state of the mice was observed for 20 min (the pre-enflurane period). During the exposure to enflurane the time for immobilization, that is, anaesthetic induction time (IT), and the incidence of EIO were measured. 3. Dizocilpine (1.0-5.0 mg/kg) and KET (80 mg/kg) significantly (P < 0.01) reduced both the incidence of EIO and IT in a dose-dependent manner. During the pre-enflurane period DIZ produced incidences (5-40%) of transient seizures in a dose-dependent manner, while KET did not induce them at all. The two GABAA antagonists had no detectable effect on the EIO. Strychnine significantly enhanced the EIO. These CNS stimulants resulted in a 3-10% incidence of transient seizure and/or opisthotonus during the pre-enflurane period, but there was no correlation between DIZ-induced seizure and EIO. 4. These results suggest that the EIO is mediated by the NMDA and the STR-sensitive glycine receptors, but not the GABAA receptor.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic-pharmacodynamic modelling of meperidine in goats (II): Modelling

Simultaneous pharmacokinetic-pharmacodynamic (PK-PD) models of meperidine in goats were established by utilizing the P3 wave of the cerebral evoked potentials as an analgesic measurement. An effect compartment linked to the central compartment was postulated in the models. The hypothetical drug amount in the effect compartment was related to the observed analgesia through the Hill equation. After intramuscular (i.m., n = 16) and intravenous (i.v., n = 13) dosing (5 mg/kg), the elimination rate constants of meperidine in the effect compartment (Ke0) were 0.3744 +/- 0.2546 and 0.1123 +/- 0.0428 min-1, drug concentrations in the effect compartment generating half maximal analgesia (EC(50)) were 0.70 +/- 0.33 and 0.41 +/- 0.26 microgram/ml, the maximal effects (Emax) were 89.63 +/- 15.63 and 85.92 +/- 9.64%, and the Hill coefficients (S) were 2.61 +/- 1.21 and 2.37 +/- 1.15, respectively. Ke0 and EC(50) with i.m. dosing were significantly greater than with i.v. injection. However, administration route had no influence on S, Emax and the total amount of effect (AUE). The predicted peak effect (Emax) of 64.44 +/- 14.64 and 66.02 +/- 11.51% were achieved at 14.7 +/- 7.4 and 8.5 +/- 2.2 min after i.m. and i.v. dosing, respectively. Peak analgesia appeared much later than peak plasma concentration, but simultaneously with peak CSF level both after i.m. and i.v. dosing. An obvious hysteresis was demonstrated between plasma concentration and analgesic effect. This study demonstrates that meperidine analgesia can be predicted using a PK-PD model, but not by PK data alone. Both i.m. and i.v. administration routes were evaluated kinetically and dynamically.

High-dose ketamine does not induce c-Fos protein expression in rat hippocampus

The effects of high-dose ketamine on the c-fos protein (c-Fos) expression were investigated in rat by an immunohistochemical technique. The administration of 100 mg/kg ketamine i.p. induced seizure-like activity (limbic seizure). No c-Fos immunoreactivity was observed in hippocampus, piriform cortex and amygdala, while it was observed in neocortex and thalamus. These findings disagree with the reports that ketamine depresses the neuronal function of the neocortex and thalamus, while it stimulates the limbic system.

Concurrent increases in brain electrical activity and intracranial blood flow velocity during low-dose ketamine anaesthesia

The purpose of the present study was to assess the effects of low-dose ketamine on spontaneous brain electrical activity (EEG) and intracranial blood flow velocity. Twenty healthy volunteers were divided into two groups: Group I (n = 10) received 0.25 mg.kg-1 ketamine iv; Group II (n = 10) received 0.5 mg.kg-1 ketamine iv. Mean arterial blood pressure (MAP), heart rate (HR), end-tidal PCO2 (PETCO2), and arterial oxygen saturation (SaO2) were measured. The EEG was recorded from temporo-occipital recording sites over both hemispheres. Blood flow velocity in the middle cerebral artery was measured using a transcranial Doppler ultrasound system. All variables were evaluated at baseline and for 60 min following ketamine. Administration of ketamine resulted in increases of MAP and HR in both groups to a similar degree. The PETCO2 and SaO2 did not change in either group over time. Ketamine caused a dose-dependent, transient shift in the EEG to synchronous high-voltage slow waves with an increase in total power (Group I: 301 +/- 38%; Group II: 104 +/- 28%). These changes were associated with dose-dependent increases in mean blood flow velocity (Group I: 35 +/- 7%; Group II: 68 +/- 10%). Our data suggest that increases in intracranial blood flow velocity are closely correlated to increases in neuronal activity and are not secondary to changes in systemic haemodynamic variables.

Anesthetic modulation of cerebral hemodynamic and evoked responses to transient middle cerebral artery occlusion in cats

We measured cerebral blood flow and somatosensory evoked potentials during transient focal cerebral ischemia in cats to compare the effects of four commonly used anesthetic regimens: ketamine/fentanyl/N2O (fentanyl), pentobarbital, ketamine/alpha-chloralose (alpha-chloralose), and ketamine/halothane/N2O (halothane). Six cats in each group were subjected to 60 minutes of left middle cerebral artery occlusion followed by 120 minutes of reperfusion. Although the amplitude of the initial somatosensory evoked potential wave complex was highest in the alpha-chloralose group (58.6 +/- 16.5 microV) and smallest in the halothane group (27.5 +/- 5.7 microV), amplitude fell by 75% in all groups upon occlusion. Baseline cerebral blood flow varied substantially between groups (e.g., in the right intersylvian gyrus: fentanyl, 96 +/- 12; pentobarbital, 30 +/- 5; alpha-chloralose, 24 +/- 3; and halothane, 76 +/- 11 ml/min/100 g). Occlusion decreased cerebral blood flow to subcortical (e.g., left caudate) structures in all groups (fentanyl, 29 +/- 11%; pentobabital, 45 +/- 12%; alpha-chloralose, 27 +/- 13%; and halothane, 18 +/- 5% of baseline). Postischemic hyperemia occurred in the cortical regions of cats anesthetized with pentobarbital or alpha-chloralose that had reduced cerebral blood flows during occlusion but not in cats anesthetized with fentanyl (cerebral blood flow during occlusion not different from that of cats anesthetized with pentobarbital or alpha-chloralose) or halothane. After 120 minutes of reperfusion, cerebral blood flow had returned to baseline values in all groups. Recovery of cerebral blood flow and somatosensory evoked potential amplitude at that time did not differ among groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of dizocilpine maleate (MK-801), an antagonist of the N-methyl-D-aspartate receptor, on neurologic recovery and histopathology following complete cerebral ischemia in primates

The present study was designed to determine if the noncompetitive excitatory amino acid antagonist, dizocilpine maleate, when administered after a 17 min period of complete cerebral ischemia in primates, would improve postischemic neurologic function and hippocampal histopathologic outcome when compared to placebo-treated animals. Ten pigtail monkeys were anesthetized and subjected to complete cerebral ischemia using an established neck tourniquet model. Five minutes postischemia, five monkeys received dizocilpine 300 micrograms/kg i.v. over 5 min, followed by an infusion of 150 micrograms/kg/h for 10 h. This produced plasma levels of the drug in excess of 30 ng/ml for the duration of the infusion. An additional five monkeys were treated with an identical volume of saline placebo. All monkeys received intensive care for the initial 24 to 48 h postischemia. At 96 h postischemia, there was no significant difference in neurologic function between the two groups (p = 0.53, with the placebo group having the numerically better outcome). There also was no significant difference between hippocampal histopathology scores between dizocilpine and placebo-treated monkeys. The authors conclude that dizocilpine is not an efficacious therapy in the treatment of neurologic injury that occurs following complete cerebral ischemia in this primate model.

Determination of regional blood flow in abdominal organs and other structures in normal female rats and in rats with TAA-induced chronic liver injury using 99mTc labelled HSA-microsphere technique

A method for simultaneous determination of cardiac output and regional blood flow distribution in a chronically instrumented, unrestrained rat preparation for different experimental conditions (i.e. conscious, free movement; general anesthesia) and in an experimental chronic liver injury model is described. The use of a modified radioactive microsphere reference sample method using 99mTc labelled HSA-microspheres provides valid measurements of cardiac output [255 +/- 21.6 ml/(min.kg b.wt.)] and of the determined blood flow rates of abdominal organs (with separate determination of arterial and portal-venous hepatic blood flow rates; the latter by means of arterial blood flow measurement of the gastrointestinal tract and the spleen), the myocard, the adrenals, the kidneys, and various brain regions. Furthermore, it is demonstrated that this measuring approach with chronical preparation can also advantageously be used in pharmacological or pathogenetical studies, especially because of the simple measuring equipment and the comparatively low costs that offer a broader application.

The effect of the excitatory amino acid receptor antagonist dizocilipine maleate (MK-801) on hemispheric cerebral blood flow and metabolism in dogs: modification by prior complete cerebral ischemia

The effect of the N-methyl-D-aspartate (NMDA) receptor antagonist dizociplipine maleate (MK-801) on cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO2), intracranial pressure and systemic variables was examined in 6 normal dogs (Group I). In 6 additional dogs (Group II), the effects of a prior 11 min episode of complete cerebral ischemia on the response to dizocilipine was studied. CBF was measured with a sagittal sinus outflow technique and CMRO2 was calculated as the product of CBF and the arterial to sagittal sinus O2 content difference. Dizocilipine was administered as a 150 micrograms/kg i.v. bolus followed by a 75 micrograms.kg-1.h-1 infusion for 90 min. Plasma dizocilipine levels were greater than 25 ng/ml for the duration of the infusion. The CSF levels were approximately half the plasma levels. Five minutes after initiation of dizocilipine treatment, Group I dogs experienced a 63% increase in heart rate (P less than 0.01) and an 8% decrease in the mean arterial blood pressure (P less than 0.05). Over the same time interval. CBF increased by 85% (P less than 0.01) and intracranial pressure nearly doubled (P less than 0.05). In addition, dizocilipine treatment in all Group I animals resulted in EEG quasiperiodic bursts of delta-waves and polyspikes on a background of beta-activity. With the exception of the intracranial pressure, the above changes in systemic and cerebral variables persisted for the duration of the drug infusion. Intracranial pressure was no longer significantly elevated after 80 min of drug infusion. Hemispheric CMRO2 was unchanged by dizocilipine in Group I dogs. There was a decrease in the cortical glucose level at the end of the study, but no significant change in phosphocreatine, ATP, lactate, or energy charge when compared with 6 laboratory normals. An identical dose of dizocilipine administered after an 11 min episode of complete cerebral ischemia resulted in no significant changes in either cerebral or systemic variables. The absence of systemic effects in Group II dogs suggests that dizocilipine administration in normal dogs results in a centrally mediated activation of the peripheral sympathetic nervous system. The uncoupling of CBF and CMRO2 observed following dizocilipine treatment is similar to that reported for two other known NMDA antagonists, ketamine and phencyclidine. If administration of dizocilipine results in improved histopathological and neurological outcome following an episode of complete cerebral ischemia, this improvement is unrelated to changes in postischemic CBF or hemispheric CMRO2.

Effects of ketamine on the dynorphin levels and the ethylketocyclazocine (EKC) receptor binding in discrete regions of rat brains

Intraperitoneal (ip) injection of ketamine increased the concentration of dynorphin in the cortex of rat brain, while decreased it in the septal area. The affinity of ethylketocyclazocine (EKC) receptor binding was decreased in the cortex, but increased in the septal area after pretreating the rats with ketamine. This suggests that the dynorphin neuronal system is stimulated in the cortex and suppressed in the septal area by ketamine. In other 5 brain areas, ketamine had no effect on neither dynorphin concentration nor EKC receptor binding. As dynorphin was reported to produce seizure and spike discharge in the cortex while suppressed the hippocampal EEG of rat brain, it is likely that the dynorphin neuronal system may play at least a part in ketamine induced electrophysiological changes in the brain.

Outpatient sedation for ocular examination

Outpatient sedation of infants, uncooperative children and, rarely, adults provides an opportunity to perform certain ophthalmologic diagnostic procedures such as tonometry, ophthalmoscopy and various electrophysiological studies (e.g., electroretinography and visual evoked response testing) without the expense and usage of an operating room. Many drugs have been recommended and used; all have limitations. The advantages and disadvantages of the more commonly used agents are reviewed. The known effects of these drugs on ocular function are presented.

Spontaneous forebrain neuronal activity in developmentally protein malnourished rats

The characteristics of the spontaneous discharges of populations of single neurons in the neocortex and thalamus of rats reared under chronic protein malnutrition (8% casein) or a normal diet (25% casein) were evaluated. Results from 700 neurons showed the malnourished rats had fewer fast firing cells, an overall lower discharge rate and an altered firing pattern (fewer cells which exhibited bursting activity). These findings are the first demonstration of altered neuronal discharges in the forebrains of adult malnourished rats.

The effects of stimulation of substantia innominata and sensory receiving areas of the forebrain upon the activity of neurons within the amygdala of the anesthetized cat

The present study investigated the response characteristics of individual neurons in the amygdala following stimulation of the substantia innominata (SI), and compared these responses with those elicited by stimulation of insular and temporal polar cortices and the lateral olfactory tract (LOT). Recordings were made from single units within the medial, central, basal, and lateral amygdaloid nuclei of anesthetized, male cats. Stimulating electrodes were located in the SI, LOT, and sylvian cortex (SG). Unit responses were classified as either excitation or inhibition. Excitatory responses were further divided into fixed latency excitation (FLE) and variable latency excitation (VLE) based on the variability of the onset latency of the response. The majority of responses to SI stimulation were of the FLE type, implying a direct orthodromic, monosynaptic activation of amygdaloid units. Proportionally more FLE responses were recorded laterally, especially in the magnocellular basal nucleus, compared to VLE responses which were more common in the medial and central nuclei. SI stimulation consistently affected the activity of many more units than did SG or LOT stimulation. The onset latencies of the population of cells exhibiting excitatory responses elicited by SI stimulation were distributed bimodally, and this may reflect a dual projection pathway of amygdaloid afferents from this basal forebrain region. This correlates with anatomical descriptions indicating that SI projections to amygdala pass via the ventral amygdalofugal pathway as well as in the stria terminalis. Excitatory onset latencies of responses to SI stimulation were the shortest in the lateral and magnocellular basal nuclei and the longest in the parvocellular basal nucleus. Amygdaloid units exhibited convergent input from the stimulus sites. A clear topographical distribution of units was not demonstrated. The data suggests that units receiving a convergent input were rarely driven monosynaptically by more than one stimulus site. The basal nucleus contained the smallest fraction of units exhibiting a convergent input. A small population of antidromic responses was recorded and indicates that within the system studied the caudal aspect of the basal nucleus is a major source of amygdaloid efferents. Antidromically driven units did not exhibit transynaptic responses following stimulation of any of the test sites.

Activation of the supraspinal pain inhibition system by ketamine hydrochloride

The neurophysiologic mechanism of ketamine-induced analgesia was studied in cats under conditions of electrolytic decerebration or pentobarbital anesthesia. Injection of bradykinin into the femoral artery served as the noxious stimulus and the neural response in the lateral funiculus of the spinal cord was recorded by the multi-unit activity technique. Ketamine depressed the bradykinin-induced response more markedly in decerebrate, non-anesthetized cats than in pentobarbital-anesthetized cats. The depressant action disappeared following cervical cord transection at C1, in both decerebrate non-anesthetized and pentobarbital-anesthetized cats. Thus the analgesic action of ketamine is probably exerted mainly through activation of the supraspinal pain inhibition system and a direct action on the spinal cord nociceptive neural mechanism, if any, is slight. The excitatory action of ketamine on the supraspinal pain inhibition system is susceptible to the depressant action of pentobarbital.

Complications related to the administration of general anesthesia in 600 developmentally disabled dental patients

A total of 600 handicapped patients had dental rehabilitation under general anesthesia during an eight-year period. Handicaps included mental retardation, cerebral palsy, Down syndrome, seizure disorders, autism, cystic fibrosis, osteogenesis imperfecta, and muscular dystrophy. No significant complications developed in the majority of patients. This is attributed to thorough preoperative evaluation, appropriate anesthetic management, and vigilant postoperative observation.