The mechanism of inhibitory actions of propofol on rat supraoptic neurons

A Comparative Study of Common Anesthetics Propofol, Sevoflurane, Isoflurane and Ketamine on Lipid Membrane Fluidity

The membrane fluidity increases induced by popular anesthetic agents (propofol, isoflurane, sevoflurane, and ketamine/xylazine) were measured at the clinical and supra-clinical concentrations in red blood cell (RBC) membrane as well as four model membranes. Membrane fluidity changes were monitored using the excimer/monomer (E/M) ratio of dipyrene-PC and fluorescence anisotropies of DPH-PC and TMA-DPH. Propofol, sevoflurane and isoflurane increased membrane fluidity instantaneously. The largest increase occurs in membranes made of saturated lipids. RBCs were labeled with TMA-DPH, and the increase in membrane fluidity at clinical concentrations of isoflurane and sevoflurane was more than that induced by ten times the legal limit of alcohol in human blood. However, membrane fluidity was essentially unchanged by ketamine/xylazine up to 210 µM. These results strongly correlate with our recent in vivo experiments and reveal a clear connection between increasing membrane fluidity in model membranes, increasing the blood-brain barrier (BBB) permeability in mice, and inducing effective anesthesia in animals. Interestingly, at the most commonly used clinical concentrations, the membrane fluidity increases induced by propofol, sevoflurane, and isoflurane were very similar, despite the fact that different categories of anesthetics were used and their chemical concentrations were different by 100 times. This indicates that at clinical concentrations of these anesthetics, a similar level of membrane disruption at the BBB is achieved. Thus, our results strongly support the lipid hypothesis of the mechanism of general anesthetics.

Establishment and validation of a predictive nomogram for polyuria during general anesthesia in thoracic surgery

BACKGROUND

To develop and evaluate a predictive nomogram for polyuria during general anesthesia in thoracic surgery.

METHODS

A retrospective study was designed and performed. The whole dataset was used to develop the predictive nomogram and used a stepwise algorithm to screen variables. The stepwise algorithm was based on Akaike's information criterion (AIC). Multivariable logistic regression analysis was used to develop the nomogram. The receiver operating characteristic (ROC) curve was used to evaluate the model's discrimination ability. The Hosmer-Lemeshow (HL) test was performed to check if the model was well calibrated. Decision curve analysis (DCA) was performed to measure the nomogram's clinical usefulness and net benefits. P < 0.05 was considered to indicate statistical significance.

RESULTS

The sample included 529 subjects who had undergone thoracic surgery. Fentanyl use, gender, the difference between mean arterial pressure at admission and before the operation, operation type, total amount of fluids and blood products transfused, blood loss, vasopressor, and cisatracurium use were identified as predictors and incorporated into the nomogram. The nomogram showed good discrimination ability on the receiver operating characteristic curve (0.6937) and is well calibrated using the Hosmer-Lemeshow test. Decision curve analysis demonstrated that the nomogram was clinically useful.

CONCLUSIONS

Individualized and precise prediction of intraoperative polyuria allows for better anesthesia management and early prevention optimization.

Dose-dependent changes in orientation amplitude maps in the cat visual cortex after propofol bolus injections

A general intravenous anesthetic propofol (2,6-diisopropylphenol) is widely used in clinical, veterinary practice and animal experiments. It activates gamma- aminobutyric acid (GABAa) receptors. Though the cerebral cortex is one of the major targets of propofol action, no study of dose dependency of propofol action on cat visual cortex was performed yet. Also, no such investigation was done until now using intrinsic signal optical imaging. Here, we report for the first time on the dependency of optical signal in the visual cortex (area 17/area 18) on the propofol dose. Optical imaging of intrinsic responses to visual stimuli was performed in cats before and after propofol bolus injections at different doses on the background of continuous propofol infusion. Orientation amplitude maps were recorded. We found that amplitude of optical signal significantly decreased after a bolus dose of propofol. The effect was dose- and time-dependent producing stronger suppression of optical signal under the highest bolus propofol doses and short time interval after injection. In each hemisphere, amplitude at cardinal and oblique orientations decreased almost equally. However, surprisingly, amplitude at cardinal orientations in the ipsilateral hemisphere was depressed stronger than in contralateral cortex at most time intervals. As the magnitude of optical signal represents the strength of orientation tuned component, these our data give new insights on the mechanisms of generation of orientation selectivity. Our results also provide new data toward understanding brain dynamics under anesthesia and suggest a recommendation for conducting intrinsic signal optical imaging experiments on cortical functioning under propofol anesthesia.

Transient distal renal tubular acidosis with nephrogenic diabetes insipidus after general anaesthesia in a dog

A 3-year-old, 3.5 kg, female spayed Pomeranian was referred due to persistent vomiting, anorexia, polyuria and polydipsia, 7 days after receiving general anaesthetic for a medial patellar luxation correction. Physical examination revealed lethargy, tachypnoea and 7% dehydration. Complete blood count and serum chemistry results were unremarkable, and venous blood gas analysis revealed hypokalaemia and hyperchloraemic metabolic acidosis with a normal anion gap. Urinalysis revealed a urine specific gravity (USG) of 1.005, pH of 7.0 and proteinuria, and the bacterial culture was negative. Based on these results, the dog was diagnosed with distal renal tubular acidosis, and potassium citrate was prescribed to correct metabolic acidosis. In addition, concurrent diabetes insipidus (DI) was suspected because the dog showed persistent polyuria, polydipsia and a USG below 1.006 despite dehydration. After 3 days of initial treatment, acidosis was corrected, and vomiting resolved. Desmopressin acetate and hydrochlorothiazide were also prescribed for DI, but the USG was not normalized. Based on the insignificant therapeutic response, nephrogenic DI was highly suspected. DI was resolved after 24 days. This case report describes the concomitant presence of RTA and DI in a dog after general anaesthesia.

Perioperative Diabetes Insipidus Caused by Anesthetic Medications: A Review of the Literature

Diabetes insipidus (DI) is an uncommon perioperative complication that can occur secondary to medications or surgical manipulation and can cause significant hypovolemia and electrolyte abnormalities. We reviewed and evaluated the current literature and identified 24 cases of DI related to medications commonly used in anesthesia such as propofol, dexmedetomidine, sevoflurane, ketamine, and opioids. This review summarizes the case reports and frequency of DI with each medication and presents possible pathophysiology. Medication-induced DI should be included in the differential diagnosis when intraoperative polyuria is identified. Early identification, removal of the agent, and treatment of intraoperative DI are critical to minimize complications.

Interactions of antiepileptic drugs with drugs approved for the treatment of indications other than epilepsy

Introduction: Comorbidities of epilepsy may significantly interfere with its treatment as diseases in the general population are also encountered in epilepsy patients and some of them even more frequently (for instance, depression, anxiety, or heart disease). Obviously, some drugs approved for other than epilepsy indications can modify the anticonvulsant activity of antiepileptics. Areas covered: This review highlights the drug-drug interactions between antiepileptics and aminophylline, some antidepressant, antiarrhythmic (class I-IV), selected antihypertensive drugs and non-barbiturate injectable anesthetics (ketamine, propofol, etomidate, and alphaxalone). The data were reviewed mainly from experimental models of seizures. Whenever possible, clinical data were provided. PUBMED data base was the main search source.Expert opinion: Aminophylline generally reduced the protective activity of antiepileptics, which, to a certain degree, was consistent with scarce clinical data on methylxanthine derivatives and worse seizure control. The only antiarrhythmic with this profile of action was mexiletine when co-administered with VPA. Among antidepressants and non-barbiturate injectable anesthetics, trazodone, mianserin and etomidate or alphaxalone, respectively, negatively affected the anticonvulsant action of some antiepileptic drugs. Clinical data indicate that only amoxapine, bupropion, clomipramine and maprotiline should be used with caution. Possibly, drugs reducing the anticonvulsant potential of antiepileptics should be avoided in epilepsy patients.

Propofol downregulates the activity of glutamatergic neurons in the basal forebrain via affecting intrinsic membrane properties and postsynaptic GABAARs

Propofol anesthesia rapidly causes loss of consciousness, while the neural mechanism underlying this phenomenon is still unclear. Glutamatergic neurons in the basal forebrain play an important role in initiation and maintenance of wakefulness. Here, we selectively recorded the activity of glutamatergic neurons in vGlut-2-Cre mice. Propofol induced outward currents in a concentration-dependent manner. Bath application of propofol generated membrane hyperpolarization and suppressed the firing rates in these neurons. Propofol-induced stable outward currents persisted after blockade of the action potentials, implying a direct postsynaptic effect of propofol. Furthermore, propofol selectively increased the GABAergic inhibitory synaptic inputs via affecting the GABAARs, but did not affect the glutamatergic transmissions. Together, propofol inhibits the excitability of the glutamatergic neurons via direct influencing the membrane intrinsic properties and the inhibitory synaptic transmission. This inhibitory effect might provide a novel mechanism for the propofol-induced anesthesia.

Effects of anesthetics on post-operative 3-month neuroendocrine function after endoscopic transsphenoidal non-functional pituitary adenoma surgery

BACKGROUND

Anesthetic techniques can affect perioperative neuroendocrine function. The objective of this study was to compare 3-month post-operative neuroendocrine functional outcomes between sevoflurane and propofol anesthesia in patients undergoing endoscopic transsphenoidal surgery (ETS) for removal of non-functional pituitary adenomas (NFPAs) retrospectively.

METHODS

Among 356 patients who underwent ETS for removal of NFPAs under sevoflurane-remifentanil anesthesia (sevoflurane group, n = 103) or propofol-remifentanil anesthesia (propofol group, n = 253), 92 patients in each group were selected and their 3-month post-operative neuroendocrine functional outcomes (primary outcome measure) were compared after propensity score matching.

RESULTS

Overall changes in post-operative 3-month neuroendocrine function compared to pre-operative baseline did not differ between the sevoflurane and propofol groups (worsened: 32.6% vs 29.3%, persistently decreased: 9.8% vs 12.0%, improved: 12.0% vs 20.7%, normalized: 9.8% vs 12.0%, persistently normal: 18.5% vs 19.6%; P = .400). The incidence of pituitary hormone deficiency at 3 months post-operatively did not differ between the sevoflurane and propofol groups (adrenocorticotropic hormone deficiency: 18.5% vs 17.4%, P = 1.000; thyroid-stimulating hormone deficiency: 10.9% vs 3.3%, P = .081; gonadotropin deficiency: 54.3% vs 48.9%, P = .555; growth hormone deficiency: 45.7% vs 48.9%, P = .768; panhypopituitarism: 1.1% vs 1.1%, P = 1.000).

CONCLUSION

In patients undergoing ETS for removal of NFPAs, the effects of both sevoflurane-remifentanil and propofol-remifentanil anesthetic techniques on post-operative 3-month neuroendocrine functional outcomes were similar, suggesting that propofol and sevoflurane can be freely used in such patients in terms of post-operative intermediate-term neuroendocrine functional outcome.

Attenuation of increased intraocular pressure with propofol anesthesia: A systematic review with meta-analysis and trial sequential analysis

Attenuation of an increase in intraocular pressure (IOP) is crucial to preventing devastating postoperative visual loss following surgery. IOP is affected by several factors, including the physiologic alteration due to pneumoperitoneum and patient positioning and differences in anesthetic regimens. This study aimed to investigate the effects of propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia on IOP. We searched multiple databases for relevant studies published before October 2019. Randomized controlled trials comparing the effects of propofol-based TIVA and volatile anesthesia on IOP during surgery were considered eligible for inclusion. Twenty studies comprising 980 patients were included. The mean IOP was significantly lower in the propofol-based TIVA group after intubation, pneumoperitoneum, Trendelenburg positioning, and lateral decubitus positioning. Moreover, mean arterial pressure and peak inspiratory pressure were also lower after intubation in the propofol-based TIVA group. Trial sequential analyses for these outcomes were conclusive. Propofol-based TIVA is more effective than volatile anesthesia during surgery at attenuating the elevation of IOP and should be considered, especially in at-risk patients.

Variation in intraocular pressure caused by repetitive positional changes during laparoscopic colorectal surgery: a prospective, randomized, controlled study comparing propofol and desflurane anesthesia

Laparoscopic surgery is often prolonged and requires positional changes to facilitate surgical access. Previous studies reported intraocular pressure (IOP) changes in one fixed position. This study investigated the effect of desflurane and propofol anesthesia on IOP during repeated positional changes. A total of 46 patients undergoing laparoscopic colorectal surgery were randomized into desflurane or propofol groups. IOP was measured using a handheld tonometer at seven time points: before induction (baseline), after endotracheal intubation, after pneumoperitoneum, after the first Trendelenburg and right tilt position, after reverse Trendelenburg and right tilt position, after the second Trendelenburg and right tilt position and before endotracheal extubation. Trendelenburg positioning raised IOP in both groups. In the desflurane group, IOP at the first Trendelenburg position was 6.27 and 8.48 mmHg higher than baseline IOP in left and right eye, respectively; IOP at the second Trendelenburg position was 7 and 9.44 mmHg higher than baseline in left and right eye, respectively. In the propofol group, IOP at the first Trendelenburg position was 2.04 and 4.04 mmHg higher than baseline in left and right eyes, respectively. It was 3.04 and 4.87 mmHg higher than baseline in left and right eye, respectively, at the second Trendelenburg position. In the desflurane group, 56.52% patients exhibited high IOP (≥ 25 mmHg) compared with 13.04% in the propofol group at the second Trendelenburg position in the right eyes (P = 0.005). There was a positive correlation between IOP and peak inspiratory pressure (P < 0.001). Propofol anesthesia mitigated wide variations in IOP caused by repetitive positional changes during laparoscopic colorectal surgery.

Intraocular Pressure Changes during Laparoscopic Surgery in Trendelenburg Position in Patients Anesthetized with Propofol-based Total Intravenous Anesthesia Compared to Sevoflurane Anesthesia: A Comparative Study

Background:

Intraocular pressure (IOP) is increased during laparoscopic surgery with Trendelenburg position and may contribute to deleterious effects on optic nerve in susceptible patients.

Aims:

The primary objective of this study is to compare the effects of propofol-based total intravenous anesthesia (TIVA) with those of sevoflurane anesthesia on IOP in patients undergoing lower abdominal laparoscopic surgery in Trendelenburg position. Secondary objectives are to compare hemodynamic changes, mean arterial pressure (MAP), end-tidal CO₂, and peak inspiratory pressure changes.

Materials and Methods:

Sixty patients with physical status American Society of Anesthesiologists classes I and II were randomly allocated in two groups: Group A (propofol) and Group B (sevoflurane). IOP along with other parameters was measured at seven points including baseline (T0), 5 min after induction (T1), 5 min after CO₂ pneumoperitoneum in supine position (T2), 30 min after CO₂ pneumoperitoneum with Trendelenburg position (T3), 5 min after returning to supine position (T4), 5 min after CO₂ desufflation (T5), and 5 min after extubation (T6).

Results:

The change in IOP was different between the two groups. Maximum rise in IOP was seen at T3, and mean ± standard deviation IOP was 15.5 ± 0.9 mmHg and 19.8 ± 1.2 mmHg in Group A and Group B, respectively (P < 0.01). In Group A (propofol), IOP remained almost equal to the baseline value at T3 and the IOP difference was 0.3 ± 0.9 mmHg less than baseline (statistically insignificant, P > 0.05), while in Group B (sevoflurane), IOP increased significantly at T3 and the difference was 4.0 ± 1.2 mmHg (P < 0.001). The IOP was significantly greater (P < 0.01) from T2 to T6 in sevoflurane group than propofol group.

Conclusion:

Propofol-based TIVA is more effective than inhalational anesthesia with sevoflurane in attenuating the increase in IOP during laparoscopic surgery requiring CO₂ pneumoperitoneum with Trendelenburg position.

Effects of Propofol on Excitatory and Inhibitory Amino Acid Neurotransmitter Balance in Rats with Neurogenic Pulmonary Edema Induced by Subarachnoid Hemorrhage

INTRODUCTION

Propofol exhibits neuroprotective effects mediated by the inhibition of excitatory amino acid (EAA) neurotransmitter release and potentiation of inhibitory amino acid (IAA) neurotransmitters. To our knowledge, this is the first study to investigate the effects of propofol on the EAA and IAA balance in neurogenic pulmonary edema (NPE).

METHODS

Sixty male Wistar rats were randomized to Sham, NPE, Low-dose propofol, and High-dose propofol groups. NPE was induced via rapid injection of autologous blood (0.5 ml) into the cisterna magna. The Low- and High-dose propofol groups were pretreated with boluses of 2 and 5 mg kg(-1), respectively, prior to blood injection, followed by continuous propofol infusion at 6 and 15 mg kg(-1) h(-1), respectively. The mean arterial pressure (MAP), heart rate, intracranial pressure (ICP), peak inspiratory pressure (PIP), and arterial blood gases were continuously recorded. After 2 h, the lung wet-to-dry weight ratio, total protein concentration in the bronchoalveolar lavage fluid (BALF), brain water content, cortical EAA and IAA levels, chest X-ray, and histological staining of lung sections were evaluated.

RESULTS

Blood injections into the cisterna magna induced NPE and hemodynamic changes. Propofol alleviated the increases in the MAP, ICP, and PIP, improved oxygenation and histopathological changes, ameliorated pulmonary and cerebral edema, increased the IAA brain levels, and decreased the ratio of Glu to γ-aminobutyric acid.

CONCLUSIONS

The current findings suggest that propofol improves NPE likely via IAA accumulation and the regulation of EAA and IAA balance, which may represent an effective treatment for NPE.

Transient Intraoperative Central Diabetes Insipidus in Moyamoya Patients Undergoing Revascularization Surgery: A Mere Coincidence?

We present 2 patients with Moyamoya disease undergoing revascularization surgery who developed transient intraoperative central diabetes insipidus with spontaneous resolution in the immediate postoperative period. We speculate that patients with Moyamoya disease may be predisposed to a transient acute-on-chronic insult to the arginine vasopressin-producing portion of their hypothalamus mediated by anesthetic agents. We describe our management, discuss pertinent literature, and offer possible mechanisms of this transient insult. We hope to improve patient safety by raising awareness of this potentially catastrophic complication.

Changes in intraocular pressure during surgery in the lateral decubitus position under sevoflurane and propofol anesthesia

Intraocular pressure (IOP) has been shown to change with body position. Several studies have shown that the lateral decubitus position (LDP) is associated with a significant increase in IOP in the dependent eye. However, whether anesthetic agents alter IOP in the LDP remains unclear. This study investigated the effect of sevoflurane and propofol anesthesia on IOP in the LDP. A total of 28 patients undergoing surgery in the LDP were included. Patients were randomly allocated to sevoflurane or propofol groups. IOP in both eyes was recorded and compared between groups at five time points: after anesthesia induction, after endotracheal intubation, at 5 min and 1 h after a positional change to the LDP, and 5 min after returning to the supine position. In the sevoflurane group, IOP was significantly increased in both dependent and non-dependent eyes 1 h after changing to the LDP. In the propofol group, IOP decreased in both dependent and non-dependent eyes after tracheal intubation, but did not increase after changing to the LDP. The number of patients in whom IOP increased to ≥28 mmHg was greater in the sevoflurane group than in the propofol group. Propofol may be better than sevoflurane for the maintenance of anesthesia in the LDP. Monitoring of IOP in the LDP might help avoid ophthalmic complications.

Ocular Complications in Laparoscopic Surgery: Review of Existing Literature and Possible Prevention and Treatment

During laparoscopic surgery, ocular complications are possible, sometimes leading to devastating visual losses, hardly susceptible to recovery, although rare. Principal ocular adverse events are represented by corneal abrasions and the perioperative visual loss (POVL). POVL onset is related to intraocular pressure elevations (particularly after patient positioning in Trendelenburg or prone decubitus, depending on the surgical procedure), anesthesiologic factors and patients' characteristics. In the light of evidence from the existing literature, the authors suggest surgical and anesthesiologic measures to prevent and manage ocular complications in laparoscopic surgery. Apart from general recommendations, this article indicates practical guidelines specific for robot-assisted laparoscopic interventions and spinal surgery, as well as laparoscopic colorectal resection, radical prostatectomy, and gynecologic surgery. In conclusion, in order to better manage these complications, it is advisable to develop an interdisciplinary collaboration between surgeons, anesthesiologists, and ophthalmologists, on a procedural and medico-legal level, with the intent of mutual training.

Effect of intravenous anesthetic propofol on synaptic vesicle exocytosis at the frog neuromuscular junction

AIM

To investigate the presynaptic effects of propofol, a short-acting intravenous anesthetic, in the frog neuromuscular junction.

METHODS

Frog cutaneous pectoris nerve muscle preparations were prepared. A fluorescent tool (FM1-43) was used to visualize the effect of propofol on synaptic vesicle exocytosos in the frog neuromuscular junction.

RESULTS

Low concentrations of propofol, ranging from 10 to 25 μmol/L, enhanced spontaneous vesicle exocytosis monitored by FM1-43 in a Ca(2+)-dependent and Na(+)-independent fashion. Higher concentrations of propofol (50, 100, and 200 μmol/L) had no effect on spontaneous exocytosis. By contrast, higher concentrations of propofol inhibited the Na(+)-dependent exocytosis evoked by 4-aminopyridine but did not affect the Na(+)-independent exocytosis evoked by KCl. This action was similar and non-additive with that observed by tetrodotoxin, a Na(+) channel blocker.

CONCLUSION

Our data suggest that propofol has a dose-dependent presynaptic effect at the neuromuscular transmission which may help to understand some of the clinical effects of this agent on neuromuscular function.

Magnetoencephalography using total intravenous anesthesia in pediatric patients with intractable epilepsy: lesional vs nonlesional epilepsy

PURPOSE

Magnetoencephalography (MEG) provides source localization of interictal spikes. We use total intravenous anesthesia (TIVA) with propofol to immobilize uncooperative children. We evaluate the effect of TIVA on interictal spikes in children who have intractable epilepsy with or without MRI lesions.

METHODS

We studied 28 children (3-14 years; mean, 6.6). We intravenously administered propofol (30-60 microg/kg/min) to record MEG with simultaneous EEG. We evaluated MEG spike sources (MEGSSs). We compared spikes on simultaneous EEG under TIVA with those on scalp video-EEG without TIVA.

RESULTS

There was a significant decrease in frequent spikes (10 patients, 36%) on simultaneous EEG under TIVA compared to those (22 patients, 79%) on scalp video-EEG without TIVA (P<0.01). MEGSSs were present in 21 (75%) of 28 patients. Clustered MEGSSs occurred in 15 (83%) of 18 lesional patients but in 3 (30%) of 10 nonlesional patients (P<0.05). MEGSSs were more frequently absent in nonlesional (6 patients, 60%) than lesional (one patient, 5%) patients (P<0.01). Thirteen patients with MRI and/or histopathologically confirmed neuronal migration disorder most frequently showed clustered MEGSSs (11 patients, 85%) compared to those of other lesional and nonlesional patients.

CONCLUSION

Propofol-based TIVA reduced interictal spikes on simultaneous EEG. TIVA for MEG still had utility in identifying spike sources in a subset of pediatric patients with intractable epilepsy who were uncooperative and surgical candidates. In lesional patients, MEG under TIVA frequently localized the clustered MEGSSs. Neuronal migration disorders were intrinsically epileptogenic and produced clustered MEGSSs under TIVA. Nonlesional patients often had no MEGSS under TIVA.

Effects of midazolam on acquisition and extinction of conditioned taste aversion memory in rats

Some intravenous anesthetic agents such as midazolam are known to induce anterograde and retrograde amnesia. We analyzed the effect of midazolam by the conditioned taste aversion (CTA) acquisition and retention. After the rats were offered 0.1% sodium saccharin (Sac) as conditioned stimulus (CS), an intraperitoneal (i.p.) injection of several concentrations (5-30mg/kg) of midazolam was followed by an i.p. injection of 0.15M LiCl (2% of body weight) as unconditioned stimulus (US). The rats, which acquired CTA by every CS-US paradigm, strongly avoided Sac on the 1st test day after conditioning and maintained the avoidance for 3 days. We have already reported that Sac intake abruptly increased on the 2nd test day and the almost complete extinction occurred on the 3rd test day after conditioning by injection of subhypnotic dose of propofol before LiCl-injection. In contrast, we found that subhypnotic dose of midazolam suppressed not only CTA acquisition, but also CTA retention. On the other hand, an alpha2-adrenergic blocker, yohimbin (1mg/kg) suppressed only the CTA retention. These results suggest that the subhypnotic doses of midazolam firstly affect the acquisition mechanism of the CTA memory (CTAM), resulting the suppression of the retention of CTAM.

Dynamics of neuronal assemblies are modulated by anaesthetics but not analgesics

BACKGROUND AND OBJECTIVE

We compared heart rate dynamics during surgical levels of propofol and sevoflurane anaesthesia in a highly standardized setting.

METHODS

We recorded electrocardiography from 24 anaesthetized healthy male subjects. In the first parallel part of the study, the subjects were anaesthetized either with sevoflurane (n = 8) or propofol (n = 8) targeted to match 1.0, 1.5 and 2.0 minimal alveolar concentration/effective concentration 50. In the second part, a separate group (n = 8) underwent four different anaesthetic regimens targeted to bispectral index 40: sevoflurane alone, sevoflurane + 70% nitrous oxide, propofol alone and propofol + 70% nitrous oxide. The electrocardiography data were analysed using conventional time and frequency domain methods, and the approximate entropy method, which estimates the complexity of the data.

RESULTS

The induction of anaesthesia was followed by an overall reduction of heart rate variability, evident in all frequency bands in the spectral analysis, and also in the time domain measures. Approximate entropy decreased at 1 effective concentration 50 with propofol and at 2 minimal alveolar concentration with sevoflurane. In the second part of the study, the time domain variables and high-frequency spectral power were all similarly reduced by sevoflurane and propofol anaesthesia, with and without nitrous oxide. Approximate entropy tended to decrease during propofol anaesthesia.

CONCLUSIONS

Hypnotic levels of sevoflurane and propofol anaesthesia suppressed the heart rate variability measured using conventional analysis methods. Deeper surgical levels of anaesthesia also reduce the complexity of heart rate variability.

The effect of the lateral decubitus position on the intraocular pressure in anesthetized patients undergoing lung surgery

BACKGROUND

Changing the body position alters the intraocular pressure (IOP). The aim of this study was to investigate the alteration in IOP of the eyes after a positional change from a supine position to a lateral decubitus position in anesthetized patients, in order to detect differences in IOP between the two eyes, possibly due to a gravity effect, in the lateral decubitus position.

METHODS

IOP was measured in 20 patients undergoing lung surgery. IOP in both eyes was recorded prior to anesthesia in the supine position (baseline), after anesthetic induction but before tracheal intubation in the supine position, at the end of central venous catheterization in the Trendelenburg position, 5 min after a positional change to the lateral decubitus position, once every 30 min until the end of surgery in the lateral decubitus position, and 5 min after changing back to the supine position.

RESULTS

The median IOP (16.3 mmHg; 25-75% percentile, 13-20 mmHg) in the dependent eye 5 min after changing to the lateral decubitus position increased significantly from the baseline median IOP (14.3 mmHg; 13-17.3 mmHg; P < 0.05). The increase in median IOP in the dependent eye persisted until the end of surgery in the lateral decubitus position (19 mmHg; 16.5-22.3 mmHg; P < 0.01 vs. baseline). The median IOP in the dependent eye was significantly higher than that in the non-dependent eye when anesthetized patients were placed in the lateral decubitus position (P < 0.01), and the mean differences in IOP between the eyes in the lateral decubitus position ranged from 2.9 to 4.1 mmHg.

CONCLUSION

The IOP was higher in the dependent eye than in the non-dependent eye in anesthetized patients in the lateral decubitus position, and the IOP in the dependent eye increased in anesthetized patients compared with that in awakened and supine-positioned patients.

Inhibition of Persistent Sodium Current Fraction and Voltage-gated L-type Calcium Current by Propofol in Cortical Neurons: Implications for Its Antiepileptic Activity

PURPOSE

Although it is widely used in clinical practice, the mechanisms of action of 2,6-di-isopropylphenol (propofol) are not completely understood. We examined the electrophysiologic effects of propofol on an in vitro model of epileptic activity obtained from a slice preparation.

METHODS

The effects of propofol were tested both on membrane properties and on epileptiform events consisting of long-lasting, paroxysmal depolarization shifts (PDSs) induced by reducing the magnesium concentration from the solution and by adding bicuculline and 4-aminopyridine. These results were integrated with a patch-clamp analysis of Na(+) and high-voltage activated (HVA) calcium (Ca(2+)) currents from isolated cortical neurons.

RESULTS

In bicuculline, to avoid any interference by gamma-aminobutyric acid (GABA)-A receptors, propofol (3-100 microM) did not cause significant changes in the current-evoked, sodium (Na(+))-dependent action-potential discharge. However, propofol reduced both the duration and the number of spikes of PDSs recorded from cortical neurons. Interestingly, relatively low concentrations of propofol [half-maximal inhibitory concentration (IC(50)), 3.9 microM) consistently inhibited the "persistent" fraction of Na(+) currents, whereas even high doses (< or =300 microM) had negligible effects on the "fast" component of Na(+) currents. HVA Ca(2+) currents were significantly reduced by propofol, and the pharmacologic analysis of this effect showed that propofol selectively reduced L-type HVA Ca(2+) currents, without affecting N or P/Q-type channels.

CONCLUSIONS

These results suggest that propofol modulates neuronal excitability by selectively suppressing persistent Na(+) currents and L-type HVA Ca(2+) conductances in cortical neurons. These effects might cooperate with the opening of GABA-A-gated chloride channels, to achieve depression of cortical activity during both anesthesia and status epilepticus.

Propofol-block of SK channels in reticular thalamic neurons enhances GABAergic inhibition in relay neurons

The GABAergic reticular thalamic nucleus (RTN) is a major source of inhibition for thalamocortical neurons in the ventrobasal complex (VB). Thalamic circuits are thought to be an important anatomic target for general anesthetics. We investigated presynaptic actions of the intravenous anesthetic propofol in RTN neurons, using RTN-retained and RTN-removed brain slices. In RTN-retained slices, focal and bath application of propofol increased intrinsic excitability, temporal summation, and spike firing rate in RTN neurons. Propofol-induced activation was associated with suppression of medium afterhyperpolarization potentials. This activation was mimicked and completely occluded by the small conductance calcium-activated potassium (SK) channel blocker apamin, indicating that propofol could enhance RTN excitability by blocking SK channels. Propofol increased GABAergic transmission at RTN-VB synapses, consistent with excitation of presynaptic RTN neurons. Stimulation of RTN resulted in synaptic inhibition in postsynaptic neurons in VB, and this inhibition was potentiated by propofol in a concentration-dependent manner. Removal of RTN resulted in a dramatic reduction of both spontaneous postsynaptic inhibitory current frequency and propofol-mediated inhibition of VB neurons. Thus the existence and activation of RTN input were essential for propofol to elicit thalamocortical suppression; such suppression resulted from shunting through the postsynaptic GABA(A) receptor-mediated chloride conductance. The results indicate that propofol enhancement of RTN-mediated inhibitory input via blockade of SK channels may play a critical role in "gating" spike firing in thalamocortical relay neurons.

Major Role For Tonic GABAA Conductances in Anesthetic Suppression of Intrinsic Neuronal Excitability

Anesthetics appear to produce neurodepression by altering synaptic transmission and/or intrinsic neuronal excitability. Propofol, a widely used anesthetic, has proposed effects on many targets, ranging from sodium channels to GABAA inhibition. We examined effects of propofol on the intrinsic excitability of hippocampal CA1 neurons (primarily interneurons) recorded from adult rat brain slices. Propofol strongly depressed action potential production induced by DC injection, synaptic stimulation, or high-potassium solutions. Propofol-induced depression of intrinsic excitability was completely reversed by bicuculline and picrotoxin but was strychnine-insensitive, implicating GABAA but not glycine receptors. Propofol strongly enhanced inhibitory postsynaptic currents (IPSCs) and induced a tonic GABAA-mediated current. We pharmacologically differentiated tonic and phasic (synaptic) GABAA-mediated inhibition using the GABAA receptor antagonist SR95531 (gabazine). Gabazine (20 μM) completely blocked both evoked and spontaneous IPSCs but failed to block the propofol-induced depression of intrinsic excitability, implicating tonic, but not phasic, GABAA inhibition. Glutamatergic synaptic responses were not altered by propofol (≤30 μM). Similar results were found in both interneurons and pyramidal cells and with the chemically unrelated anesthetic thiopental. These results suggest that suppression of CA1 neuron intrinsic excitability, by these anesthetics, is largely due to activation of tonic GABAA conductances; although other sites of action may play important roles in affecting synaptic transmission, which also can produce strong neurodepression. We propose that for some anesthetics, suppression of intrinsic excitability, mediated by tonic GABAA conductances, operates in conjunction with effects on synaptic transmission, mediated by other mechanisms, to depress hippocampal function during anesthesia.

Intravenous Subhypnotic Propofol in Central Pain

OBJECTIVE

To validate IV subhypnotic propofol, a gamma-aminobutyric acid A (GABA-A) agonist, as a diagnostic test for central pain.

METHODS

The efficacy of systemic propofol (0.2 mg/kg IV bolus) was evaluated in a double-blind, placebo-controlled and crossover fashion on both spontaneous ongoing pain and allodynia in 44 patients with chronic central pain of both brain and cord origin.

RESULTS

Propofol was significantly superior to the placebo (Intralipid, Kabi Pharmacia) in reducing the intensity of spontaneous ongoing pain for up to 1 hour after the injection: 24 of 44 patients (55%) receiving propofol showed a significant reduction in spontaneous pain, whereas only 6 patients showed this after the placebo. Propofol also significantly reduced the intensity of both mechanical and cold allodynia. In a few cases, only the evoked components were abolished but not the spontaneous pain. In general, the side effects were minimal and consisted mainly of transitory burning upon injection of both propofol and placebo and slight lightheadedness in a few cases.

CONCLUSIONS

Systemic propofol induces analgesic effects on all studied components of central pain and highlights the key role of GABA modulation in central pain.

Interactions between non-barbiturate injectable anesthetics and conventional antiepileptic drugs in the maximal electroshock test in mice--an isobolographic analysis

The aim of this study was the isobolographic evaluation of interactions between three non-barbiturate intravenous anesthetics and conventional antiepileptic drugs in the maximal electroshock-induced seizures in mice. Electroconvulsions were produced by means of an alternating current (ear-clip electrodes, 0.2-s stimulus duration, tonic hindlimb extension taken as the endpoint). Adverse effects were evaluated in the chimney test (motor performance) and passive avoidance task (long-term memory). Plasma levels of antiepileptic drugs were measured by immunofluorescence. Obtained results indicate that ketamine acts synergistically with valproate and carbamazepine. Also the combinations of propofol and valproate or phenobarbital led to synergistic interactions. An antagonism was found between etomidate and carbamazepine or phenobarbital. On the other hand, interactions between diphenylhydantoin and injectable anesthetics proved to be additive. The only exception was the combination of diphenylhydantoin and propofol (1:3). Pharmacokinetic phenomena do not seem to interfere with the observed interactions, since none of anesthetics influenced the free plasma concentrations of antiepileptic drugs. Referring to undesired effects, only propofol impaired long-term memory. Although propofol did not disturbed motor coordination, it enhanced motor impairment caused by carbamazepine and diphenylhydantoin. Results of the present study suggest that etomidate needs to be avoided in epileptic patients due to a possibility of negative interactions with some antiepileptic drugs and seizure precipitation.

Inhibition by propofol of intracellular calcium mobilization in cultured mouse pituitary cells

Propofol inhibited regulated secretion of the neuropeptide beta-endorphin from AtT-20 cells, a pituitary tumor cell line. Neuropeptide secretion depends on an increase of intracellular calcium (Ca(2+)) levels. We investigated the hypothesis that propofol altered intracellular Ca(2+) levels in AtT-20 cells. Propofol (100 microM) did not inhibit Ca(2+)-induced secretion of beta-endorphin from digitonin-permeabilized cells. Thus, propofol did not inhibit neuropeptide secretion by blocking the effects of increased intracellular Ca(2+). Intracellular Ca(2+) was measured in intact cells using a Ca(2+)-sensitive dye. Ca(2+) transients were generated by depolarization with KCl or by incubation with thapsigargin (an inhibitor of Ca(2+) uptake into the endoplasmic reticulum). Propofol inhibited generation of Ca(2+) transients in intact cells by KCl (half-maximal inhibitory concentration of 14.9 microM; P < 0.05). Nitrendipine also inhibited potassium-induced Ca(2+) peaks. Propofol 50 microM reduced the thapsigargin-induced Ca(2+) peak to 47% of control (P < 0.05). Thapsigargin-induced Ca(2+) peaks were not affected by calcium channel blockade by nitrendipine. Propofol inhibited the stimulus-induced increase in intracellular Ca(2+). Propofol inhibited thapsigargin-induced Ca(2+) transients, but nitrendipine did not, indicating that propofol had effects on intracellular Ca(2+) independent of blockade of L-type Ca(2+) channels. Propofol may inhibit release of Ca(2+) from intracellular stores. These results are consistent with the hypothesis that propofol inhibits neuropeptide secretion by inhibiting the stimulus-induced increase in intracellular Ca(2+).

IMPLICATIONS

Propofol may block both entry of calcium into cells and release of calcium from intracellular stores, thereby inhibiting regulated secretion of neuropeptides. Study of the effects of propofol on intracellular calcium metabolism may increase understanding of how propofol alters brain function and may aid development of better IV anesthetics.

Effects of etomidate, ketamine or propofol, and their combinations with conventional antiepileptic drugs on amygdala-kindled convulsions in rats

Ketamine, etomidate and propofol modified behavioral and electrographic correlates of kindled seizures in rats. In detail, ketamine (5 mg/kg) and propofol (15 mg/kg) significantly increased afterdischarge threshold, reduced seizure severity and shortened seizure and afterdischarge durations. Etomidate (7.5 mg/kg) was effective in terms of seizure and afterdischarge durations. Moreover, the combinations of ketamine (2.5 mg/kg) with carbamazepine (15 mg/kg) or valproate (50 mg/kg; all drugs at their subeffective doses), reduced the severity and duration of kindled seizures. The antiseizure potency of the ketamine/carbamazepine combination was comparable to that of carbamazepine alone administered at 20 mg/kg, while the effect of ketamine/valproate was comparable to the efficacy of valproate alone at 100 mg/kg. However, the combinations of ketamine with phenobarbital or diphenylhydantoin did not exert any protective action. Propofol and etomidate entirely failed to interact with conventional antiepileptics. The combinations of ketamine with carbamazepine or valproate did not induce any significant motor impairment in the chimney test or memory deficit in the passive avoidance task. A pharmacokinetic interaction, at least in plasma, can be excluded, because ketamine (2.5 mg/kg) did not affect the free plasma concentrations of carbamazepine or valproate. Results of the present study may suggest that there may be no risk of negative interactions between injectable anesthetics and antiepileptics in cases of partial epilepsy.

Effects of General Anesthetics on Regulation of the Peripheral Vasculature

The heart is a passively filling pump in a circulatory system that is connected in series with distensible blood vessels. Therefore, systemic blood pressure and tissue perfusion depend upon adequate peripheral vascular tone as well as myocardial function. Likewise, pharmacologic agents that alter circulatory stability can affect one or both of these components. The generalized depressor effects of general anesthetics have been well known clinically for over 50 years. Moreover, there are many similarities in basic cellular regulatory mechanisms among the different tissue types, and general anesthetics are well known to distribute freely among the perfusion-rich tissues (eg, central nervous system, cardiovascular system, and renal system). Therefore, it is likely that the hemodynamic depression resulting from the systemic administration of anesthetics results from actions on regulatory mechanisms of the peripheral vasculature as well as on the heart. The peripheral vasculature is regulated by extrinsic neural, endothelial, and humoral mechanisms, which interact with each other as well as with intrinsic membrane and intracellular systems within the vascular smooth muscle cell. Different general anesthetics have been found to act on specific mechanisms at each of these levels. However, the large number and complexity of these known mechanisms, as well as the many anesthetic agents, has made it extremely difficult to determine which are significant in terms of the meaningful mechanisms that are responsible for anesthetic action, major side effects, or both. Current knowledge about the effects of general anesthetics on both the extrinsic intrinsic regulatory mechanisms of peripheral vascular control is reviewed.

Intraocular pressure changes during laparoscopy in patients anesthetized with propofol total intravenous anesthesia versus isoflurane inhaled anesthesia

We examined intraocular pressure (IOP) changes during gynecologic laparoscopy performed under either thiopental-isoflurane anesthesia or total IV propofol anesthesia. Forty adult women with no preexisting eye disease scheduled for gynecologic CO(2) insufflation laparoscopy were included in the study. Heart rate, mean arterial blood pressure, peak and plateau airway pressure, ETCO(2), and IOP (using a Schioetz tonometer) were measured at defined intervals during the procedure. IOP decreased significantly after the induction of anesthesia in both groups, and remained so throughout the procedure in the propofol group. In the isoflurane group, however, IOP was increased significantly above the preinduction level after pneumoperitoneum with head-down position. There was no correlation between IOP and blood pressure or airway pressure. In conclusion, propofol total IV anesthesia may be a better choice for laparoscopic surgery should control of IOP be a concern.

IMPLICATIONS

In this study, we examined the effect of two anesthetic techniques on the intraocular pressure changes during laparoscopic surgery in healthy subjects. Propofol IV anesthesia protected against increases in intraocular pressure with pneumoperitoneum and head-down position.

Subhypnotic doses of propofol accelerate extinction of conditioned taste aversion

Subhypnotic doses of propofol accelerate extinction of conditioned taste aversion. Some intravenous anesthetic agents including propofol is known to induce anterograde and retrograde amnesia. We evaluated whether propofol affect the long-term memory formed by the conditioned taste aversion (CTA) paradigm. Rats were allowed a 4h access to water through the experiments. After preconditioning water intake, the rats were offered 0.1% sodium saccharin (Sac) as conditioned stimulus (CS) for 20 min. An intraperitoneal (i.p.) injection of several concentrations (0.5-100 mg/kg) of propofol 10 min after Sac exposure was followed by an i.p. injection of 0.15M LiCl (2% of body weight) as unconditioned stimulus (US) 30 min after CS-exposure. The volumes of intake of Sac for 20 min were measured on the successive 4 days. The rats, which acquired CTA by every CS-US paradigm, strongly avoided Sac on the first test day after conditioning and maintained the avoidance for 3 days. However, when subhypnotic dose of propofol was injected before LiCl-injection, Sac intake abruptly increased on the second test day and the almost complete extinction occurred on the third test day after conditioning. The extinction process of CTA was barely affected by hypnotic dose of propofol. These results suggest that propofol affects the retention mechanism of the CTA memory in a dose-dependent manner. Subhypnotic dose of propofol may affect the sub-cellular process of the memory consolidation in CTA.

Suppression of the hyperpolarization-activated inward current contributes to the inhibitory actions of propofol on rat CA1 and CA3 pyramidal neurons

Intracellular and field potential recordings were taken from the hippocampal CA1 and CA3 neurons in rat brain slices to investigate the effects of 2,6 di-isopropylphenol (propofol) on the neuronal excitability during GABA(A)-C1 channel blockade by picrotoxin (100 microM). Propofol produced a membrane hyperpolarization and an inhibition of the magnitude of the 'voltage sag' that was mediated by the activation of a hyperpolarization-activated inward current (I(H)). Propofol (>100 microM) decreased the spontaneous discharge rate of epileptiform burst responses in CA1 neurons up to 38+/-6% of the control level. Propofol also markedly reduced the duration of both spontaneous and evoked epileptiform burst responses. A propofol-induced decrease in the spontaneous discharge rate in CA3 neurons was coincident with that in CA1 neurons. The effects of propofol on the membrane potential and spontaneous discharge rate but not on the duration of burst responses were duplicated by ZD7288 (potent selective antagonist for I(H) channels), indicating that the blockade of I(H) significantly contributes to reduction of cell's excitability. The present study suggests that various actions including suppressive effects on I(H) contribute to the anesthetic and anti-convulsant properties of propofol.

Effects of halothane and propofol on excitatory and inhibitory synaptic transmission in rat cortical neurons

General anesthetics are thought to act on both excitatory and inhibitory neuronal pathways at both post- and presynaptic sites. However, the literature in these regards is somewhat controversial. The aim of the present study was to reassess the relative importance of the various anesthetic actions using a common preparation. Rat cortical neurons in primary culture were used to record spontaneous miniature postsynaptic currents by the whole-cell patch-clamp technique. Halothane at clinically relevant concentrations prolonged the decay phase of spontaneous miniature inhibitory postsynaptic currents (mIPSCs) recorded in the presence of tetrodotoxin and at higher concentrations decreased the frequency of mIPSCs. The mIPSC amplitudes underwent little change. Spontaneous action potential-dependent IPSCs recorded in the absence of tetrodotoxin were similarly affected by halothane. Halothane also decreased the frequency of spontaneous miniature non-N-methyl-D-aspartate (NMDA) excitatory postsynaptic currents (mEPSCs) as well as spontaneous action potential-dependent NMDA EPSCs and non-NMDA EPSCs without affecting their decay phase. The halothane effect on mIPSC and mEPSC frequency was dependent on the external calcium concentration. In contrast to halothane, the only effect of propofol was the prolongation of the decay phase of mIPSCs and IPSCs. The prolongation of mIPSCs and IPSCs by halothane and propofol coupled with the ineffectiveness on mEPSCs and EPSCs suggests a selective postsynaptic modulation of GABA(A) receptors. The additional calcium-dependent inhibition of mIPSC and mEPSC frequency by halothane (but not propofol) suggests a more general mechanism by this anesthetic on presynaptic transmitter release.

Propofol suppresses a hyperpolarization-activated inward current in rat hippocampal CA1 neurons

We examined the effect of propofol and thiopental, intravenous anesthetics, on the hyperpolarization-activated inward current (I(H)), whose functional role on the neuronal activity has been evaluated. Whole-cell recordings of I(H) evoked by hyperpolarizing step pulses were taken from hippocampal CA1 neurons in rat brain slices. Propofol reduced I(H) current in a dose-dependent manner. However, thiopental had no significant effect on the activation of I(H). According to the functional role of I(H), the suppression of I(H) should result in a reduction of neuronal activity. We suggest that the effectiveness of propofol as an anticonvulsant or an antiemetic is associated with the blockade of the I(H) channel.

Structure-specific membrane-fluidizing effect of propofol

1. While recent studies about the pharmacological mechanism of the intravenous anaesthetic propofol (2,6-diisopropylphenol) have focused on its interaction with functional proteins, there is the possibility that propofol alters membrane properties to produce anaesthesia. In the present study, the structure-specific effects of propofol on liposomal model membranes were studied. 2. The effect of propofol on the phase transition of membrane phospholipid was analysed spectrophotometrically using 1,2-dipalmitoyl-L-alpha-phosphatidylcholine liposomes. Propofol (50-200 micromol/L) lowered the phase transition temperature to fluidize membranes. 3. Membrane fluidization was also analysed by measuring fluorescence polarization of liposomes consisting of 1,2- dipalmitoyl-L-alpha-phosphatidylcholine, 1-palmitoyl-2-oleoyl-L- alpha-phosphatidylcholine and cholesterol with different probes. Propofol fluidized all liposomal membranes in the concentration range 5-500 micromol/L by acting on both the inner and outer layers of the membranes. 4. The membrane effects of propofol were compared with those of 2,6-dialkylphenols, 1,3-dialkylbenzenes, 2-alkylphenols and alkylbenzenes. Although the membrane-fluidizing effects were shared by a series of structural analogues, propofol was most effective in fluidizing membranes, especially liposomal membranes consisting of 20 mol% cholesterol and 80 mol% 1-palmitoyl-2-oleoyl-L-alpha-phosphatidylcholine. 5. Lipophilicity was compared between propofol and its structural analogues using their capacity factors, determined by reverse-phase high-performance liquid chromatography. The potency of propofol to fluidize membranes was much greater than anticipated from its lipophilicity. 6. At 0.125-1.0 micromol/L, almost corresponding to clinically relevant concentrations, propofol significantly enhanced membrane fluidity of cholesterol-containing 1-palmitoyl-2-oleoyl-L-alpha-phosphatidylcholine liposomes. 7. These results indicate that propofol fluidizes membranes in a structure-specific manner through an interaction with membrane lipids. Such a membrane effect may be responsible for the mode of anaesthetic action of propofol.