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Deguchi H, Furutani K, Mitsuma Y, Kamiya Y, Baba H. Propofol reduces the amplitude of transcranial electrical motor-evoked potential without affecting spinal motor neurons: a prospective, single-arm, interventional study. J Anesth 2021; 35:434-441. [PMID: 33825982 DOI: 10.1007/s00540-021-02927-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Propofol inhibits the amplitudes of transcranial electrical motor-evoked potentials (TCE-MEP) in a dose-dependent manner. However, the mechanisms of this effect remain unknown. Hence, we investigated the spinal mechanisms of the inhibitory effect of propofol on TCE-MEP amplitudes by evaluating evoked electromyograms (H-reflex and F-wave) under general anesthesia. METHODS We conducted a prospective, single-arm, interventional study including 15 patients scheduled for spine surgery under general anesthesia. Evoked electromyograms of the soleus muscle and TCE-MEPs were measured at three propofol concentrations using target-controlled infusion (TCI: 2.0, 3.0, and 4.0 µg/mL). The primary outcome measure was the left H-reflex amplitude during TCI of 4.0- compared to 2.0-µg/mL propofol administration. RESULTS The median [interquartile range] amplitudes of the left H-reflex were 4.71 [3.42-6.60] and 5.6 [4.17-7.46] in the 4.0- and 2.0-μg/mL TCI groups (p = 0.4, Friedman test), respectively. There were no significant differences in the amplitudes of the right H-reflex and the bilateral F-wave among these groups. However, the TCE-MEP amplitudes significantly decreased with increased propofol concentrations (p < 0.001, Friedman test). CONCLUSION Propofol did not affect the amplitudes of the H-reflex and the F-wave, whereas TCE-MEP amplitudes were reduced at higher propofol concentrations. These results suggested that propofol can suppress the TCE-MEP amplitude by inhibiting the supraspinal motor pathways more strongly than the excitability of the motor neurons in the spinal cord.
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Affiliation(s)
- Hiroyuki Deguchi
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8520, Japan
| | - Kenta Furutani
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8520, Japan.
| | - Yusuke Mitsuma
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8520, Japan
| | - Yoshinori Kamiya
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8520, Japan
| | - Hiroshi Baba
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, 1-754 Asahimachi-Dori, Chuo-ku, Niigata, 951-8520, Japan
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Kondo T, Toyota Y, Narasaki S, Watanabe T, Miyoshi H, Saeki N, Tsutsumi YM. Intraoperative responses of motor evoked potentials to the novel intravenous anesthetic remimazolam during spine surgery: a report of two cases. JA Clin Rep 2020; 6:97. [PMID: 33300097 PMCID: PMC7726079 DOI: 10.1186/s40981-020-00401-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/11/2020] [Accepted: 11/26/2020] [Indexed: 12/03/2022] Open
Abstract
Background Remimazolam is a novel short-acting benzodiazepine characterized by metabolism independent from organ function. We report intraoperative MEP responses of two patients who underwent spine surgery under general anesthesia using remimazolam. Case presentation In case 1, MEP monitoring was successfully performed with the use of a fixed dose of remimazolam at 0.5 mg/kg/h and remifentanil at 0.2 μg/kg/min. In case 2, an increasing dose of remimazolam from 0.5 to 1.5 mg/kg/h during the operation did not affect MEP signals. In both cases, remimazolam was titrated to maintain the values of entropy electroencephalogram (EEG) monitoring at 40–60. Conclusions General anesthesia using remimazolam and remifentanil can be a valuable alternative for spine surgery with MEP monitoring by EEG to assess the optimal dose.
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Affiliation(s)
- Takashi Kondo
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Yukari Toyota
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Soshi Narasaki
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Tomoyuki Watanabe
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Hirotsugu Miyoshi
- Department of Anesthesiology and Critical Care, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Noboru Saeki
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Yasuo M Tsutsumi
- Department of Anesthesiology and Critical Care, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Ugawa R, Takigawa T, Shimomiya H, Ohnishi T, Kurokawa Y, Oda Y, Shiozaki Y, Misawa H, Tanaka M, Ozaki T. An evaluation of anesthetic fade in motor evoked potential monitoring in spinal deformity surgeries. J Orthop Surg Res 2018; 13:227. [PMID: 30185199 PMCID: PMC6126029 DOI: 10.1186/s13018-018-0934-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/30/2018] [Indexed: 12/18/2022] Open
Abstract
Background Intraoperative neuromonitoring using motor evoked potentials (MEP) satisfactorily detects motor tract integrity changes during spinal surgery. However, monitoring is affected by “anesthetic fade,” in which the stimulation threshold increases because the waveform amplitude decreases with the accumulation of propofol. Therefore, the purpose of this study was to clarify the effect of anesthetic fade on transcranial MEPs by investigating the time-dependent changes of amplitude during spinal deformity surgeries. Methods We retrospectively reviewed medical records of 142 spinal deformity patients (66 patients with idiopathic scoliosis, 28 with adult spinal deformities, 19 with neuromuscular scoliosis, 17 with syndromic scoliosis, and 12 with congenital scoliosis). The average age was 28 years (range, 5 to 81 years). MEPs were recorded bilaterally from the abductor digiti minimi (ADM) and abductor hallucis (AH) muscles during spinal deformity surgeries. The Wilcoxon signed-rank test was used to investigate the time-dependent changes of amplitude after propofol infusion to evaluate anesthetic fade effects. Results The average time to baseline from initial propofol infusion was 113 min (range, 45 to 182 min). In the ADM, the amplitude was 52% at 1 h after initial propofol infusion, 102% at 2 h, 105% at 3 h, 101% at 4 h, 86% at 5 h, and 81% at 6 h. Compared to the 2-h time point, MEP decreased significantly by 16% at 5 h (P < 0.0005) and by 21% at 6 h (P < 0.05). In the AH, the amplitude was 49% at 1 h after initial infusion of propofol, 102% at 2 h, 102% at 3 h, 92% at 4 h, 71% at 5 h, and 63% at 6 h. Compared to the 2-h time point, MEP decreased significantly by 10% at 4 h (P < 0.005), by 31% at 5 h (P < 0.0000005), and by 39% at 6 h (P < 0.05). Conclusions MEP amplitude significantly decreased in the upper limbs at 5 and 6 h and in the lower limbs at 4, 5, and 6 h after the initial infusion of propofol, respectively. The influence of anesthetic fade could influence false positive MEPs during long spinal surgeries.
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Affiliation(s)
- Ryo Ugawa
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Tomoyuki Takigawa
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan.
| | - Hiroko Shimomiya
- Division of Medical Support, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Takuma Ohnishi
- Division of Medical Support, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Yuri Kurokawa
- Division of Medical Support, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Yoshiaki Oda
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Yasuyuki Shiozaki
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Haruo Misawa
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
| | - Masato Tanaka
- Department of Orthopedic Surgery, Okayama Rosai Hospital, 1-10-25 Chikko-Midorimachi, Okayama City, Okayama, 702-8055, Japan
| | - Toshifumi Ozaki
- Department of Orthopedic Surgery, Okayama University Hospital, 2-5-1 Shikata-cho, Okayama City, Okayama, 700-8558, Japan
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Lo YL, Tan YE, Raman S, Teo A, Dan YF, Guo CM. Systematic re-evaluation of intraoperative motor-evoked potential suppression in scoliosis surgery. Scoliosis Spinal Disord 2018; 13:12. [PMID: 29988605 PMCID: PMC6027569 DOI: 10.1186/s13013-018-0161-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/12/2018] [Indexed: 11/10/2022]
Abstract
Background Motor- (MEP) and somatosensory-evoked potentials (SSEP) are susceptible to the effects of intraoperative environmental factors. Methods Over a 5-year period, 250 patients with adolescent idiopathic scoliosis (AIS) who underwent corrective surgery with IOM were retrospectively analyzed for MEP suppression (MEPS). Results Our results show that four distinct groups of MEPS were encountered over the study period. All 12 patients did not sustain any neurological deficits postoperatively. However, comparison of groups 1 and 2 suggests that neither the duration of anesthesia nor speed of surgical or anesthetic intervention were associated with recovery to a level beyond the criteria for MEPS. For group 3, spontaneous MEPS recovery despite the lack of surgical intervention suggests that anesthetic intervention may play a role in this process. However, spontaneous MEPS recovery was also seen in group 4, suggesting that in certain circumstances, both surgical and anesthetic intervention was not required. In addition, neither the duration of time to the first surgical manoeuver nor the duration of surgical manoeuver to MEPS were related to recovery of MEPS. None of the patients had suppression of SSEPs intraoperatively. Conclusion This study suggests that in susceptible individuals, MEPS may rarely occur unpredictably, independent of surgical or anesthetic intervention. However, our findings favor anesthetic before surgical intervention as a proposed protocol. Early recognition of MEPS is important to prevent false positives in the course of IOM for spinal surgery.
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Affiliation(s)
- Yew Long Lo
- 1Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Outram Road, Academia Level 4, Singapore, 169608 Singapore.,2Duke-NUS Medical School, Singapore, Singapore
| | - Yam Eng Tan
- 3Singapore General Hospital, Singapore, Singapore
| | | | - Adeline Teo
- 3Singapore General Hospital, Singapore, Singapore
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Wang Y, Wu J, Lin Q, Nauta H, Yue Y, Fang L. Effects of general anesthetics on visceral pain transmission in the spinal cord. Mol Pain 2008; 4:50. [PMID: 18973669 PMCID: PMC2584043 DOI: 10.1186/1744-8069-4-50] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Accepted: 10/30/2008] [Indexed: 12/30/2022] Open
Abstract
Current evidence suggests an analgesic role for the spinal cord action of general anesthetics; however, the cellular population and intracellular mechanisms underlying anti-visceral pain by general anesthetics still remain unclear. It is known that visceral nociceptive signals are transmited via post-synaptic dorsal column (PSDC) and spinothalamic tract (STT) neuronal pathways and that the PSDC pathway plays a major role in visceral nociception. Animal studies report that persistent changes including nociception-associated molecular expression (e.g. neurokinin-1 (NK-1) receptors) and activation of signal transduction cascades (such as the protein kinase A [PKA]-c-AMP-responsive element binding [CREB] cascade)-in spinal PSDC neurons are observed following visceral pain stimulation. The clinical practice of interruption of the spinal PSDC pathway in patients with cancer pain further supports a role of this group of neurons in the development and maintenance of visceral pain. We propose the hypothesis that general anesthetics might affect critical molecular targets such as NK-1 and glutamate receptors, as well as intracellular signaling by CaM kinase II, protein kinase C (PKC), PKA, and MAP kinase cascades in PSDC neurons, which contribute to the neurotransmission of visceral pain signaling. This would help elucidate the mechanism of antivisceral nociception by general anesthetics at the cellular and molecular levels and aid in development of novel therapeutic strategies to improve clinical management of visceral pain.
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Affiliation(s)
- Yun Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, PR China.
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Kakinohana M, Miyata Y, Tomiyama H, Sugahara K. Nitrous oxide can enhance the hypnotic effect, but not the suppression of spinal motor neuron excitability by propofol in humans. J Anesth 2006; 20:173-8. [PMID: 16897235 DOI: 10.1007/s00540-006-0394-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Accepted: 02/09/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE We investigated whether nitrous oxide can enhance the suppressive effect of propofol on spinal motor neuron excitability in humans. METHODS Sixteen adult patients were prospectively randomly assigned to be given either propofol alone (group P; n = 8) or a supplement of 66% nitrous oxide with propofol (group PN; n = 8) for intraoperative sedation. Propofol was administered by a target-controlled infusion system to maintain sequentially increasing plasma propofol concentrations (Cpt) of 0.5, 0.8, 1.0, 1.3, 1.5 and 1.8 microg x ml(-1) in all patients. Assessment of the patient's level of sedation in both groups was performed with the Wilson Sedation Scale (WSS). F-wave analysis on the left abductor pollicis brevis muscle was carried out for the assessment of spinal motor neuron excitability at each plasma propofol concentration. RESULTS Significant differences in the WSS scores between group P and group PN were observed at 0.8, 1.0, 1.3, and 1.5 microg x ml(-1) of Cpt (group P < group PN; P < 0.01). Cpt greater than 1.0 microg x ml(-1) significantly reduced F-wave persistence in a concentration-dependent manner, and the ICpt 50 and ICpt 95 values for plasma propofol concentration (plasma propofol concentrations that produced 50% and 95% inhibition of the baseline, respectively) were 1.05 and 1.95 microg x ml(-1) in group P, and 1.07 and 2.14 microg x ml(-1) in group PN, respectively. CONCLUSION These results suggest that nitrous oxide can enhance the hypnotic effect, but not the suppression of spinal motoneuron excitability by propofol in humans at clinical levels of Cpt.
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Affiliation(s)
- Manabu Kakinohana
- Division of Anesthesia, Okinawa Prefectural Miyako Hospital, Okinawa, Japan
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Ahrens J, Haeseler G, Leuwer M, Mohammadi B, Krampfl K, Dengler R, Bufler J. 2,6 di-tert-butylphenol, a nonanesthetic propofol analog, modulates alpha1beta glycine receptor function in a manner distinct from propofol. Anesth Analg 2004; 99:91-96. [PMID: 15281510 DOI: 10.1213/01.ane.0000120083.10269.54] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The anesthetic propofol (2,6 diisopropylphenol) mediates some of its effects by activating inhibitory chloride currents in the lower brainstem and spinal cord. The effects comprise direct activation of gamma-aminobutyric acid-A and glycine receptors in the absence of the natural agonist, as well as potentiation of the effect of submaximal agonist concentrations. Replacement of propofol's isopropyl groups by di-tert-butyl groups yields a compound without in vivo anesthetic effects. We have studied the effects of propofol and 2,6 di-tert-butylphenol on chloride inward currents via rat alpha1beta glycine receptors heterologously expressed in human embryonic kidney cells. Propofol, but not 2,6 di-tert-butylphenol, directly activated glycine receptors; half-maximal current activation was observed with propofol 114 +/- 27 microM. Both compounds potentiated the effect of a submaximal glycine concentration (10 microM) to a maximum value of 136% +/- 71% (propofol) and 279% +/- 109% (2,6 di-tert-butylphenol) of the response to glycine 10 microM. The 50% effective concentration for this effect was 12.5 +/- 6.4 microM and 9.4 +/- 10.2 microM for propofol and 2,6 di-tert-butylphenol, respectively. Propofol and its nonanesthetic structural analog do not differ in their ability to coactivate the glycine receptor but differ in their ability to directly activate the receptor in the absence of the natural agonist.
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Affiliation(s)
- Jörg Ahrens
- Departments of *Anaesthesiology and ‡Neurology and Neurophysiology, Hannover Medical School, Hannover, Germany; and †University Department of Anaesthesia, The University of Liverpool, Liverpool, United Kingdom
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