9A

THIS MONTH IN

Anesthesiology
Placental Transfer and Fetal Metabolic Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery . . . . . . . . . . . . . . . . . . . 506
Use of ephedrine versus phenylephrine for treatment of hypotension during spinal anesthesia for cesarean delivery remains controversial despite the observation that ephedrine use is associated with depression of fetal acid– base status. The authors hypothesized that the mechanism underlying this fetal acidosis is transfer of ephedrine across the placenta and stimulation of metabolism in the fetus. In this randomized double-blind study, 104 women undergoing elective cesarean delivery with spinal anesthesia received infusion of phenylephrine or ephedrine titrated to systolic blood pressure. Placental transfer was greater for ephedrine (median umbilical venous [UV]/maternal arterial [MA] plasma concentration ratio 1.13 vs. 0.17). Ephedrine crosses the placenta to a greater extent and the associated increased fetal concentrations of lactate, glucose, and catecholamines support the hypothesis that depression of fetal pH and base excess with ephedrine is related to metabolic effects secondary to stimulation of fetal beta adrenergic receptors. See the accompanying Editorial View on page 470

Predictors of Postoperative Pain and Analgesic Consumption: A Qualitative Systematic Review (Review Article) . . . . . . . . . . . . . . . . . . 657
Preexisting pain, anxiety, age, and type of surgery are significant predictors for postoperative pain.

Perioperative Peripheral Nerve Injuries: A Retrospective Study of 380,680 Cases during a 10-year Period at a Single Institution . . . . . . . . . . . . . . 490
Databases were searched for peripheral nerve injuries over a 10-year period at a single institution. See the accompanying
Editorial View on page 464

Epinephrine Impairs Lipid Resuscitation from Bupivacaine Overdose: A Threshold Effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
This study compared the effect of escalating doses of epinephrine in combination with lipid infusion on recovery from bupivacaine overdose using a rat model. Epinephrine improved the initial return of spontaneous circulation (rate-pressure product Ͼ 30% baseline) but only 3 of 5 rats at 10 mcg/kg and 1 of 5 rats at 25 mcg/kg sustained return of spontaneous circulation by 15 min. Lipid alone resulted in slower but more sustained recovery. Epinephrine doses greater than 10 mcg/kg increased lactate, worsened acidosis, and resulted in poor recovery at 15 min compared with the lipid only group. Epinephrine doses greater than 10 mcg/kg impair lipid resuscitation from bupivacaine overdose in rats, possibly by inducing hyperlactatemia. See the accompanying Editorial View on page 467

Effects of Remifentanil on the Spectrum and Quantitative Parameters of Electroencephalogram in Propofol Anesthesia . . . . . 574
Coadministration of opioids challenges the reliability of the spectral properties of the electroencephalogram in the depthof-anesthesia estimation.

Does Postoperative Delirium Limit the Use of Patient-controlled Analgesia in Older Surgical Patients? . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
In previous studies, postoperative pain was an independent predictor of postoperative delirium. This study examined whether postoperative delirium affects patient-controlled analgesia (PCA) use in older patients undergoing noncardiac surgery and receiving PCA for postoperative analgesia. Of 335 elderly patients, 68% developed delirium by postoperative day 2. Despite more opioid use, patients with delirium reported higher visual analog scale scores than those without delirium. Future studies on delirium should consider the role of pain and pain management as potential etiologic factors.

Precision of Traditional Approaches for Lumbar Plexus Block: Impact and Management of Interindividual Anatomic Variability . . . . . . . . . . 525 Role of Central and Mixed Venous Oxygen Saturation Measurement in Perioperative Care (Review Article) . . . . . 649
Venous oxygen saturation as a therapeutic target may be associated with improvements in outcome. Traditional approaches to the lumbar plexus (LP) using surface landmarks can be inaccurate. The aim of this study was to determine the accuracy of traditional approaches to the LP and determine if modifications could increase their accuracy. The LP region of 48 formalin-fixed cadavers was dissected and relevant landmarks were marked. Analyses showed that Pandin’s approach was too medial (13 Ϯ 5 mm) and all others were too lateral: Winnie (17 Ϯ 8 mm), Chayen (8 Ϯ 5 mm), Capdevila (6 Ϯ 4 mm), and Dekrey (17 Ϯ 6 mm). Using the posterior superior iliac spine (PSIS) and third lumbar vertebra as landmarks, a proximity to the LP Ͻ 5.0 Ϯ 0.3 mm was reached. Relying on the position of the PSIS eliminates the gender and sided differences as well as individual body size that can be problematic for LP blockade.

Anesthesiology, V 111, No 3, Sep 2009

᭜ EDITORIAL VIEWS
Anesthesiology 2009; 111:461–3 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Expanding our Horizons
Transition of Acute Postoperative Pain to Persistent Pain and Establishment of Chronic Postsurgical Pain Services
Editor’s Note: This is the third in a series of four Editorial Views on long-term outcomes after anesthesia and surgery. This series adds to other recent Editorial Views in ANESTHESIOLOGY and includes a discussion of broadening our research outside of the operating room to prevention of wound infections, cancer spread, cardiovascular morbidity and mortality, chronic postsurgical pain, and rare complications. ANESTHESIOLOGY will sponsor special sessions in 2010 on the topic of long-term outcomes at annual meetings of the Japanese Society of Anesthesiologists, the European Society of Anesthesiology, and the American Society of Anesthesiologists. James C. Eisenach, M.D., Editor-in-Chief

ACUTE postoperative pain should not be considered simply an uncomfortable symptom that disappears when surgical wounds heal. Instead, pain reflects a complex constellation of evolving effects at peripheral, spinal, and cerebral levels involving several neurotransmitters and modulators, including the immune system. Although most patients expect to experience pain after surgery, the pain experience in this setting can be exaggerated by psychologic and pharmacologic factors. For example, level of anxiety is known to correlate with severity of pain from nociceptive stimuli, and days or weeks before the surgical procedure, patients may be mentally stressed by impending anesthesia and surgery, with their potential for adverse outcomes. In addition, surgical tissue injury occurs during anesthesia, which may be important because anesthetic drugs interfere with sensory perception, but their effects on pain processing are not necessarily unidirectional. For example, potent opioids produce both antinociception and hyperalgesia.1 Halogenated vapors, given to produce unconsciousness and amnesia, also activate peripheral pronociceptive ionic channels, thereby augmenting neurogenic inflammation.2 Postoperative pain is an association of somatic, inflammatory, neuropathic, and — at times — visceral pain. Postoperative pain results not only from local tissue injury, leading to spontaneous firing of nociceptors and their increased sensitivity to stimuli (primary hyperalgesia), but also from central nervous system changes resulting in sensitization and pain from a wider area (secondary hyperalgesia). In the last decade, secondary hyperalgesia has prompted particular attention for several reasons. First, secondary
Accepted for publication May 19, 2009. The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated with the topic of this article.

hyperalgesia reflects transformations within the central nervous system that augment pain perception from injured and surrounding areas. Interestingly, this phenomenon, which has been primarily studied in the spinal cord, reflects neuroplastic changes, which share many features of mechanisms of memory at supraspinal sites. Second, most of the medications used to alleviate postoperative pain have minor effects on this secondary hyperalgesia, possibly explaining why large series still report insufficient postoperative pain relief.3 Finally, secondary hyperalgesia is thought to be a basis for chronic postsurgical pain (CPSP).4 The criteria for the diagnosis of CPSP were defined by the International Association for the Study of Pain 10 yr ago. CPSP is a pain syndrome that develops postoperatively and lasts at least 2 months with other causes for pain (e.g., recurrence of malignancy, chronic infection, etc.) being excluded; pain continuing from a preexisting disease is also an exclusion.5 CPSP is not restricted to major surgeries (cardiac, thoracic, abdominal, and orthopedic) and amputations; it is also observed after simple procedures such as inguinal hernia repairs, mastectomies, and Cesarean deliveries. Anesthesiologists are just now realizing the high estimated incidence of CPSP and how we might attempt to prevent it. About 30% of patients are reported to suffer moderate-to-severe CPSP after specific types of major surgery. Even after minor procedures, approximately 5% of patients suffer severe CPSP.6 Although the reported prevalence is high, most anesthesiologists are unaware of this problem because they don’t see large numbers of patients with CPSP in their practice. How can we explain this discrepancy? The most likely possibility is that the follow-up of these patients is lost for the anesthesiologists in charge. Patients suffering persistent pain weeks or months after sur461

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EDITORIAL VIEWS

gery are cared for by their surgeon or primary caregiver rather than by their anesthesiologist. Several predictive factors for CPSP have been identified, related to both patient and surgical factors. Factors linked to the patients include female gender, young age, obesity, preoperative anxiety and/or catastrophizing, and preexisting pain. Part of the interindividual variability in pain sensitivity is caused by genetic polymorphisms of genes involved in endogenous pain control. In this regard, some protective genotypes (homozygous carriers of a GTP cyclohydrolase 1 haplotype) or phenotypes (children born of mothers with a familial history of hypertension) have been isolated.7,8 Nevertheless, according to the complexity of the mechanisms involved in pain perception, the recently isolated favorable haplotypes are not necessarily protective against all types of hyperalgesia (e.g., somatic vs. visceral).9 At the present time, the development of this area of study is inadequate to allow systematic genotype screening to discriminate populations at risk of developing CPSP. Another way to predict CPSP is by testing preoperative experimental pain. In this regard, psychophysical measures exploring “static” pain parameters (pain thresholds, magnitude estimation of suprathreshold nociceptive stimuli, and tolerance) have been regularly reported to predict the intensity of acute postoperative pain in the early phase after surgery.10 Nevertheless, these measures of response to an acute, phasic, experimental stimulus are less indicative of the complex pain modulation process that occurs after surgery. Some aspects of such modulation can be quantified by using the “dynamic” psychophysical measures of temporal summation and evocation of diffuse noxious inhibitory control, a measure recently reported to predict the risk of CPSP after thoracotomy.11 Factors linked to surgery include invasive procedures: redo interventions, surgery in a previously injured area, and particular surgical techniques.12 Most of these factors also predict the intensity of acute postoperative pain; however, acute pain intensity per se is a strong predictor for development of CPSP.6 Although, adequate treatment of acute postoperative pain is mandatory, there is no consistent evidence in large series of patients that it necessarily prevents the development of CPSP. Once established, CPSP of neuropathic or inflammatory origin is difficult to treat; CPSP is thus an important cause for referral to chronic pain facilities.13 Anesthesiologists have therefore adapted various strategies aimed at reducing the intensity of acute postoperative pain and therefore perhaps the incidence of CPSP. The critical question, of course, is whether anesthetic technique significantly influences development of CPSP. Divergent opinions are found in the literature. Some investigators are convinced that surgery, by cutting nerves or initiating prolonged inflammatory reactions, is the major determinant.14 Consistent with this theory, some investigators have demonstrated in limited series of patients that
Anesthesiology, V 111, No 3, Sep 2009

potent analgesia combined with antihyperalgesic medications influences the incidence of CPSP.15 However, no large prospective trial has confirmed that any specific anesthetic intervention reduces the risk of CPSP. A better understanding of the determinants of CPSP might be obtained by considering the physiologic role of pain, a concept often ignored in the setting of perioperative care. Pain is part of an extraordinary sensory modality that serves not only to detect threats (including imperceptible ones such as viral invasion) but also to promote survival, learning, and memory. Given that hyperalgesia and nociceptive inhibitory systems are part of a natural perception process, why do some patients develop CPSP and the majority do not? An explanation may be found in the “generalized hypervigilance” hypothesis which some believe to be a mechanism leading to fibromyalgia. These patients show robust perceptual amplification that is not restricted to pain perception, but is also observed with other sensory modalities.16 The consequence of a hypervigilant state is dysregulation in the mechanism of discrimination. Interestingly, fibromyalgesia patients share many common characteristics with patients at risk of developing important acute postoperative pain and CPSP (female gender, anxiety, catastrophisation, etc.). Moreover, a history of trauma (including surgery) is frequently reported as a precipitating factor of this disease.17 In this regard, CPSP may be part of a hypervigilant disease initiated in vulnerable population by the preoperative stress or by surgery itself. In summary, CPSP is a relatively recently recognized entity, and precise distinctions between physiologic and pathologic contributions remains unclear. Large-scale prospective studies including careful enquiries concerning preoperative pain and risk factors are required to determine its exact incidence and the respective role of surgery and anesthetic techniques. Large prospective studies will similarly be needed to determine which, if any, anesthetic interventions reduce the risk of CPSP. Just as anesthesiologists responded to patients’ need for better management of acute postoperative pain by the establishment of acute postoperative pain services, the time is right for us to consider establishing specifically dedicated facilities to take care of CPSP patients. Doing so, surgeons or the other medical practitioners could directly refer their patients instead of entrust them to one or other unrelated pain clinic. These new “CPSP services” would certainly help to more accurately determine the true incidence of this phenomenon, to uncover the populations at risk, and to provide early treatment strategies. Such a service would also provide an ideal venue to monitor the link between perioperative analgesic management and CPSP development. The need is clearly there for our patients, and who better to treat and eventually prevent CPSP than us?

EDITORIAL VIEWS

463

Marc De Kock, M.D., Ph.D., Department of Anesthesiology, Catholic University of Louvain, St Luc Hospital, Brussels, Belgium. dekock@anes.ucl.ac.be

References
1. Angst MS, Clark JD: Opioid-induced hyperalgesia: A qualitative systemic review. ANESTHESIOLOGY 2006; 104:570–87 2. Matta JA, Cornett PM, Miyares RL, Abe K, Sahibzada N, Ahern GP: General anesthetics activate a nociceptive ion channel to enhance pain and inflammation. Proc Natl Acad Sci U S A 2008: 105;8784–9 3. Apfelbaum JL, Chen C, Meha SS, Gan TJ: Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003; 97:534–40 4. Eisenach JC: Preventing chronic pain after surgery: Who, how, and when? Reg Anesth Pain Med 2006; 31:1–3 5. Macrae WA, Davies HTO: Epidemiology of Pain. Edited by Crombie IK. Seattle, IASP Press, 1999, pp 125– 4 6. Kelhet H, Jensen T, Woolf C: Persistent post surgical pain: Risk factors and prevention. Lancet 2006; 367:1618–25 7. Tegeder I, Costigan M, Griffin RS, Abele A, Belfer I, Smidt H: GTP cyclohydrolase and tetrahydrobiopterin regulate pain sensitivity and persistence. Nat Med 2006; 12:1269–77 8. France CR, Taddio A, Shah VS, Page ´ MG, Katz J: Maternal family history of hypertension attenuates neonatal pain. Pain 2009; 142:189–93

9. Lazarev M, Lamb J, Barmada MM, Dai F, Anderson MA, Max MB, Whitcomb DC: Does the pain-protective GTP cyclohydrolase haplotype significantly alter the pattern or severity of pain in humans with chronic pancreatitis? Mol Pain 2008; 4:58 10. Granot M, Lowenstein L, Yarnitsky D, Tamir A, Zimmer EZ: Postcaeseraen section pain prediction by experimental pain assessment. ANESTHESIOLOGY 2003; 98:1422–6 11. Yarnitsky D, Crispel Y, Eisenberg E, Granovsky Y, Ben-Nun A, Spercher E, Best LA, Granot M: Prediction of chronic post-operative pain: Pre-operative DNIC testing identifies patients at risk. Pain 2008; 138:22–8 12. Foss NB, Kristensen MT, Palm H, Kehlet H: Postoperative pain after hip fracture is procedure specific: Br J Anaesth 2009; 102:111–6 13. Crombie IK, Davies HT, Macrae WA: Cut and thrust: Antecedent surgery and trauma among patients attending a chronic pain clinic. Pain 1998; 76:167–7 14. Aasvang EK, Hansen JB, Kehlet H: Pre-operative pain and sensory function in groin hernia (published on-line January 13, 2009). Eur J Pain 2009 15. Lavand’homme P, De Kock M, Waterloos H: Intraoperative epidural analgesia combined with ketamine provides effective preventive analgesia in patients undergoing major digestive surgery. ANESTHESIOLOGY 2005; 103:813–20 16. Hollins M, Harper D, Gallagher S, Owings EW, Lim PF, Miller V, Siddiqi MQ, Maixner W: Perceived intensity and unpleasantness of cutaneous and auditory stimuli: An evaluation of the generalized hypervigilance hypothesis. Pain 2009; 141:215–21 17. White KP, Carette S, Harth M, Teasel RW: Trauma and fibromyalgesia: Is there an association and what does it means? Semin Arthritis Rheum 2000; 29:200–16

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stretch. and neurosurgery had higher risk. distress. The Scream. isch464 Anesthesiology. WELCH et al. spinal anesthesia. a problem especially true for retrospective studies performed at tertiary medical centers where patients do not necessarily have long-term care. the authors should be congratulated for the extensive efforts they used to compensate for the problems posed by the retrospective methodology. patients from age 13 to 86 yr of age were identified with new neuropathies. Upper extremity injuries predominated by a 60:40 margin. in an effort to specifically seek new nerve injuries that were likely the result of intraoperative or immediate postoperative care. but likely exceeds 0. there was approximately one anesthetized patient each month in the University of Michigan Medical Center who had additional unexpected pain. whereas monitored anesthesia care. the true incidence of perioperative neuropathies is still unclear. Interestingly.1. That is. and even peripheral nerve block were not. No 3. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.1 This retrospective analysis from the University of Michigan collates three concurrent data sets (quality assurance. and billing codes) to summarize the clinical experience with nerve injuries at one large tertiary university hospital from 1997 to 2007. perioperative neuropathies may result from excessive pressure (compression). They found that perioperative nerve injuries were associated with medical conditions afflicting the health and function of small blood vessels. orthopedic. an internal closed-claims collection. patients with few identified comorbid illnesses (American Society of Anesthesiologists Classes 1 and 2) were equally vulnerable to developing a perioperative neuropathy.000 anesthetics during a 10-yr epoch. Perioperative Nerve Injury: A Silent Scream? This article has been selected for the ANESTHESIOLOGY CME Program.2. Regardless of methodology. ending in 2007. Mashour GA: Perioperative peripheral nerve injuries: A retrospective study of 380. although the authors were diligent. which is often assumed (“res ipsa loquitor”) to be the cause of unexpected perioperative nerve injury? What Characterized the Nerve Injuries Seen in This Study? In their remarkable effort. Previous prospective studies have shown that a number of perioperative neuropathies are first identified more than 48 h after surgery. as compared with those of American Society of Anesthesiologists Classes 3. As a profession. of a nerve within an appropriately padded and positioned limb in the operating room. how many patients with new peripheral nerve injuries were identified in more than one database? As reported. 4.Anesthesiology 2009.400). add 112 well-documented adverse events from 380. 2009. general. Thus. diabetes. Welch et al. which are critical to the sustenance of major peripheral nerves. 111:464 – 6 Copyright © 2009. and patients undergoing cardiac. retrospective studies of perioperative nerve injuries document only injuries that are either sufficiently symptomatic to be noted in records or missed entirely in postoperative surveillance. general and epidural anesthesia were significantly associated with nerve injury. although demographics of weight or body surface area were not included. Mechanisms of Perioperative Nerve Injuries Accepted for publication May 11. they did not report the crossover identification rates between the three databases. The authors are not supported by. 1893). Theoretically. Twothirds of the recorded injuries were sensory only. collated the anesthetic outcomes from a single institution of over 380. Second. Sep 2009 . Lippincott Williams & Wilkins. Moreover. and perhaps a disability unrelated to his or her primary operation.03% (1:3. Brummett CM. These conditions included hypertension. Welch TD. and smoking (hazard ratios of 2. and 5. Guglani P. Inc. 111:490 –7. ANESTHESIOLOGY 2009. the American Society of Anesthesiologists. nor maintain any financial interest in.680 cases during a 10-year period at a single institution. have we been deaf to a silent “Scream” (with apologies to Edvard Munch. it appears that each database contributed new cases that were not found in the other databases. the authors sought information on peripheral neuropathies that were identified only during the first 48 h postoperatively. First. Inc. 2. V 111. Shanks AM.4. This lack of cross-identification suggests a high likelihood that other cases were missed. ᭜ This Editorial View accompanies the following article: Welch MB. Nonetheless. but there were likely other patients who developed these problems. Tremper KK. Interestingly. and will probably require a major prospective study.03%. followed by combined motor and sensory (27%) or isolated motor injuries (just 16%). The casual reader might be reassured by the relatively low global frequency of nerve injuries at 0.680 patients to the third most commonly recognized cause of anesthesia litigation: Perioperative nerve injuries. There are a number of potential reasons that the current study may have underestimated the incidence of nerve injuries. any commercial activity that may be associated with the topic of this editorial. respectively). and 2. Third. using three separate departmental and institutional databases to identify patients with potential perioperative neuropathies.

rendering them more vulnerable to injury in the perioperative period. yet unknown.. Such uninterrupted pressure can ultimately produce nerve ischemia and injury. unmedicated volunteers were able to perceive sensory alterations or paresthesias resulting from direct pressure applied to the ulnar nerve. relatively minor insults. laceration of a nerve. Inappropriate placement of noncompliant external objects or improper arm positioning (such as allowing the elbow to rest on the steel frame of a surgical table) may create external pressure on the ulnar nerve. the two separate insults along the course of the same nerve may produce significant axonal disruption and clinical symptoms. While either injury alone is subclinical. Lippincott Williams & Wilkins. Double crush was first described in 1973 by Upton and McComas.2 and reflects the phenomenon whereby one compressive lesion occurring along a nerve renders the nerve less tolerant of compression at the same or a second locus. Smoking. a number of reported upper extremity perioperative nerve injuries have occurred and resulted in medicolegal claims even when the patient was awake and conscious during lower extremity surgery under regional anesthesia. V 111. (Reprinted from Lobato. Together. some evidence highlights the increased susceptibility of the ulnar nerve to ischemia. Double Crush Syndrome and Anesthetic Implications An additional factor which may contribute to perioperative nerve dysfunction is the phenomenon of the double crush syndrome. most peripheral nerves are intolerant of prolonged stretch beyond 5% of normal resting length.4 Finally. metabolic derangement.) Anesthesiology. In a separate study. insult. General Impressions Evidence is rapidly mounting that indicates that mechanisms of perioperative nerve injury are complex and multifactorial. Indeed. an ulnar nerve injury occurred despite the specific documentation of protective padding at the elbow. This phenomenon is schematically illustrated in figure 1. In addition. as compared with either the radial or median nerves. these may result in a permanent nerve injury. the present study found that patients undergoing monitored anesthesia care did not develop peripheral nerve injuries. Curiously. trapping it as it courses within the rigid bony canal of the superficial postcondylar groove at the elbow. pp 821– 843: Positioning by Robert C. The left hammer represents a (perhaps chronic) proximal injury. This syndrome describes the coexistence of two (or more) clinical or subclinical insults along the course of a nerve. nerves with a preexisting injury or compression are at much greater risk of a second. Gravenstein. However. The authors postulated that these patients were sufficiently alert to move uncomfortable extremities and prevent the stresses that may have caused clinical symptoms of nerve injury. and the right hammer represents a second (more acute) distal injury. 1. Indeed. direct trauma. despite significant alterations in somatosensory evoked potential latencies.6 This finding suggests that awake patients may not perceive sensory changes of adversely affected limb nerves during surgery. and may not alter their limb position automatically to a “safer” position. Two subclinical insults along the course of one nerve constitute the double crush syndrome.3 In addition. and Kirby Complications in Anesthesiology. factors. possibly subclinical. While the exact mechanism is not definitively understood. Sep 2009 . and may account for acute clinical symptoms of perioperative nerve injury. In 27% of cases reviewed by Welch et al. Prielipp. Clinically. and other. certain medical diseases and/or concomitant drug therapy may have physiologic and/or toxic effects on peripheral nerves. and diabetes may all contribute to microvascular changes as identified here by Welch et al. Nerve compression may occur via external or internal mechanisms. 2008. Fig. proximal upper extremity nerve root pathology has been shown to lessen the median nerve compression necessary to produce symptoms of carpal tunnel syndrome and to worsen outcome after carpal tunnel decompression. previously described somatosensory evoked potential data demonstrated that only 50% of awake. No 3. Philadelphia. Alvine and Shurrer5 detected bilateral nerve conduction abnormalities in 12 of 14 patients who presented with unilateral symptoms of a perioperative ulnar neuropathy. it likely involves disturbances in axonal flow of nutrients and/or disruption of the architecture of neurofilaments. many diseases and conditions as well as medications and toxins may predispose patients to neuropathic injury. Thus. clinicians must remain alert to patient position at all times and modes of anesthesia care. used with permission.EDITORIAL VIEWS 465 emia. Chapter 57. Therefore. which may contribute to the development of peripheral neuropathies and may well predispose peripheral nerves to be more vulnerable to other. Morell and Richard C. Extremes of extension or flexion should generally be avoided to minimize this risk.. hypertension.

Sep 2009 . Santos CC. Warner DO. Prielipp RC. This observation is further amplified by the finding that ulnar nerve injury occurs with nearly equal frequency in medical and surgical patients hospitalized for more than 2 days. Morell RC. Prospective studies suggest that many nerve injuries initially become symptomatic more than 2 days after surgery and anesthesia. Matsumoto JY. we theorize that transient perioperative edema results in excess pressure under the transcarpal ligament. Maxson PM: Ulnar neuropathy in medical patients. 110:25–9 4. ANESTHESIOLOGY 2009. and that some adverse events classified as perioperative neuropathies have their origins and onset beyond the operating room or postoperative care unit.D. 91:345–54 7. Hyperextension of the elbow may stretch the median nerve and contribute to postoperative disability. Anesth Analg 1998. and excessive or prolonged pressure during surgery. combined with prolonged periods of bedrest in the supine position (whether during or after surgery. Lancet 1973. ANESTHESIOLOGY 1999. and individuals may or may not reposition afflicted limbs on their own. V 111. causing a step-off from the operating room table. Alvine FG. Maxson PM: Ulnar neuropathy in surgical patients.D. No 3. direct pressure in this area may occur with a mismatched armboard. Mashour GA: Perioperative peripheral nerve injuries: A retrospective study of 380. For example. ANESTHESIOLOGY 1999. Walker FO. Hutchinson DT. 69:255–9 6. 87:677–80 5. M.edu References 1. University of Minnesota Medical School. Despite avoidance of traction.680 cases during a 10-year period at a single institution. ether screens.7. Clin Neurol Neurosurg 2008. Tremper KK. Guglani P. Minneapolis. The use of shoulder braces coupled with steep head-down positioning has been implicated in the development of compression and brachial plexus injuries. and operating room equipment may also produce direct pressure in vulnerable areas. 111:490 –7 2. Moghtaderi A. Harper CM. Brummett CM.* Mark A. Minnesota. scope. and other carpal tunnel connective tissue may cause short-term symptoms that mimic ulnar or median neuropathies. prielipp@umn.† *Department of Anesthesiology. that awake patients vary in their ability to detect peripheral nerves at risk.466 EDITORIAL VIEWS Fortunately. or for hospitalization as a result of strictly medical conditions). Bennett J. Schurrer ME: Postoperative ulnar-nerve palsy. Richard C. 92:613–5 Anesthesiology. Warner MA. Brachial plexus injuries may occur by hyperabduction of the arm to Ͼ90 degrees. Ulnar neuropathy may occur despite the specific use of extensive padding of extremities during surgery and proper positioning of both arms. Pace NL: Rapid onset of ulnar nerve dysfunction during transient occlusion of the brachial artery. Schroeder DR.. Izadi S: Double crush syndrome: An analysis of age. †Mayo Clinic College of Medicine. McComas AJ: The double crush in nerve entrapment syndromes. M. multifactorial. and incompletely understood. denote the (minimal) frequency. Butterworth J: Ulnar nerve pressure: Influence of arm position and relationship to somatosensory evoked potentials. Warner. Upton AR. and clinicians should always endeavor to optimize limb positioning. In the latter instance. Thus. Minnesota. Retractor holders. ANESTHESIOLOGY 2000. Shanks AM. Schroeder DR. Summary The data from Welch et al. perioperative peripheral nerve injuries can and do occur.1 The etiology of perioperative peripheral nerve injuries remains complex. gender and body mass index. Are there predisposing factors? J Bone Joint Surg Am 1987. Warner MA. Prolonged pressure on the radial nerve as it courses in the spiral groove of the humerus may result in an ischemic/pressure perioperative neuropathy. etiologies for some perioperative neuropathies are reasonably clear. Rochester.8 In addition. it appears evident that perioperative neuropathies occur despite appropriate positioning and padding of limbs during surgery. predisposing anatomic and other risk factors in men (because of anatomical gender variations of the cubital tunnel). 2:359–62 3. Swenson JD. stretch. We also have observed and are aware of a number of cases of transient median and ulnar nerve dysfunction that mimic carpal tunnel syndrome and vice versa. may contribute to the development of perioperative ulnar nerve injury. Warner DO. perhaps excessively stretching major nerve axons beyond their resting length. Harper CM. 90:54–9 8. and demographics of perioperative neuropathies that impact clinicians in daily practice. Bromberg M. Prielipp. Welch TD. Welch MB.

induction of an expanded plasma lipid phase serving to sequester toxins of high lipophilicity. Cardiac Arrest or cardiovascular collapse caused by local anesthetic.Anesthesiology 2009. * Resuscitation Council of the United Kingdom.” This revolution has been largely driven by some elegant animal work from the laboratory of Guy Weinberg. increasingly.3 Alternative postulates favor a metabolic mechanism with bolus free fatty acid provision overcoming pharmacologic inhibition to mitochondrial oxidative phosphorylation. accumulating case report data. What formulation of free fatty acids and phospholipids is best? What infusion protocol delivers optimum balance between efficacy and safety? Perhaps most significant.D.5 mcg/kg epinephrine–treated animals.14 Therefore. and none of failure. it seems timely to consider just how many questions surrounding this novel therapy remain unanswered.1 At a juncture when the uptake of lipid is almost universal. rate pressure product. is how to incorporate lipid emulsion into standard resuscitation algorithms. This fundamental absence of defined mechanistic action of lipid poses significant unknowns when assessing the potential benefit (or otherwise) of adjuvant drugs in resuscitation. some 2.resus. examine resuscitation outcome after incremental single-dose epinephrine. on average. Available at: http://www. Feinstein DL. and that of the ubiquitous epinephrine in particular. known to result in poorer outcome when injected in a variety of cardiac arrest scenarios. however. and lesser return of spontaneous circulation might superficially be deemed unsurprising. The “lipid sink” has been forwarded as one potential explanation. Ripper R.5 min sooner in animals receiving epinephrine—intuitively beneficial for the hearts of both patient and treating clinician. despite the best intentions of clinicians and journal editors. Bupivacaine-induced Cardiac Arrest Fat Is Good—Is Epinephrine Really Bad? LIPID emulsion as therapy for local anesthetic–induced cardiotoxicity has come a long way since its chance discovery a decade ago. 1. This is undoubtedly true in the case of lipid therapy where numerous reports of positive outcome.5 It is not inconceivable that all hypotheses may eventually be implicated as being in part causative. Di Gregorio G.. and metabolic metrics were identical at 15 min. until they’re lipemic and dead. favoring dissemination of cases wherein outcome has proven favorable. In this issue of ANESTHESIOLOGY. no matter how impressive. and formative in the latest work from Hiller et al. nor maintain any financial interest in. That bolus injection of lipid emulsion may result in seemingly miraculous recovery from inadvertent local anesthetic overdose seems beyond doubt. fail to become data until the true denominator of frequency of use is considered. however. Edelman L. 2009. No 3. Hiller et al. initial success with any therapy is subject to significant reporter and publication bias.e. have crowded the literature.4 or via elevation of intramyocyte calcium concentration. Transit from laboratory bench top to the antidote cupboards of operating theaters and. Yet sporadic anecdotes such as these. 111:498 –505. Massad M.13. Inc. Kelly K. emergency and critical care units worldwide has been swift. coadministered with lipid emulsion. however. Conversely stated.org. High-dose epinephrine is. this despite initial augmentation of spontaneous circulation. reminders that the poisoned patient “cannot be considered dead. Anesthesiology. Inherent in this question is the role of additional agents used during cardiac arrest. There is much pertaining to the administration of lipid that remains unknown. Despite much basic science work we are still unclear how IV injection of lipid emulsion results in amelioration of local anesthetic–induced cardiotoxicity. The finding of significantly reduced hemodynamic and metabolic metrics in the 10 mcg/kg epinephrine group requires greater notice. V 111. Guidelines endorsing lipid* now hang prominently anywhere regional anesthesia is practiced. Regardless. Case compilation in a formal registry of use is now urgently required. suggesting that any potential benefit arising from sooner return of spontaneous circulation is in part offset by detrimental metabolic consequences of adrenergic stimulation. Edelman G. ANESTHESIOLOGY 2009. animals treated with 25 mcg/kg epinephrine had a deleterious outcome. bupivacaine) in the present study is new.htm.. Inc. Posted 1 July 2008. Perhaps most informative.uk/ pages/caLocalA. is the comparison of recovery in the lipid-only. At clinically endorsed levels epinephrine resulted in lesser postrecovery cardiovascular parameters and increased serum lactate. Circulatory return developed.. any commercial activity that may be associated with the topic of this article. 111:467–9 Copyright © 2009. the 467 ᭜ This Editorial View accompanies the following article: Hiller DB. In their experimental model. the same investigators that brought us lipid question the coadministration of epinephrine in lipid-based resuscitation from bupivacaine-induced cardiac arrest. and 2. M.2. survival. By all measures (including an ingeniously constructed recovery index). The authors are not supported by. the finding that (while not strictly “high”) elevated dose epinephrine is associated with lactic acidemia. However. Sep 2009 . Weinberg GL: Epinephrine impairs lipid resuscitation from bupivacaine overdose: A threshold effect. the American Society of Anesthesiologists. Lippincott Williams & Wilkins. and not in the least absence of efficacious alternate antidotes for what remains a feared complication of regional anesthesia. in a rodent model of bupivacaine-induced asystole. A wealth of animal data2– 4 and accumulating cases purporting successful resuscitation outcome6 –12 provide a compelling argument. pulmonary edema. while the causative mechanism (i. Accepted for publication May 18.

Conversely. harveym@waikatodhb. in numerous additional cases epinephrine was injected.C. Feinstein DL. New Zealand. Ziegeler JC.* Grant Cave. Weinberg et al. Few studies have compared lipid alone with vasopressors in local anesthetic–induced cardiac arrest. Lamb J.Ch. No 3. Massad M. Ripper R. Ramaraju GA. as compared with lipid alone. not only more acidotic.B. Edelman G.5 U/kg. Mazoit JX. Waikato Hospital.21 Lamentably. Ludot H. Martyn Harvey. Anesth Analg 2008. ANESTHESIOLOGY 1998.20 demonstrate no benefit to resuscitation with lipid injection compared with saline. McCahon R. Anesth Analg 2007. Evaluation of the Association of Anaesthetists of Great Britain and Ireland lipid infusion protocol in bupivacaine-induced asystole in whole rabbits conferred a mere 50% survival rate when epinephrine was repeatedly administered at 100 mcg/kg. 111:498 –505 2. may in part underpin these findings..B.E. we just don’t know.M. but subjected to prolonged asphyxia and basic life support resuscitation before lipid administration— both potent stimulants to endogenous epinephrine release. Stehr SN: Reversal of central nervous system and cardiac toxicity following local anesthetic intoxication by lipid emulsion injection. and what part (metabolic villain or accumulating innocent) does lacticacidemia play? Certainly elevated lactate was associated with both increased epinephrine dose and poorer outcome in the Anesthesiology. Weinberg GL: Epinephrine impairs lipid resuscitation from bupivacaine overdose: A threshold effect. Lipid emulsion has furthermore been shown to be detrimental in animal models of sole asphyxia-induced cardiac arrest. Xian H. have demonstrated both epinephrine15 and vasopressin16 to result in lesser hemodynamic and metabolic recovery. Stehr SN. Belouadah M. Ripper R.nz References 1. V 111. Present evidence is insufficient to endorse omission of epinephrine from lipid-based resuscitative algorithms.17 demonstrated combination epinephrine/ vasopressin to effect superior recovery as compared with lipid alone. the affinity of lipid emulsion to bind local anesthetics conversely diminishes with reduction in pH.† *Department of Emergency Medicine. Litz RJ. therefore. Resultant exacerbation in cardiotoxicity and reduced efficacy of the sink function of lipid emulsion are likely contributors to the outcomes observed in this study. Cwik MJ: Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Hicks et al. Koch T. Foxall G. F. Garcia-Amaro MF. Malinovsky JM: Successful resuscitation after ropivacaine and lignocaine–induced ventricular arrhythmia following posterior lumbar plexus block in a child.19 Furthermore. and inherently greater oxygen debt incurred with myocardial fatty acid oxidation. F. Roessel T. Smith HM. Mayr et al. Hoffman W: Lipid emulsion infusion rescues dogs from bupivacaine–induced cardiac toxicity. Segura LG. Hu ¨ bler M: The effects of lipid infusion on myocardial function and bioenergetics in l-bupivacaine toxicity in the isolated rat heart.8 have been reported with lipid infusion alone. Hardman JG. Successful human reports of local anesthetic–induced cardiotoxicity treated with lipid emulsion have variably included administration of epinephrine. Hiller DB. Sep 2009 work of Hiller et al. however. with both vasopressors implicated in development of pulmonary edema and worsening lactic acidosis.A. What basis then is there for causality? Cardiotoxicity of local anesthetics is known to increase in the presence of acidosis. Abolishment of ventricular arrhythmias6 and reversal of local anesthetic– induced central nervous system and cardiac toxicity7. 106: 1572–4 7.A.lipidregistry. Bacaner M: Long-chain fatty acids activate calcium channels in ventricular myocytes.C. Torsher LC: Simulation education in anesthesia training: A case report of successful resuscitation of bupiva- .E. What. Tharin JY. New Zealand. Oertel R. and in particular elevation of serum lactate concentration. in the July issue of ANESTHESIOLOGY. epinephrine administration is known to result in acidemia. in rodent models of bupivacaine-induced asystole. But is epinephrine really bad when coadministered with lipid emulsion in local anesthetic–induced cardiac arrest? Data to date certainly points to harm when administered in excess. Support for the hypothesis that hyperadrenergic stimulation may be detrimental can be inferred from recent studies showing little or no benefit when lipid was combined with high dose epinephrine in local anestheticinduced cardiac arrest. when coadministered with epinephrine at 100 mcg/kg and vasopressin at 1.M.B. Additional direct causal effects of lactic acid on bupivacaine toxicity may yet be elucidated.23 further compounding failing myocardial energetics in the presence of a metabolic poison.. the issue of hypoxia notwithstanding. Feinstein DL.18 The stoichiometric differences in phosphate-to-oxygen ratios. in their swine model of bupivacaineinduced cardiac arrest complicated by significant asphyxia. ANESTHESIOLOGY 2009. Note added in proof: A newly created registry of lipid use is accessible via the link http://www. Di Gregorio G. Huang JM. Lipid-treated pigs were. But questions about our current practice have been raised. Edelman L.Ch. M. 104:186–92 5. Bedforth NM: Levobupivacaineinduced seizures and cardiovascular collapse treated with Intralipid. 88:1071–5 3. the significance of which may rival the discovery of lipid itself. in bupivacine-intoxicated swine. but what about doses currently advocated? Or indeed lower still? In truth.. Pexa A. Kelly K. Anaesthesia 2007. Anesth Analg 2008. Weinberg GL. Reg Anesth Pain Med 2003. So what is happening here. 89:6452–6 6.22 By numerous mechanisms. must we conclude? Clearly lipid emulsion is superior therapy to epinephrine and vasopressin alone. Conversely.468 EDITORIAL VIEWS omission of epinephrine conferred no disadvantage to resuscitation outcome in the authors’ model. Epinephrine was reported as being no better than a saline bolus in the former experiment. Jacob AK.9 –12 Would successful return of spontaneous circulation in these cases have been achieved with cardiopulmonary resuscitation and lipid alone? Would physiologic parameters have proven to be more favorable post recovery? We will never know. before lipid infusion and eventual favorable outcome. M. and in many repeated. †Hutt Hospital. Lower Hutt. Intracellular lactate is furthermore known to inhibit glycolysis via increased NADH/NAD (dihydronicotinamide adenine dinucleotide/nicotinamide adenine dinucleotide) ratios. Heller AR. 28:198–202 4. Dilger JA. Hamilton. VadeBoncouer T. Deussen A. Proc Natl Acad Sci U S A 1992. Weinberg G.B. 62:516–8 8.govt.org. 106:1575–7 9.

Litz RJ. Feinstein DL: Resuscitation with lipid versus epinephrine in a rat model of bupivacaine overdose. Eisenkraft JB: Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacainerelated cardiac arrest.anesthesiology. 84:92–4 22. Shah N. ANESTHESIOLOGY 2009. Callaham M. Anesth Analg 2008. Bause. Mu ¨ ller T. Gritsch C. . . M.com.P. Wenzel V. 110:380–6 23. 108:1163–8 19. Br J Anaesth 2000. Markos F. Anaesthesia 2006. Edelman L. Massad M. 61:800–1 12.H. Tang W. Hicks SD.. Di Gregorio G. Fischer GW. UJYC@aol. English physician William Harvey (1578 –1657) published this 1639 version. Minshall RD. Shah SJ: Intravenous lipid infusion in the successful resuscitation of local anesthetic-induced cardiovascular collapse after supraclavicular brachial plexus block. Inc. 106:1566–71 18. Kelly K. Benhamou D: Binding of long-lasting local anesthetics to lipid emulsions. ASA’s Wood Library-Museum of Anesthesiology. (Copyright © the American Society of Anesthesiologists. 111:138 – 46 21. Anesth Analg 2008. Gazmuri RJ: Epinephrine increases the severity of postresuscitation myocardial dysfunction. 105:217–8 11. 106:1578–80 13. ANESTHESIOLOGY 2009. Cleveland. Crit Care Med 2009. translated from Latin. Thoma RB. From cardiovascular monitoring and physiology to vascular access and beyond. Warren JA. Logue ES. he titled Anatomical Exercises on the Motion of the Heart and Blood in Animals. Beloeil H. . Barton CW. Strohmenger HU: A comparison of the combination of epinephrine and vasopressin with lipid emulsion in a porcine model of asphyxial cardiac arrest after intravenous injection of bupivacaine. M. Radda GK: Is lactate-induced myocardial ischaemic injury mediated by decreased pH or increased intracellular lactate? J Mol Cell Cardiol 1995. William Harvey’s impact on today’s clinical practice of medicine remains monumental.” Courtesy of the Wood Library-Museum. and Clinical Associate Professor. Feinstein DL. Miller DR. Di Gregorio G. Schwartz D. 108:907–13 16. Mitterschiffthaler L. Suffoletto BP. Georgescu A. 106:1581–4 10.EDITORIAL VIEWS 469 caine–induced cardiac arrest linked to recent simulation training. Le Guen R. Massad M. which. Itzkovich CJ. Empey PE. Luckner G. Ripper R. and is in a state of ceaseless motion.D. Besides addressing the concerns of his critics Parisano and Primrose. the 1639 edition above depicts how valves permit venous return of blood solely toward the heart. Poloyac SM. Harvey M. Lindner KH. Anaesthesia 2009. Yang L. Neurauter A. No 3. Abel M. Porter JM. With Refutations by Emilio Parisano and James Primrose. 37:993–9 17. Ripper R. Mazoit JX. Winterbottom T: Evaluation of the Association of Anaesthetists of Great Britain and Ireland lipid infusion protocol in bupivacaine induced cardiac arrest in rabbits. Ohio. Madsen CD. Callaway CW. ANESTHESIOLOGY 2008. Schwartz D. Shorten GD: Effects of respiratory and metabolic pH changes and hypoxia on ropivacaine-induced cardiotoxicity in dogs. Opie LH. Case Western Reserve University. Weinberg GL: Lipid emulsion is superior to vasopressin in a rodent model of resuscitation from toxin-induced cardiac arrest. Salcido DD. Zheng S. Harvey MG. JAMA 1992. Saunders CE. Snow HM. Harvey hoped to reach an even broader range of academicians with his message that the “blood in the animal body is impelled in a circle.org.) George S. Kazemi A: Intralipid infusion diminishes return of spontaneous circulation after hypoxic cardiac arrest in rabbits. Sun S. Weinberg GL. 268: 2667–72 14. Honorary Curator. Illinois. Pointer J: A randomized clinical trial of high-dose epinephrine and norepinephrine versus standarddose epinephrine in prehospital cardiac arrest. Anesth Analg 2009. Mayr VD. Rosenblatt MA. Kelly K. Cave G. V 111. 64:732–7 20. Stehr SN. Noc M. Menegazzi JJ: Lipid emulsion combined with epinephrine and vasopressin does not improve survival in a swine model of bupivacaineinduced cardiac arrest. Circulation 1995. Popp M. 92:3089–93 15.. Ori C. Cave G. Anesthesiology. Koch T: Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion. Clarke K. Anesth Analg 2008. 27:1369–81 Ⅵ ANESTHESIOLOGY REFLECTIONS Harvey’s De Motu Cordis Eleven years after releasing the first edition. Cross HR. Weil MH. Park Ridge. This image appears in color in the Anesthesiology Reflections online collection available at www. ANESTHESIOLOGY 2006. Sep 2009 .

The next week. resulting in a relatively hypermetabolic state. were a bit more surprising. Umbilical arterial pH was lower in the ephedrine group (7. and invited me to write this editorial. Indirect evidence for this theory was provided in a variety of ways: umbilical artery-vein differences. Anesthesiology.8 The question of how to prevent or treat hypotension during spinal anesthesia for Cesarean section has been a central question in obstetric anesthesia for decades. Blood pressure was better maintained in the phenylephrine group. and my personal practices in using the drug. On the tram.g. Accepted for publication May 18. The author is not supported by. with an incidence 470 ᭜ This Editorial View accompanies the following article: Ngan Kee WD.2. Sep 2009 . Ϫ1. “What do I say if they ask me what drug I would use for hypotension during Cesarean section? Is phenylephrine an acceptable answer?” The response from the audience of predominantly nonobstetric anesthesia providers is perhaps not so shocking.9).3–5 and Asia6. Ngan Kee and his colleagues in Hong Kong. to begin our respective journeys home. nausea and vomiting). 7. Maternal side effects were decreased with phenylephrine. V 111. had convinced several colleagues at his institution to also do so. “What is your first-line drug to treat hypotension at Cesarean section.8 vs. 111:470 –2 Copyright © 2009. metaraminol) are safe and generally more effective than ephedrine at preventing maternal hypotension and its symptoms (e.1.15 In the current study.11–14 have demonstrated that phenylephrine or other ␣-agonists (e. many by Dr. blinded studies in Europe. Eisenach emailed me to tell me that he had started using phenylephrine infusions. or even believes in the principle of evidence-based practice. I asked the audience. ephedrine or phenylephrine?” Ninety percent responded ephedrine. despite the fact that there exists over a decade of fairly consistent evidence from well-designed. A few weeks later. Supported by NIH grant R01HD48805.2 the United States.10 Multiple reports in the 1990s and early 21st century. The answer has been called the Holy Grail of obstetric anesthesia. as they came from the Editor-in-Chief of this Journal. composed of a mixture of anesthesiologists and certified registered nurse anesthetists (CRNAs). the American Society of Anesthesiologists. however. Burden of Proof IN early 2009. The comments of my colleague on the tram. Lippincott Williams & Wilkins.g. and the lack of observable differences in uteroplacental perfusion that could otherwise explain a deleterious effect of ephedrine on neonatal pH or base excess. one of our current departmental Fellows. One of the final discussions at the conference had concerned treatment/prevention of hypotension during spinal anesthesia for Cesarean delivery. with higher PCO2 (56 mmHg vs. Inc. asked me. 2009. No 3. is willing to change his or her practice on the basis of the available information. randomly assigned 104 patients undergoing elective Cesarean section with spinal anesthesia to groups receiving infusions of either ephedrine (8 mg/ml) or phenylephrine (100 ␮g/ml). based on classic studies in sheep that suggested deleterious effects of pure ␣-adrenergic agonists on uteroplacental blood flow.33). randomized clinical trial comparing phenylephrine infusion to ephedrine infusion for the prevention and treatment of hypotension at Cesarean section under spinal anesthesia. I asked my colleague what he generally used to treat hypotension during Cesareans and he responded “Boluses of ephedrine or phenylephrine. 111:506 –12. Tan PE. In addition. the dependence on ephedrine dose. interprets evidence correctly.25 vs. randomized. any commercial activity that may be associated with the topic of this editorial.9 For decades ephedrine was the drug of choice. Ng FF. Inc. it has become clear that ephedrine use often leads to lower neonatal pH and a higher incidence of neonatal acidosis than does the use of phenylephrine or other pure ␣-agonists. 49 mmHg) and a more negative base excess (Ϫ4.” The following month. Karmakar MK: Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery.7 supporting the proposition that phenylephrine is at least as safe and effective and probably preferable to ephedrine for the treatment or prevention of hypotension at Cesarean section. Switzerland. Dr.3– 6. nor maintains any financial interest in. The question from the Fellow reflects the fear and insecurity that all of us felt as we approached our oral exam.Anesthesiology 2009. I had spoken about the evidence in favor of phenylephrine infusions. a 2-day symposium on Obstetric Anesthesia had just ended and my colleague and I stepped onto the tram in Basel. with fewer episodes of hypotension and need for rescue boluses. who had done his residency in our institution and was quite familiar with both the evidence for and our practice in using phenylephrine infusions and who was about to sit for his oral American Board of Anesthesiologists examination.1. The cause of this relative acidosis has been postulated not to be directly related to uteroplacental blood flow (fetal asphyxia) but rather to the effect of ephedrine as a metabolic stimulant within the fetus. whose clinical practice is and has been predominantly in obstetric anesthesia... as does most of the rest of my group. Not every anesthesiologist or CRNA reads every journal. as I began a lecture at a continuing medical education course. Khaw KS. even when we thought we knew the answer to a clinical question. ANESTHESIOLOGY 2009. Ngan Kee et al. In this issue of ANESTHESIOLOGY. We wondered what those Board examiners knew (or didn’t know) and what they would accept as answers. Ngan Kee et al. report on a blinded. titrated to maintain baseline preoperative systolic blood pressure.

Datta S: Phenylephrine in treating maternal hypotension due to spinal anaesthesia for caesarean delivery: Effects on neonatal catecholamine concentrations. is a bit more time consuming than simply injecting boluses from a syringe. Roger-Christoph S. Concentrations of glucose. and productive clinical investigations of Ngan Kee and colleagues in Hong Kong. highquality. studies elsewhere have confirmed the major findings. Second. we should not be so quick to change long-accepted practices based on one (or two or perhaps three) studies. Indeed. The current study is well-done. the results are almost certainly valid. Kokri MS: Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. No 3.17 Fifth.1–5. and confirmation from other centers and investigators should be required before widespread acceptance of any clinical recommendation. setting up an infusion. However. Thus. and episodes of hypotension. as is the case with ephedrine boluses or infusions. typically a pH difference of 0. and it should probably be the default choice for prevention and treatment of hypotension during spinal anesthesia for elective Cesarean delivery in the absence of a specific contravening rationale or contraindication. Division of Obstetric Anesthesia. ANESTHESIOLOGY 2001. Arthur GR.2. even that of very well-informed anesthesiologists. Ugeskr Laeger 2006. Afshari A. The pH and base deficit differences are consistent and statistically significant in most studies. Richard M. the preferred method of administering phenylephrine (and probably ephedrine) based on the evidence. Cohen SE: Phenylephrine added to prophylactic ephedrine infusion during spinal anesthesia for elective cesarean section. It is the therapeutic strategy that most anesthesiologists would want for themselves or family members as patients.. Carpenter M. and they result in higher neonatal pH and lower base deficits. you’ll like it. 39:901–5 4. What are we then to make of the fact that practice. and norepinephrine were significantly higher in the umbilical blood of the ephedrine group. thanks in large part to the consistent. ANESTHESIOLOGY 2002.16. Mowbray P. there are those who still do not quite believe the evidence is convincing.13 Finally. As the famous Alka-Seltzer ad from the 1970s said. Ph. many clinicians may just not think it worth their while to learn a new strategy. Fourth. Frederickson WL.” and so will your patients. LaPorta RF. Ryall DM.24 but doses in the range of 25–100 ␮g/min titrated to maintain maternal blood pressure near baseline values appears to be very effective and relatively easy to employ. College of Physicians & Surgeons of Columbia University. New York. These findings confirm the previously held suspicion that ephedrine crosses the placenta more readily than phenylephrine and support the concept that an increase in fetal metabolism caused by ephedrine is the cause of the increase in base deficit and increase in other markers of fetal metabolic stress. and more work in this area is both needed and ongoing. Benhamou D. The weight of the evidence has now equaled the burden of proof. As many have learned in a different context. Cooper DW. even some who would Anesthesiology. may argue that the safety and superiority of ␣-agonist vasopressor treatment has not been demonstrated in parturients with severe preeclampsia or other scenarios with significantly decreased uteroplacental flow and/or increased resistance. acid base status and Apgar scores. A variety of specific dosing strategies can be used and have been published. some clinicians. Moller AM. Smiley. with umbilical concentrations of phenylephrine 10 –20% of maternal.18 However. especially when conventional therapy is reasonably effective and reasonably safe. Third. it must be acknowledged that much of the work demonstrating the efficacy or superiority of phenylephrine comes from the Ngan Kee group. 95:668–74 . Riley ET. The “burden of proof” should be on the new therapy. and perhaps more importantly.19 –22 Titrated phenylephrine infusions minimize maternal nausea. Hangaard N: [Comparison of prophylactic infusion of ephedrine and phenylephrine during Cesarean section under spinal anaesthesia].02 or 0. rms7@columbia.EDITORIAL VIEWS 471 of nausea or vomiting of 35% in the ephedrine group versus 2% (1 patient) with phenyephrine. the evidence now is sufficient for a change in attitude and practice to be strongly encouraged. Sep 2009 concede the evidence in favor of phenylephrine for routine elective Cesarean delivery. First. especially in a “safety-first” subspecialty such as obstetric anesthesiology that deals with a predominantly healthy population. the phenylephrine versus ephedrine issue is perceived as not being quite a life and death issue.edu References 1.D. it is consistent with almost every study done over the past 15 yr comparing the two interventions at comparable doses. lactate. does not seem to have changed in response to the evidence? If the Holy Grail has been found and is readily accessible.05. Desira WR.. the investigators measured maternal and umbilical arterial and venous phenylephrine and ephedrine concentrations. epinephrine. for the first time in studies comparing ephedrine and phenylephrine. Department of Anesthesiology. New York. recent experience with perioperative ␤-adrenergic antagonist recommendations and some studies of tight glucose control suggest that clinicians should be appropriately wary of following every new evidenced-based trend. 168:1428–31 2. why are so few celebrating or drinking from it? Several explanations suggest themselves. of course. whereas ephedrine concentrations were comparable to maternal concentrations. This recommendation is finding its way into review articles from a variety of countries. a buy-and-hold strategy may frequently be superior to a day-trader approach in which a clinician attempts to adopt every new trend and piece of evidence that presents itself. “Try it. Acta Anaesthesiol Scand 1995. vomiting.D. Most importantly. 97:1582–90 3. Fetal:maternal ratios of ephedrine were significantly higher than those for phenylephrine. but they are not all that dramatic.23.6. PH-5. and our clinical burden should be to incorporate the evidence into our routine practice. M. V 111. Mercier FJ.

Macarthur A. Ngan Kee WD. 58:125–30 16. Chui K. Lee A: Multivariate analysis of factors associated with umbilical arterial pH and standard base excess after Caesarean section under spinal anaesthesia. Edouard D. Bennett A. Bader AM. Karmakar MK. metaraminol. Beilin Y: The treatment should not be worse than the disease. De la Dorie A. Dyer RA. Sep 2009 . Schoeman LK. Br J Anaesth 1994. Mercier FJ. and methoxamine on uterine blood flow in the pregnant ewe. James MF: Hemodynamic changes associated with spinal anesthesia for cesarean delivery in severe preeclampsia. Br J Anaesth 2004. Khaw KS. Ngan Kee WD. Lau TK. 63:1319–26 8. Datta S: Phenylephrine in the prevention of hypotension following spinal anesthesia for cesarean delivery. Roger-Christoph S: [Spinal anaesthesia for caesarean section: Fluid loading. Br J Anaesth 2006. Ngan Kee WD. Gin T: A randomized double-blinded comparison of phenylephrine and ephedrine infusion combinations to maintain blood pressure during spinal anesthesia for cesarean delivery: The effects on fetal acid-base status and hemodynamic control.472 EDITORIAL VIEWS 5. Boys RJ: Randomized trial of bolus phenylephrine or ephedrine for maintenance of arterial pressure during spinal anaesthesia for Caesarean section. ANESTHESIOLOGY 1974. 3:301–5 6. Watkins E. 108:771–2 18. Robson SC. Moran DH. 42:208–13 21. Karmakar MK: Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Br J Anaesth 1996. Perillo M. Ng FF. Lyons G: Equivalent dose of ephedrine and phenylephrine in the prevention of post-spinal hypotension in Caesarean section. Lee BB: Comparison of metaraminol and ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective cesarean section. Lee A. Riley ET: Obstetric anesthesia controversies: Vasopressor choice for postspinal hypotension during cesarean delivery. 103:744–50 24. Bonnet MP. Lombard CJ. Khaw KS. ANESTHESIOLOGY 2006. Ngan Kee WD. 45:115–32 20. Khaw KS. ANESTHESIOLOGY 2009. 107:1295–302 7. 108:802–11 17. No 3. 19:238–43 23. Gogarten W: [Prevention and treatment of hypotension during Caesarean delivery]. 40:354–70 11. 96:95–9 12. Int Anesthesiol Clin 2007. Ng FF. Ng FF. Columb MO. Langesaeter E: Is it more informative to focus on cardiac output than blood pressure during spinal anesthesia for cesarean delivery in women with severe preeclampsia? ANESTHESIOLOGY 2008. Anaesthesia 2003. Ng FF: Prevention of hypotension during spinal anesthesia for cesarean delivery: An effective technique using combination phenylephrine infusion and crystalloid cohydration. Ralston DH. 111:506–12 9. Khaw KS. Khaw KS. mephentermine. 95:307–13 13. LaPorta RF. Wilkes MP. Ngan Kee WD. Shnider SM. Piercy JL. Hanaf A. J Clin Anesth 1991. Anaesthesia 2008. Hall PA. Ngan Kee WD. Redfern N. ANESTHESIOLOGY 2001. 92:469–74 Anesthesiology. Can J Anaesth 2002. ANESTHESIOLOGY 2008. Anasthesiol Intensivmed Notfallmed Schmerzther 2007. DeLorimier AA: Effects of equipotent ephedrine. Reed AR. Kocarev M. Khaw KS: Vasopressors in obstetrics: What should we be using? Curr Opin Anaesthesiol 2006. 73:471–4 15. Thomas DG. Lau TK. Ng FF: Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. 76:61–5 14. Wilson RC. Ngan Kee WD. Ng KL: Randomised double-blinded comparison of phenylephrine versus ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section. Lewis M: Spinal anaesthesia for caesarean section: Comparison of infusions of phenylephrine and ephedrine. V 111. 49:536–9 10. 26:688–93 22. Anesth Analg 2008. Ngan Kee WD. 104:1348–9. Erler I. Ann Fr Anesth Reanim 2007. Banu F. vasopressors and hypotension]. Moufouki M. Macarthur A: Solving the problem of spinal-induced hypotension in obstetric anesthesia. Hughes D. Khaw KS. Tan PE. Saravanan S. author reply 1349 19. ANESTHESIOLOGY 2005.

machines can lead us into error just as verbal reports can. He noted the strong bias among clinicians and clinical researchers towards finding “objective” measures of pain. It would be wonderfully helpful to have objective signs of subjective change. Sympathetic activation is not a unitary process. and different triggers may activate different components of the sympathetic nervous system.2 attempt to validate a new pain measure for children. Ledowski T: Monitoring skin conductance: A tool for the assessment of postoperative pain in children? ANESTHESIOLOGY 2009.6 Hullett et al. This bias is often unjustified. Anesthesiology. despite the rapidly changing physiologic circumstances during recovering from general anesthesia. . the results should give considerable caution regarding clinical use of skin conductance fluctuations as a clinical measure of pain in children. we discuss a proposed pain measure by Hullett et al. and more reliable.5 Behavioral measures are widely used for infants and nonverbal subjects of all ages. and suffering. nor maintain any financial interest in. Many clinicians and researchers have a bias towards physiologic measures and against self-report. Lippincott Williams & Wilkins. We agree with the authors that more work needs to be done before this novel measure can be endorsed as a clinical pain measure in children.”1 1 Fifty years ago.5% for the whole sample and only 28. and they may underrate pain intensity relative to self-report measures in patients with persistent pain. Accepted for publication May 18. The authors suggest that fluctuations in skin conductance could be used in children with developmental delays. There are many natural patient groups that one should study to establish that this physiologic measure is specific for nociception/pain rather a range of other physiologic. Equipment costs. Pascoe E. Beecher reviewed challenges in use of subjective responses in clinical practice and clinical research. any commercial activity that may be associated with the topic of this article. but it was also found on repetition of the pains that they had lost their effectiveness to produce the galvanic skin response. or psychological processes in children. In this editorial.3–5 Different measures are required to assay the sensory. Perioperative and Pain Medicine. spiritual-existential. Chambers N. . Supported by the Sara Page Mayo Endowment for Pediatric Pain Research and Treatment. This measure has not been studied in this population. 2009. emotional. 111:473– 4 Copyright © 2009. Massachusetts. Sep 2009 . are particularly helpful and allow a better interpretation than would be provided solely by calculation of sensitivity and specificity. No 3.2 in this issue of ANESTHESIOLOGY. Boston. disability. Lange J. believing that the former measures are more scientific. 111:513–7. and social dimensions of pain. Consider a hypothetical infant or nonverbal child with well-controlled postoperative pain.1% for the 4 –7 yr olds). Surely we would not want to have a patient receive medication because the machine said so. Pain Measurement and Beecher’s Challenge 50 Years Later “THERE is a very great and understandable desire on the part of many people for objective indicators of subjective phenomena . If early hypovolemic or distributive shock led to sympathetic activation and high scores for fluctuations in skin conductance. The authors compared fluctuations in skin conductance to age-appropriate standardized behavioral and self-report pain measures. Pioneers in pain management and palliative care from the 1940s to the 1970s emphasized interrelationships among nociception. and he cited some problems with pain measurement based on indices of sympathetic activation. the measure shows relatively poor specificity and poor positive predictive value (35. Department of Anesthesiology. almost two thirds of the total sample would be unnecessarily treated. . but it seems unlikely that many such aids will be readily available in any precise way for years to come. Preuss J. The use of receiver operating characteristics curves and the presentation of statistics such as positive predictive value. impairment. Inc. behavioral. and these children 473 ᭜ This Editorial View accompanies the following article: Hullett B. pain experience. and machine failures need to be considered before implementation of any new clinical measurement technology. If used as a criterion for analgesic administration. The sample size is suitably large. It is believed that the galvanic skin response is an indicator of the threat contained in the procedure and is thus only indirectly related to pain intensity. but with slowly progressive internal bleeding or septicaemia. even if they are telling us that they are not in pain. As noted by the authors. Nevertheless. V 111. Boston. There is a potential for harm in basing clinical decisions on a false-positive pain measure. training costs. Inc. Zamudio I. namely fluctuations in skin conductance per second. pharmacological. Skin conductance can be responsive to many factors unrelated to pain. The authors are not supported by. then it could be a serious mistake to treat the infant or child with additional analgesics based on these scores.Anesthesiology 2009. the American Society of Anesthesiologists.”1 “A relationship between galvanic skin response and intensity of pain has been reported. Children’s Hospital. Receiver operating characteristics curve analysis should be used more widely. They are sensitive to fear or anxiety as well as pain. They made a reasonable attempt to control for the effects of anxiety and body temperature. There are several strengths to this paper. and we briefly consider the promise of future “objective” pain measures based on brain imaging or brain electrical recording.

Mikulis DJ. 1959. Backman SB. under a range of situations such as those listed in appendix 2. Children’s Hospital Eastern Ontario Pain Scale. toddlers. Adults and children ages 4 yr and older with low and high self-reported pain scores receiving medications with adrenergic agonist or adrenergic receptor blocking effects. Dalhousie University.. By strong agreement. or regional ratios of oxy. Preuss J. Activity. paraplegia with lower body stimuli that evoke autonomic hyperreflexia. Low cost. Beecher HK: Measurement of Subjective Responses. Nicholson K. Plourde G. Massachusetts. pp 57–98 2. New York. J Pain Symptom Manage 1990. 111:513–7 3. NY. 56:195–7 5. Davis KD: Altered central somatosensory processing in chronic pain patients with “hysterical” anesthesia. items 1–3. Study of some of these patient groups will help evaluate the sensitivity. we list some nonpainful clinical conditions that may influence measurements based on sympathetic activity. Meek J. Zubieta J: Human brain mechanisms of pain perception and regulation in health and disease. Neurology 2003. sympathetic blockade associated with regional anesthesia.11 Currently. 2:30 9. Children and adults who are afraid or anxious but having no pain. physical exam. 2. Perioperative and Pain Medicine. Gallella S. Chambers N. behavioral observation. Giannoylis I. laboratory information. single-photon emission computed tomography. Berde CB: Discordance between self-report and behavioral pain measures in three. Acute postoperative pain c... Proc R Soc Med 1963. 100:386–94 10.g. Appendix 2: Test Situations for Candidate Physiologic Measures of Pain Intensity 1. and positive and negative predictive value under a range of clinical conditions listed in appendix 2. M. ANESTHESIOLOGY 1971. Adults and children ages 4 yr and older with low and high selfreported pain scores with clinical conditions that affect sympathetic responses. brain imaging techniques are neither sufficiently practical to fit criterion 1 in appendix 1.g.to deoxy. and nonverbal adults with low and high previously validated behavioral pain/distress scores (e.7–12 Methods of imaging such as positron-emission tomography. portable. for awards for pain and suffering in lawsuits. Beyer JE. Sensory and emotional aspects of pain may show distinct signatures in different patient groups. we offer a provisional list of criteria that should be met for a candidate physiologic measure of pain intensity. Lange J. reliable. it remains difficult to predict whether advances in brain imaging and other technologies will make assessment of pain and suffering more science than art 50 yr from now. Flor H.. 4. Nat Rev Neuroscience 2006. autonomic neuropathies. Saunders C: The treatment of intractable pain in terminal cancer.R.D. Pediatrics. Boston. e. and physiologic measurement with the history. 3. Nikolajsen L. 7:873–81 11. Experimental pain. Sep 2009 Charles Berde. Positron-emission tomography and single-photon emission computed tomography require exposure to radioisotopes. Cry. shock. Harvard Medical School. Fitzgerald M: Cortical pain responses in human infants. it is conceivable that imaging studies could be used in the future for disability determinations in the workplace. according to age and clinical context) over a range of clinical conditions such as those listed in 1–3 above. high specificity. Pascoe E. Borsook D. Hofbauer RK.harvard. respectively. Oxford University Press. Cantarella A. Ph. 34:50–9 6. †Departments of Psychology. Strong agreement with self-report pain scales in articulate subjects ages 4 yr and older. Halifax. 2.hemoglobin. Treede R. Apkarian A. or for confirmation of psychiatric diagnoses. Mol Pain 2006. blood flow. Bushnell M. .† *Department of Anesthesiology. Infants. In appendix 2. Fiset P.. Eur J Pain 2005. V 111. easy to use. analgesia and analgesics.474 EDITORIAL VIEWS may be particularly vulnerable to physiologic perturbations and to adverse events from overmedication. charles. specificity.S. O. and chronic pain. Ledowski T: Monitoring skin conductance: A tool for the assessment of postoperative pain in children? ANESTHESIOLOGY 2009. nor have they been fully evaluated from the viewpoint of defining sensitivity. Livingston W: Pain Mechanisms.D.. Several distinct types of recurrent episodic pain and chronic persistent pain. Torgerson WS: On the language of pain. This should include strong agreement for patients/subjects with: a. Bushnell MC: Cortical correlates of the conscious experience of pain. or others. MacMillan. Nova Scotia. and functional magnetic resonance imaging detect signals reflecting regional brain glucose use. pain assessment and measurement remain imperfectly solved problems for clinicians and researchers.C. specificity. anemia. ANESTHESIOLOGY 2004. In summary. and Psychiatry. acute pain. Hullett B. Crawley AP. Imaging and electrophysiologic studies have produced surprising findings in patients with several types of chronic pain. Children’s Hospital Boston. McGrath PJ. Strong agreement with self-report in subjects with experimental pain. Kwan CL. Worley A. Quantitative Effects of Drugs. Consolability Scale. cold exposure. 9:463–84 8. 1943 4. Along with guiding clinical pain assessment and treatment and drug development. Brain imaging is a very active area of pain research that might afford the possibility of improved pain measurement in the future.D. Boyd S. 60:1501–7 12. congestive heart failure. including repetitive stimulation b. No 3.to seven-year-old children following surgery. Premature Infant Pain Profile. Canada.berde@childrens. 5:350–6 7. 26:3662–6 Appendix 1: Some Proposed Criteria for Ideal Physiologic Measures of Pain Intensity 1. It remains a clinical art to combine patients’ reports. 3. and positive and negative predictive value of proposed physiologic pain measures. and overall clinical context in guiding clinical judgments and therapeutic interventions. we mean high sensitivity. Legs. low risk. Mailis-Gagnon A. fever. and functional magnetic resonance imaging requires prolonged immobility for paradigms with repetitive on-off stimuli to permit signal averaging. New York.* Patrick McGrath. J Neurosci 2006. Zamudio I. including magnetic or electric source potential mapping or processed electroencephalographic measures are used as surrogate measures of regional brain electrical activity. Face. near infrared spectroscopy. Jensen TS: Phantom limb pain: A case of maladaptive CNS plasticity. In appendix 1. Ph. and excellent positive and negative predictive value over the full range from mild to severe pain intensities. Becerra LR: Breaking down the barriers: fMRI applications in pain. Anesthesiology. In considering the state of our science and clinical practice now 50 yr after Beecher’s summary of the problem of measurement of subjective responses. Downar J. hypovolemia.edu References 1. as surrogate measures of regional neuronal metabolic activity. Other measures. Slater R.C. F. Melzack R.

France. Buikema H. emergency surgery. have significantly contributed to improvements in quality of care and perioperative outcome. 111:475–7 Copyright © 2009.11 those with three or more risk factors who sustained an adverse cardiac event were also more likely to have endured intraoperative tachycardia. the American Society of Anesthesiologists. Isoflurane treatment attenuated the maximal aortic contractile responses to phenylephrine.4%) plus nitrous oxide (66%) in oxygen (33%).4%) in oxygen (33%) or isoflurane (1. and both Dr.4 In their studies. 111:600 – 8. In this manner. Houwertjes MC. Placing Physiologic Normalization into Clinical Context It is not possible to ascribe a benefit to the “normalization” achieved by the administration of nitrous oxide because there was no “nonanesthetized” control group. Pennsylvania. and no assessment of long-term outcome. mitigated the isoflurane-induced attenuation of phenylephrine responses. However. and others will exert a positive long-term clinical benefit. Thereafter. vascular responsiveness was assessed ex vivo in aortic rings. In addition. Samarska et al. Epema AH. in the shock state the addition of nitrous oxide induced acidosis when compared with isoflurane. or shock plus fluid resuscitation. corroborating earlier reports with volatile anesthetics. Nonetheless. to attend the World Congress in Anaesthesia. ANESTHESIOLOGY 2009. Even though animals were at different depths of anesthesia under these conditions. Patients with two or more risk factors who had an adverse cardiac event were more likely to have had intraoperative hypotension (mean arterial pressure less than 50 mmHg or decreased by 40%. A recent analysis started this process by evaluating the importance of intraoperative physiologic variables to determine long-term cardiovascular outcomes and death. Inc.6 Yet recent clinical studies have reported minor difference in blood pressure when comparing nitrous oxide or air as the carrier gas. coupled with improved patient monitoring. this finding corroborates previous studies demonstrating the vasoconstrictive properties of nitrous oxide. Rather our discipline needs to focus on endpoints of anesthetic management that are important by virtue of the fact that patient outcome is affected. Dr. Sanders have acted in this capacity for Air Liquide Sante ´ International. Paris. and hypertension. van Meurs M.1–3 In this issue of ANESTHESIOLOGY. Anesthesiology. their data have led them to the conclusion that nitrous oxide promotes hemodynamic stability. and underwent a sham procedure.5 Shock. Sanders has received an unrestricted travel grant from BOC Ltd.. Molema I. Unfor475 ᭜ This Editorial View accompanies the following article: Samarska IV. United Kingdom. cerebrovascular disease. Does Correcting the Numbers Improve Long-term Outcome? ADVANCES in the understanding of anesthetic pharmacology and perioperative physiology. obesity. therefore. also observed that nitrous oxide exposure was associated with a higher mean arterial blood pressure in the sham-treated animals despite the increased depth of anesthesia4. Wulfert FM.10 Data from this large cohort study identified higher-risk patients as having two or more comorbidities: Age. hemorrhagic shock. and further physiologic differences (such as oxygenation) confounds clear interpretation of the experimental findings. 2009. Maze has acted as a paid consultant for Air Products. anesthesiologists need to determine the modifiable risk factors occurring in the perioperative period that may be manipulated to improve outcomes. describe preclinical research that addresses the anesthetic modulatory effects on the physiologic adaptation to hemorrhagic shock. Maze and Dr. Dr. lasting at least 10 min) among other modifiable risks. When Can Modifying Intraoperative Numbers Improve Long-term Outcome? Identification of patient comorbidities is critical to understanding risk stratification of vulnerable patients and. V 111. previous cardiac intervention. physiologic variables should not be used as surrogate markers for long-term outcomes unless their association is tightly correlated. Guildford.Anesthesiology 2009. either isoflurane (1. their level of care. mice were exposed to anesthesia. Air Products and BOC Ltd. Lippincott Williams & Wilkins. and speculate that nitrous oxide may induce increased perioperative hemodynamic stability. during which time hemodynamic measurements were obtained. Sep 2009 . No 3.6 –9 Thus it is highly speculative that the modest increments (of the order of 10 mmHg) reported by Samarska et al. no correlation with postoperative hemodynamic changes. Samarska et al. with or without resuscitation. The ex vivo effects induced by in vivo isoflurane exposure were mitigated when supplemented with nitrous oxide. congestive cardiac failure. the authors attribute the pharmacologic properties of nitrous oxide for “normalizing” vasoreactivity. Accepted for publication May 26. Henning RH: Adjunct nitrous oxide normalizes vascular reactivity changes after hemorrhagic shock in mice under isoflurane anesthesia. especially as there is a tendency to view improvement as simply an intraoperative endpoint within anesthesiology. Allentown. In addition. although the biphasic pattern of relaxation and then contraction with acetylcholine was altered. Inc. the authors’ interest in improving hemodynamic stability in the postoperative period is commendable. have funded and continue to fund work in these authors’ laboratories. Similar to previous data for vascular surgical patients.

Sc. Of course it is possible that the study may find that the higher intraoperative mean arterial blood pressure induced by nitrous oxide may improve outcomes. Ch.ac.23 ENIGMA-II will be a 7. halogenated volatile anesthetics consistently demonstrate superior organ-protective effects as compared with nitrous oxide or intravenous agents in experimental studies.18. and Intensive Care.24 Going beyond the results that are based on cohorts of “average” patients. robert. M. Defining how to “correct the numbers” is a critical part of this approach. but how? Perhaps if tachycardia predisposes patients with three or more cardiovascular risk factors to adverse cardiac events. Anesth Analg 2008. suggesting that this effect will be too modest alone (approximately 10 mmHg) to alter cardiac risk. the long-term outcomes between the nitrous oxide and no nitrous oxide groups were not different.14 –16 This may translate into improved tolerance to lower perfusion pressure or reduced oxygen supply with an anesthetic technique that is based solely on halogenated volatile anesthesia.. V 111.19. While the purported increased hemodynamic stability (“correcting the numbers”) with nitrous oxide has been regarded as good for cardiac risk..11 to determine long-term patient outcomes. Our discipline’s research program has to focus on long-term outcomes to improve endpoints that both matter to the patient and improve the efficiency of healthcare resource use. adequately powered studies are required to further investigate these findings. United Kingdom.C.476 EDITORIAL VIEWS tunately the study was underpowered to ascertain an independent effect of the hemodynamic variables on adverse cardiac events. It is more than likely that anesthesiologists can continue to improve long-term patient outcomes. Whatever the results of ENIGMA II. may reduce this potential benefit accrued from the volatile anesthetic gas.Sci.13 These findings also question the clinical significance of nitrous oxideinduced improvement in intraoperative mean arterial blood pressure.12 Exposing patients with fewer risk factors may merely increase their chance of hypotension and thus increase their cardiac and stroke risk.* Mervyn Maze. Pain Medicine.A. then these are the subjects who are most likely to benefit from perioperative ␤-blockade.A. Long-term Anesthetic Effects: Nitrous Oxide Case Study The use of nitrous oxide for the maintenance of anesthesia exemplifies the need to focus on long-term outcomes. Thus the addition of nitrous oxide. Br J Anaesth 1987.B.. F. Again this may be secondary to raised homocysteine levels in the nitrous oxide group (although these were not measured). *Department of Anaesthetics. Robert D.17 Nitrous oxide may also influence cardiac risk by increasing homocysteine levels. Lagasse RS: The right stuff: Veterans Affairs National Surgical Quality Improvement Project. The trial has a solid scientific foundation.R.P.R.. Whether postoperative hemodynamic parameters are improved after nitrous oxide exposure remains unknown. Imperial College London. 59:834–41 2.19 Raised homocysteine levels predispose to higher cardiac risk in the community20 and in cardiac surgical patients21 via endothelial dysfunction and possible effects on coagulation. using careful clinical phenotyping that will be guided in the future by biomarkers that evolve from postgenomic research endeavors.S.22. long-term follow-up of these patients has not been conducted).Med.11. anesthesiologists will need to further personalize care for the individual patients. Therefore. B.uk References 1. Sanders. increased homocysteine levels have been noted with nitrous oxide-based anesthesia (however. other factors may mitigate this benefit. No 3.18.19 Putatively related to this increased perioperative myocardial ischemia. F.C. nitrous oxide administration was recently associated with an increased number of delayed ischemic neurologic events in a post hoc subgroup analysis of the intraoperative hypothermia for aneurysm surgery trial. Clearly it is important to “correct the numbers” intraoperatively. we need studies to define how these values should be modified. Critically though.. but we need the studies to demonstrate how. Both our specialty and the welfare of our patients will benefit from rigorous translation of the evidence from well-conducted clinical research into practice.C. 107:1772–4 . ␤ ϭ 0. F. M.23 with proof of principal demonstrated in smaller clinical trials. the use of nitrous oxide to improve hemodynamic stability based on the assumption that it will alter long-term patient outcomes may be flawed. Similarly. It is therefore timely that the ENIGMA-II trial protocol has recently been published. Holland R: Anaesthetic mortality in New South Wales. outcomes that matter to the patient. F.B.05..18 To further ignite debate.22 ENIGMA-II is designed to ask whether nitrous oxide predisposes to adverse cardiac events based on its ability to modify homocysteine levels. individual anesthetic effects on cellular metabolism could also be important.000-patient study designed to evaluate whether avoidance of nitrous oxide administration is associated with a 25% decrease risk of cardiac events or death (␣ ϭ 0. for example. the critical approach here is to focus on long-term patient outcomes. and that of physiologic changes in the postoperative period. Sep 2009 Impact of Long-term Outcome Studies Long-term outcomes studies are needed to define the optimal anesthetic management for the more than 234 million patients who undergo surgery each year.8 Anesthesiology. while “sparing” the volatile.1)..R.B.sanders@imperial.B.

Vollset SE: Plasma homocysteine levels and mortality in patients with coronary artery disease. and blood volume in humans. Ma D. 91:1073–9 19. vascular. Schouten O. Inada T. Greenspan L. 106:1039–48 13. Regenbogen SE. Choi P: Effects of extended- release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised controlled trial. Ballotta A. 109:707–22 24. 103:1174–82 17. Beattie S. Torner J. Cromheecke S. Sessler D. Xu S. Eur Heart J 2009. 371:1839–47 14. N Engl J Med 1997. 19:461–74 16. Br J Anaesth 1998. Circulation 2006. Kaisti KK. Bax JJ. ANESTHESIOLOGY 2008. Klootwijk P. Sep 2009 . Paech M. 99:603–13 18. No 3. Maze M: Biologic effects of nitrous oxide: A mechanistic and toxicologic review. Berry WR. 372:139–44 Anesthesiology. Chan M. Brozzi S. Lenhardt R. Mehta RH: Pre-operative homocysteine levels and morbidity and mortality following cardiac surgery. Shanks AM. Meeus R. Scheinin H: Effects of sevoflurane. Preckel B. Mayfield JB: The impact of intraoperative monitoring on patient safety. 44:140–5 7. Haynes AB. Todd MM. Gawande AA: An estimation of the global volume of surgery: A modelling strategy based on available data. Ma ´laga G. Nyga ˚rd O. 110:563–73 9. Hindman B. 157:488–94 23. Sanders RD. and urological surgery. Kertai MD. and adjunct nitrous oxide on regional cerebral blood flow. Schlack W: Effects of nitrous oxide on the rat heart in vivo: Another inhalational anesthetic that preconditions the heart? ANESTHESIOLOGY 2005. Thompson KD. Spence JD: Nitrous oxide-induced increased homocysteine concentrations are associated with increased postoperative myocardial ischemia in patients undergoing carotid endarterectomy. De Hert SG. 101:299–310 15. Anesth Analg 2008. Lancet 2008. Spiss CK. Van der Linden PJ. Fra ¨ssdorf J. Meij SH. Chrolavicius S. van Sambeek MR. Best Pract Res Clin Anaesthesiol 2005. O’Reilly M. Sipila ¨ H. ANESTHESIOLOGY 2003. 109:657–63 20. Englesbe MJ. ANESTHESIOLOGY 2008. ANZCA Trials Group: Nitrous oxide and perioperative cardiac morbidity (ENIGMA-II) Trial: Rationale and design. Houwertjes MC. Anesth Analg 2000. Tera ¨s M. Schroeder DR. Feringa HH. V 111. Weimann J. Kurz A. Anesth Analg 1985. Leslie K. Greif R. 80:169–73 10. Chan MT. Clarke W. Badner N. Villar JC. Costa E. Devereaux PJ. Lanier WL. 64:1–6 6. Fleischmann E. Forbes A. Zhang L. Hoffman BB. Jacka M. Boersma E. McIlroy DR. Thomson IR. Rothman ED. Lancet 2008. IHAST Investigators: Effect of nitrous oxide use on long-term neurologic and neuropsychological outcome in patients who received temporary proximal artery occlusion during cerebral aneurysm clipping surgery. Kaye DM. Pasternak JJ. Frigiola A. Stockman BA. Silbert BS. Myles PS. 111:600 – 8 5. Hennings RH: Adjunct nitrous oxide normalizes vascular reactivity changes after hemorrhagic shock in mice under isoflurane anesthesia. Wijeysundera DN. Avezum A. Chen S: Effect of nitrous oxide anesthesia on plasma homocysteine and endothelial function. 30:995–1004 22. oxygen consumption. Beattie WS. Tomlinson J. Yang H. Boncilli A. Metsa ¨honkala L. Devereaux PJ. Anesthesiol Clin 2006. ANESTHESIOLOGY 2009. Montori VM. Freeman D. Guyatt G. Nordrehaug JE. Inada K. Galal W. Tsujimoto G. Awan S. Myles PS. Lancet 2005. De Blier IG. Maze M: Prolonged hyporesponsiveness of vascular smooth muscle contraction after halothane anesthesia in rabbits. propofol. 24:407–17 4. Rusy DA. Can J Anaesth 1997. Lipsitz SR. McCluskey S. Xavier D. Ueland PM. Fee JP: Cardiovascular effects of 50% nitrous oxide in older adult patients anaesthetized with isoflurane or halothane. Leslie K. 366:1101–7 8. ten Broecke PW. Smith CM. Pogue J. Oikonen V. Sanders RD. Outcomes Research Group: Nitrous oxide and risk of surgical wound infection: A randomised trial. ANESTHESIOLOGY 2004. Pais P. 114:I344–9 12. Am Heart J 2009. Yasugi H: Haemodynamic comparison of sevoflurane and isoflurane anaesthesia in surgical patients. Epema AH. Wulfert FM. Fu ¨ lesdi B. Karkouti K. McGregor DG. La ˚ngsjo ¨ JW. Yusuf S. Rodrigus IE: Cardioprotective properties of sevoflurane in patients undergoing coronary surgery with cardiopulmonary bypass are related to the modalities of its administration. Badner NH. Farstad M. Ranucci M. Symons JA. Wallace S. Samarska IV. Toma O. Tait G: Does tight heart rate control improve beta-blocker efficacy? An updated analysis of the noncardiac surgical randomized trials. Liu L. Peyton P. Maze M: Anaesthesia induced neuroprotection. 110:58–66 11. 337:230–6 21. Jamrozik K. McKinney MS. van Meurs M. Aalto S. Rosenberg AL. Akc ¸a O. ANESTHESIOLOGY 2009. Molema I. Sessler DI. Beattie WS.EDITORIAL VIEWS 477 3. Herbst F. ANESTHESIOLOGY 2009. Tremper KK: Preoperative and intraoperative predictors of cardiac adverse events after general. Takubo K. Weiser TG. Weber NC. Chan MT. Lau CW. POISE Study Group. Poldermans D: High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Campbell DA. Refsum H. Nelis A. Kawachi S. Klein J. Kheterpal S. Tai M. Hinkka S. Van Reeth V. Buikema H.

Winston-Salem. 2009. [A1621] “NGAL as a Biomarker of Acute Kidney Injury in Cardiac Surgery: Impact of Baseline Renal Function” by David R 478 Anesthesiology. The University of Iowa. Iowa. A wave of new biomarkers exploring central nervous system. and the cardiovascular system is under scientific development and clinical validation. M. both in perioperative and critical care medicine. Ph. 2009.D. Joseph P.D. Ph. M. Journal-related Activities and Other Special Activities at the 2009 American Society of Anesthesiologists Annual Meeting Bruno Riou. Missouri. and the possibility to detect it by using new biomarkers. Ddimer. New Orleans. This Symposium will have invited formal presentations which describe two different stories. Anesthesiology Research Laboratories. The first story is that of an established biomarker. Barbara Phillips-Bute. Thomas Lee.§ David J. Brennan.D. V 111. Louisiana The 18th Annual Journal Symposium will be a multifaceted session that explores the latest scientific concepts and investigations of the role of biomarkers in perioperative outcome assessment. Wake Forest University School of Medicine. M. Newman. Submitted for publication June 15. Department of Anesthesiology. Department of Anesthesiology.D. Department of Anesthesia. France. Ph. Paris.. Ph. Assistant Professor.. which occupies an important place in current cardiovascular medicine. Gergis Professor of Anesthesia and Vice Chair for Research. Accepted for publication June 16. Lippincott Williams & Wilkins. The third lecture will present the methodological approaches and concepts appropriate to readers of the diagnostic and prognostic biomarkers literature. 111:478 – 84 Copyright © 2009.D.. Morial Convention Center.D.Ⅵ SPECIAL ANNOUNCEMENTS Anesthesiology 2009. Presentations at the Symposium by our three invited lecturers and interactive discussion with the authors of the selected scientific posters will address many of these questions regarding biomarkers and perioperative outcome. Université Pierre et Marie Curie-Paris 6. ࿣ Professor.. cardiac troponin. Division of Clinical and Translational Research. Fleisher. Research Assistant Professor.D. Louis. acute kidney injury. October 20.. ‡ Samir D. Pennsylvania: “An Established Biomarker: Cardiac Troponin” H.. The Symposium will be facilitated by Journal Editors Bruno Riou. Department of Anesthesia.. Houle.. Ph. University of Pennsylvania Health System. Chairman.* Evan Kharasch.D. kidney. and we are seeing a biomarkers revolution similar to the imaging revolution. and Mary B. The three invited speakers for this Symposium are ● ● ● Lee A. North Carolina. the American Society of Anesthesiologists. M. University of Zurich. Washington University.D.D. France. Each of the three lecturers will highlight the best science * Professor of Anesthesiology and Critical Care. Inc. CRP.. Room 395–396.D. North Carolina: “How to Read a Paper on a Biomarker” These lectures will be followed by a walk-around poster discussion of nine posters selected for their relevance to the Symposium topics of biomarkers and perioperative outcome. “Biomarkers of Brain Injury and Postoperative Cognitive Dysfunction after Major Noncardiac Surgery” by David L. The authors studied six serum biomarkers (BNP. M. M.† Timothy J. The text for each abstract can be found at the American Society of Anesthesiology (ASA) abstract Web site or in the CD-ROM that is included in this issue of the Journal. Washington University School of Medicine.‡ Alain Borgeat. Missouri. M. and a third which presents conceptual approaches to reading the evolving biomarkers literature.. NSE. Inc. Shelden Professor of Anesthesiology and Director. inflammation and sepsis. † Russell D. M. Paris. Philadelphia. whether as a clinical investigator or as a practitioner. 8:00 AM to 11:00 AM. St. Murray. Assessing the validity and clinical use of biomarkers is complex and requires considerable effort.. 2009. New York: “An Evolving Domain: Biomarkers of Acute Kidney Injury” Timothy T. and S100␤) and observed that they do not predict postoperative cognitive dysfunction and are not associated with apolipoprotein 4 genotype. MMP-9. Department of Anesthesiology.. New York.D.D. Sep 2009 . The second story is that of an evolving domain. Iowa City. M. but they may provide novel approaches for diagnosis and/or prognosis of clinical outcome. Duke University Medical Center... Ph. and Evan D.D. from University Pierre et Marie Curie. St. available to support their recommendations for optimally managing these challenging issues. Kharasch. McDonagh.D.. Switzerland. Mathew. Ph. No 3. § Professor of Anesthesiology. Daniel T.࿣ 18th Annual ANESTHESIOLOGY Journal Symposium: Biomarkers and Perioperative Outcomes Tuesday.D. Louis. Laskowitz. Zurich. Durham. Department of Anesthesia. Mark F. College of Physicians and Surgeons of Columbia University.

Timothy J. Dmitry Robertman. Massachusetts General Hospital. France. Meng Xu. Florian Weis. Jingqin Luo. Ohio. Miguel Albuquerque. University of Pennsylvania. New Orleans. Matthew Lambert. Vale ´rie Paradis. Durham. [A1625] “Preoperative BNP Is Superior to Postoperative BNP for Predicting PostCABG Hospital Stay and Mortality” by Amanda A. Peter A. Louisiana This is the second annual session of abstracts sponsored by ANESTHESIOLOGY and selected by Dr. Charlottesville. while the biomarker NGAL is not affected. Boston. Using the Diagnostic and Statistical Manual of Mental Disorders. [A1624] “Do Increasing Intraoperative Glucose Concentrations Worsen Outcomes After Cardiac Surgery?” by Alaa A. the impact of postoperative sepsis . [A1619] “Genetic Predictors of Increased Pain after Thoracotomy” by E. and were selected from the top-rated abstracts as scored by each scientific subcommittee that evaluated abstracts for presentation at the Annual Meeting. Sepsis has been widely investigated in the intensive care unit setting. Collard. H. and is known to be associated with increased mortality and morbidity. Abd-Elsayed. Muehlschlegel. William D. but not in diabetic patients. Bittner. The authors showed that elevated serum glucose at admission is associated with increased mortality in nondiabetic patients undergoing coronary artery bypass graft surgery. Anil Vachani. Brigham and Women’s Hospital. Massachusetts. The authors observed that severe intraoperative hyperglycemia (Ͼ 200 mg/dl ) were significantly associated with prolonged intubation and serious postAnesthesiology. [A1594] “Temporal Trends in Postoperative Sepsis following Elective Surgery in a Nationwide Sample in the US” by Brian T. White. The abstracts were selected based on broad interest and scientific importance. Ho ˆpital Beaujon. 8:00 AM to 10:00 AM. Body. No 3. Nemergut. Boston. [A1626] Best Abstracts of the Meeting: ANESTHESIOLOGY Editors’ Picks Monday. Ludwig-Maximilians University. “Sleep Apnea as the Main Risk Factor for Postoperative Delirium in Elderly Knee Arthroplasty Patients” by Madan M. 2009. Gustav Schelling. The authors report that low plasma levels of the antiinflammatory and neuroprotective endocannabinoids may predict early postoperative brain dysfunction after cardiac surgery. Brennan and Dr. This study opens new insights into the risk factors associated with postoperative delirium and warrants further investigations to refine our understanding of this problem. St. Pennsylvania. Bateman. New York. V 111. Andrew Ochroch. Philadelphia. Andra Duncan. Shernan. Room 252–254. New York. Edward A. Germany. Fox. These investigators examined in elderly patients undergoing elective knee arthroplasty which factors can correlate with the occurrence of postoperative delirium. Kwatra. Cleveland Clinic Foundation. Missouri. Postoperative delirium is a major concern in the elderly and is associated with increased mortality and morbidity. University of Virginia. Virginia. Munich. which will be presented in traditional oral format followed by a brief discussion. Charles D. Gebhard Wagener. Clichy. [A1623] “Value of Plasma Proteome Analysis for Diagnosis of Early Sepsis After Liver Transplantation” by Catherine Paugham-Burtz. Saarene Panossian. The authors observed that preoperative BNP better predicts hospital length of stay and 5-yr mortality than postoperative BNP in patients undergoing coronary artery bypass graft surgery. Thomas Lee. Massachusetts. Edward C. Duke University Medical Center. Amy London. since the pathophysiologic mechanism for delirium is unknown. Columbia University. Jochen D. only sleep apnea was significantly associated with the occurrence of postoperative delirium. Cleveland. However. Markus Landinger. The risk of adverse outcome was not significantly modified with lower hyperglycemia. Evan Kharasch. Jacques Belghiti.SPECIAL ANNOUNCEMENTS 479 Mcllroy. criteria. Sep 2009 operative infection after cardiac surgery. and observed that a combination of five plasma proteins can help to diagnose postoperative infection. The authors studied the plasma protein profile of patients undergoing liver transplantation to identify a specific profile. The authors showed that several haplotypes of OPRM1 (a gene involved in ␮ opioid receptor) were associated with increased acute pain after thoracotomy. [A1618] “Admission Serum Glucose and Poor Outcome after Emergency Coronary Bypass Surgery” by Robert Thiele. 4th Edition. delirium was diagnosed in 25% of patients. Louis. Stanton K. the performance of the biomarker being better in patients with normal preoperative renal function. Alain Borgeat. Among preexisting diseases in this population. Somnath Bose. Kanetsky. There is no effective therapy. The authors showed that the relationship between NGAL and acute kidney injury after cardiac surgery depends on baseline renal function. This session highlights 12 outstanding abstracts. [A1620] “Low Preoperative Endocannabinoid Levels Predict Early Cognitive Dysfunction after Cardiac Surgery” by Theresia Englmeier. North Carolina. [A1622] “Specificity of the Urinary Biomarkers KIM-1 or NGAL to Detect Perioperative Kidney Injury” by Jerry Morrissey. October 19. Jacob Raphael. Simon C. Jean Mantz. Morial Convention Center. Daniela Hauer. The authors showed that occult kidney cancer influences urine KIM-1 concentrations and thus confounds the use of this biomarker to detect acute kidney injury. Washington University School of Medicine.

Massachusetts General Hospital. Durham. [A1596] “ABCB1 Gene Modulates the Intensity of Postoperative Pain in Children” by Chantal Mamie. Stephen A. During extensive physiologic monitoring. but retinal vein occlusion decreased. Alan J. Illinois. In this study. Zhiquan Zhang. hydroxy-methyl-glutaryl-Coenzyme A reductase inhibitors. Switzerland. Young-Ming Yu. Cognitive dysfunction affects a majority of patients who survive after subarach- . Nuri B. Morris. Ansgar M. Tompkins. animals were treated with simvastatin or a farnesyltransferase inhibitor (FTI-277). Lombard.480 SPECIAL ANNOUNCEMENTS has been to date poorly documented. Prior treatment with statins. Warner. Avidan. postnatal Day 5 rhesus macaques were exposed to isoflurane for 5 h at concentrations that maintained a light surgical plane of anesthesia. [A1599] “Persistent Neuronal Degeneration in Hippocampal CA1 following Experimental SAH in the Rat” by Frederick W. Both simvastatin and FTI-277 treatment improved survival two-fold after lipopolysaccharide injection compared to vehicle. the in-hospital mortality rate declined from 44. Alfredo Morabia. Logistic regression models examined the data in 2-yr increments. Olney. A significant trend of high pain at rest 30 min after extubation across genotypes was found. This group has collected a very large number of admissions (Ͼ 2. Geneva. Boston.9% in 2006. Fischman. The authors found that the incidence of postoperative sepsis increased from 0. investigators examined isofluraneinduced apoptosis on postnatal Day 5 in a rhesus macaque brain with an emphasis on evaluating glioapoptosis.3% in 1997 to 0. Ronald G. reduces the incidence and mortality of sepsis. This resulted in the selection of over 5 million hospital discharges from 1996–2005. White matter cell profiles were characteristic of glial cells.4% in 1997 to 34% in 2006. Sep 2009 tion. Ho ˆpitaux Universitaires de Gene `ve. The odds of developing ischemic optic neuropathy have not changed during this period. such as farnesylation. [A1597] “Isoflurane-induced Oligoapoptosis in Neonatal Rhesus Macaque Brain” by John W. David S. Despite considerable progress in pain medicine. [A1598] “Perioperative Visual Loss: Incidence Trends 1996 to 2005” by Steven Roth. Michael A. Duke University Medical Center. suggesting the 3435C/T single nucleotide polymorphism of the ABCB1 gene influenced postoperative pain intensity in children: TT homozygotes seemed protected against high pain while CC homozygotes had exacerbated pain percepAnesthesiology. In the isoflurane-exposed brains. the causes of interindividual variability in intensity of postoperative pain are not understood. has been proposed to mediate the lipid-lowering–independent beneficial effects of statins in patients with sepsis. Chicago. The brains from these postnatal Day 5 macaques were compared to controls that were exposed to room air.000) for analysis. Shriners Hospital. Inhibition of isoprenylation. P-glycoprotein 1 (MDR1). [A1595] “Statin and Farnesyltransferase Inhibitor Improved Survival Following LPS Challenge in Mice” by Shohei Shinozaki. coded by the ABC1 gene. Brain sections were evaluated for markers of apoptotic cells. there was an increase in cells dying by apoptosis in cerebrocortical gray matter regions and in white matter cortical and subcortical regions. Genetic factors are suggested. Motomu Kobayashi. North Carolina. University of Chicago. It was previously observed that anesthetic drugs trigger apoptosis of glial cells as well as neurons in rodents. Brambrink. St. A cohort of 137 children aged 4–16 yr were followed after orthopedic or abdominal surgery with postoperative morphine patient-controlled analgesia for the first 24 h. Melinda Drum. Further study will evaluate whether these changes are a result of modified anesthetic and surgical practice. The potential impact on myelination and neurocognitive function requires further study. After lipopolysaccharide injection. Improved survival with these inhibitors was accompanied by decreased apoptotic changes in the spleen and liver. Genotyping for the ABCB1 3435C/T single nucleotide polymorphism may predict pain responses in operated children allowing adaptation of the patientcontrolled analgesia prescription. Farber. Outcome was postoperative pain intensity at different times. For all surgical procedures. These authors investigated the effects of statin and farnesyltransferase inhibitors on survival following lipopolysaccharide challenge in mice. Impairment of MDR1 could result in an increase of opioid concentration in the brain. farnesyltransferase inhibitors may be a potential molecular target to treat patients with endotoxemia. Furthermore. Yang Shen. odds ratios for ischemic optic neuropathy and cortical blindness did not change over the evaluation period. Perioperative visual loss is a devastating complication in surgical patients. These investigators evaluated the Nationwide Inpatient Sample and selected principal procedure codes for eight commonly performed in-patient surgical procedures and for perioperative visual loss. Huaxin Sheng.000. Washington University School of Medicine. or vehicle twice daily for 3 days. Massachusetts. However. Back. Masao Kaneki. Michela Rebsamen. Michael S. No 3. is known to transport opioids across the blood-brain barrier in the brain-to-blood direction. These findings suggest that inhibition of protein farnesylation may contribute to the protective effects of statins against endotoxininduced mortality. Missouri. including cells selectively marked for glia. Further evaluation indicated that these apoptotic glial cells were immature oligodendrocytes. V 111. Exposing infant rhesus macaque brains to isoflurane for 5 h caused a 10-fold increase in oligodendrocyte apoptosis. The overall incidence of postoperative visual loss declined from 1996–2005. This study clearly raised two major questions: How to explain the increase in severe postoperative sepsis? And why is there a decline of in-hospital mortality? Future studies focusing on these issues are warranted. Louis.

Domino. Forty days after SAH. Rong Lu.J. Tissue from the heart was examined for novel estrogen receptor messenger ribonucleic acid. Schumacher. Baltimore. Fitzgibbon. Fifty-one claims were for medication management among 294 chronic pain claims. visual spatial memory correlated with hippocampal CA1 neuronal survival 5 weeks after SAH. Bispectral index and acoustic evoked potential index were also recorded. nerve injury. Bern. The results showed that plasma clearance of CNS 7056 was about three times greater than that for midazolam. and may also contribute to the diverse action of estrogen observed in tissues. No 3. The estrogen receptor has been implicated in sex-specific differences in cardiac physiology and pathophysiology. Heyse Bjo ¨rn. Laparoscopic surgery is suggested in this context.5%). The NSRI best predicted loss of response to painful stimulus. No serious side effect was observed. NSRI values were computed. Previous studies indicated an increase in chronic pain liability related to medication management by anesthesiologists. These data suggest that prolonged treatments for several weeks may improve functional outcome after SAH. Denmark.R.M. Peter M. Bern University Hospital. This first study warrants further investigation to refine the potential use of CNS 7056 in clinical practice. Copenhagen University. Edward Michna. such as ovary and uterus. As compared with midazolam. D. Michel M. Hugo Vereecke. and there is to date no knowledge about predisposing factors to identify groups at risk. randomized. neuronal degeneration in the hippocampus is occurring. Because of this trend. Kilpatrick. Compared to other . Rigshospitalet. heat pain response. These variants were greater in the heart as compared with other tissues. G. California. The ideal hypnotic for anesthesia and sedation is still not available. Linda S. Rathmell. onset and offset of CNS 7056 were more rapid. V 111. Pharmacodynamic parameters were assessed with the modified observer’s assessment of alertness/sedation and bispectral index. In this study. Switzerland. University of Washington. pain coping strategies. K. James P. especially in the heart. Johns Hopkins Hospital. depression screening. Stephens. There is still no valid assessment of pain during surgery. comparing CNS 7056 and midazolam. Washington. A correlation between persistent postherniotomy pain and preoperative pain-related impairment. Pallob Kundu. Medication management claims were compared to other chronic pain claims from 2005–2008. Aasvang. Goldwater. double-blind. At each propofol concentration. Henrik Kehlet. [A1601] “Noxious Stimulation Response Index (NSRI): Validation of a Novel Anesthetic Depth Index” by Martin Luginbuehl. Borkett. Struys. These results indicate that even 40 days after SAH. Karen B. Recently this group of investigators presented an index (NSRI) based on a sequential hypnotic-opioid interaction model. Antonik. Copenhagen. In a prospective cohort study. a new benzodiazepine derivate. the specific estrogen receptor subtypes present in cardiac tissue have not been examined. supplementing electroencephalography-derived parameters. A Phase-1. Los Angeles. [A1602] Anesthesiology. These preliminary results suggest CNS 7056 may be a valuable drug for sedation and perhaps anesthesia. These messenger ribonucleic acid variants were examined for estrogen binding and for binding of other proteins related to estrogen’s actions. University of California. Sep 2009 “A Phase I SAD Study Evaluating the Safety. assessed by the validated activities assessment scale (AAS). Persistent postherniotomy pain is a major problem. Two novel spliced variants were identified in the part of the receptor that binds estrogen. and pain intensity at 30 days was found. and pain-related impairment. Maryland. single-dose escalation study was conducted. The main outcome was pain-related impairment at 6 months postoperatively ( follow-up rate of 95.J. This natural isoform of the estrogen receptor regulates the wild-type receptor function. NSRI may be a promising anesthetic depth indicator.SPECIAL ANNOUNCEMENTS 481 noid hemorrhage (SAH). [A1603] “Predictive Factors for Persistent Postoperative Pain: The Copenhagen Stuttgart Hernia Study” by Eske K.S. Tilbrook. there was a decreased number of intact neurons and an increased number of damaged neurons in the SAH group. Pharmacokinetics and Pharmacodynamics of CNS 7056” by L. The pharmacokinetic behavior of CNS 7056 was linear and dose-dependent. and the presence or absence of eyelash reflex and of a movement response to a 2-s tetanic stimulation of the volar forearm were recorded. [A1600] “Identification and Role of Estrogen Receptor Alpha Novel Splice Variants Isolated from Heart” by Ligia Toro. Los Angeles. These results suggest that patients with high preoperative pain response should be operated on with the surgical procedure less likely to inflict nerve damage. From the predicted propofol and remifentanil effect site concentrations recorded immediately before stimulation. Reinhard Bittner. Enrico Stefani. In previous studies using a rat model of SAH. Estrogen’s diverse effects on tissues are mediated by estrogen receptor alpha. These investigators examined the pharmacokinetics and pharmacodynamics of CNS 7056. Eliza Gmaehle. Forty-five patients received remifentanil target-controlled infusion and different propofol target-controlled infusion concentrations. characteristics of medication management claims from the ASA Closed Claims Project were investigated. the observer assessment of alertness and sedation score (OAAS/S). 19 potential predisposing risk factors were investigated in 463 patients using a standardized questionnaire including pain. G. investigators examined damaged neurons using neuronal staining after experimental SAH. [A1604] “Medication Management in Chronic Pain Malpractice Claims” by Dermot R. Thus far. Seattle.

patients tended to be younger and male. Marjorie Steigler. simulation is considered an essential element of patient safety programs. One of the presentations will describe the steps to assure that the content and construct of the scenario is valid. David Geffen School of Medicine at University of CaliforniaLos Angeles. Durham.M. Duke University School of Medicine. No 3. Room 386–387. The implementation of simulation training into Maintenance of Certification in Anesthesia (MOCA) will be described with the procedures and expectations for training center accreditation. 19 anesthesiologists aged Ͻ45 yr and 17 aged Ͼ45 yr were assessed on performance in a simulated “cannot intubate. M. Director of Simulation Center. In the assessment of novice anesthesiology residents. decision-making. These topics will be discussed in the abstracts that will be presented after the three invited speakers.482 SPECIAL ANNOUNCEMENTS chronic pain claims. Christine S. New Orleans. Louis. The authors conclude that most anesthesia malpractice claims for medical management problems involved chronic pain patients with a history of risk behaviors associated with addiction and medication misuse. [A1617] “Simulation Impact on Decision Making and Cricothyrotomy Skills” by Bruno Borges. 1:00 PM to 3:00 PM. 2009. Massachusetts General Hospital. cannot ventilate” scenario before and after videoassisted expert debriefing focused on communication. Director of Simulation Center. John T. Many of these studies describe how simulation is used to enhance skills communication. Toronto. Risk factors for medication misuse occurred in 83% of the opioid management claims. Northwestern University Feinberg School of Medicine. Robert J. and simulation as a method to improve clinical and translational research. Professor of Anesthesiology. 40 anesthesia residents were trained in speaking up across authority gradients. Sullivan. Opioids were prescribed in 68% of the cases. In this abstract. The three invited speakers for this session are ● ● 2nd Annual ANESTHESIOLOGY/FAER Session: Simulation in Anesthesia Practice Tuesday. October 20. the virtual environment. Simulation has stimulated a renewed interest in learning strategies. and performance assessment. Hwan Joo. human factors research. [A1605] A number of the presentations illustrate the broad applications of simulation. Simulation training is used to train anesthesiologists in “speaking up across authority gradients. M. David Birnbach. Ontario. In addition. and cricothyrotomy skills. as anesthesiologists age. Taekman. Assistant Professor of Anesthesiology. North Carolina: “High-Fidelity Simulation/Virtual Environments to Improve the Safety and Efficiency of Clinical Trials” “Speaking up across authority gradients: Are these simulator lessons retained and transferred?” by May C. Before and after training. Viren Naik. and more recently as a method to assess performance and maintain practice skills and competence. California: “Simulation Centers Accreditation: High Quality Training Endorsed by the ABA and ASA” Jeffrey M. Heinz Bruppacher. Illinois. Canada. Rochlen. Anesthesiology. Jeremy VandenBerg. Daniel Raemer. and psychomotor tasks.D. Death was the most common outcome. there was greater interrater variability using global rating scales as compared with the performance checklists. [A1615] “Comparing Inter-Rater Reliability of Global and Checklist Scores for Novices in Simulated Scenarios” by Lauryn R. Missouri: “Setting Performance Standards for a Simulation-based Anesthesia Assessment” Randy Steadman. Boston. Morial Convention Center. teamwork. These two session will describe the curriculum expectations as well as the potential limitations of a simulation-based performance assessment.” patient-care “hand-offs. and that the participant scores are both valid and reproducible as measures of skill. curriculum design.D. 22 first-yr anesthesiology residents were assessed on their performance during 6 simulated scenarios at Day 0 and Week 6 of training. Park. [A1608] .. In many of the presentations. In this abstract. Massachusetts. The training improved their effectiveness in speaking up across authority gradients.. Los Angeles. McCarthy. decision-making. In this abstract. The scenario is the key element of a simulation curriculum. Saint Michael’s Hospital. Sep 2009 ● David Murray. Chicago. as well as in decision making about caesarian section and cricothyroidotomy. Pian-Smith.. V 111.” “just-in-time” airway management skills. the residents reviewed videos of relatively contraindicated actions during obstetric anesthesia care. The lower cricothyrotomy scores and longer performance times of the Ͼ45 yr group suggests that. M.D. One of the sessions will describe two innovative programs. Professor and Vice Chair of Anesthesiology. including lectures by invited speakers that will be accompanied by the presentation of 12 posters selected for their relevance to the session topic. St. Washington University School of Medicine. and back pain was the primary chronic pain diagnosis. teaching of technical skills may need to be modified to account for changes in psychomotor skill. Louisiana Simulation plays an increasing role in training of physicians. the efficacy of a simulation-based curriculum is reported. Sylvain Boet.

Stanford. Results suggest that multisource evaluation combined with simulation may be an assessment technique more directly related to actual medical ability. Howard-Quijano. Robert Wood Johnson Medical School. California. Stiegler. Jack Boulet. Quraishi. Viren N. Although correct maneuvers were initiated. David Geffen School of Medicine. California. [A1607] “Benchmarking Skills of Anesthesiology Residents Using Multisource Ratings and Medical Simulation” by Seshadri Mudumbai. and peer rating of overall clinical ability. University of California. No correlation was found between expert assessment and self-assessment. Root cause analysis training resulted in retention of knowledge and increased positive attitude towards systems improvement. [A1610] “The 5-min Rule for Perimortem Cesarean Delivery: Should We Move to the Operating Room?” by Steven Lipman. In this abstract. Greg Staman. Steven K. Nashville. Naik. 21 anesthesia residents participated in a simulated pediatric cardiac arrest scenario to assess their pediatric resuscitation skills. Saint Michael’s Hospital. The results suggest that anesthesiology residents need additional pediatric resuscitation training. Tejal Raju. The Children’s Hospital of Philadelphia. Mathew D. Vanderbilt University Medical Center. W. implementation was not ideal for age. In this abstract. Yue Ming Huang. Los Angeles. eight timed stat cesarean section simulations were performed to assess the feasibility of delivering a fetus in the operating room within 5 min of maternal cardiac arrest. In this abstract. Canada. 24 anesthesiology residents evaluated their own nontechnical skill performance in a simulated crisis scenario before and after reviewing a video of their performance. Anesthesiology. Shawn Colborn. Cecilia Canales. either before or after video review. Gaba. and may advance patient safety through more effective communication. Oregon. Sujatha Devale. Torjman. Pennsylvania. just-in-time. Jason Slagle. St. Brendan Carvalho. In this abstract. Howard. the top and bottom cohort of a third-yr anesthesiology resident class was determined by attending. Elizabeth H. Bosseau Murray.or weight-specific treatments. multi-disciplinary. [A1614] “A Handoff Training and Improvement Initiative: The Curriculum Design” by Arna Banerjee. V 111. Nadkarni. Cooper University Hospital. Toronto. No 3. Sinz. Chandra. Deven B. Audrey Kuntz. Seven residents subsequently participated in seven simulated scenarios each. VA Palo Alto Health Care System/Stanford University. and delivery should therefore be performed in the patient’s room. In this abstract. Los Angeles. Students were more proficient at managing scenarios that simulated more common critical events. New Jersey. Washington University. Steadman. Walls. Sep 2009 Ontario. Bruppacher. senior medical students were evaluated on their performance during nine simulated acute care scenarios. [A1609] “Accuracy of Self Assessment for Crisis Resource Management Before and After Video Review” by Sylvain Boet. Portland. David M. simulation-based overtraining. No impact on success or adverse events was found. Philadelphia. Heinz R. Oregon Health and Science University. Stephen J. The results suggest that scenarios with lesser performance are areas of possible simulation-based training intervention to improve skill. [A1606] “Does Every Code Need a Reader? Observed Improvement of Rare Event Management with Read Checklist” by Amanda Burden. and their scores were found to correlate with ability ranking. David Murray. Matthew Weinger.SPECIAL ANNOUNCEMENTS 483 “Simulation of Hyperkalemic Cardiac Arrest to Assess Residents’ Pediatric Resuscitation Skills” by Kimberly J. Sheila Cohen. [A1612] “High-Fidelity Simulation as an Experiential Model for Teaching Root Cause Analysis” by Sadeq A. Camden. 45 anesthesiology residents were randomized to receive root cause analysis training before or after participation in simulated scenarios in which medical errors occur or receive no root cause analysis training. Marc C. Julie Woodhouse. surgeon. Ron M. In this abstract. The training improved resident procedural participation. A significant improvement in quality of actual handoffs between anesthesia providers and registered nurses was found after training. In this abstract. the performance of pediatric residents on airway management in the pediatric intensive care unit was evaluated before and after a 14-month. Bould. [A1616] . Results suggest that delivery within 5 min cannot be achieved if the patient is moved to the operating room. Randolph H. [A1611] “Effect of Just-in-Time simulation training on Pediatric resident performance of intubation in PICU” by Akira Nishisaki. In this abstract. Kimatian. PACU Handoff Project Team. Vinay M. Tennessee. act. Palo Alto. Introduction of an individual to read the cognitive aid aloud enabled residents to make better use of the cognitive aid. nurse. as compared with those who tried to think. California. Louis. nine anesthesiology residents were evaluated on their use of cognitive aids during rare and catastrophic event management. trained registered nurses assessed the quality of handoffs between 118 anesthesia providers and 124 postanesthesia unit registered nurses before and after simulation-based handoff training. [A1613] “Medical Student Performance in Simulated Acute Medical Scenarios” by James Fehr. In this abstract. and read the cognitive aid alone. University of Medicine and Dentistry of New Jersey. Missouri. Marjorie A. Stanford University School of Medicine.

University of California.D. F. William L.. Lunch will be provided! This year’s Celebration of Research will take place on Monday during the Annual Meeting. 12:30 PM to 2:00 PM. Young. M.S. Additional information regarding journal-related activities and FAER-related activities will be included in the Celebration of Research booklet distributed at the 2009 Annual Meeting. will serve as moderator. M.. Director. Louisiana.484 SPECIAL ANNOUNCEMENTS 7th Annual Celebration of Research Monday. 2009. Department of Anesthesia and Perioperative Care. V 111.D. Duke University School of Medicine. Assistant Professor of Anesthesiology. and the recipient of the 2009 Presidential Scholar Award. M.. Sep 2009 . No 3.. Eisenach. Durham. North Carolina. Professor of Neuro- logic Surgery and Neurology. Convention Center. The recipients of the 2009 Residents’ Research Awards will also be introduced during the Celebration event. Featured speakers will be the 2009 recipient of the ASA Excellence in Research Award.A. Professor and Vice Chair. October 19.E. New Orleans. San Francisco.D. Mihai V. Anesthesiology. Editor-in-Chief of ANESTHESIOLOGY. James C. Podgoreanu. Center for Cerebrovascular Research.

“Ultimately.” It is this approach that distinguishes his career—and that points the way for anesthesiology to continue to thrive. Inc. V 111. recipient of the American Society of Anesthesiologists 2009 Excellence in Research Award.” which was just renewed for a second 5-yr term. For one. Bill Young is also a prolific investigator whose work has had an impact on the scholarly development of neuroanesthesia. Department of Anesthesiology. after clinical anesthesia training at New York University Medical Center. When interviewed for our department’s recent 50th Anniversary. M. An accomplished anesthesiologist. After early studies on the cerebral effects of anesthetics. Recipient of the 2009 Excellence in Research Award Ronald D. his success supports the direction that the Foundation for Anesthesia Education and Research and the American Society of Anesthesiologists pursued in those days. the American Society of Anesthesiologists. William L. His unwavering dedication to excellence has had an enormous impact on faculty members in our department and across the entire UCSF campus. at a time of leadership change in our department. Lippincott Williams & Wilkins.Anesthesiology 2009. where he completed clinical and research fellowships. Bloomington. M. New York. his productivity in research and NIH grant funding has been incredibly consistent. he gradually moved to more unexplored pathophysiological areas in anesthesia.. William L. San Francisco. the current status of our specialty should be an effect—not a cause— of the questions we ask and our reach should exceed our grasp. M. 111:485– 6 Copyright © 2009. and it is hard to imagine a more deserving colleague. neurocritical care. No 3.* THE American Society of Anesthesiologists Excellence in Research Award is the highest honor our society can bestow on an investigator. Indiana. neurology and other various neuroscience fields. pathophysiology. Accepted for publication June 16. The work also led to epidemiological. “Integrative Study of Brain Vascular Malformations. Submitted for publication June 15. San Francisco (UCSF) is the 2009 recipient. The substance of his research is even more impressive. Bill grew up in Munster. Indiana and attended both undergraduate and medical school at Indiana University. Livingston Endowed Chair in the Department of Anesthesia and Perioperative Care at the University of California. When he arrived at UCSF. Studying patients with giant 485 Anesthesiology. He is the Principal Director of a program project grant. 2009. which is associated with arteriovenous malformation treatment. Bill approached cerebrovascular biology of vascular remodeling and angiogenesis using molecular and genetic techniques. In l985. Young. radiology. clinical risk prediction. Miller. William L.D. This led to the understanding of reperfusion hyperemia or perfusion pressure breakthrough. Young. In 2000. M. 2009. Inc. Sep 2009 . and care of patients with neurovascular disease. He quickly evolved into a productive and successful National Institutes of Health (NIH)-funded investigator in the specialty of anesthesiology. and imaging studies. Bill’s focus and calm dedication to excellence has been inspiring to me personally and serves as a role model for our entire faculty. This remarkable run began when * Professor and Chairman. He has had continuous NIH funding since 1990. two concurrent NIH grants since 1994. he joined the faculty at the Columbia University College of Physicians and Surgeons. and at least three and up to five NIH grants concurrently since l999. the James P. Bill was an early recipient of the Foundation for Anesthesia Education and Research award system. he relocated to UCSF where he became the Livingston Professor and Vice Chairman of Anesthesia and Perioperative Care. as well as on our ability to understand the mechanisms.. Young.D.. California. University of San Francisco School of Medicine. Bill said. His establishment of the multidisciplinary UCSF Center for Cerebrovascular Research has provided the vehicle for extending the boundaries of our specialty’s influence to include neurosurgery. and intraoperative neurosurgery. And.D. New York. today.D.

New York). Reaching the limits of current physiologic technology. and Neurosurgical Anesthesia.” Indeed. V 111. Since 1997. and previously on the associate Editorial Board of ANESTHESIOLOGY. which took place in Madrid. He was one of the first to be recognized by the NIH for mentoring efforts by receipt of a K24 award in l999. he was selected to cochair the first-ever National Institute of Neurological Disorders and Stroke workshop on vascular malformations of the brain. Cornell University (Ithaca. He has had remarkable success in helping junior faculty obtain career development awards. K23. his journey began at the bedside. Bill recognized that real progress would only occur through a thoughtful laboratory and bedside approach. No 3. with over 300 attendees. which he now conducts at the level of Program Director of a NIH Program Project grant. Perhaps the most intriguing evidence of Bill’s multifaceted approach to his work and his world is that he is a professional-grade jazz pianist. Spain. In addition. The workshop. since 2005.486 SPECIAL ANNOUNCEMENTS cerebral aneurysms. and UCSF. and K25) and three American Heart Association development awards. By using the unique skill sets gained from his training in anesthesia. In 2008. Bill Young clearly deserves our society’s highest honor in research: the Excellence in Research Award. For all of these reasons and more. serving on the editorial boards of the Journal of the American Heart Association. he provided our postdinner music. he’s been a member of the Clinical Neuroscience and Disease Study Section. who has provided remarkable support in what continues to be a remarkable career. then we should strive to understand the totality of the disease process and not accept any a priori limitations to the nature of the questions we ask nor investigations we pursue. Sep 2009 . he used “network” models. for which I am the primary editor. involved an international roster of some 50 clinical and basic science experts. he has served on various NIH review committees and. I have seen and heard him work easily into “jam sessions” with professional jazz musicians. Anesthesiology. Stroke. including serving as primary mentor on seven funded NIH K awards (K08. He also is coeditor of a major text entitled Cerebrovascular Disease and one of four consulting editors for the 7th Edition of Anesthesia. Bill has been instrumental in expanding the number of anesthesiologists conducting high-level basic and clinical research. and for our Department’s 50th Anniversary party. Bill is also someone the NIH turns to when it needs leaders. including innovative collaborations with bioengineers and imaging scientists. He would say. Why hire someone else when Bill could do the job as well as anyone? I should also acknowledge Bill’s wife Chantal. Several of his trainees are faculty in institutions that include Columbia University. thus instigating the most innovative and productive physiologic approach to understanding these disorders to date. filling a critical need that has been well recognized by American Society of Anesthesiologists leadership and several Rovenstine Lecturers. Bill Young has made major contributions to understanding both the biology and management of neurovascular disorders that many anesthesiologists must manage. “If anesthesiologists take care of vascular disease patients. His editorial responsibilities also are extensive.

2009. Accepted for publication June 16. 111:487–9 Copyright © 2009. Newman. stay up nights seeking the answer to a problem. 2009. M. and translational functional genomics. which is part of the pleasure of finding things out.. Podgoreanu described for the first time in cardiac surgical patients the emergence and progressive synchronization of high-frequency microvascular oscillations under conditions of nonpulsatile perfusion (during cardiopulmonary bypass) in the absence of cardiac and respiratory activity.” —Richard Feynman MIHAI Podgoreanu.. molecular variability in the host responses to surgical insult. Durham. M. focused on understanding the origin and control mechanisms of oscillations in microvascular flow in response to various physiologic perturbations. M. the American Society of Anesthesiologists. Department of Anesthesiology. To expand his repertoire into animal models of disease. The desire to develop as a perioperative physician-scientist and acquire the necessary knowledge to apply molecular medicine tools to * Professor and Merel H. and the well-known variability in perioperative clinical trajectories of patients undergoing cardiothoracic surgery. an internationally acclaimed expert in molecular pharmacology.. Mihai quickly became the central cog in the Perioperative Genomics and Safety Outcome Study (PEGASUS). recipient of the American Society of Anesthesiologists 2009 Presidential Scholar Award. This work was recognized nationally in 2001. Recipient of the 2009 Presidential Scholar Award Mark F. climb the steepest obstacles to the next fragment of understanding. Mihai Podgoreanu.edu Submitted for publication June 15. Lippincott Williams & Wilkins.2 These early investigations sparked his curiosity to understand the complex interplay between variability in physiologic parameters. when he was named the winner of the resident research contest at the Postgraduate Assembly of the New York Society of Anesthesiologists. the 2009 recipient of the Presidential Scholar Award. Sep 2009 . he pursued the clinician-scientist track under the mentorship of David Silverman. is a wonderful testament to the passion for discovery that should drive anesthesiology to the highest levels of modern science.* “You see? That’s why scientists persist in their investigations.D. why we struggle so desperately for every bit of knowledge.D. V 111. At Yale.D. Mihai Podgoreanu. Inc. a large Department of Anesthesiology genomics project focused on understanding the role of genetic variability in organ injury and dysfunction after cardiac surgery. No 3. both ex vivo and in vivo. North Carolina) in the summer of 2000. degree from Carol Davila University in Bucharest.D. Romania and trained as an anesthesiology resident at Yale University. New Haven.1 This phenomenon is particularly important now with the advent of axial-flow ventricular assist devices. thus demonstrating their peripheral origin and providing insights into parasympathetic vasoregulatory mechanisms in response to systemic depulsation. M. to finally reach that joyous moment of the kick in the discovery. Connecticut. Duke University Medical Center. newma005@mc. and laid the foundations of a new field based on the use of genomic 487 Anesthesiology.D.duke. He combined this 3-yr continuum of subspecialty training with a postdoctoral fellowship in molecular genetics in the laboratory of Debra Schwinn. cardiovascular autonomic control. Dr. where he embarked on a 2-yr cardiothoracic anesthesia fellowship.D. He received a postdoctoral fellowship award from the American Heart Association to study the effects of genetic variants in the ␤2 adrenergic receptor on adverse cardiac surgical outcomes. followed by a critical care medicine fellowship. Harmel Chair.Anesthesiology 2009. cardiac surgical outcomes brought him to Duke University (Durham.. M. Under Dr. North Carolina. Schwinn’s mentorship. Expanding on investigations in healthy volunteers. Mihai obtained his M. Inc. he participated during his residency in a project examining the effects of lidocaine on human lung fibroblasts and endothelium in a rat tracheal ring model system.

By effectively interfacing cutting-edge genomic and molecular investigative tools with clinical practice. visiting professorships. In parallel with this pioneering work. with a primary focus on inflammation and metabolic deregulation. and 3) identify and test new molecular targets for cardioprotection.488 SPECIAL ANNOUNCEMENTS technologies in perioperative medicine (i. Receipt of funding in the first peer-review cycle was an attestation to the quality of this proposal. but all of medicine. Podgoreanu was senior investigator on the first comprehensive study of myocardial metabolic responses to cardioplegic arrest in humans using novel quantitative targeted metabolomic approaches. In the fall of 2007 he was awarded a second R01 grant from the National Institutes of Health titled “Cross-species analysis of myocardial † http://pegasus. Dr. Dr. Despite the difficult times we are facing in many ways..” which incorporates novel comparative and evolutionary biology approaches to delineate the mechanisms by which robust “planned” environmental perturbations associated with cardiac surgery interact with genetic susceptibility to result in perioperative myocardial injury.16 Such systems-level approaches are extremely relevant to the perioperative clinician. Most recently. 2009. No 3. perioperative genomics). resulting in several awards.”3 In 2005. and peer-reviewed publications.duke.e. Podgoreanu is the type of individual who provides hope and inspiration for our specialty. as they will enable us to anticipate the consequences of surgical perturbations and design personalized preventive strategies for organ protection.15 cell model systems and integrative computational biology support in a comprehensive programmatic translational approach to study host responses to surgical injury and the robust stressors characteristic of the perioperative period. and Dr. Podgoreanu has formally mentored 12 trainees at different levels on various projects related to applications of functional genomics to perioperative medicine. Podgoreanu successfully transitioned to independent investigator status by receiving an R01 grant from the National Heart Lung and Blood Institute to study the role of genetic variants in progression and severity of saphenous vein graft disease and 5-yr incidence of major adverse cardiac events after coronary artery bypass surgery (“Genetics of myocardial adverse outcomes and graft failure after CABG”—GeneMAGIC). References 1. Dr. Capitalizing on his premed experience in mathematics. Mihai has given 30 lectures. susceptibility to perioperative stress. The success of his leadership in this area is evidenced by a series of publications identifying key genetic variants associated with major adverse postoperative events after cardiac and major surgery. To improve understanding of the scientific principles. Podgoreanu assumed leadership of the multidisciplinary Duke Perioperative Genomics Program and expanded it beyond pure genetic epidemiology studies to include relevant small and large animal models of disease. In this regard. Evaluations from anesthesiology residents have consistently ranked Dr. That he has succeeded in this effort so early in his career is a testament to his skills and his “passion to discover.3–9 as well as several review articles and book chapters introducing the concept of perioperative genomics to the broader cardiovascular and anesthesia communities. 97:1110–7 Anesthesiology.10 –12 including the first genomics chapter in a premier anesthesiology textbook. Mihai’s teaching contributions are multiple and reflect his dedication to research and use of that research to influence clinical care. ANESTHESIOLOGY 2002. he established the Systems Modeling of Perioperative Cardiovascular Injury Laboratory. which applies systems biology approaches to address three main goals: 1) understand mechanisms underlying acute myocardial responses to surgical ischemia–reperfusion injury. cardiac and major surgery can be considered a suitable experimental system that recapitulates several adverse environmental effects and gene-environment interactions. Accessed June 15. both at the national and international level. 2) discover organ-specific biomarkers that differentiate clinically relevant subtypes of perioperative myocardial injury. Podgoreanu has designed an educational Web site for Duke’s Perioperative Genomics Program. presentations at national and international meetings.” We are honored to be his partners in anesthesiology and critical care medicine. Podgoreanu’s teaching dedication and skills in the top 5th percentile among his peers. Dr. and computational issues associated with perioperative genomics research as well as being able to quickly update the existing level of knowledge in the field.edu.13 He was a Vivien Thomas Young Investigator Award finalist at the American Heart Association 2005 Scientific Sessions for his study titled “Inflammatory gene polymorphisms and risk of postoperative myocardial infarction following cardiac surgery. science offers greater opportunity to triumph over disease than ever before. Dr. When he is not doing the work described above.14. epidemiological study design. El-Moalem HE. Sep 2009 . and grand rounds over the past 5 yr. V 111. his work expands not only our specialty.† As evidence of his rapidly rising stature. Dr. Podgoreanu MV. he plays a major role in the department in provision of clinical care for cardiac surgical and critically ill patients. Silverman DG: Synchronous rhythmical vasomotion in the human cutaneous microvasculature during nonpulsatile cardiopulmonary bypass. This is a physician-scientist to watch. He is involved in the Cardiothoracic Anesthesia Fellow Seminar Series by providing basic science reviews on mechanisms of perioperative organ injury and advanced cardiovascular physiology. In the 5 yr since his faculty appointment at Duke. Podgoreanu has seized the moment. Stout RG.

Nielsen DM. Cullen B. Morris RW. Milano CA. Schwinn DA. 36:1854–8 5. Schwinn DA: Association of genetic polymorphisms with risk of renal injury after coronary bypass graft surgery. Morris RW. Schwinn DA. Schwinn DA. Phillips-Bute B. Morris RW. Newman MF. 46:1965–77 11. Podgoreanu MV. Phillips-Bute B. Stafford-Smith M: Genetic factors contribute to bleeding after cardiac surgery. Akhtar S. Clinical anesthesia. White WD. Newman MF. 3:1206–12 10. Podgoreanu MV. Podgoreanu MV. Philadelphia. Bennett E. Phillips-Bute B. No 3. de Lange F. Minerva Anestesiol 2008. Mackensen GB: A novel survival model of cardioplegic arrest and cardiopulmonary bypass in rats: A methodology paper. Sato Y. 119:1736–46 Anesthesiology. Smith PK. Mathew JP. Stafford-Smith M. Schwinn DA: Inflammatory gene polymorphisms and risk of postoperative myocardial infarction after cardiac surgery. Am J Kidney Dis 2005. van der Westhuizen J. 70:953–9 8. Br J Anaesth 2004. Newman MF. Psychosom Med 2008. 49:1934–42 6. Morris RW. Podgoreanu MV. Winn MP. Grocott HP. Stroke 2005. Circulation 2009. Turer AT. Swaminathan M. Circulation 2006. Newman MF: Relationship of genetic variability and depressive symptoms to adverse events after coronary artery bypass graft surgery. Podgoreanu MV: Metabolomic profiling reveals distinct patterns of myocardial substrate use in humans with coronary artery disease or left ventricular dysfunction during surgical ischemia/ reperfusion. 130:330–9 15. Morris R. Blumenthal JA. Schwinn DA. Stafford-Smith M. Rinder CS. eds.SPECIAL ANNOUNCEMENTS 489 2. Laskowitz DT: APOE polymorphism is associated with risk of severe sepsis in surgical patients. Newgard CB. Mathew JP. Newman MF: Genetic variants in P-selectin and C-reactive protein influence susceptibility to cognitive decline after cardiac surgery. Schwinn DA: Genomics and the circulation. Yoshitani K. In: Barash P. V 111. Newman MF: Perioperative Genetics and Safety Outcomes Study (PEGASUS) Investigative Team Genetic polymorphisms and the risk of stroke after cardiac surgery. 5th ed. Schwinn DA: Differential cardiac gene expression during cardiopulmonary bypass: Ischemia-independent upregulation of proinflammatory genes. Stafford-Smith M. Glower DD. Nielsen DM. Schwinn DA. Blumenthal JA. J Cardiothorac Surg 2008. Grocott HP. Brull SJ: Effect of lidocaine on endothelin-1-mediated airway smooth muscle contraction in the rat trachea. Podgoreanu M. Welsby IJ. Sep 2009 . Podgoreanu MV. Moretti EW. White WD. pp 133–48 14. Mathew JP. Podgoreanu MV. 93:140–8 12. StaffordSmith M. Mathew JP. Mathew JP: Genomic basis of perioperative medicine. Grocott HP. Stevens RD. Podgoreanu MV. Michelotti GA. J Thorac Cardiovasc Surg 2005. 22:23–37 13. Smith M. Mba UU. Morris RW. 74:643–50 3. Grocott HP. 2005. Bain JR. J Am Coll Cardiol 2007. Welsby IJ. Hauser EH. Stoelting RK. Podgoreanu MV. Crit Care Med 2005. Lippincott Williams & Wilkins. Mathew JP. Mathew JP. Podgoreanu M. Smith MP. Grocott HP. Podgoreanu MV. J Thromb Haemost 2005. Newman MF. White WD. Mathew JP. 114:I275–81 4. Best Pract Res Clin Anaesthesiol 2008. 45:519–30 9. Smith M. Podgoreanu MV. Lin S. Schwinn DA: New paradigms in cardiovascular medicine: Emerging technologies and practices: Perioperative genomics. Podgoreanu M. Muehlbauer MJ. Schwinn DA. 3:51 16. Schwinn DA. Podgoreanu M: Pharmacogenomics and end-organ susceptibility to injury in the perioperative period. Grocott HP. Mackensen GB. Mathew JP. Milano C. Moulin VG. Morris RW. 33:2521–6 7. J Am Coll Cardiol 2005. Harrison BA.

nerve injuries comprise 15–16% of the claims. Ann Arbor.8.4 Occasionally. Sep 2009 . No 3..9 and ulnar nerve injury.4. and surgical specialty were evaluated for associations. 2008. More importantly. Abstract presented at the American Society of Anesthesiologists Annual Meeting. Please see: Prielipp RC.8–11. closed claims. Ph. Box 0048. 1500 East Medical Center Drive. In addition.8. Support was provided solely from the institutional and/or departmental sources. Michigan. 111:490 –7 Copyright © 2009. 2009.† Terrence D. Departments of Anesthesiology and Neurosurgery.1–3 In the most recent American Society of Anesthesiologists (ASA) closed claims analysis. Florida. positioning. Orlando. ᭜ This article is accompanied by an Editorial View. and after review. Accepted for publication April 24.* Chad M.D. and institution-wide billing code databases for peripheral nerve 490 Anesthesiology..2 The fact that this percentage was relatively unchanged between studies performed almost a decade apart underscores the need for a more comprehensive understanding of risk factors for this persistent problem. Michigan. Welch. to determine whether injury is associated with the type of anesthetic technique or surgical specialty.‡ Kevin K. Patient preoperative characteristics.10.11.D. Results: Of all patients undergoing 380. however.† George A. # Assistant Professor.6. Warner MA: Perioperative Nerve Injury: A Silent Scream? ANESTHESIOLOGY 2009.D.D. Address correspondence to Dr.6 orthopedic procedures. and metabolic/environmental abnormalities. compression. have focused on specific comorbidities and types of neuropathy. Received from the Department of Anesthesiology. Significant associations were also found with the following surgical specialties: Neurosurgery.D. ࿣ Research Assistant. University of Michigan Health System. and institution-wide billing code databases were searched for peripheral nerve injuries over a 10-yr period. Previous studies. and surgical conditions. encompassing both upper and lower extremity nerve injuries in all anesthetic modalities. Tremper. www.Ⅵ PERIOPERATIVE MEDICINE Anesthesiology 2009. this is the first study to identify associations of nerve injuries with hypertension. M.2. Conclusions: To our knowledge. closed claims (CC). Michigan 48109-0048. Department of Anesthesiology.13 and age.# This article has been selected for the ANESTHESIOLOGY CME Program. † Clinical Lecturer. 2008.D.680 anesthetics during a 10-yr period. Ph..D. Shanks.S.8. M. Division of Pain Medicine. Ann Arbor.D.13 gender. the association of nerve injury with certain surgical specialties has never been evaluated. ‡ Resident Physician. Background: Peripheral nerve injuries represent a notable source of anesthetic complications and can be debilitating. including diabetes. such as laboring patients. the American Society of Anesthesiologists. This was accomplished by reviewing the quality assurance (QA). 185 patients were initially identified as having nerve injuries..03%). Lippincott Williams & Wilkins. The most likely pathologic mechanisms of injury include stretch.11 Furthermore.org. Brummett. anesthetic modality..11 vascular disease..11 extremes in weight.11. The location and type of the injury were also identified. Department of Internal Medicine. cbrummet@med. Submitted for publication December 10. General and epidural anesthesia were associated with nerve injuries. Recent data in a more current and broader surgical population. 111:464 – 6.9. and diabetes mellitus were significantly associated with perioperative peripheral nerve injuries. and surgical specialty. Perioperative Peripheral Nerve Injuries A Retrospective Study of 380.. Welch. M. defined as a new sensory and/or motor deficit.umich. tobacco use.§ Amy M. V 111. Nerve complications as a result of the surgical procedure itself were excluded.9. 112 met our definition of a perioperative nerve injury (frequency ‫ ؍‬0.7 the lithotomy position. this is the largest number of consecutive patients ever reviewed for all types of perioperative peripheral nerve injuries.9. Inc. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.7. Each reported case was individually reviewed to determine whether a perioperative injury occurred. and to determine the 10-yr frequency of perioperative peripheral neuropathies. M.11–13 Despite being a common comorbidity associated with neuropathy in medical patients.. the quality assurance.6. anesthetic modality. Ann Arbor. ischemia. M. University of Michigan Health System. Mashour. cardiac surgery. Methods: At a tertiary care university hospital. perioperative neuropathy associations between patient variables and common comorbidities have been conflicting among studies. * Resident Physician.680 Cases during a 10-year Period at a Single Institution Marnie B. direct trauma from peripheral nerve blocks and neuraxial techniques can cause injury. Brummett: Department of Anesthesiology. and an expert review panel assisted in the adjudication of unclear cases. and orthopedic surgery.14 hypertension has never been studied as an independent risk factor in the surgical setting.࿣ Pankaj Guglani. M. Inc.12 tobacco use. Hypertension. October 18. The goals of the present study were as follows: To determine whether injury is associated with preexisting patient characteristics.2 The etiology of perioperative peripheral nerve injury can be a result of a variety of factors.anesthesiology. is lacking. M. It is believed that such injuries can sometimes be associated with patient comorbidities.8. general surgery. The objective of this study was to identify associations with peripheral nerve injury in a broad surgical population cared for in the last decade.edu.9. This article may be accessed for personal use at no charge through the Journal Web site. PERIOPERATIVE peripheral nerve injury represents a notable source of anesthetic complications and can be very debilitating. § Professor.8.1.5 Some preexisting risk factors and intraoperative conditions have been demonstrated in well-designed studies. University of Michigan Health System.8. 1H247 University Hospital.

” Areas also exist for free text entry of postoperative events.0 –956. 955. faculty anesthesiologists. The Quality Assurance (QA) database is a voluntary reporting system that allows reports of complications in the postoperative period from predefined pick lists. The medical registration numbers of patients identified through this method were cross-referenced with our institution’s perioperative clinical information sys- Fig. The QA database has been in place at our institution for over 10 yr and contains voluntary reports of complications by the anesthesiology residents. injuries for all patients who underwent anesthetic management over a 10-yr period at our institution. including “New Peripheral Nerve Injury. under “Inpatient Post-op Visit. and 956. 2). V 111. full allegation.6 (Injury to peripheral nerve(s) of pelvic girdle and lower limb). Sep 2009 .” “sensory.” or “motor.” “tingling. CNS ‫ ؍‬central nervous system.” “numbness. 1). Michigan) approval.” “nerve. A potential peripheral nerve injury was identified by one of three ways in the QA system.” “tingling.9 (Injury to peripheral nerve(s) of shoulder girdle and upper limb) and 956.” “New Peripheral Nerve Injury” can be selected from a predefined pick list (fig. No 3. 1.” The third and final database searched was the institution-wide outpatient and inpatient medical diagnoses and billing codes database. MI ‫ ؍‬myocardial infarction.” The second database searched was the departmental CC database. as they are discussed weekly during Morbidity and Mortality conferences. Materials and Methods We defined a perioperative peripheral nerve injury as a new (within 48 h) sensory and/or motor deficit in any patient who had been sedated or anesthetized. The voluntary reporting system allows reports of complications in the operating room (OR) or postanesthesia care unit (PACU) period from predefined pick lists. OR ‫؍‬ operating room.” or “motor.0 –955. Second. tertiary care university hospital from May 1997 to May 2007. a record has been kept of claims filed against the Department of Anesthesiology. Ann Arbor. The International Classification of Diseases. QA events are used for research and internal review.6 (Injury to peripheral nerve(s) of pelvic girdle and lower limb). Nerve injuries were identified in a retrospective manner using three distinct databases at a large.” “sensory. Injuries as a result of the surgical procedure itself were excluded.9 (Injury to peripheral nerve[s] of shoulder girdle and upper limb). The Quality Assurance (QA) database was one of the three databases searched for perioperative peripheral nerve injuries.” “nerve.” “weakness.” CNS ‫ ؍‬central nervous system. After obtaining institutional review board (University of Michigan. Third.9 (Injury to nerve roots and spinal plexus).” “weakness.0 –956. Specifically. 9th Edition codes searched for inpatient visits were 955. Anesthesiology.” “numbness. 2. we first searched the Department of Anesthesiology’s QA database.0 –953. and key issues were searched for the words “neuropathy.” the free text was searched for the words “neuropathy. The free text of the initial complaint.PERIOPERATIVE PERIPHERAL NERVE INJURIES 491 Fig. under “OR/PACU Events. under “Comments. the Current Procedural Terminology (CPT) codes searched for outpatient visits were 953. including “Peripheral neurologic deficit within 48 hours post-op. and certified registered nurse anesthetists.0 –955. Over the last 10 yr.” “Peripheral neurologic deficit within 48 hours post-op” can be selected from a predefined pick list (fig. PACU ‫ ؍‬postanesthesia care unit. First.

faculty anesthesiologists.680 cases. Next.544 individual patients with the medical diagnosis over the 10-yr period. In the group that developed neuropathy.e. These patients were cross-referenced with the 380. The medical diagnoses database contained 15. This review determined whether a peripheral nerve injury actually occurred. For analysis. Entries are chosen from a predefined pick list. Results A total of 380.680 cases involving anesthetic care during the specified 10-yr interval. The additional 12 cases were individually assessed by the expert review panel. the patient must have developed the complaint within 48 h of the surgery. or both) was then identified from the QA database and/or the patient’s medical records. Of the remaining 121 cases. CMB and PG completed fellowship training in pain. The youngest patient was 13 yr old and the oldest 86 yr old. If there was a disagreement about the case. The number of cases searched from the CC database was 978. The panel identified an additional three cases for a total of 112 perioperative peripheral nerve injuries out of 380.16 This panel adjudicated cases in which it was difficult to determine whether the injury met our definition of peripheral nerve injury. 47 from the CC database. Surgical specialty listed was the primary service and did not account for any secondary surgical services involved. along with the location (upper extremity. Of the 480 possible cases. Sep 2009 comorbidities.. Associations were made among anesthesia technique and location of the neuropathy. Chicago. or both motor and sensory) of the neuropathy. The aforementioned three databases yielded 480 cases of potential perioperative peripheral nerve injuries (fig. GAM completed fellowship training in neuroanesthesia. ASA Class 1 or 2 and ASA Class 3. and 2. central neurologic events. Waukesha. The mean patient age was 46 yr. anesthetic techniques. Specific ages were only available for patients who developed a neuropathy. age. and that most likely is not a result of the surgery itself. hypertension. epidurals. the location of the injury (upper extremity. resolving peripheral nerve blocks. database reported and if the neuropathy was either sensory or motor only. ASA status was collapsed into a binomial variable for ease of interpretation. 4. and diabetes mellitus. or nerve damage clearly from the surgical procedure itself. preexisting neurologic deficits that were unchanged. 3). PG. specifically. according to the following definition: A new sensory and/or motor deficit that appears within 48 h of a procedure involving anesthetic care. Horner’s syndrome. Of those. and patients’ electronic medical record. or both) and nature of the neuropathy (motor. General Electric Healthcare.985. and spinals. and 295 from the billing code database. i. 138 were identified from the QA database. but the injury itself could have been diagnosed either in the electronic medical record or by the billing codes at any point in time after the surgery. The surgical specialty was also identified for each case. The QA database contained 380. the same patients with the same date of anesthetic care. or if it was both sensory and motor. a group discussion took place and a consensus was reached. QA database. were eliminated. V 111. tobacco use. lower extremity. duplicate cases. coronary artery disease.933. there was no significant difference in the .680 surgeries occurred under anesthetic management over a 10-yr period at our institution. Finally. or 5. The mean age is reported as a continuous variable. Agreement from two of the three members of the panel was necessary to make a decision. tem (Centricity. A review panel was formed consisting of faculty anesthesiologists from the University of Michigan (CMB.492 WELCH ET AL. lower extremity. From these three separate databases. Associations were then investigated for preexisting Anesthesiology. renal disease. 359 cases were eliminated because they did not fit the definition of perioperative peripheral nerve injury. all cases were divided according to the presence or absence of neuropathy. Cases that were eliminated involved resolving epidural or spinal anesthetics. Statistics Statistical analysis was performed using SPSS version 15 (SPSS Inc.15. The following patient variables were searched: ASA status. To clarify. Men made up 54% of the cases and women 46% of the cases. 109 clearly fit the definition of a perioperative peripheral nerve injury. high spinals. perioperative data were collected from the routine clinical documentation entered by anesthesiology residents. and surgical service using hazard ratios (HRs) with 95% confidence intervals (CI). WI) to identify patients who had a peripheral nerve injury diagnosed by the billing codes and also underwent anesthetic management during the specified 10-yr period.. surgical service and the location of the neuropathy. The following anesthetic variables were searched: Anesthetic modality and anesthetic procedures. sex. GAM). resulting in the previously mentioned 295 cases. IL).680 patients in the perioperative clinical information system.863 total patient encounters or single medical diagnoses. and certified registered nurse anesthetists in the QA database. The databases by which the injuries were identified were noted for each of the positive neuropathy cases. No 3. sensory only. sensory. including peripheral nerve blocks. incomplete documentation. Potential cases of nerve injury were reviewed by the authors using additional information from the CC database. and both CMB and GAM have done original research on topics related to the peripheral nervous system. or both) and characteristics (motor only.

436 (7.0–1.478 (5.8 (1.8%) 4.5–3.9 (1. Preexisting Patient Characteristics and Associations with Peripheral Nerve Injury Patient Characteristic No Neuropathy (n ϭ 380. Horners syndrome (n = 1) Total number of cases of perioperative peripheral nerve injury over a 10-year period (n = 112) number of ASA Class 1 and 2 patients (28%) when compared with the ASA Class 3.4 (1.0–3. Nine of the 12 patients were eliminated.1 (1. CI 1.6) 0.8–0.3) were found to have associations with injury.1) 2.2 (0. and diabetes mellitus (HR 2.4 –5.4 – 4.0) Epidural General PNB MAC Spinal 28. tobacco use (HR 2.863 patient encounters) Anesthetics over same 10-year period (n = 380.1) Five preexisting patient characteristics were searched for associations with perioperative peripheral nerve injuries. General (HR 2.5–3.1.568) Neuropathy (n ϭ 112) HR (95% CIs) cases of peripheral nerve injury that involved monitored anesthetic care.798 (16%) 20.3–3. Bold indicates significant values.4). 12 were unclear and reviewed by an expert panel. HR ϭ hazard ratio.3–3.4. No 3.057 (9. and orthopedic surgery (HR 2. CI 2.168 (6.3–3. Perioperative peripheral nerve injuries were identified by searching three separate large databases.6) 2.0–3.8%) 28.4) 1. CI 1. Table 2. The cases identified through the three methods were hand-reviewed.1) (table 1).03%). Three medical conditions were found to be associated with injury: Hypertension (HR 2.6%) 17 (15%) 40 (34%) 21 (19%) 10 (8.7– 4.6%) 0 (0%) 1 (0. and 5 patients (34%).3) 2. as it did not fit the definition of perioperative peripheral nerve injury described in the Methods section. Bold indicates significant values.7.4%) 28 (25%) 95 (85%) 4 (3. The Quality Assurance (QA) and Closed Claims (CC) databases are specific to the Department of Anesthesiology and were searched for possible cases of nerve injury. cardiac surgery (HR 2.3) 2. CI 1.PERIOPERATIVE PERIPHERAL NERVE INJURIES 493 Perioperative Peripheral Nerve Injuries Over a 10-Year Period Fig. 4. 95% CI 1.8.5%) 254.2).3–3.7%) 18.680 cases) CC database search (n = 978 cases) Institution-wide inpatient and outpatient billing code search (n = 15. Many cases clearly did not fit the definition for perioperative peripheral nerve injury associated with anesthesia and/or positioning and were excluded.8 (0. n ϭ number of cases.7–4.5%) 14 (12%) 2. Sep 2009 .433 (4. Coronary artery disease and renal disease were not associated with injury.8%) 58.0. PNB ϭ peripheral nerve block.6.680 anesthetics) Cross referenced 138 possible cases of peripheral nerve injury 47 possible cases of peripheral nerve injury 295 possible cases of peripheral nerve injury Potential cases of peripheral nerve injury (n = 480) Cases eliminated: clearly did not fit definition of perioperative peripheral nerve injury (n = 353) Potential cases of peripheral nerve injury (n = 127) Cases clearly fitting definition of perioperative peripheral nerve injury (n = 115) Unclear cases reviewed by expert panel (n = 12) Cases eliminated by expert panel (n = 9) Potential cases of peripheral nerve injury (n = 118) Cases eliminated: insufficient documentation to determine location of injury (n = 5).964 (7.2. Anesthetic Technique and Associations with Peripheral Nerve Injury Anesthetic Technique No Neuropathy (n ϭ 380.3).3–5. Hypertension.8–5.7).680 cases (0. Two patients had both upper and lower extremity injuries from a single case.7– 6. CI 1.0. QA database search (n = 380.9%) 76. and four were found to be associated with injury: Neurosurgery (HR 2. Five anesthetic techniques were searched for associations with perioperative peripheral nerve injuries. The locations of the injuries were identified and are displayed in table 4. The total number of perioperative peripheral nerve injuries identified over a 10-yr period at our institution was 112 out of a possible 380.3). One case of Horner’s syndrome postoperatively was also eliminated.2).142 (20%) 37. tobacco use. There were no Table 1. Billing codes associated with peripheral nerve injury were selected and cross-referenced against patients who had anesthetics over the study period.6) and epidural anesthesia (HR 4.6) 1. n ϭ number of cases. No associations were found with spinal anesthesia and peripheral nerve blocks (table 2). The institution-wide inpatient and outpatient billing code database includes all patient encounters throughout the institution over the same time period as the anesthetics in the QA and CC databases.4–4. V 111.1 (0. Of the remaining cases. 3. Fifteen different surgical services were searched (table 3).2 (1. and diabetes mellitus were associated with perioperative peripheral nerve injury. general surgery (HR 2. Sixty-five were upper extremity and 45 were lower extremity injuries.352 (67%) 6.7–6.681 (1.1 (2. An additional five cases were eliminated because of lack of clear documentation supporting a peripheral nerve injury. CI 1.985.568) Neuropathy (n ϭ 112) HR (95% CIs) Diabetes mellitus Hypertension Tobacco use Renal disease Coronary artery disease 26. CI 1. CI 1. General and epidural anesthetics were associated with perioperative peripheral nerve injury. Anesthesiology. MAC ϭ monitored anesthesia care. HR ϭ hazard ratio.7 (1.1.8) 0.

Ophthy ϭ ophthalmology. but in a more generalized population involving all anesthetic techniques.7%) 36.9–0.9%) 30. OMFS ϭ oral maxillofacial surgery.3–3.23 or because they were disease states that chronically disrupt blood flow. such as that of a diabetic.345 (2. and 27 were both motor and sensory injuries. a chronically dysfunctional nerve.0) 1.22 In support of All surgical services were searched for associations with perioperative peripheral nerve injuries.8%) 6 (5. Neuraxial techniques (epidurals and spinals) were more commonly associated with lower extremity injuries.8%) 7.740 (9. smoking. Thus. Upper extremity injuries were more prevalent than lower extremity injuries.256 (1. this is the first study to associate hypertension specifically with perioperative peripheral nerve injury.9 (0.5%) 28.8%) 5145 (1.0–1.417 (8.3–5.7%) 2 (1. respectively.1–1.17.183 (4. which proved to be an independent risk factor for lithotomy-associated lower extremity neuropathy. Hypertension is a chronic disease process that affects blood flow.0 (1.4–5.2) 1. 58%.353) General (n ‫ ؍‬36.9%) 2 (1.1%) 20 (18%) 23 (21%) 4 (2.7%) 0 (0%) 14 (13%) 1 (0.126 (1. * Not determined cases were documented as plexopathies.3–3.0 (1.5–4.0–1.18 It was found to be a risk factor in the development of ulnar neuropathy and lower extremity neuropathy in the lithotomy position.0%) 58.0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 3 (2. Table 3.8 (0.4%) 9 (8.1%) 10.7%) 2. and orthopedic surgery were associated with perioperative peripheral nerve injury.7%) 43.0) 0.8) Sensory Motor Both motor and sensory Not determined 67 16 27 2* The type of the perioperative nerve injuries was determined from the electronic medical records.048 (0.894 (1.5–2. and hypertension.326 (15%) 4. Location of Peripheral Nerve Injury Location of Injury Number of Cases Upper extremity Lower extremity Both upper and lower extremity 65 45 2 The locations of the perioperative nerve injuries were determined from the electronic medical records.0–1.4%) 513 (0.0) 1.4%) 17.0–1.7 [2.0 (1.1%) 17.863 (2. 67 were sensory injuries.5) 0. n ϭ number of cases. or both (table 5).9%) 6.7) 2.494 WELCH ET AL. odds ratio 5. GYN ϭ gynecology.5%) 1696 (0.846 (1.029).7–5.0) 1. Neurosurgery.048) Trauma (n ϭ 5.11 but was also shown to not be associated with injury in patients undergoing total knee athroplasty. Sensory neuropathies were more prevalent than motor neuropathies or combined sensory and motor neuropathies. HR ϭ hazard ratio. or 0.1 (0.3–5.0 (1.311) Radiology (n ϭ 3. ischemia and infarct are mechanisms of localized injury to the peripheral nerves of an anesthetized patient.313) Pulmonary (n ϭ 513) Oncology (n ϭ 10. The number of upper extremity injuries between cardiac surgery and other surgical services was not significantly different (75% vs.680 cases.9 (0.3 (0. No previous study has evaluated whether or not this common chronic medical condition is a risk factor for injury. respectively.4 (0.7) 1. Two cases could not be determined.762) Orthopedics (n ‫ ؍‬43.7. Sep 2009 . motor.313 (1.568) (n ϭ 112) HR (95% CIs) Table 5.866) Ophthy (n ϭ 30. The type of the neuropathy was identified as sensory. Since the disruption of the blood supply to the nerves is integral to the mechanism of injury. respectively).0 (1. P ϭ 0. There could be other reasons why hypertensive patients have more nerve injury.1) 2.290) 13. and thus may leave the nerve more susceptible to injury.6%) 3 (2. may be more susceptible to injury from acute ischemic or mechanical insult.9%) 3.14. Anesthesiology.03%.8 (1.22.7]). 39%.311 (1.6%) 38.699) Transplant (n ϭ 6. OB ϭ obstetrics.5–2.9 (0. general surgery. Diabetes is a known cause of chronic neuropathy and vascular disease. tobacco use.7) 1.2 (0.5 (0. as compared with those identified in the QA database (69% vs.14. The 10-yr frequency of perioperative peripheral nerve injuries was 112 of 380.5–4. but were repeatedly described as a “plexopathy. Discussion Our results demonstrate significant associations between perioperative nerve injury and diabetes mellitus.260) Thoracic (n ϭ 6. and it was originally described as a potential cause of perioperative neuropathy in case reports.20.8%) 5. Associations between Surgical Service Peripheral Nerve Injury Surgical Service No Neuropathy Neuropathy (n ϭ 380.11 The associations found in our study support some of the previous findings.436 (3. Table 4.9) 0.0–1.127) Plastic (n ϭ 17. Interestingly.5 (0. Bold indicates significant values.417) Urology (n ϭ 58.189) OB (n ϭ 28.676 (12%) 6. Sixteen were motor injuries.2) 1.” Patients in the CC database were more likely to have a motor component to their neuropathy.147) GYN (n ϭ 17.518 (4.19.9%) 8 (7.4) 1.342) OMFS (n ϭ 4.2 (0.0) 0.9.12 Conflicting results have also been found for tobacco use.572) Burn (n ϭ 1.7–12.1–5. V 111. Type of Peripheral Nerve Injury Type of Injury Number of Cases Neurosurgery (n ‫ ؍‬13.1–0. Two patients had both upper and lower extremity injuries from a single case.1) 1. cardiac surgery. including a propensity for hemodynamic instability or the predisposition for other comorbidities associated with peripheral nerve injury.3) 2.696) Psychiatry (n ϭ 7.8%) 3 (2.4) 0. 31%.520) ENT (n ϭ 38.8) 1.7%) 4 (3.5–1. as compared with all other techniques (71% vs.5%) 10.4%) 7.9) 0.0) 1.7 (1.3–3.9 (0. the finding that diabetes.563 (7.19 –21 We selected particular variables from the QA predefined pick lists because of suggested associations with neuropathies. ENT ϭ otolaryngology. No 3.10. and hypertension are associated with perioperative neuropathies parallels the association with peripheral neuropathy in medical patients.897) Cardiology (n ϭ 5. As mentioned.2–14.287 (10%) 10 (8.446) Cardiac (n ‫ ؍‬10. Moreover.850) Vascular (n ϭ 7.5 one can hypothesize that patients with already compromised vasculature will be more susceptible to perioperative injury as well.8 but not for ulnar nerve neuropathy.0 (1.0 (1.8.

We are further investigating prone positioning in an ongoing study. urology and gynecology) were not associated with nerve injury. although lithotomy position for longer than 2 h has been shown to be a major risk factor for injury.1 In the present study. including internal jugular vein cannulation.6 The distribution of the location of injuries in our study was consistent with previous work (table 4).28 While not a statistically significant result. In addition. but did not reach. cardiac surgery patients tended to have higher rates of upper extremity neuropathy as compared with other surgical patients in the neuropathy group (75% vs..12 We found significant associations with the techniques of general and epidural anesthesia. Recommendations have been made for the positioning of children. Given the low number of injuries with these anesthesia techniques. it is difficult to draw any significant conclusions. which was also shown in a previous CC study. The frequency of prone positioning involved in orthopedics and neurosurgery may have caused nerve injury. Upper Anesthesiology. Thus.037% and 0.8.31 Unlike previous studies. Other studies. a population that has been largely excluded in previous studies. table 5). Warner et al. six nerve injuries occurred in children.7. It is not surprising that patients would deem a neuropathy in which there was a loss of physical function to be more significant.000 procedures between 1987 and 1993. Sep 2009 extremity injuries were more common than lower extremity injuries.1 and was significant in the present study. the patients identified through the CC database were significantly more likely to have a motor component (motor or both motor and sensory) to their injury. significant association with injury. The lack of association with monitored anesthetic care deserves mention and is not unexpected. Specifically.8 In addition.30 included all anesthetic techniques and found an incidence of injury of 0. 58%. It is notable that services that regularly position their patients in a prolonged lithotomy position (i. To our knowledge. sedation cases are usually shorter. No associations were found with peripheral nerve blocks. More than half of the injuries identified were primarily sensory symptoms (67 of 112. general surgery. it is reasonable to consider each anesthetic technique with its own particular opportunities for risk. as well as the hypothermia and hemodynamic changes during bypass. The wide range in ages in the current study demonstrates the broad scope of this problem. Our result is also lower than previously reported. stating the incidence to be 0. but our study design does not allow confirmation of this hypothesis. ASA status does not seem to be associated with neuropathies. length of case.1.5%.028%1. and perioperative positioning.26 In addition.680 consecutive surgical patients over a 10-yr period was 0.29 reported in 1973 an incidence of 0. These results stand in contrast to recent data showing a higher incidence of injury with peripheral nerve blocks (3%) than central neuraxial anesthesia (0.2. It has been well established that cardiac surgery has a high incidence of nerve injury.11% in 81. orthopedic surgery. the use of pneumatic tourniquets has been associated with perioperative neuropathy in two previous studies. in addition to those discussed above. given the higher incidence of postpartum peripheral nerve injuries of 0. however.014%).24 Also. There has been limited scientific evidence to guide the prevention of this complication.9. internal mammary artery dissection.PERIOPERATIVE PERIPHERAL NERVE INJURIES 495 an ischemic etiology. as conscious patients should retain more of their protective reflexes and be able to reposition themselves. The ASA practice advisory for the prevention . monitored anesthetic care. especially regarding positioning. and stretching of brachial plexus with retraction.8. and neurosurgery were also found to be associated with injury. No 3. Blitt et al. Our findings that general and epidural anesthetics are associated with injury are somewhat surprising given the recent incidence data.000 general surgery patients. with the 1. respectively). The frequency of perioperative peripheral nerve injuries in 380. but these studies have varied widely in their methods. V 111.11 and an easy explanation for the difference may be depth of sedation. however. a previous study of CC data revealed that general anesthesia is less frequently associated with nerve injury than regional anesthesia.03%.8 there was no association found between men and nerve injury. or spinal anesthesia. there were no cases of injury associated with monitored anesthesia care. This is the first study of associations between particular surgical services and perioperative neuropathy.25 which we confirmed. Parks et al.5% incidence derived from a prospective study. Cardiac surgery has been linked with more upper extremity injuries because of a variety of reasons.2 Associations between neuraxial techniques and lower extremity neuropathy have also been reported. These findings indicate that patients with a motor component to their injury are more likely to pursue legal measures.27. which is surprising. Peripheral nerve blocks were trending towards.e. obstetrics was not associated with more nerve injuries. this is the largest number of consecutive patients ever reviewed for all types of perioperative peripheral nerve injuries.92%. based mainly on anatomic and physiologic differences between adults and children. Potential mechanisms for the association with cardiac surgery include the median sternotomy leading to brachial plexus injuries. as compared with patients identified through the QA system. Interestingly.11 reviewed much larger numbers of patients but focused exclusively on ulnar neuropathy and lower extremity neuropathy in the lithotomy position. have reported cases of injury with sedation. excluding those who received central neuraxial anesthesia and peripheral nerve blocks. which has not previously been reported.14% based on a retrospective review of 50.

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of perioperative peripheral neuropathies recommends a preoperative assessment to determine whether the position can be tolerated, various considerations for each position, a postoperative assessment to lead to early recognition of peripheral neuropathies, and better documentation. Better documentation can help the practitioner focus on certain aspects of positioning and also provide information that can be later used for refinements in patient care.32 We believe that anesthetic documentation of positioning should be improved in all patients, as past investigations have shown it to be inadequate.33 This is an area of perioperative anesthetic care that needs further research, as multiple closed claims analysis still judge anesthetic care, positioning, and padding inadequate in a significant percentage of cases.1,33 Limitations This study has several limitations. The capture of perioperative peripheral nerve injuries will be incomplete when reviewing data in a retrospective manner, as evident by our discrepancies of cases in the three methods of retrospective review. The analysis of the QA database relies on self-reporting, and complications tend to be underreported. Thus, we expect the actual incidence to be higher because of the self-reporting nature of the QA database. Although there are limitations inherent to a retrospective methodology, we have attempted to minimize them by employing three different databases. It is important to note, however, that the primary goal of the current study was to identify associations and risk factors for perioperative peripheral nerve injury, rather than the precise incidence. It is unclear whether a decreased capture rate of injury would have biased the associations identified. Another area of limitation pertains to exactly which patient and surgery characteristics were available in the QA database. We are currently investigating more variables from our electronic medical records system, as over the last 5 yr the preoperative and intraoperative data capture has expanded significantly. The QA system also did not allow us to identify the location of the injury in every case. Yet another limitation is the very definition of the perioperative peripheral nerve injury: A new sensory and/or motor complaint that appears within 48 h of a procedure involving anesthetic care. The definition was formulated in this manner based on a structured, predefined pick list in the QA system and applied to other methods of identifying cases. In previous studies, however, it has been shown that appearance of peripheral nerve injuries can be delayed for weeks after anesthesia and surgery.2,11 Whereas narrowing the definition to the first 48 h postoperatively may miss some cases of injury, it may target those that occurred perioperatively and limit those that occurred postoperatively, such as from lying in bed during a long hospital stay.34 Finally, the results of this study may be limited in their generalAnesthesiology, V 111, No 3, Sep 2009

izability, given the fact that it is from a single large tertiary care university hospital. As with most retrospective studies, these patients were not followed long-term, so it is unknown whether these injuries persisted, and to what degree of severity and consequence to the patient.

Conclusion
By a retrospective review of three distinct databases over a 10-yr period, hypertension was newly identified as being significantly associated with a higher risk of perioperative peripheral nerve injuries, in addition to diabetes and tobacco use. Four surgical services, general anesthesia and epidural anesthesia were also uniquely noted to have associations. Future prospective studies are warranted to better understand the risk factors associated with and methods for prevention of this potentially devastating complication.

References
1. Cheney FW, Domino KB, Caplan RA, Posner KL: Nerve injury associated with anesthesia: A closed claims analysis. ANESTHESIOLOGY 1999; 90:1062–9 2. Kroll DA, Caplan RA, Posner K, Ward RJ, Cheney FW: Nerve injury associated with anesthesia. ANESTHESIOLOGY 1990; 73:202–7 3. Warner MA: Perioperative neuropathies. Mayo Clin Proc 1998; 73:567–74 4. Dylewsky W, McAlpine FS: Peripheral Nervous System, Positioning in Anesthesia & Surgery, 3rd Edition. Edited by Martin JT, Warner MA. Philadelphia, W.B. Saunders, 1997, pp 299–318 5. Winfree CJ, Kline DG: Intraoperative positioning nerve injuries. Surg Neurol 2005; 63:5–18 6. Wong CA, Scavone BM, Dugan S, Smith JC, Prather H, Ganchiff JN, McCarthy RJ: Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstet Gynecol 2003; 101:279–88 7. Horlocker TT, Cabanela ME, Wedel DJ: Does postoperative epidural analgesia increase the risk of peroneal nerve palsy after total knee arthroplasty? Anesth Analg 1994; 79:495–500 8. Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG: Lower-extremity motor neuropathy associated with surgery performed on patients in a lithotomy position. ANESTHESIOLOGY 1994; 81:6–12 9. Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM: Lower extremity neuropathies associated with lithotomy positions. ANESTHESIOLOGY 2000; 93:938–42 10. Alvine FG, Schurrer ME: Postoperative ulnar-nerve palsy. Are there predisposing factors? J Bone Joint Surg Am 1987; 69:255–9 11. Warner MA, Warner ME, Martin JT: Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients. ANESTHESIOLOGY 1994; 81:1332–40 12. Horlocker TT, Hebl JR, Gali B, Jankowski CJ, Burkle CM, Berry DJ, Zepeda FA, Stevens SR, Schroeder DR: Anesthetic, patient, and surgical risk factors for neurologic complications after prolonged total tourniquet time during total knee arthroplasty. Anesth Analg 2006; 102:950–5 13. Weber ER, Daube JR, Coventry MB: Peripheral neuropathies associated with total hip arthroplasty. J Bone Joint Surg Am 1976; 58:66–9 14. Zarrelli MM, Amoruso L, Beghi E, Apollo F, Di Viesti P, Simone P, Italian General Practitioner Study Group: Arterial hypertension as a risk factor for chronic symmetric polyneuropathy. J Epidemiol Biostat 2001; 6:409–13 15. Brummett CM, Norat MA, Palmisano JM, Lydic R: Perineural administration of dexmedetomidine in combination with bupivacaine enhances sensory and motor blockade in sciatic nerve block without inducing neurotoxicity in rat. ANESTHESIOLOGY 2008; 109:502–11 16. Mashour GA, Moulding HD, Chahlavi A, Khan GA, Rabkin SD, Martuza RL, Driever PH, Kurtz A: Therapeutic efficacy of G207 in a novel peripheral nerve sheath tumor model. Exp Neurol 2001; 169:64–71 17. Jones HD: Ulnar nerve damage following general anaesthetic. A case possibly related to diabetes mellitus. Anaesthesia 1967; 22:471–5 18. Massey EW, Pleet AB: Compression injury of the sciatic nerve during a prolonged surgical procedure in a diabetic patient. J Am Geriatr Soc 1980; 28:188–9 19. Shaw JE, Hodge AM, de Courten M, Dowse GK, Gareeboo H, Tuomilehto J, Alberti KG, Zimmet PZ: Diabetic neuropathy in Mauritius: Prevalence and risk factors. Diabetes Res Clin Pract 1998; 42:131–9

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20. Vinik AI, Park TS, Stansberry KB, Pittenger GL: Diabetic neuropathies. Diabetologia 2000; 43:957–73 21. Richardson JK, Jamieson SC: Cigarette smoking and ulnar mononeuropathy at the elbow. Am J Phys Med Rehabil 2004; 83:730 –4 22. Upton AR, McComas AJ: The double crush in nerve entrapment syndromes. Lancet 1973; 2:359–62 23. Cornblath DR, Mendell JR, Kissel JT: Evaluation of the Patient with Peripheral Neuropathy, The Challenges, Diagnosis and Management of Peripheral Nerve Disorders. Edited by Mendell JR, Kissel JT, Cornblath DR. New York, Oxford University Press, 2001, pp 3–9 24. Brull R, McCartney CJ, Chan VW, El-Beheiry H: Neurological complications after regional anesthesia: Contemporary estimates of risk. Anesth Analg 2007; 104:965–74 25. Lederman RJ, Breuer AC, Hanson MR, Furlan AJ, Loop FD, Cosgrove DM, Estafanous FG, Greenstreet RL: Peripheral nervous system complications of coronary artery bypass graft surgery. Ann Neurol 1982; 12:297–301 26. Casscells CD, Lindsey RW, Ebersole J, Li B: Ulnar neuropathy after median sternotomy. Clin Orthop Relat Res 1993; 291:259–65

27. Grocott HP, Clark JA, Homi HM, Sharma A: “Other” neurologic complications after cardiac surgery. Semin Cardiothorac Vasc Anesth 2004; 8:213–26 28. Sharma AD, Parmley CL, Sreeram G, Grocott HP: Peripheral nerve injuries during cardiac surgery: Risk factors, diagnosis, prognosis, and prevention. Anesth Analg 2000; 91:1358–69 29. Parks BJ: Postoperative peripheral neuropathies. Surgery 1973; 74:348–57 30. Blitt CD, Kaufer-Bratt C, Ashby J, Caillet JR: QA program reveals safety issues, promotes development of guidelines: Arizona practice is model. J Clin Monit 1995; 11:76–9 31. LeBard SE: Pediatrics, Positioning in Anesthesia & Surgery, 3rd Edition. Edited by Martin JT, Warner MA. Philadelphia, W.B. Saunders, 1997, pp 251–66 32. Practice advisory for the prevention of perioperative peripheral neuropathies: A report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. ANESTHESIOLOGY 2000; 92: 1168–82 33. Fritzlen T, Kremer M, Biddle C: The AANA Foundation Closed Malpractice Claims Study on nerve injuries during anesthesia care. AANA J 2003; 71:347–52 34. Warner MA, Warner DO, Harper CM, Schroeder DR, Maxson PM: Ulnar neuropathy in medical patients. ANESTHESIOLOGY 2000; 92:613–5

Ⅵ ANESTHESIOLOGY REFLECTIONS Darwin Etherizes Venus Flytraps

In his 1875 text Insectivorous Plants, naturalist Charles Darwin noted that the “plant, commonly called Venus’ fly-trap, from the rapidity and force of its movements, is one of the most wonderful in the world.” While investigating anesthetics’ effects on the botanical carnivore’s leaf-closing, he tried chloroform and then ether vapors. Using a 2-oz. vessel, the naturalist determined that the flytrap’s leaf required 24 hr to recover sensibility from 20 min exposure to “15 minims” of ether, but only 52 min to recover from 3 min exposure to “10 drops” in a larger bottle. Darwin conceded that he did not know whether “the larger doses of . . . ether, which caused the leaves to close slowly, acted on the sensitive filaments or on the leaf itself. . . .” His son George provided the illustration above of an unclosed leaf of Dionaea muscipula, whose Latin name actually means “Venus mousetrap.” (Copyright © the American Society of Anesthesiologists, Inc. This image appears in the Anesthesiology Reflections online collection available at www.anesthesiology.org.) George S. Bause, M.D., M.P.H., Honorary Curator, ASA’s Wood Library-Museum of Anesthesiology, Park Ridge, Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland, Ohio. UJYC@aol.com.

Anesthesiology, V 111, No 3, Sep 2009

Anesthesiology 2009; 111:498 –505

Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Epinephrine Impairs Lipid Resuscitation from Bupivacaine Overdose
A Threshold Effect
David B. Hiller, M.D.,* Guido Di Gregorio, M.D.,† Richard Ripper, C.V.T.,‡ Kemba Kelly, M.S.,‡ Malek Massad, M.D.,§ Lucas Edelman, B.S.,࿣ Guy Edelman, M.D.,# Douglas L. Feinstein, Ph.D.,** Guy L. Weinberg, M.D.††

Background: Lipid emulsion infusion reverses local anestheticinduced cardiac toxicity, but the effect of adding epinephrine has not been studied. We compared escalating doses of epinephrine on recovery with lipid infusion in a rat model of bupivacaine overdose. Methods: Rats anesthetized with isoflurane received an IV bolus of 20 mg/kg bupivacaine, producing asystole (zero time) in all animals. Ventilation (100% oxygen) and chest compressions were started immediately, and at 3 min the rats received one of six IV treatments (n ‫ ؍‬5 for all groups): 5 ml/kg saline followed by infusion for 2 min at 1.0 ml ⅐ kg؊1 ⅐ min؊1, and a second 5 ml/kg bolus at 5 min; or the same bolus and infusion treatment using 30% lipid emulsion plus a single injection of epinephrine at one of five doses: 0 (lipid control), 1, 2.5, 10, or 25 mcg/kg. An electrocardiogram and arterial pressure were monitored continuously, and arterial blood gas was measured at 7.5 and 15 min. Results: Epinephrine improved initial return of spontaneous circulation (rate-pressure product > 30% baseline) but only 3 of 5 rats at 10 mcg/kg and 1 of 5 rats at 25 mcg/kg sustained return of spontaneous circulation by 15 min. Lipid alone resulted in slower but more sustained recovery. Epinephrine doses above a threshold near 10 mcg/kg increased lactate, worsened acidosis, and resulted in poor recovery at 15 min, as compared with lipid controls.

There was tight correlation of epinephrine dose to serum lactate at 15 min. Conclusions: Epinephrine over a threshold dose near 10 mcg/kg impairs lipid resuscitation from bupivacaine overdose, possibly by inducing hyperlactatemia.

᭛ ᭜

This article is featured in “This Month in Anesthesiology.” Please see this issue of ANESTHESIOLOGY, page 9A. This article is accompanied by an Editorial View. Please see: Harvey M, Cave G: Bupivacaine-induced Cardiac Arrest: Fat is Good. Is Epinephrine Really Bad? ANESTHESIOLOGY 2009; 111:467–9.

* Postdoctoral Fellow, ‡ Senior Research Associate, # Professor, ** Research Professor, Department of Anesthesiology; § Professor, Department of Surgery; ࿣ Research Assistant, Department of Anesthesiology, University of Illinois College of Medicine at Chicago, Chicago, Illinois. † Research Associate, Department of Anesthesiology, University of Illinois College of Medicine at Chicago and University of Padua, Italy. †† Professor, Department of Anesthesiology, University of Illinois College of Medicine at Chicago and Jesse Brown VA Medical Center, Chicago, Illinois. Received from the Department of Anesthesiology University of Illinois College of Medicine at Chicago and the Jesse Brown VA Medical Center, Chicago, Illinois. Submitted for publication February 2, 2009. Accepted for publication May 11, 2009. Supported in part by VA Merit Grant (Dr. Weinberg), Jesse Brown VA Medical Center, Chicago, Illinois. Dr. Weinberg was awarded United States patent 7,261,903 B1 “Lipid Emulsion in the Treatment of Systemic Poisoning.” He does not have equity interest or agreements with any company or commercial entity related to this method. He has never received a salary or support from any company. He does not intend to prohibit or restrict the practice of this method on any patient requiring this treatment. Dr. Weinberg also created and maintains www.lipidrescue.org, an educational, noncommercial Web site providing information and a forum for discussing the use of lipid emulsion in treating cardiac toxicity. He derives no salary or support related to this Web site. Address correspondence to Dr. Weinberg: Department of Anesthesiology, M/C515, University of Illinois Hospital, 1740 W. Taylor, Chicago, Illinois 60612. guyw@uic.edu. This article may be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.

LIPID emulsion therapy is gaining acceptance as an antidote to systemic local anesthetic toxicity.1 There is substantial experimental evidence that lipid emulsion can mitigate the cardiotoxic effects of bupivacaine overdose.2,3 Recent case reports4 – 8 support these findings and indicate that lipid infusion can rapidly reverse cardiovascular collapse secondary to systemic local anesthetic toxicity, even when conventional resuscitation measures have failed. No study to date has specifically examined the effect of epinephrine on the efficacy of lipid reversal of local anesthetic-induced cardiac toxicity. Because patients will generally receive vasopressor therapy recommended in the Advanced Cardiac Life Support protocol during severe local anesthetic-induced cardiac toxicity, it is important to determine the effects of lipid infusion in the presence of epinephrine. We have previously shown that lipid provides superior recovery from bupivacaine overdose as compared with repeated bolus injections of epinephrine.9 Despite rapid initial recovery of systolic blood pressure, rats treated with epinephrine uniformly showed declining hemodynamic function after 10 min. We use an intact animal model of bupivacaine overdose to test the effect of escalating doses of epinephrine on recovery from local anesthetic overdose during resuscitation with lipid infusion. Based on our previous findings, we hypothesized that injection of high-dose epinephrine could impair recovery. However, we further theorized that smaller epinephrine doses could speed early resuscitation without adverse effects on longerterm recovery.

Materials and Methods
Experimental Model The following protocol was approved by the Animal Care Committee and Biologic Resources Laboratory at the University of Illinois (Chicago, Illinois) and the Institutional Animal Care and Utilization Committee of the Jesse Brown Veterans Administration Medical Center (Chicago, Illinois). Thirty healthy, male Sprague-Dawley rats weighing between 370 and 425 g were anesthetized 498

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in a bell jar with isoflurane to allow tracheal intubation. All animals were then placed on a heated stand under a warming lamp and mechanically ventilated with 1–2% isoflurane in 100% oxygen, using a Harvard rodent ventilator model 680 (Harvard Apparatus, South Natick, MA) to deliver a tidal volume of 2.5 ml at a starting rate of 65–70 breaths/min. Catheters were inserted into the left internal jugular vein, the left carotid artery, and the left femoral vein. Electrocardiography information using three subcutaneous needle electrodes and the carotid pressure were recorded continuously throughout the experiment by a PowerLab data archiving and retrieval system using Chart 5.2.1 (ADInstruments, Colorado Springs, CO). All animals were allowed to stabilize for 10 min at 1.5% isoflurane and 100% oxygen, and arterial blood gas measurements (i-STAT1 Analyzer, i-STAT Corp., East Windsor, NJ) before the bupivacaine challenge were made to confirm a pH between 7.35 and 7.45 and a serum lactate below 2.0. Arterial blood gas samples were analyzed at the experimental midpoint (7.5 min) and at the end of the experiment (15 min after onset of asystole). Animals were randomized by blind number drawing in advance of the experiment to one of six treatment groups: Saline control or lipid plus a single bolus of epinephrine at one of five doses: 0 (lipid control), 1, 2.5, 10, or 25 mcg/kg. The laboratory personnel were not blinded to the treatment; however, a subsequent offline data compilation was made from archived files of each experiment, which were blinded regarding the group. Bupivacaine Infusion and Resuscitation Protocol Isoflurane was discontinued and bupivacaine was immediately infused as a 20 mg/kg bolus over 20 s—a dose that reliably produces asystole from which hemodynamic recovery will not occur with only ventilation and chest compressions. All rats developed asystole by the end of the bupivacaine infusion, and this was taken as zero time. Manual chest compressions to achieve a ratepressure product (RPP; RPP ϭ systolic pressure x heart rate) of at least 50% of baseline were started immediately and interrupted for 5 s every minute to assess native RPP and QRS duration. RPP correlates closely with myocardial oxygen consumption10 and can be taken as an indication of myocardial work. Mechanical ventilation with 100% oxygen was continued throughout the experiment. All IV treatments were initiated at 3 min according to the following regimens: Saline control, 5 ml/kg bolus over 20 s followed by a continuous infusion of 1.0 ml ⅐ kgϪ1 ⅐ minϪ1 for 2 min and another 5 ml/kg bolus at the 5 min time point; lipid groups, 30% Intralipid (Fresenius Kabi, Uppsala, Sweden) was given by bolus (at 3 and 5 min) and by infusion at volumes and rates identical to that of the saline control (bolus 5 ml/kg, infusion 1.0 ml · kgϪ1 ⅐ minϪ1 for 2 min, bolus 5 ml/kg). This regimen was found in preliminary experiments to optimize recovery
Anesthesiology, V 111, No 3, Sep 2009

in this model of bupivacaine overdose. In the lipid control, no epinephrine was administered, while the other groups received a single injection of epinephrine with the initial lipid bolus at doses of 1, 2.5, 10, or 25 mcg/kg. Chest compressions were stopped for native RPP Ն 30% of baseline value, which was our criterion for return of spontaneous circulation (ROSC). All chest compressions were stopped at the 10 min time point regardless of RPP and subjects were evaluated for sustained or nonsustained recovery until the 15 min time point when arterial blood was drawn for analysis and animals were euthanized by anesthetic overdose. We define a recovery index which incorporates both the fraction of time after treatment spent in spontaneous circulation (minutes in ROSC/12 min) and the RPP at 15 min (recovery index ϭ fractional ROSC ϫ RPP15 min). In this index, early ROSC increases the first term and high RPP at experiments’ end increases the second term; similarly, slow recovery or late failure are penalized and decrease the recovery index. Statistical Analysis Power analysis was based on results of previous experiments comparing RPP at 10 min among various treatment groups; specifically, power was set at 0.8, significance criteria was set at 0.05, effect size was estimated as 2, and sigma (SE) at 0.9. The null hypothesis is that no difference exists between treatments regarding recovery of hemodynamics or metabolic measures during resuscitation from bupivacaine-induced arrest. This yielded a sample size of n ϭ 5 for each group. All data were analyzed using GraphPad Prism 4 (GraphPad Software, San Diego, CA). Baseline parameters were analyzed by one-way ANOVA; posttests were not required as there were no intergroup differences in any parameter. All experimental parameters were compared across time by two-way ANOVA with repeated measures and Bonferroni posttests when significance was achieved (alpha set at 0.05) for differences over time between groups. Only differences compared with the lipid control group at 15 min are reported, though other significant within- and between-group differences were found at various times. Differences at 15 min were only considered to be significant when posttests indicated P Ͻ 0.05 for differences found by two-way ANOVA across the entire time course of the experiments. By the experiments’ end, cardiovascular collapse in three animals in two groups (epinephrine 10 and 25 mcg/kg) had progressed to the point of no cardiac (electrical or pressor) activity. We recognized that the zero-value RPPs could be considered statistically problematic, and chose to carry forward each animal’s RPP from the 12.5 min time-point. We believe that this is a statistically conservative approach that reduces the chance of a Type I error but avoids losing important and meaningful data. Values for the derived recovery index

01). Asterisks represent significance of differences from lipid control for groups within the ellipses at 7.1895 31.5.001) and 25 (P Ͻ 0.517 7. BE ϭ base excess.5 (52. At 5 min. Baseline values for major parameters showed no difference among the six groups. n ϭ 5 for all groups.735 57.0 Ϯ 0.1120 30.5 min for the epinephrine 10 ␮g/kg and epinephrine 25 ␮g/kg groups. Baseline Values of Key Parameters for All Six Groups Saline 0 (mcg/kg) 1 (mcg/kg) 2.05 for all comparisons with lipid control.2 Ϯ 0. Anesthesiology.2 39. base excess. Animals receiving the highest dose of epinephrine reliably had the worst metabolic profiles.866 1. or 25 mcg/kg) as indicated at the top of each row.49 Ϯ 0.653 7.50 Ϯ 0. after which they compare unfavorably to the lipid control.092 Ϯ 0. P values are given for comparison with the lipid control.01. 10.6. and none in any group achieved ROSC by 3 min (IV treatment point).0 43. and 2.361 Ϯ 0.0 Ϯ 2.707 60. Significance of difference versus lipid control is shown for each group.3 Ϯ 0.0598 30. P Ͻ 0. 1.0495 30.1446 30.713 1.5 mcg/kg 10 mcg/kg 25 mcg/kg 0 0 0 0 0 0 0 0 4 5 5 5 0 4 5 5 4 5 0 5 5 5 3 3 1 5 5 5 3 1 n ϭ 5 for all conditions. HCO3 ϭ blood bicarbonate concentration. 2.001) mcg/kg groups scored significantly lower than the 0. Hemodynamics: RRP was the key metric of cardiac function in this model. ** P < 0.8 Ϯ 0.47 Ϯ 0.0 Ϯ 0.0 (64.757 6.4 39.583 58.71 1. and HCO3 were found at 15 min in saline control. the 10 (19.001) mcg/kg epinephrine.5 mcg/kg treatment groups.0152 465 Ϯ 52. Recovery in terms of mean RPP Ϯ SE versus time is shown in figure 1. However.961 7.0 Ϯ 0. No 3.863 Ϯ 3.5 Ϯ 1.8 Ϯ 0. epinephrine 10 ␮g/kg.579 7.538 7.998 0. and 15 min. .5.176 Ϯ 1. All values are compared only to the lipid control. 1.8 Ϯ 0.1 Ϯ 4. baseline data sets were interrogated and passed the D’Agostino-Pearson normality test.010 Ϯ 0.8 Ϯ 0. Animals Attaining Return of Spontaneous Circulation for Each Group and Time 3 min 5 min 7. This is the crossover point for the higher-dose epinephrine groups.0.09 1. RPP ϭ rate-pressure product (heart rate ϫ systolic blood pressure).388 7.48 Ϯ 0.5 Ϯ 0. A fraction of animals receiving epinephrine 10 mcg/kg (1 of 5) and 25 mcg/kg (2 of 5) were found to have no heartbeat at 15 min.0. 1.50 1. V 111.05). Mean lactate values at 15 min were different from lipid control for the groups receiving 10 (P Ͻ 0.80 58.5 (mcg/kg) 10 (mcg/kg) 25 (mcg/kg) RPP (mmHg/min) pH PaO2 (mmHg) PaCO2 (mmHg) Lactate (mM/l) HCO3 (mM/l) BE (mM/l) 61.410 Ϯ 0. *** P < 0.9 Ϯ 1.6 Ϯ 3. Table 2 identifies the number of animals attaining ROSC criteria (Ͼ30% baseline RPP) in each group over time.1922 30. Error bars represent SE. ROSC among all animals in a group was achieved only in the lipid control and the two groups receiving lower doses of epinephrine.5 min 10 min 15 min Fig.662 7.1 Ϯ 3. all other groups received lipid plus a single bolus of epinephrine at one of five doses (0. Our recovery index (units ϭ 10Ϫ3 mmHg/minϪ1 given as means Ϯ SEM are shown in parenthesis) indicated that the 1. PaCO2 ϭ partial pressure of carbon dioxide in blood. n ‫ ؍‬5 for each group.46 Ϯ 0.7 Ϯ 8.374 61.00812 519 Ϯ 65. At 7. All individual. All animals were asystolic by the end of the bupivacaine infusion (zero time).6 Ϯ 0.1 Ϯ 0.445 7.5 39.2 42.2 39.632 All values are mean Ϯ SEM. P Ͼ 0.136 6. were compared by one-way ANOVA and post hoc tests performed using the Bonferroni method.048 Ϯ 2.00920 543 Ϯ 33. The top row defines treatment groups: Saline control (no lipid). Significant decrements of arterial PO2 were seen in the higher-dose epinephrine treatment groups. no differences were found at 7. RPP ‫ ؍‬rate-pressure product.132 Ϯ 0.764 Ϯ 3.5 ␮g/kg (P < 0.00491 511 Ϯ 46.001). Metabolics Blood gas values at 15 min are shown in table 3.001. epinephrine 2.0 Ϯ 0.5 Ϯ 0.059 Ϯ 1.8 Ϯ 0.5 min only the Table 2.4) mcg/kg treatment groups did not differ from the 0 (48. Table 1. Notably. and the groups treated with 10 and 25 mcg/kg epinephrine.01) and 25 (6.500 HILLER ET AL. Rate-pressure product versus time for all six experimental groups. Sep 2009 Saline Lipid control 1 mcg/kg 2.0169 589 Ϯ 30. epinephrine 1 ␮g/kg (P < 0.674 7. P Ͻ 0. PaO2 ϭ partial pressure of oxygen in blood.628 7.968 Ϯ 0. 10. Significant depression of pH.1) and 2.0238 434 Ϯ 45. and epinephrine 25 ␮g/kg (P < 0. There were no differences in any parameter among the six groups.4 Ϯ 5. Results Baseline values: Mean values for all baseline physiologic parameters are shown in table 1.926 Ϯ 3.49 Ϯ 0.1) mcg/kg group despite their rapidity of recovery.

20 Ϯ 0.5 21. 1). PaO2 ϭ partial pressure of oxygen in blood.‡‡ It is important to note that in our model. BE.3 calcium channel blocker.01† 170 Ϯ 37 308 Ϯ 89 218 Ϯ 103 111 Ϯ 25‡ 61 Ϯ 12* 104 Ϯ 31* 45. and all animals in the lipid control group had achieved ROSC. There are now more than a dozen reports in the peer-reviewed literature documenting successful lipid-based resuscitation of patients with apparently life-threatening overdoses of lone and combined local anesthetics14 and other drugs.26 Ϯ 0. PaCO2. PaCO2 ϭ partial pressure of carbon dioxide in blood. while the mean RPPs of the groups receiving the two highest epinephrine doses were in steep but negative slopes.5 56. including the use of highdose epinephrine. Mean RPPs in the saline control were below ROSC criteria at all time points. Although epinephrine continues to be used clinically for virtually all types of cardiac arrest. interpretation of such interspecies dose comparisons is not straightforward.4 Ϯ 0. the effects on resuscitation of combining lipid with epinephrine were unknown and comprise the main focus of this study.6 Ϯ 3. a surrogate for myocardial work.org.11 It has been shown to reverse hemodynamic compromise in experimental models of local anesthetic.02 7. at higher doses epinephrine clearly adversely affected both metabolic and hemodynamic recovery profiles. No 3.26 Ϯ 0.9 vasopressin. All animals receiving epinephrine appear to recover faster than the lipid control. BE ϭ base excess. RPP was our preferred hemodynamic metric.4 Ϯ 6. Notably.01. and caution should be used in extrapolating these results to a clinical situation.21 Ϯ 0.001). the higher doses of epinephrine (25 mcg/kg) are actually much lower than what is traditionally considered high-dose epinephrine treatment (0.13 Ϯ 0.5 Ϫ2.4 Ϯ 0.7 Ϯ 1. Sep 2009 .5 24.6 Ϯ 1. V 111. by 7.1† Ϫ1. including bupropion15 and quetiapine.1† The asterisk represents statistical difference at 15 min as compared with lipid control. 1). It is apparent that the timing for scoring recovery has important and potentially obfuscating effects on in- Anesthesiology. 1. ‡ P Ͻ 0. since it correlates closely with myocardial oxygen consumption. sustained recovery did not occur at the two higher doses of epinephrine.2 Ϯ 0. All animals receiving doses of epinephrine of 0.12 and tricyclic antidepressant13 overdose.05. 7.0 Ϯ 2.17 However. Accessed April 14. our data suggest that caution should be exercised in adding epinephrine to a lipid emulsion treatment protocol.9 Ϯ 1.2. although the lipid control animals and those receiving the lower epinephrine doses all had sustained RPPs at or above baseline values. where n ϭ 4 for PO2.8 Ϯ 0. Comparisons with saline control confirmed that infusion of lipid emulsion alone is an effective means of reversing local anesthetic–induced cardiac collapse. * P Ͻ 0.EPINEPHRINE IMPAIRS RESUSCITATION 501 Table 3.18 or the combination of those vasopressors with respect to all measured hemodynamic and metabolic variables at 10 min.6 Ϯ 1.16 It is noteworthy that in many reports the patients had already failed conventional resuscitative efforts. However.8† 25. however.8 Ϫ1.7† 20.8 Ϯ 1. group receiving 25 mcg/kg differed from lipid control (P Ͻ 0.5 mcg/kg) in terms of rapid recovery. several studies to impair outcomes in clinical resuscitation.0‡ 16. Discussion We found in this rodent model of bupivacaine overdose that a single injection of epinephrine of 10 mcg/kg or greater impairs lipid-based resuscitation.1 Ϫ7. while those given larger doses of epinephrine had unfavorable recovery profiles. n ϭ 5 for all cells except at 10 mcg/kg.02 7.0 Ϯ 0. † P Ͻ 0.6 26. The 15-min values for RPP showed two discrete groups of animals among lipid-treated rats (fig.04* 7. HCO3 ϭ blood bicarbonate concentration. We previously showed in a similar rodent model of bupivacaine-induced asystole that lipid is superior to epinephrine.9 Ϯ 6. or 2.5 mcg/kg 10 mcg/kg 25 mcg/kg Values are mean Ϯ SEM. Mean Arterial Blood Gas Parameters at 15 min pH PaO2 (mmHg) PaCO2 (mmHg) BE mM/l HCO3 mmol/l Saline Lipid control 1 mcg/kg 2.1‡ Ϫ10. Lipid emulsion infusion is an effective means of treating cardiac toxicity caused by overdose of lipophilic drugs. This shifted the apparent recovery curves so that at 5 min all epinephrine-treated animals had attained ROSC.8 42. and HCO3 because of failure of the blood gas machine. We measured recovery when lipid is combined with epinephrine across more than a log of doses (1–25 mcg/kg).6 Ϯ 2.7 53.4 49.1 mg/kg or 100 mcg/kg) as defined by the 1992 American Heart Association guidelines for cardiopulmonary resuscitation and found in ‡‡ Other anecdotal examples of successful lipid-based resuscitation can be found at the educational Web site www. 2009. However.6 Ϯ 0.6 Ϫ5.01 7.1 Ϯ 1.5 mcg/kg attained ROSC by 15 min.31 Ϯ 0.2 53. Mean RPP in the latter groups were at or below the criteria for ROSC by 15 min. while no lipid controls or saline-treated animals were above ROSC criteria. all animals receiving epinephrine initially achieved ROSC more rapidly than the lipid control group.001.1 Ϯ 1.5 min these lines crossed (fig. While dose-response experiments suggest a potential advantage of very small epinephrine doses (1 or 2.03* 7.lipidrescue.

found that a combination of base excess more negative than -4 mM and a lactate greater than 1. Metabolic and hemodynamic correlates. r ϭ 0. as compared with the lipid control.5 min. transient. and reduces myocardial function after resuscitation.5 mcg/kg and 10 mcg/kg. n ‫ ؍‬90.853. slope ϭ 0. Base excess. *** P < 0. since all groups had the same baseline physiologic status and received the same bupivacaine challenge. 3. Sep 2009 Fig. or poor recovery. increases myocardial oxygen demand. conversely. Intergroup differences in outcome were therefore attributable to the specific epinephrine dose given.5.21 Clinical studies show no advantage to high-dose versus standard-dose epinephrine in resuscitation. 7. a recovery index with a mean value near or equal to baseline RPP indicates an early ROSC with sustained recovery. physiologic status. can cause pulmonary edema. and both clinical22 and laboratory23. line plotted using linear regression. and 15 min. reduces subendocardial perfusion. a much lower recovery index indicates either a delayed. Error bars represent SEM. Significance of difference versus lipid control is shown for each of the epinephrine treated groups. and lactate was increased at 15 min in the groups receiving the higher doses of epinephrine. Negative base deficit and elevated lactate are clinical predictors of bad outcome in the critically ill. Metabolic parameters of recovery also varied according to the dose of epinephrine. RPP ‫؍‬ Rate-pressure product. Measures of RPP at 5 min alone would exactly invert our main finding that the increasing doses of epinephrine are associated with progressively poorer hemodynamic recovery at 15 min (fig. it has not been shown to be superior to a placebo in any clinical trial.1804 Ϯ 0. (A) Blood lactate levels at the end of the experiment (15 min) across a range of epinephrine doses. No 3.24 data suggest that higher doses of epinephrine worsen outcome in various shock states. the later decline in function of the higher-epinephrine treated groups suggests that early recovery in itself is not a sufficient or accurate predictor of recovery quality. However.0230) was stronger and the slope .001.001. above which epinephrine is overtly deleterious. V 111. *** P < 0.502 HILLER ET AL. or if the persistent adrenergic stimulation contributed to their decline. It is arguable whether patients in such clinical studies merely received more epinephrine support secondary to their poor baseline Anesthesiology. The correlation held at the halfway point (7. pH.20 Epinephrine is arrhythmogenic. terpreting such results (table 2). Our findings clearly indicate a strong negative effect of epinephrine doses at 10 mcg/kg or greater on hemodynamic recovery. Strength of correlation indicated by Pearson’s r for both plots. While there appeared to be a statistical advantage in early recovery for all epinephrine-treated groups. This index showed no overall recovery benefit of the lower epinephrine doses.25 Smith et al. the question of cause versus effect is addressed in our study. and HCO3 were all substantially reduced. However. The paradox of transient recovery in the higher-epinephrine groups followed by late failure is a key finding of our study. cardiopulmonary resuscitation regimen. The correlation of epinephrine with adverse outcomes is not a novel observation. Fig. Significance of difference is shown for lipid control versus each of the epinephrine treated groups. 2). This incongruity justified using a recovery index as an added measure that includes both early recovery and late survival as important factors in assessing recovery.5 mM on admission to the intensive care unit had a sensitivity of 80% and specificity of 59% for mortality. and lipid treatment. Error bars represent SEM (B) Blood lactate levels plotted with linear regression against rate-pressure product for all treatment groups at baseline. These observations support the notion that repeated epinephrine during resuscitation from local anesthetic overdose could be generally deleterious and particularly impair the efficacy of lipid-based resuscitation. there appears to be a threshold dose-effect in our model occurring between 2. 3A). RPP ‫ ؍‬rate-pressure product. We found that serum lactate levels correlated very closely with the dose of epinephrine (fig. In our model. Rate-pressure product at the end of the experiment (15 min) across a range of epinephrine doses. 2. Although epinephrine is recommended in the American Heart Association Advanced Cardiac Life Support guidelines19 and is universally used in resuscitation of the pulseless patient.

A parallel plot of the change in lactate can be made for each animal versus the epinephrine dose and yields a mirror image of the ⌬-RPP plot (fig. This relationship can be examined by matching the change in RPP from 7. line fit to a Boltzmann sigmoidal curve.951. Epinephrine stimulates lactate production in well-oxygenated skeletal muscle by increasing the activity of the Naϩ/Kϩ-adenosine triphosphatase. adverse effect of epinephrine on overall recovery seen in figure 2 and table 2. The ⌬-lactate corresponds to lactate clearance.32. (A) The change in rate-pressure product (⌬-RPP) between 7.33 This relationship is confirmed for our experimental model by the double plot of ⌬-lactate versus ⌬-RPP (fig. lactate.315 Ϯ 0.EPINEPHRINE IMPAIRS RESUSCITATION more positive by the end of the experiment (15 min. 4. slope ϭ 0. indicating the correlation of the (unfavorable) change in lactate late in the experiment with increasing epinephrine dose. Sep 2009 503 Fig. 7. but injection of 10 and 25 mcg/kg epinephrine was associated with dose-related increases in fluid collected in the expiratory limb of the circuit. Lipid alone and with smaller doses of epinephrine did not produce pulmonary edema. curve fit by a two-phase exponential. This plot confirms that the lipid control and the groups receiving the smaller epinephrine doses have uptrending RPP. It is well documented in various shock states that lactic acid levels and lactic acid clearance correlate with patient survival. Error bars represent SEM. 4B).5 to 15 min (⌬-RPP) in each animal with the corresponding dose of epinephrine (fig. 3B). which has been reported to correlate closely with clinical recovery in specific shock states.0212). in part. r ‫ ؍‬0. which shows that animals with the greatest drop in lactate have the most improvement in RPP. (B) The change in blood lactate levels (⌬-lactate) between 7.32.33 suggesting that elevated lactate could be a cause as well as a sentinel of poor cardiac function. n ϭ 90). r ϭ 0.5 and 15 min over a range of epinephrine doses. (C) ⌬-RPP versus ⌬-lactate.31 and the strong dose-effect correlation we found supports this notion.29 While shock states produce hyperlactatemia through both adrenergic stimulation (endogenous and exogenous) and tissue hypoxemia.15. the apparently causal relationship of epinephrine dose to poor RPP.72. it is likely here that both mechanisms contribute. V 111. This leads to the possibility that augmenting serum lactate could explain. No 3. a . The potential relevance of this effect is borne out by the further correlation of hemodynamic function with serum lactate levels (fig. It is well established that epinephrine enhances lactate production through direct metabolic effects mediated by activation of the beta(2)-adrenergic receptor. We found by plotting the RPP versus lactate in pooled data from all animals at three time points (baseline. 4C).5 and 15 min) that there was a strong negative correlation of RPP to serum lactate under all conditions (r ϭ 0.779.5 and 15 min over a range of epinephrine doses. linear regression. Dynamics of metabolic and hemodynamic correlations. The dynamics of recovery in this model are particularly interesting and lend some insight into the potentially causal association of epinephrine. The same phenomenon has been reported in clinical scenarios where patients received high doses of vasopressors during resuscitation. and depressed cardiac function. The degree of increase or decline in RPP over the second half of the experiment is seen to correlate closely with the dose of epinephrine. 4A). the nearly perfect correlation of epinephrine dose with serum lactate at the experiment’s end appears to be causally related to the Anesthesiology. The current model differs from the previous reports by virtue of an interval of 3 min between asystole (zero time) and treatment. We also confirmed our previous observation that at higher doses epinephrine might contribute to pulmonary edema in this experimental system. slope ϭ Ϫ6610 Ϯ 567.26 –28 and beta blockade inhibits this effect. Therefore.34 These findings are consistent with the previously reported data from a similar model that indicate that the use of epinephrine is deleterious to the resuscitation from bupivacaine-induced asystole. However. and those receiving the higher doses of epinephrine exhibit decreasing RPP in the second half of the experiment. it is possible that the metabolic contribution is greater30.

28:198–202 3. ANESTHESIOLOGY 1998. if transient. further study will be needed to confirm or refute our conclusion that epinephrine above a threshold dose impairs recovery from bupivacaine in general and the effectiveness of lipid reversal in particular. Feinstein DL. the difference in endpoints could possibly result in scoring as survivors animals in the porcine study that would not have met our ROSC criteria. No 3. and neurologic) postsurgical. 88:1071–5 4. Hardman JG. Hence. nearly universal inclination to use epinephrine for all pulseless patients. improvement in the hemodynamic profile. similar rodent models in our laboratory have reliably predicted hemodynamics and have been translated into favorable clinical outcomes in resuscitation from local anesthetic toxicity. and 0. Cwik MJ: Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats.8 U/kg). short experimental duration.. Lamb J. Our findings further suggest that epinephrine-induced hyperlactatemia is detrimental to hemodynamic recovery. Barlow J. However. but reliably predicted subsequent cardiovascular decline. 10 min). This dilemma is aggravated by the well-entrenched. Picard J. inotropy and vasopressor effects which transiently augment cardiac output and coronary perfusion pressure. This point is particularly critical. Ward SC. Foxall G. Bedforth NM: Levobupivacaineinduced seizures and cardiovascular collapse treated with Intralipid.37 Physicians facing a patient with cardiac compromise as a result of local anesthetic overdose will require specific guidance on how best to integrate lipid infusion with conventional resuscitation measures.36 Alternately. Epinephrine remains a first-line drug for advanced cardiac life support because of its positive chronotropy. unfortunately.38 have recently shown in the context of resuscitation using high doses of epinephrine (Ͼ100 mcg/kg) that lipid provides no recovery benefit over saline controls in a model of bupivacaine overdose. The clinical tendency to use epinephrine is often reinforced by a rapid. Ramaraju GA. the injection of repeated bolus epinephrine doses might aggravate the toxicity by intense generalized vasoconstriction and elevated lactate production. and cast more doubt on the wisdom of using epinephrine to treat local anesthetic overdose. However. fixed lipid treatment regimen. The underlying mechanism of this biphasic pattern is not precisely known. However. However. 62:516–8 . This phenomenon was replicated in our experimental system. a longer time to end of experiment (15 min vs. data indicating failed recovery with lipid infusion were reported by Mayr et al. Survival was scored as a systolic pressure greater than 80 mmHg and was found in 0 of 5 lipidtreated animals and 5 of 5 animals receiving multiple rounds of epinephrine (45. the very high dose of bupivacaine and lipid infusions. V 111.4. Reg Anesth Pain Med 2003. Epinephrine has been compared experimentally to lipid-based resuscitation in other laboratories with apparently conflicting results. Interpretation and clinical extrapolation from our study is limited by our use of a small animal. Weinberg G. We have confirmed that infusion of lipid emulsion reverses cardiac toxicity in this rodent model of bupivacaine overdose. The difference in outcome versus our current study could be explained by the introduction of asphyxia as a confounder. 64:122–5 2. Note added in proof: Hicks et al. postexperimental recovery. pulmonary. Harrop-Griffiths W: Guidelines and the adoption of ‘lipid rescue’ therapy for local anaesthetic toxicity.4. The single injection across a range of epinephrine doses was designed to yield a formal dose-response for the effect of epinephrine on efficacy of lipid infusion. The no-treatment interval was intended to more closely mimic the clinical scenario of a short delay to the availability of lipid for infusion. lack of evaluation for a full (cardiovascular. Meek T. heart rate and RPP were not reported by Mayr et al.35 in a porcine model of bupivacaine overdose. These data support our findings that predict that administering such high doses of epinephrine would preclude effective lipid reversal of bupivacaine toxicity. since there is evidence that this impairs lipid-based resuscitation. They gave bupivacaine 5 mg/kg and then stopped ventilating the animals until 1 min past the onset of asystole. VadeBoncouer T. Sep 2009 diac arrest.504 HILLER ET AL. Garcia-Amaro MF. and direct comparisons of recovery profiles are not possible. The fixed lipid regimen avoids the confounding variable as a result of variations in this treatment. Ripper R. a potential confounder. despite misleading appearances to the contrary. Anaesthesia 2007. For instance. particularly for drug-induced carAnesthesiology. Weinberg GL. and use of a single epinephrine injection across a range of (much smaller) doses. and the use of isoflurane. 45. and 200 mcg/kg) plus vasopressin (0. Anaesthesia 2009. the dose-response plot clearly indicates the adverse hemodynamic and metabolic effects of concomitant injections of epinephrine above a dosing threshold on the efficacy of lipid-based resuscitation. and specifically implicates epinephrine-induced hyperlactatemia as a possible mechanism of delayed cardiovascular collapse. but the paradox provides further evidence against a clinical advantage to using epinephrine. Caution must be exercised in extrapolating our findings to the clinical situation. Hoffman W: Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity. Zumpe R. The longer time frame allows observation of later hemodynamic recovery. References 1. our data and those of other investigators suggest that large doses of epinephrine may not always be to the patients’ advantage. McCahon R. since our results suggest the two approaches are to some degree physiologically inimical. 0. Analysis of the data further suggests that the hemodynamic and metabolic deterioration are interrelated. Local anesthetic cardiac toxicity reduces myocardial contractility and is worsened by tissue acidosis.

25:139–45 12. 51:412–5 16. 354:505–8 32. Edelman L. Subcommittees and Task Forces of the American Heart Association: 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Salcido DD. Gazmuri RJ. Resuscitation 2007. Tang W. Suffoletto BP. 106:1581–4 9. Fukuda H: Amrinone is superior to epinephrine in reversing bupivacaine-induced cardiovascular depression in sevoflurane-anesthetized dogs. 105:7–8 38. Bisera J: Progressive myocardial dysfunction after cardiac resuscitation. 64:191–4 17. Newman PJ. Resuscitation 2002. Gibot S: Increased aerobic glycolysis through beta2 stimulation is a common mechanism involved in lactate formation during shock states. Litz RJ. Cave G: Intralipid outperforms sodium bicarbonate in a rabbit model of clomipramine toxicity. Jorgensen CR. Weil MH. Gobel FL. Nelson RR. Sirianni AJ. McCarter FD. Miller DR. Anaesthesia 2006. Wang L. Itzkovich CJ. No 3. Feinstein DL. 61:800–1 6. Smith I. Su M. Shelly DA. 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Romaschin A. Wira C: Effective lactate clearance is associated with improved outcome in post-cardiac arrest patients. Vandycke C. Circulation 2005. 102:542–8 24. Weinberg GL: Limits to lipid in the literature and lab: What we know. Anesth Analg 2009. 75:229–34 33. McNamara PJ. V 111. Bur A. 111:138–46 Anesthesiology. 92:3089–93 25. Weinberg GL: Lipid emulsion is superior to vasopressin in a rodent model of resuscitation from toxin-induced cardiac arrest. Friend LA. Can J Clin Pharmacol 2005. 106:1340–2 15. James JH. Jacob AK. Wenzel V. Wagner KR. Muller AA.a meta-analysis. Wilson GJ. 12:e240–5 35. Nierman SR. Segura LG. Abel M. Dorian P: Epinephrine and vasopressin during cardiopulmonary resuscitation. Uncles DR. Mitterschiffthaler L. Mayr VD. Finn SD. Di Gregorio G. 52:415–9 31. Luchette FA. Levsky ME. Perez E. Hirabayashi Y. Luckner G. ANESTHESIOLOGY 1995. Goyal N. J Trauma 1993. Donnino MW. Scalea TM. Friend LA. Wang L. Massad M. Harvey M. Balasubramaniam A. Sankey SS. Friend LA. 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Ngan Kee..A. however. The original recommendations in favor of ephedrine were based on animal and in vitro data that showed that ephedrine has lesser propensity to cause vasoconstriction of the uteroplacental circulation compared with ␣-adrenergic agonists.. 111: 470 –2. § Research Nurse.§ Manoj K.Ch. M.71). and umbilical venous blood samples were taken for measurement of blood gases and plasma concentrations of phenylephrine. 506 Anesthesiology.Sc.. Sep 2009 . Therefore. F.org.3 The mechanism underlying these observations is uncertain. The associated increased fetal concentrations of lactate.B. Hong Kong.. Please see: Smiley RM: Burden of proof. page 9A. particularly for spinal anesthesia. 0. 2007. several studies have shown that the risk of fetal acidosis is greater with spinal anesthesia compared with general anesthesia.5 Historically. lactate. and catecholamines support the hypothesis that depression of fetal pH and base excess with ephedrine is related to metabolic effects secondary to stimulation of fetal ␤-adrenergic receptors.edu.S.83 vs. there are few experimental data available on comparative placental transfer of vasopressors and little information to support this hypothesis. Karmakar..† Perpetua E.8 Little regard was given to the possibility that vasopressors may have direct effects on the fetus.. Pattaya.. umbilical arterial.M.A.6 and metaraminol. B.H. maternal arterial. Lippincott Williams & Wilkins.R. Ngan Kee: Department of Anaesthesia and Intensive Care.K.. Shaukeiwan. Received from Department of Anaesthesia and Intensive Care.A.R. Previously presented in part as a poster at the 15th ASEAN Congress of Anaesthesiologists.. Thailand.. www. F.K.B. This article may be accessed for personal use at no charge through the Journal Web site.. F.A.B. 111:506 –12 Copyright © 2009. Despite historical evidence suggesting uteroplacental blood flow may be better maintained with ephedrine.17).4.13 vs. China.5. Placental Transfer and Fetal Metabolic Effects of Phenylephrine and Ephedrine during Spinal Anesthesia for Cesarean Delivery Warwick D. Recently. Submitted for publication February 5.B.Sc.Z.C. ephedrine. double-blind study to quantify and compare placental transfer of ephedrine and phenylephrine and the effect of these vasopressors on a number of biochemical markers of metabolism in mother and newborn when used to maintain blood pressure during spinal anesthesia for elective Cesarean delivery. Address correspondence to Dr. M. China.2 and a recent large retrospective study has found that neonatal mortality of very preterm infants born by Cesarean delivery under spinal anesthesia was greater than that of comparable infants delivered under general anesthesia. Hong Kong. The umbilical arterial/umbilical venous plasma concentration ratio was greater for ephedrine (median 0. F.D..Anesthesiology 2009. The ephedrine sulfate reference standard used in the assays was provided free-of-charge by Mayne Pharma (Hong Kong) Ltd. ‡ Senior Technician.A. umbilical arterial and umbilical venous pH and base excess were lower. ᭛ ᭜ This article is featured in “This Month in Anesthesiology. 0. R. The authors hypothesized that the mechanism underlying this is transfer of ephedrine across the placenta and stimulation of metabolism in the fetus.Phil. especially in comparison with other vasopressors such as phenylephrine4.† Background: Use of ephedrine in obstetric patients is associated with depression of fetal acid-base status. glucose.N. it has been postulated that a mechanism explaining the acid-base changes associated with ephedrine is stimulation of fetal metabolism after placental transfer of ephedrine and stimulation of fetal ␤-adrenergic receptors.H. 2009. F.C. ephedrine was recommended as the vasopressor of choice in obstetrics but there is now increasing evidence that ephedrine has the propensity to decrease fetal pH and base excess. glucose. B.C. Hong Kong. Prince of Wales Hospital. Umbilical arterial PCO2 and umbilical venous PO2 were greater in the ephedrine group.M. Accepted for publication May 15. Conclusions: Ephedrine crosses the placenta to a greater extent and undergoes less early metabolism and/or redistribution in the fetus compared with phenylephrine. Results: In the ephedrine group. but recent data suggest that an important contributing factor may be the widespread use of ephedrine to treat and prevent hypotension during regional anesthesia. and norepinephrine were greater. Khaw.anesthesiology. whereas umbilical arterial and umbilical venous plasma concentrations of lactate. the American Society of Anesthesiologists. epinephrine. its effects on neonatal outcome are controversial.” Please see this issue of ANESTHESIOLOGY. Tan. warwick@cuhk. The Chinese University of Hong Kong. Methods: A total of 104 women having elective Cesarean delivery under spinal anesthesia randomly received infusion of phenylephrine (100 ␮g/ml) or ephedrine (8 mg/ml) titrated to maintain systolic blood pressure near baseline. Inc.M. Ng. and norepinephrine. the overall effect of the vasopressors on fetal oxygen supply and demand balance may favor phenylephrine. Shatin. Inc.A. China. M.‡ Floria F.1 Although it is generally accepted that regional anesthesia confers greater safety for the mother compared with general anesthesia. At delivery.. November 10.B. M. The work described in this paper was substantially supported by a grant from the Research Grants Council of the Hong Kong Special Administrative Region. This article is accompanied by an Editorial View. No 3.6 However. For example.A. M. V 111.K. REGIONAL anesthesia is normally preferred for Cesarean delivery because it avoids the maternal risks of general anesthesia such as aspiration of gastric contents and difficulty with airway management. † Associate Professor. we designed this randomized. glucose.hk. 2009. China (Project No.H. The Chinese University of Hong Kong. CUHK4467/04M). F.S.A.* Kim S.N. The Chinese University of Hong Kong.. * Professor. Department of Anaesthesia and Intensive Care.7 The reason why ephedrine is associated with fetal acidosis is unknown. Placental transfer was greater for ephedrine (median umbilical venous/maternal arterial plasma concentration ratio 1. epinephrine.B. ANESTHESIOLOGY 2009.

(2) plasma concentrations of lactate and glucose by using the Vitros DT60 II Chemistry System (Ortho-Clinical Diagnostics.0.. Blood pressure was measured at 1-min intervals beginning 1 min after spinal injection. The patient was then returned to the left-tilted supine position. and signs of onset of labor. a 5. Cary. but these levels were not recorded as part of the study. until terminating the study at uterine incision. Hemodynamic data were downloaded to a computer at 5-s intervals. United Kingdom). and the surgeon was invited to scrub.6 mg of IV atropine. was recorded. and the infusion was continued if systolic blood pressure was less than or equal to baseline and stopped if systolic blood pressure was greater than baseline. Replacement randomization was used when the codes were generated to ensure equal numbers in each group. Sudbury. No 3. SAS Institute Inc. If there were more than two consecutive episodes of hypotension (defined as systolic blood pressure less than 80% of baseline) a “rescue” IV bolus of 100 ␮g of phenylephrine was given. On arrival to the operating room. Five minutes after intrathecal injection. contraindications to spinal anesthesia. the upper sensory level of anesthesia was recorded by assessing loss of pinprick discrimination. (4) plasma concentrations of phenylephrine or ephedrine by using methods described in appendix 2. Baseline systolic blood pressure and heart rate were calculated as the mean of the three recordings. Patients were randomly allocated to have their blood pressure maintained using an infusion of either phenylephrine 100 ␮g/ml (phenylephrine group) or ephedrine 8 mg/ml (ephedrine group) by drawing of sequentially numbered sealed envelopes that each contained a computer-generated randomization code (Statview for Windows 5. the drugs were prepared in identical syringes by one of the investigators who was not involved with subsequent patient management or data collection. Statistical Analysis No preliminary data for umbilical arterial or venous concentrations of vasopressors were available. Blood pressure measurements were continued until they became consistent (three successive measurements of systolic blood pressure that had a difference of no more than 10%). A 16-gauge IV cannula was then inserted into a forearm vein under local anesthesia and connected by using a wide-bore infusion set to a 1-l bag of warmed lactated Ringer’s solution. rapid IV fluid infusion (maximum 2 l) was started by fully opening the valve of the infusion set with the fluid bag suspended 1.PLACENTAL TRANSFER OF PHENYLEPHRINE AND EPHEDRINE 507 Materials and Methods The study was approved by the Joint Chinese University of Hong Kong – New Territories East Cluster Clinical Research Ethics Committee.5% bupivacaine (10 mg) and 15 ␮g of fentanyl were injected intrathecally. Shatin. Spinal anesthesia was induced in the right lateral position. so sample . during which blood pressure was measured every 1–2 min. Watford. the infusion was continued unless systolic blood pressure was more than 120% of baseline. The incidence of hypertension. and patients were positioned in the left-tilted supine position for several minutes. We recruited 104 American Society of Anesthesiologists physical status 1 and 2 women with term singleton pregnancies scheduled for elective Cesarean delivery under spinal anesthesia.11. Herts. the following measurements were made: (1) blood gases by using a Rapid Point 400 analyzer (Bayer Diagnostics Mfg [Sudbury] Ltd. and was registered in the Centre for Clinical Trials Clinical Registry of the Chinese University of Hong Kong (unique trial number CUHK_CCT00079). with 0. and the vasopressor was commenced at 60 ml/h. Exclusion criteria were hypertension (systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90 mmHg). Sep 2009 comparative potency. Raritan. (3) plasma concentrations of epinephrine and norepinephrine by using methods described in appendix 1. All patients gave written informed consent. At the time of delivery. a 25-gauge pencil-point needle was inserted at what was estimated to be the L3-4 or L4-5 vertebral interspace and 2.1. The concentrations of vasopressors were chosen on the basis of previously published estimates of Anesthesiology. NC). After delivery.12 At intrathecal injection. defined as systolic blood pressure greater than 120% of baseline. With these samples.to 10-ml sample of maternal arterial (MA) blood was taken with a heparinized syringe by radial artery puncture. Immediately after delivery. Further checks of the block height were made as required before the start of surgery.5 m above the operating table. if accompanied by hypotension.10 The vasopressors were infused by using a syringe pump (Graseby 3500 Anaesthesia Pump. samples of umbilical arterial (UA) and umbilical venous (UV) blood were taken from a double-clamped segment of cord. Supplemental oxygen was not given unless arterial oxyhemoglobin saturation was less than 95%. Subsequently. United Kingdom) that was connected via fine-bore tubing to the IV cannula by using a 3-way stopcock. After skin infiltration with lidocaine. Patients received oral famotidine and sodium citrate as premedication. Graseby Medical Ltd. systolic blood pressure was measured every 1 min. known fetal abnormality. V 111.. standard noninvasive monitoring was applied. Hong Kong. NJ). Bradycardia (heart rate less than 50 beats/min) was treated by stopping the vasopressor and. For 2 min. cardiovascular or cerebrovascular disease. No intravenous prehydration was given. Surgical times and the incidences of nausea or vomiting were recorded.0 ml of hyperbaric 0. Infusion rates were adjusted to maintain systolic blood pressure near to baseline values by using a previously described regimen. China.9 To facilitate double-blinding. Apgar scores were assessed 1 and 5 min by the attending pediatrician.

14 0.9 to –1.41 to 7.41 to 7. UV/MA and UA/UV plasma concentration ratios for phenylephrine and ephedrine are shown in figure 1. There was no difference between groups in patient characteristics (table 1).9) T4.9] 7.3 [5.68 0.3) T6 [T4–T7] 27. MA plasma concentrations of glucose.94 0.6] 49 7.3 [5. Assuming SD of 0. phenylephrine.6 [23. size calculation was based on potential differences in UA pH. mmHg Base excess. and norepinephrine were all greater in the ephedrine group compared with the phenylephrine group.14 to 7. mmHg Po2.29] 56 [48 to 66] 20 [17 to 24] –4. V 111.05 were considered significant. Results All 104 patients completed the study.98 Ͻ0.1.13 [interquartile range 1. all other scores at 1 min and 5 min were 7 or greater. Insufficient blood was obtained from varying numbers of patients in Table 2. mmol/l Umbilical arterial Number of samples pH Pco2. in anticipation from previous experience that obtaining sufficient maternal arterial and umbilical cord blood would likely be difficult in a proportion of cases. mmHg Base excess. glucose.001 Ͻ0. the sample size was arbitrarily increased by one-third to give a final sample size of 52 patients per group. s 32 (4. the Wilcoxon signed-ranks test for paired data.7) 70 (10.35] 46 [43 to 49] 28 [25 to 32] –1.3–30.7] 45 7.2 to –0. UA PCO2 and UV PO2 were greater in the ephedrine group compared with the phenylephrine group.42 [7.84].7) 70 (15.03 Ͻ0.9] 7.23] vs. mmHg Base excess.34] 47 [42 to 51] 30 [27 to 33] –4.92 0.34 Values are mean (standard deviation) or median [interquartile range].5) 157 (4. min Incision-to-delivery interval. min Uterine incision-todelivery interval. as indicated in the tables. Chicago.1 to –1.4 to –0.1 (SPSS Inc.. IL). Table 1.0412 and anticipated difference of 0.0–31. epinephrine. One neonate in the phenylephrine group had an Apgar score of 6 at 1 min. UA and UV pH and base excess were lower in the ephedrine group compared with the phenylephrine group.5] 51 7.8 [–8. For the ephedrine group versus the phenylephrine group. All analyses were performed using SPSS 15. and norepinephrine were all greater in the ephedrine group compared with the phenylephrine group.34 [7.35] 49 [42 to 54] 20 [18 to 22] –1.0.3 [–6.57 Ͻ0. Ephedrine Group P Value Maternal arterial Number of samples pH Pco2. P ϭ 0.4–11.001 0.2] 88 [60–119] 32 (4.33 to 7.71 [0.22]. Other data were compared using the Mann–Whitney U test for unpaired data. P Ͻ 0. P Ͻ 0.7 to –3. Plasma concentrations of lactate. 45 7.58 0.6 [–2. Blood Gases Phenylephrine Group each group for the different assays. UA and UV plasma concentrations of lactate.14 0. glucose.11– 0. 0.42 [7. epinephrine.83 [0.30 to 7.3 [–2.9 [–3.75– 0.3] 51 7.5 [T3–T6] 27.7) 156 (5.3] 87 [60–125] 0. mmol/l Values are number or median [interquartile range].91] vs. mmHg Po2. However.001 Anesthesiology.49 0. kg Height.01–1. the UV/MA ratio was greater (median 1.26 to 7.508 NGAN KEE ET AL.31 [7.001) and the UA/UV ratio was greater (0. and the chisquare test or Fishers’ exact test for categorical data. for the purpose of analysis.15 0.001).03.6 [22.3 [–3.33 [7.001 Ͻ0.001 0. cm Block height.0] 52 7. mmHg Po2.25 [7. dermatome Induction-to-delivery interval. epinephrine.44] 33 [30 to 35] 111 [101 to 123] –2.6] 0. The plasma concentration of epinephrine was below the lower limit of detection (20 pg/ml) in 16 MA and three UV samples in the ephedrine group and seven MA samples in the phenylephrine group. Sep 2009 . Birthweight and Apgar scores were similar between groups. norepinephrine. each of these results was assigned a value of 19 pg/ml. yr Weight.43] 34 [32 to 36] 112 [99 to 122] –2.56 – 0. Patient Characteristics and Surgical Times Phenylephrine Group (n ϭ 52) Ephedrine Group (n ϭ 52) P Value Age.2–11. No 3. Results of analysis of blood gases are shown in table 2. and ephedrine are shown in table 3. mmol/l Umbilical venous Number of samples pH Pco2.4 we calculated that a sample size of 38 patients per group would be required to have 90% power with a two-sided ␣ value of 0. Hemodynamic data were excluded from analysis from one patient in each group because severe shivering caused measurement artifacts. 0.05.93 0.24 0. Patient characteristics were compared by using Student t test.17 [0.2 to –2.

V 111. ng/ml 2. Plasma concentration ratios for phenylephrine and ephedrine. Furthermore.4 [0.2 [1.2 [3.7] (45) 86 [80–94] (45) 47 [22–73] (50) 297 [223–390] (50) 366.0–594.2] (47) Ͻ0.3 [2.PLACENTAL TRANSFER OF PHENYLEPHRINE AND EPHEDRINE 509 Table 3.001 0. Plasma Concentrations of Lactate. epinephrine.001 Ͻ0. Hemodynamic changes. No 3. we found that use of ephedrine was associated with greater UA and UV plasma concentrations of lactate. pg/ml Phenylephrine.003 0. pg/ml Norepinephrine. Early studies of vasopressors in obstetrics focused mainly on differences among agents in their effect on uteroplacental blood flow. vasopressor use. ng/ml Umbilical arterial Lactate.158 [1. No patient required atropine or supplemental oxygen. ng/ml Ephedrine.4 [2. as evidenced by considerably greater values for UV/MA plasma concentration ratios in the ephedrine group. ng/ml Umbilical venous Lactate. these findings are consistent with the hypothesis that the mechanism underlying the propensity for ephedrine to cause fetal acidosis is transfer of the drug across the placenta and stimulation of metabolic processes in the fetus.7] (44) 80 [76–85] (44) 33. Together. Phenylephrine.039 Ͻ0. Data were significantly different between groups (P < 0. and Ephedrine Phenylephrine Group Ephedrine Group P Value Maternal arterial Lactate.291] (49) 5. and 75th percentiles as horizontal lines on a bar.001) for both concentration ratios.001 Values are number or median [interquartile range] (number of samples).066–9.8 which led to the clinical recommendation that ephedrine should be the vasopressor of Fig.0–2. mg/dl Epinephrine.2 [1.5 [334.001 2.403] (46) 0.5] (50) 0.9–2. which suggests that ephedrine undergoes early metabolism and/or redistribution in the fetus to a lesser extent compared with phenylephrine. Animal studies showed that the latter was better maintained with ephedrine compared with ␣-agonists. and norepinephrine and greater UV PCO2 compared with phenylephrine. mg/dl Epinephrine. Glucose.001 0.0–6.6] (52) 55 [49–60] (52) 525 [289–852] (45) 2. but the minimum recorded heart rate was lower and the incidence of bradycardia was greater in the phenylephrine group.523 [3. the UA/UV plasma concentration ratios were also greater in the ephedrine group. pg/ml Phenylephrine.3] (52) Ͻ0.568 [812–2.6–1.2 [5.4.7] (47) 2.2 [254. Discussion Our study showed that ephedrine crosses the placenta to a greater extent than phenylephrine.6 In addition.019 Ͻ0. Anesthesiology.001 2.56 0.5–545. pg/ml Norepinephrine.7–10. Box plots display the 25th. Our results confirmed the results of previous studies that have shown that use of ephedrine is associated with lower values for fetal pH and base excess compared with phenylephrine.9 [0. Patients in the ephedrine group received a smaller volume of vasopressor but had higher incidences of hypotension and nausea/vomiting and required more rescue does of phenylephrine. whiskers above and below the box indicate the 90th and 10th percentiles.7] (49) 63 [59–71] (49) 696 [507–1.4 [2. mmol/l Glucose. Data are shown for (A) umbilical venous to maternal arterial (UV/MA) and (B) umbilical arterial to umbilical venous (UA/UV) ratios.001 Ͻ0.2] (47) 4. and data beyond the 10th and 90th percentiles are displayed as individual points.5–523.5 [306. 50th.8–1. glucose.1] (50) 73 [68–79] (50) 132 [84–226] (52) 1.7–5.9] (47) 3.046 Ͻ0.4] (51) 66 [61–70] (51) 97 [50–214] (50) 446 [293–683] (50) 1. 1. and the incidence of nausea and vomiting are summarized in table 4.0–2.526–3.9–2.940] (52) 434. ng/ml Ephedrine. pg/ml Phenylephrine.538] (49) 355. mmol/l Glucose. Norepinephrine. The maximum recorded systolic blood pressure was greater in the ephedrine group. pg/ml Norepinephrine. mg/dl Epinephrine. Sep 2009 . Epinephrine.5 [19–54] (46) 115 [92–178] (45) 8. mmol/l Glucose. ng/ml Ephedrine.

it has an ␣-methyl substitution of the ethyl sidechain. beats/min Nausea or vomiting Values are median [interquartile range] or number (%). although uterine blood flow varies over a wide range. which may occur when ephedrine. any potential adverse effects of phenylephrine on uteroplacental blood flow do not appear to be detrimental because fetal acidosis is not observed with usual clinical doses of phenylephrine. in most patients. Sep 2009 ine blood flow is in excess of the minimum required to satisfy fetal oxygen demand. which phenylephrine lacks. a basic drug (pKa 9.18 Of note. Under normal clinical conditions.800 [1.17 However.14 The greater placental transfer of ephedrine compared with phenylephrine can be explained by consideration of differences in the molecular structures of these drugs. UV plasma concentrations were even greater than MA concentrations. in addition. in contrast to phenylephrine. Ephedrine also crosses the blood brain barrier and has central stimulant and appetite suppressant effects. Therefore.001 0. some caution may be prudent when using large doses of phenylephrine in the presence of clinical evidence of fetal compromise.002 0.55 0. we did not find that use of moderate doses of phenylephrine (median dose before delivery.15 If the same mechanism is present in humans. recent clinical data showing that the use of ephedrine is in fact associated with lower values for fetal pH and base excess has led to the reevaluation of older teaching. analogous to the effect observed for local anesthetics.002 0. it is possible that this may not apply in the presence of acute or chronic uteroplacental insufficiency.9] 1.13. V 111. ephedrine has significant ␤ adrenoceptor activity. mmHg Rescue phenylephrine required Incidence of hypertension Maximum recorded systolic blood pressure. However. unlike phenylephrine. the most important factor affecting short-term fetal acid-base status is probably the balance between fetal oxygen supply and demand. but a possible explanation is that it may reflect the greater vasoconstrictive effect of phenylephrine on the uteroplacental circulation. Although ephedrine may have more favorable effects on fetal oxygen supply compared with phenylephrine.14 The exact mechanism underlying this observation is uncertain. to a degree.20 ␤ stimulation has previously been shown to stimulate me- . suggesting that the efficiency of oxygen extraction by the fetus is increased when uteroplacental perfusion decreases.9] 1. These data together with the results of our current study suggest that it is also important to consider oxygen demand of the fetus.010] 13 (25%) 101 [87–108] 11 (22%) 24 (47%) 139 [129–152] 0 (0%) 70 [63–78] 18 (35%) Ͻ0.19 This effect may be accentuated as fetal pH decreases secondary to ephedrine’s metabolic effects.200 ␮g) to be associated with any evidence of detrimental effects on the fetus. Studies in sheep have shown that.6–9.725 [1. UV PO2 was lower in the phenylephrine group compared with the ephedrine group.36 0. Table 4.010] 2 (4%) 104 [96–109] 1 (2%) 21 (41%) 134 [127–140] 6 (12%) 58 [54–65] 1 (2%) 7. ephedrine lacks hydroxy-substitution of the aromatic ring. This may be the result of ion trapping.510 NGAN KEE ET AL.6).03 Ͻ0. The metabolic effects of ephedrine on the fetus can be explained by the fact that.044 0. ml Incidence of hypotension Minimum recorded systolic blood pressure. although in a recent comparison of ephedrine and phenylephrine in nonelective Cesarean delivery. we believe that currently available data favor the choice of phenylephrine. under normal physiologic conditions. becomes more protonated (ionized) when exposed to the lower pH environment of the fetus. indicating that not only did ephedrine readily cross the placenta. protects the fetus from fluctuations in uterine blood flow. This is consistent with animal studies that have demonstrated that.200–2.450–2. Thus ephedrine can be expected to have greater lipid solubility than phenylephrine. a reduction of uteroplacental perfusion caused by phenylephrine with an associated increase in fetal oxygen extraction per unit of uteroplacental blood flow would result in decreased uterine venous PO2 and thus decreased umbilical venous PO2 because the human placental is considered to function as a venous equilibrator. 100 ␮g. this advantage may be negated by its greater placental transfer and the undesirable effects of this on fetal oxygen demand. Intravenous Fluid. Hemodynamic Changes. range 0 –1. fetal oxygen uptake remains relatively constant. which explains its greater placental transfer. our results showed that the median UV/MA plasma concentration ratio for ephedrine was greater than unity. 13 [9. When comparing the net effect of vasopressors on fetal oxygen supply and demand balance.001 Ͻ0. Both ephedrine and phenylephrine are structurally related derivatives of phenylethylamine.001 choice in obstetric anesthesia because greater uteroplacental blood flow should correspond to greater oxygen supply to the fetus. In the current study. mmHg Incidence of bradycardia (heart rate Ͻ 50 beats/min) Minimum recorded heart rate. uterAnesthesiology.16 which confers a margin of safety that.33 0.7 [5. No 3. which is similar to findings from our other recent studies. ml Total intravenous fluid. However. and Vasopressor Consumption Phenylephrine Group Ephedrine Group P Value Total volume of vasopressor given.6–16.

1 to 2. Khaw KS. ANESTHESIOLOGY 2001. Ngan Kee WD. metaraminol. Lagercrantz H: Randomised controlled trial of effect of terbutaline before elective caesarean section on postnatal respiration and glucose homeostasis. 58:125–30 6. Kocarev M. Lee A: Multivariate analysis of factors associated with umbilical arterial pH and standard base excess after Caesarean section under spinal anaesthesia. Levinson G. Ioannides-Demos LL. Anesthesiology.7 it is uncertain whether this has potential to affect clinical outcome. Shnider SM.21 As a result of its indirect action. Anaesthesia 2008. 60:636–53 3. Anaesthesia 2005. Kokri MS: Fetal and maternal effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Ngan Kee WD. References 1. and acidbase balance as a function of uterine blood flow. mephentermine.6 and other ␣-agonists. Diemunsch P. and medical management. 46:679–87 2. Arch Dis Child Fetal Neonatal Ed 1999. Although the current study and other recent clinical studies have demonstrated that ephedrine is associated with a greater propensity toward fetal acidosis compared with phenylephrine4. including gestational age and characteristics of the mother. Anesth Analg 2002. Further work. Watkins E. Stock MJ: Contribution of beta 3-adrenoceptor activation to ephedrine-induced thermogenesis in humans. 244:H749– H755 17. Lee BB: Comparison of metaraminol and ephedrine infusions for maintaining arterial pressure during spinal anesthesia for elective cesarean section. and the plasma was separated and stored at – 80°C pending batch analysis. Lee A. V 111. ANESTHESIOLOGY 1978. Astrup A. Khaw KS. which suggests that the actual potency ratio may be lower. Toubro S. Ngan Kee WD. Hjertberg R. Desira WR. Ng FF: Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section. Prince of Wales Hospital. 65:1391–418 19. Rachet B. 19:678–85 21. 107:1295–302 14. Anesth Analg 2008. Wilkening RB. 95% confidence interval 1. Ancel P-Y. ANESTHESIOLOGY 2002. oxygenation. Ngan Kee WD. ANESTHESIOLOGY 2005. John Wiley and Sons.3 The exact mechanism for this finding is uncertain. Khaw KS. No 3. Liu YL. Callender K: Placental transfer of lidocaine: Effects of fetal acidosis. 94:920–6 5. Khaw KS. Chui K. 48:409–12 20. Ngan Kee WD. Int J Obstet Anesth 2009. 132:410–3 16. Anaesthesia 2003. ANESTHESIOLOGY 1974. 96:95–9 11. Meschia G: Fetal oxygen uptake. Lee A. Shnider SM. Lau TK. Ng FF. Pocock SJ: Clinical Trials. and norepinephrine in the ephedrine group. ephedrine stimulates presynaptic release of norepinephrine. Karmakar MK. 30:308–11 18. Int J Obes Relat Metab Disord 1995. Bre ´art G: Anaesthesia mode for caesarean section and mortality in very preterm infants: An epidemiologic study in the EPIPAGE cohort. Gin T: A randomized double-blinded comparison of phenylephrine and ephedrine combinations given by infusion to maintain blood pressure during spinal anesthesia for cesarean delivery: Effects on fetal acid-base status and hemodynamic control. although we found no difference in outcome in our previous study of nonelective Cesarean deliveries. Kaminski M. 97:1582–90 7. Seed PT: Anaesthesia for Caesarean section and neonatal acidbase status: A meta-analysis.7. Lau TK. Laudenbach V. 18. J Reproductive Med 1985. which likely contributed to the higher circulating plasma concentrations of norepinephrine in umbilical blood in the ephedrine group. Hawkins JL: Anesthesia-related maternal mortality. Arnaud C. Clin Obstet Gynecol 2003. Reynolds F. 1983 10. Clapp JF III: The relationship between blood flow and oxygen uptake in the uterine and umbilical circulations. Br J Anaesth 2004. Ryall DM. Ralston DH. pregnancy. 80:F88–F92 Appendix 1: Method Used to Measure Plasma Concentrations of Epinephrine and Norepinephrine Blood samples were collected and transferred into lithium heparin tubes containing dilute sodium metabisulfite as an antioxidant and were placed in ice. Norepinephrine and epinephrine were measured by using high-perfor- . Chichester. Eisler G. Ng KL: Randomized double-blinded comparison of phenylephrine versus ephedrine for maintaining blood pressure during spinal anaesthesia for non-elective Caesarean section. 40:354–70 9. A Practical Approach. China for their assistance and cooperation. Khaw KS. neonate. It is possible that the metabolic effects of ephedrine on the fetus may be more important in the presence of other factors that may affect the fetal oxygen supply:demand balance. and methoxamine on uterine blood flow in the pregnant ewe. Hong Kong. a secondary analysis of the large retrospective EPIPAGE study found that neonatal mortality of very preterm infants born by Cesarean delivery under spinal anesthesia was greater than that of comparable infants delivered under general anesthesia (adjusted odds ratio 1. Sep 2009 The authors thank the midwives of the Labour Ward. Ng FF. have been performed in low-risk elective cases when small differences in anesthetic technique are unlikely to have a major effect on neonatal outcome. Ng FF: Prevention of hypotension during spinal anesthesia for cesarean delivery: An effective technique using combination phenylephrine infusion and crystalloid cohydration.6) after adjustment for confounding variables.142–9 4. epinephrine. Mercier FJ. Wilson RC. Carpenter M. McNeil JJJ: Pharmacotherapy for obesity. Cambonie G. We also observed maternal effects of ephedrine as evidenced by greater MA plasma concentrations of glucose. It should be noted that the majority of published comparative studies. Br J Anaesth 2006. 92:469–74 13. Meschia G: Safety margin of fetal oxygenation. Saravanan S. Larroque P. ideally from prospective studies. Am J Physiol 1983. including the current study. Gin T: A quantitative systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery.PLACENTAL TRANSFER OF PHENYLEPHRINE AND EPHEDRINE 511 tabolism in fetal lambs after isoproterenol administration and in human neonates after administration of terbutaline before Cesarean delivery. Roze ´ J-C. Proietto J. These varying results illustrate the difficulty in comparing potencies of two drugs that differ in speed of onset and duration of action. Am J Obstet Gynecol 1978. Drugs 2005. Cooper DW. Burguet A. Samples were immediately centrifuged at 4°C. is required to confirm these findings. Subtil D.14 Of note. Columb MO. deLorimier AA: Effects of equipotent ephedrine. Shatin. Lyons G: Equivalent dose of ephedrine and phenylephrine in the prevention of post-spinal hypotension in Caesarean section. 95:307–13 8. 63:1319–26 15. The ratio of phenylephrine:ephedrine concentrations in the solutions we used assumed a potency ratio of 80:1 as reported by Saravanan et al.10 However. Biehl D. there was no difference between groups in the minimum recorded systolic blood pressure although maximum recorded systolic blood pressure was greater in the ephedrine group. delivery. Ngan Kee WD. patients in the ephedrine group received a smaller total volume of vasopressor compared with the phenylephrine group. 103:744–50 12. Although patients in the ephedrine group had a greater incidence of hypotension and required more rescue doses of phenylephrine. Fresson J. Ngan Kee WD. but severe or sustained hypotension and excessive use of ephedrine were suggested as possible contributing factors. Lejus C. Mowbray P.

respectively. The limits of detection for phenylephrine and ephedrine were 0. a secondary analysis was performed. Sep 2009 . A volume of 0. Subsequent to the completion of the initial analysis. Plasma was collected and stored at – 80°C pending batch analysis. The catecholamines were isolated by using alumina adsorption under basic conditions and then reextracted from the alumina using dilute acid solution before their analysis on the high-performance liquid chromatography with electrochemical detection system.2 ng/ml and 0.5 ml of plasma was used for both phenylephrine and ephedrine assays. Milford.18%) and 7. V 111. Blood samples were collected into heparinized tubes containing sodium metabisulfite as preservative. The within-day coefficients of variation for epinephrine and norepinephrine ranged from 5. plasma was transferred into a conical bottom polypropylene tube containing sodium metabisulfite solution and the internal standard. MA). The tubes were placed in ice. All analytes were isolated through liquidliquid extraction by using an organic solvent. respectively. norephedrine HCl (phenylpropanolamine). norephedrine HCl.03% (mean 6. Applied Biosystems. with correlation coefficients better than 0. For sample preparation. The assay was linear to the lower limit of detection (25 pg/ml for both epinephrine and norepinephrine).93%).90% to 8.39%). C18. MA) by using acetonitrile and 0. The betweenday coefficients of variation were 6. respectively. to ensure accuracy of the results. the internal standard.07% (SD 1.90% (mean 6. This enabled the area of external norephedrine added as internal standard to be obtained (actual area of norephedrine ϭ apparent area of norephedrine – area of metabolite).14%).05 ng/ml. The within-day variation (intraassay) for phenylephrine ranged from 3. Foster City. Quantitation was then performed by monitoring the drugs by electrochemical detection using a coulometric detector (ESA 5100A. The results showed that effect of the presence of the norephedrine metabolite in the samples was small. The area of the metabolite and ephedrine was used to obtain the ratio of metabolite over ephedrine (ratio ϭ area of metabolite/area of ephedrine). Good linear responses were obtained for both phenylephrine (0. was one of the metabolites of ephedrine.1% formic acid under gradient condition. Bedford. All results are given as adjusted values. To eliminate the area of norephedrine metabolite from the results. with correlation coefficient values 0.98%). The analytes were separated on a reversed-phased column (Ultrasphere intraperitoneal.62% (mean 8.25% (mean 4. The lowest limit of detection was at 25 pg/ml at a signal-to-noise ratio of 3. whereas that of ephedrine ranged from 4. respectively (API2000. Beckman Instruments Inc. No 3.41% to 8.33% to 13.02% (mean 10. CA). Anesthesiology. aliquots of leftover samples were retested without the addition of external norephedrine. Environmental Science Associates. A set of calibration standards with varying concentrations of the drugs was also prepared and subjected to the same cleanup procedure. This correction factor was applied to the originally calculated values for which leftover sample was not available (n ϭ 28). based on a signal-to-noise ratio of 3.93%). Fullerton. it was discovered that norephedrine.2–50 ng/ml) and ephedrine (0. with adjusted values greater than the original values by a mean difference of 2.512 NGAN KEE ET AL. By using the new values of norephedrine area. There were good linear responses for both epinephrine and norepinephrine. Blank plasma showed no interfering peak at the retention time of the analytes studied.9980. The values for MA/UV and UA/UV concentration ratios calculated by using adjusted values were virtually identical to values calculated using the original values.07% (mean 8. the ephedrine concentrations of samples were then recalculated. Appendix 2: Method Used to Measure Plasma Concentrations of Phenylephrine and Ephedrine A sensitive method was developed for the analysis of phenylephrine and ephedrine in plasma by using high-performance liquid chromatography-tandem mass spectrometry. Samples containing ephedrine at a concentration that was outside the calibration curve were diluted with blank plasma and reassayed. whereas that of ephedrine ranged from 2. Waters Corporations.05–500 ng/ml). mance liquid chromatography with electrochemical detection. This ratio was then used to calculate the area of metabolite present in the original assays (area of metabolite in sample ϭ ratio ϫ area of ephedrine).9990. and the blood samples were immediately centrifuged at 4°C. was monitored at m/z 152 ¡ 134. CA) by using a mobile phase containing methanol-citric acid-EDTA-octane sulfonic acid-water under isocratic condition.57% (mean 6. This technique was applied to 121 samples for which leftover plasma was available.53% to 10.. Therefore. Leftover plasma samples were retested to determine the amounts of norephedrine metabolite present and to quantify its effect on calculated values for ephedrine.02% to 10. Quantitation of the drugs was performed by using multiple reaction monitoring (MRM) in positive ionization mode.54% to 7. The extracts were further purified by back extraction with dilute acid before analysis using high-performance liquid chromatography-tandem mass spectrometry.88%).29%).9960 and 0.90% (mean 8. The internal standard. respectively.49% to 10. Phenylephrine and ephedrine were monitored at m/z 168 ¡ 150 and m/z 166 ¡ 148.52% to 10. The analytes were separated on a reversed phase column (Atlantis dC18.55%) and 2. The between-day variation (interassay) for phenylephrine ranged from 7.

Furthermore.‡ Italo Zamudio. Intraoperatively.1 Recent investigations3.͉͉ Elaine Pascoe.1 Early assessment and treatment of acute pain in children is crucial. ** Professor.4 suggesting the method as a suitable tool for the assessment of acute pain.* Neil Chambers.S. renal.13 was found to distinguish between no or mild versus moderate or severe pain with a sensitivity of 90% and a specificity of 64% (positive predictive value 35%. via his employer.g. the American Society of Anesthesiologists. Monitoring Electrical Skin Conductance A Tool for the Assessment of Postoperative Pain in Children? Bruce Hullett. autonomic neuropathy. Perth. ANESTHESIOLOGY 2009. In one of these studies. Submitted for publication January 7.. Lippincott Williams & Wilkins. Perth. and School of Paediatrics and Child Health.. M.** Background: Monitoring changes in electrical skin conductance has been described as a potentially useful tool for the detection of acute pain in adults. blinded. Methods: A total of 180 postoperative pediatric patients aged 1–16 yr were included in this prospective. for personal use only. in 2006. WA. Princess Margaret Hospital for Children. The aim of this study was to test the method in pediatric patients. a cutoff value of NFSC (0. Perth. # Adjunct Senior Lecturer. Department of Anaesthesia and Pain Management. Ledowski has prepared a paid report for MSI.82 (95% confidence interval 0. and School of Medicine and Pharmacology. The number of fluctuations in skin conductance per second (NFSC) was recorded simultaneously. University of Western Australia.gov. Thomas.. Dr. Address correspondence to Dr. leading to disability and suffering later in life. pain was assessed by standard clinical pain assessment tools (1–3 yr: Face Legs Activity Cry Consolability Scale. 111:473– 4. Department of Anaesthesia and Pain Management. not only for humanitarian and ethical reasons.Anesthesiology 2009. Princess Margaret Hospital for Children. A total of 180 children. neuronal). Department of Anaesthesia and Pain Management. with MSI in 2006 –2007 by providing MSI with advice related to the clinical application of the Skin Conductance monitor. were recruited after written informed consent was obtained from the parents and children–as appropriate– on the day of surgery.79 – 0. clonidine. However. Information on purchasing reprints may be found at www. M. Accepted for publication May 15. the manufacturer of the Skin Conductance device used in this study. University of Schleswig Holstein. The measurement of NFSC may therefore provide an additional tool for pain assessment in this group of patients. ANESTHESIOLOGY’s articles are made freely accessible to all readers. M. B. glycopyrrolate. M.B. and Clinical Research and Education. with attention 513 * Clinical Lecturer. However. and the trial was registered with the Australian Clinical Trials Register (ACTRN12607000474459)..B.. University of Western Australia. he collaborated. The University of Western Australia.Biostats. ledowski@health.wa. Princess Margaret Hospital for Children. pacemakers. congenital syndromes. Please see: Berde CB. University of Schleswig Holstein. and Department of Anaesthesiology and Intensive Care Medicine. V 111. cardiovascular.Sc. developmental delay. observational study. University of Western Australia. ᭜ This article is accompanied by an Editorial View.. Princess Margaret Hospital for Children. School of Medicine and Pharmacology. Ledowski: Anaesthesiology Unit in School of Medicine and Pharmacology. blinded observational study. Department of Anaesthesiology and Intensive Care Medicine. Received from Department of Anaesthesia. ͉͉ Research Assistant. Over all age groups.† James Preuss. especially younger children may be less able to understand.85). an NFSC cutoff value of 0. Sep 2009 . The area under the Receiver Operating Characteristic curve for predicting moderate to severe pain from NFSC was 0. University of Western Australia. University of Western Australia. or describe their pain in a way that health professionals can understand. Princess Margaret Hospital for Children. ‡ Research Assistant. more research is needed to prospectively investigate the observations made in this study and to determine the clinical applicability of the method. hepatic. Australia.Med. CHILDREN’S pain is a global public health issue. † Director of Anaesthesia. lack of access to patient’s hand. Materials and Methods Institutional Review Boards’ (Ethics Committee of the Princess Margaret Hospital for Children. After arrival in the recovery unit.# Thomas Ledowski. M.1) distinguished between no or mild versus moderate or severe pain with 89% sensitivity and 74% specificity. § Clinical Senior Lecturer.. but because prolonged states of pain in childhood may have significant long-term effects. and 15 patients were excluded. Inc. Anesthesiology. ketamine. American Society of Anesthesiologists Anesthetic Risk score 3–5. pediatric pain is often poorly assessed and inadequately managed. Australia. 6 months from the cover date of the issue. McGrath PJ: Pain Measurement and Beecher’s Challenge: 50 Years Later. tolerate. and history of contact reaction to adhesive tapes. School of Medicine and Pharmacology.anesthesiology.2 Most pain scoring systems used in clinical practice rely on patient cooperation and communication. No 3.D. Results: Data from 165 children were used for statistical analysis. Exclusion criteria were the presence of major systems disease (diabetes mellitus. blinded observational study was to assess NFSC as a marker of pain status (none-mild vs. 2009. 4 –7 yr: Revised Faces Scale. Australia) approval was obtained for this prospective. Perth.au. Supported by Princess Margaret Hospital Foundation.B. 2009.org or on the masthead page at the beginning of this issue. The aim of this prospective. As a result. the attending anesthetists used a general anesthetic technique of their choice. Australia.B. negative predictive value 97%). 111:513–7 Copyright © 2009. University of Western Australia. School of Paediatrics and Child Health. atropine. moderate-severe) determined by different traditional pain scoring systems in children in the postoperative setting. M.D.S. ␤-adrenoreceptor-blockers). Conclusions: NFSC accurately predicted the absence of moderate to severe pain in postoperative pediatric patients. Inc.4 in adults have shown that changes in the number of fluctuations of skin conductance per second (NFSC) reflect acute postoperative pain when compared with a patient self-rating of pain on a numeric scale. medication with drugs suspected or known to interact with the method of skin conductance (SC) monitoring (e.§ Jonas Lange. aged 1–16 yr undergoing elective surgery. 8 –16 yr: Visual Analogue Scale) at various time points during their stay in the recovery room.

All P values were two-sided. Skin Conductance Monitoring NFSC was obtained via aMEDSTORM AS 2005 monitor (Medstorm Innovations. and 8 –16 yr. reference) and single-use Ag/AgCl pediatric electrocardiogram electrodes (Neotrode.3. The median (interquartile range.79 – 0. Legs. when the patient was deemed comfortable. NC). 4 –7 yr. TX). Oslo. Electrodes were placed on the patients’ hands (measurement. All other analyses were performed by using SAS for Windows 9.. 1–3 mild.82 (95% confidence interval [CI] 0. and a score greater than 3 Anesthesiology. and a P value less than 0. and 6 –10 severe pain). On the basis of the resulting positive and negative predictive values (table 2). Characteristics of patients by age group are given in table 1. hypothenar eminence.8% (n ϭ 574) of measurements equal to or greater than 0. The median (IQR) NFSC was 0. Pain scores were obtained in 3-min intervals from arrival in the recovery room until discharge. We assumed an exchangeable correlation structure for the generalized estimating equations models. The equipment used an alternating current of 88 Hz and an applied voltage of 50 Mv (highest density 2.6 and in the 8-16 yr group by using the Visual Analogue Scale. all scoring systems ranged between 0 and 10 points (0 representing no. children were divided into three age groups. The monitor was connected to a laptop computer via a standard serial port connection to display and process the obtained data. defined as a rating of at least 4. The software was able to automatically define peaks and troughs within the mean skin conductance (amplitude threshold for detection 0.5 ␮A). with 18% (n ϭ 226) of ratings classified as moderate to severe pain. Simultaneously. ROC analyses were performed by using Stata 10. A pain score of no more than 3 was considered no to mild pain. The area under the ROC curve for predicting moderate to severe pain from NFSC was 0.0% to identify time points with moderate/severe pain out of all pain assessments (table 2).05 was considered significant. V 111. However. Characteristics of the NFSC measurements and pain ratings by age group are given in table 1. 4 –5 moderate.e. College Station. The median (IQR) pain rating was 0 (0 –2). No 3. NFSC values were then analyzed in relation to simultaneous dichotomous pain scores by using receiver operating characteristic (ROC) curves.5% (1-positive predictive value) of patients being overtreated (incorrectly defined as in moderate/severe pain) . The mean age of patients was 6.13. body temperature.4 60 subjects per age group was deemed to be sufficient to obtain a substantial amount of pain readings in the moderate-severe range. an anxiety score (Modified Yale Preoperative Anxiety Scale. and 8 –16 yr. Univariate and multivariate logistic regression analyses using generalized estimating equations to handle the repeated measurements on each patient were used to assess unadjusted and adjusted relationships between dichotomized pain and NFSC variables. Norway) by using a threeelectrode system (measurement. Pain in the 1–3 yr group was assessed by using the Face. back of hand) on arrival in recovery. with a minimum of 3 and a maximum of 18. NY). Cry. 4 –7 yr. Cary.. reference. i. Discharge from the recovery unit occurred per standard clinical practice.49). to maintaining normothermia and avoidance of abovespecified drugs. thenar eminence.3% and specificity of 64. a formal sample size calculation was not performed because NFSC has not been used in this age group before. ConMed Corp.27). Activity. with 45.85). and behaviorally appropriate with stable basic observations. Sixty patients were recruited from each of three age groups: 1–3 yr. Separate ROC analyses were performed on data for three age groups.07 (0 – 0. Age. A data-determined NFSC cutoff value of at least 0. The treatment of postoperative pain was per standard clinical practice at the study institution (fentanyl/morphine for moderate-severe pain and nonopioid analgesics for mild pain). Utica.5 in the 4 –7 yr group by using the Revised Faces Pain Scale. and Consolability score. counter. Statistical Analysis On the basis of these results of two former publications by the authors related to NFSC as a tool for assessment of postoperative pain in adults. Sep 2009 was considered moderate to severe pain. A data sampling rate of 15 s and a monitor refresh rate of 15 s were chosen for this investigation. Data from 15 patients were excluded because of technical difficulties with the skin conductance monitoring or a violation of the study protocol: nine from the 1–3 yr group and six from the 4 –7 yr age groups. In addition.0 (StataCorp.514 HULLETT ET AL.1 (SAS Institute. awake. NFSC was recorded by a second observer.13 as a cutoff value to detect moderate/ severe pain in our subjects would have resulted in 64. 1–3 yr. clinical application of NFSC of at least 0. IQR) operation time was 40 (30 –50) min and the median (IQR) recovery time was 30 (25–30) min. Different pain scores are usually used in different age groups to account for the age-related different levels of neurocognitive development. Results Data from 1. and we used robust variance estimates for all hypothesis tests.13 resulted in a test sensitivity of 90. The median (IQR) number of pain assessments was 7 (6 –9). counter.255 pairs (standard pain score ϩ NFSC) of pain assessments in 165 patients were evaluated.02 ␮S) and to calculate NFSC from this data.9 yr (SD ϭ 4. m-YPAS)7 was obtained preoperatively in children aged 3–12 yr (age range for which mYPAS has been validated) to control for the influence of anxiety on NFSC readings. and anxiety were assessed as potential confounding variables.

0 19. mean (SD) Body temperature.9 (7. 1. median (IQR) [minimum–maximum] Characteristics of patients Age.66) 5.2 64.0) 38 (8.2) 30 (8.0001). °C. Based on the complete sample of observations. suggesting no influence of the factors in our cohort (table 3).5 NPV ϭ negative predictive value.0 72.13 as a Positive Test Result Prevalence of Moderate to Severe Pain Sensitivity (%) Specificity (%) tients who also provided anxiety scores (a total of 814 pain assessments).96).13) [0–1.5 31.21) 7. When using data from paTable 2. mean (SD) Anxiety score.9 90.87).7 (2.8 23.24) 36.71– 0. but only 3. Anesthesiology. Differences in test characteristics for the three age groups can be mostly attributed to the relatively lower prevalence of moderate to severe pain in the 4 –7 yr age group and slightly higher prevalence in the 8 –16 yr group (table 2).1 (2.36) 60. The area under the ROC curve was smallest for the 1–3 yr age group (area 0.13 relative to those with NFSC less than 0. The former produces a more accurate negative test result.3 (0.5 (1.0) 12 (3. the odds of moderate to severe pain were significantly higher for patients with NFSC of at least 0.27) [0–2.61) 46.8) 0.51) 29.60) [0–2. n (%) None (0) Mild (1–3) Moderate (4–5) Severe (6–10) NFSC.9 (3.8) 103 (8.49) 29.9) 53 (11.07 (0–0.9) 30 (7.50) 315 (73. yrs.8 97. Sep 2009 . NFSC ϭ number of fluctuations per second.0 (7.70) 6.5 (8. mean (SD) Recovery time.2) 63 (13.50) 6.0 52.2) 25 (6.2% (1-negative predictive value) of patients undertreated (incorrectly defined as in no/mild pain).0001). SD ϭ standard deviation. Separate ROC analyses by age group showed some variation in the accuracy of predicting moderate to severe pain from NFSC (fig.49) 6.13 (P Ͻ 0.1 44. mean (SD) Characteristics of measurements Pain rating category.4 (0. median (IQR) [minimum–maximum] 51 426 8 (6–10) [3–15] 54 377 7 (5–8) [4–13] 60 452 7 (5–9) [3–18] 165 1255 7 (6–9) [3–18] 2.8 (9. Overall.20) [0–2. min.9 (4.13 (P Ͻ 0.76.1 9.1) 0.3 (0.93.2) 123 (9.7 (36.0 (1.07 (0–0. Fig.79) 12.1 (36.6 93. 95% CI 0.72] IQR ϭ interquartile range. Odds ratios for the association between pain ratings and NFSC were calculated. mean (SD) Operation time.79) 36.13 (0–0.48) 28. and the latter produces a more accurate positive test result.90 – 0. 95% CI 0. Characteristics of Skin Conductance Test Using the Number of Fluctuations in Skin Conductance per Second (NFSC) of at least 0. No 3.7 (48.6) 0 (0–0. age) did not substantially alter the unadjusted values.3 93.81) 6. Receiver operating curves (ROC) for the parameter number of fluctuations in skin conductance per second (NFSC) to identify all time points with moderate or severe pain as measured by standard pain scores.72] 906 (72.3 (0.7) 55 (12.SKIN CONDUCTANCE TO MONITOR ACUTE PEDIATRIC PAIN 515 Table 1. body temperature.12) 50. V 111.3 99.65] 310 (82.8 97. the odds of moderate to severe pain were again significantly higher for patients with NFSC of at least 0.1 (1. both unadjusted and when adjusted for age and body temperature (table 3). PPV ϭ positive predictive value.29) 36.4 (41.2) 0. Characteristics of the Sample Age Group 1–3 yrs 4 –7 yrs 8 –16 yrs Full Sample Characteristics of data Number of patients Total number of pain assessments Pain assessments per patient. 95% CI 0.39) 42. and body temperature. age.83.57] 281 (62.9) 43 (10. Group PPV NPV Whole sample Age 1–3 years Age 4–7 years Age 8–16 years 18.1 35.57) 30. 1).13 relative to those with NFSC less than 0.2 (0.3 85.16) 36.9 96. both unadjusted and when adjusted for anxiety (m-YPAS).78 – 0. 0. min.80).2) 123 (9. adjusting the odds ratios for potential confounders (anxiety score [m-YPAS]. largest for the 4 –7 yr group (area 0.9 67. and virtually identical to the sample result for the 8 –16 yr age group (area.5 28.

0001. only 3.g.254) Unadjusted Age. a negative test will be more accurate than a positive one when the prevalence of an event is low. For correct interpretation of our current and formally published results. All scoring systems used in our trial and previous trials are highly observer-dependent (e. Storm et al.73 6. body temperature 7.5% of patients. In addition.30 11.g. hence ultimately sympathetic tone.29 5.13 vs. This can be partially explained by the fact that we chose to emphasize sensitivity when choosing a cutoff to minimize undertreatment of pain. However. at Least 0. Confidence limits are based on robust standard errors. with the consequence of relatively more falsepositive than false-negative results. LCL ϭ lower confidence limit.13) allowed us to identify time points with moderate or severe postoperative pain with 90% sensitivity and 64% specificity.56 7. Our investigation focused on the SC parameter NFSC because it has been shown to be less influenced (compared to mean SC) by electrode placement or type of electrodes. use of NFSC values higher than the cutoff to identify states of moderate or severe pain (NFSC as positive predictor) would have resulted in an overtreatment (incorrectly diagnosed as moderate or severe pain) in 64. The difference in the potential clinical usefulness of NFSC as Anesthesiology. A clear limitation of the SC method to assess pain is the fact that SC reflects palmar sweat gland filling. Harrison11 showed no correlation between the mean SC or the amplitude of fluctuations and a painful stimulus and confirmed that NFSC did increase significantly with a painful stimulus in neonates.46 11. it has not been used as a tool for the assessment of postoperative pain until two recent publications found a strong relationship between postoperative pain and the SC parameter NFSC in adults.2% of children in moderate or severe pain would have remained undiagnosed and hence potentially undertreated.05).12. If NFSC had been used in our cohort to guide pain treatment by using an NFSC value below the cutoff to exclude moderate and severe states of pain (NFSC as negative predictor).10 Results are from generalized estimating equations assuming an exchangeable correlation structure. Discussion Though the method of monitoring changes in the electrogalvanic properties of the skin has been described by Fere as early as 1888.10 In modern anesthesia.. However. * Odds ratio greater than 1 indicates higher odds of moderate–severe pain for the number of fluctuations in skin conductance per second (NFSC) of at least 0.07 25. and any diagnostic tool for the assessment of pain would be expected to produce more false-positive than false-negative diagnoses. a cutoff value for NFSC (0. In contrast. Measuring the effect of arousal on sympathetic tone was not the subject of our investigation. age.75 12.13 However.9 To our knowledge.3.95 4.4 Previous research in neonates focused on absolute values of SC parameters but failed to provide values that would allow the clinician to discriminate between pain that is well controlled (no or mild) and pain that needs urgent attention (moderate or severe). Storm et al. Sep 2009 either negative or positive predictor for moderate/severe pain reflects the test’s high sensitivity and lower specificity.49 4.13. Therefore. specificity 74%) as well as with results for the ability of NFSC to indicate intraoperative painful stimuli. nausea) might theoretically alter the reaction of SC or its parameters to painful stimuli. Virtually independent of a test’s intrinsic accuracy (sensitivity and specificity). Despite these limiting factors. In children.9: 0.516 HULLETT ET AL. all factors that influence sympathetic tone (e.. body temperature Observations with anxiety scores (n ϭ 814) Unadjusted Anxiety score Anxiety score. Thus we are unable to comment on its extent in our cohort. No 3. hence a potential chance to electronically eliminate arousal as a confounder.73 13. but we found that preoperative anxiety measured by m-YPAS did not affect the strong association between pain ratings and NFSC.9: sensitivity and specificity 86%). Odds Ratios and 95% Confidence Limits for Predicting Pain (Moderate–Severe vs. anxiety. UCLϭ upper confidence limit.1. the prevalence of moderate and especially severe postoperative pain is likely to be low. studies in adults comparing bispectral index data and SC measures during emergence from general anesthesia have demonstrated a strong effect of arousal on sympathetic tone and subsequently SC.13) Adjustment Variable(s) Odds Ratio* 95% LCL 95% UCL All valid observations (n ϭ 1. These results match with the previously described characteristics in adult postoperative patients (Ledowski et al.50 12. We did not study state anxiety in the recovery room. None–Mild) from the Number of Fluctuations in Skin Conductance Dichotomized at 0. our results suggest a strong relationship between NFSC and acute postoperative pain. the opposite being true when the prevalence is high.73 5.4: sensitivity 89%. nurse-rated pain scores) or rely on patient cooperation . All P Ͻ 0.13 (Less Than 0. other parameters have been studied in the past.93 23. the current study is the first to describe the use of skin conductance as a tool for pain assessment in children of all ages. it needs to be emphasized that there is currently no reliable standard for the assessment of acute pain in adults and children.02 22. Table 3. the NFSC cutoff values used in adult studies were generally lower (Ledowski et al. V 111. Storm14 has claimed that painful stimuli with/without arousal did produce different waveforms of the fluctuations in skin conductance. Also contributing to the difference in the positive and negative predictive value of NFSC was the relatively low prevalence (18%) of moderate and severe pain in our subjects.4: 0. In our observational study. anxiety associated with parental separation or an unfamiliar environment may well influence sympathetic tone and therefore skin conductance.8.

Finley JD. Ledowski T. Paech MJ. Kain ZN. J Dev Behav Pediatr 1999. Jones R. Hicks CL. Storm H: Skin conductance and behaviour during sensory stimulation of preterm and term infants. Anand KJ: Long-term effects of pain in infants. 13:1–6 2. pp 43– 8 11. Preuss J. Voepel-Lewis T. Schug SA: New parameters of skin conductance compared with bispectral index monitoring to assess emergence from total intravenous anaesthesia. von Baeyer CL. Storm H. 20:253–61 3. Wiley 2002. NFSC may facilitate pain assessment in children with developmental or communication difficulties. 85:783–8 8. In particular. Ledowski T. Anaesthesia 2007. No 3. as NFSC may be influenced by factors other than pain. Paech M. McTernan C. 46:887–95 10. 23:293–7 6. Porter FL. However. Loughnan P. Bagnall AL. Storm H: Changes in skin conductance as a tool to monitor nociceptive stimulation and pain. Goodenough B: The Faces Pain Scale-Revised: Toward a common metric in pediatric pain measurement. Pain 2001. Kapila R. Rostrup M. 97:862–5 5. Paech MJ. Obuchowski NA. New York. Shayevitz JR. especially when used as a negative predictor. 93:173–83 7. Stockland O. Storm H. Sep 2009 . Br J Anaesth 2006. especially related to the limitations of the method. 62:989–93 4. Schug SA: Skin conductance monitoring compared with bispectral index monitoring to assess emergence from general anaesthesia using sevoflurane and remifentanil. Hellerud BC. Schug SA: The assessment of postoperative pain by monitoring skin conductance: Results of a prospective study. Carr DB: Why children’s pain matters. 82:603–8 12. Mayes LC. may play an important role for the assessment of acute pediatric pain. McClish DK: Statistical methods in diagnostic medicine. Ledowski T. Boyce S. 21:796–804 Anesthesiology.SKIN CONDUCTANCE TO MONITOR ACUTE PEDIATRIC PAIN 517 (visual analogue or numeric rating scales). Br J Anaesth 2007. Ford A. We conclude that NFSC. van Korlaar I. Early Hum Dev 2006. Spafford PA. All systems lack clearly specified sensitivities/specificities in the description of pain states as the subjectivity of pain does not allow comparison with absolute values for pain. Dargaville P. Storm H. and further research is required to determine the clinical applicability of the method. Cicchetti DV. is therefore required to define the precise role of NFSC assessments in the management of pediatric pain. Br J Anaesth 2006. Raeder JC: Skin conductance correlates with perioperative stress. 99:547–51 14. Harrison D. Acta Anaesthesiol Scand 2002. Paech MJ. Schug SA: Monitoring of skin conductance to assess postoperative pain intensity. Storm H. IASP Pain Updates 2005. Lien MD. Bromilow J. Pediatric Nurse 1997. Grunau RE. 97:187–91 13. Wu J. Ledowski T. V 111. Malviya S: The FLACC: A behavioural scale for scoring postoperative pain in young children. Further work. the method should not be used as a sole tool for pain assessment. Hacking R. Curr Opin Anaesthesiol 2008. 70:35–46 9. Hofstadter MB: The Yale Preoperative Anxiety Scale: How does it compare with a “Gold Standard”? Anaesth Analg 1997. Early Hum Dev 2002. Storm H. Myre K. Johnston L: Skin conductance as a measure of pain and stress in hospitalized infants. References 1. Bromilow J. Merkel SI. Zhou XH.

No 3.. even if they are deeply anesthetized..† Peter S. P ‫ ؍‬0.2. Accepted for publication May 26. However. B. The comparison to SP has merit when BIS varies widely during routine care and values above 60 occur. monitors of “hypnotic state” were developed based on detectable differences in the electroencephalogram of human subjects who responded. Norwood. The comparison to an SP group is suboptimal. Julie Gaither reports no conflict of interest. October 19.. nor can such studies be staged experimentally in an ethical way. Inc. Lippincott Williams & Wilkins.Anesthesiology 2009.3%) and new words (distractors). After recovery from anesthesia. Georgia). MA) is a monitor of hypnotic state that can help to avoid light hypnosis (i. and therefore consciousness facilitated memory function.A. Emory University School of Medicine.N.001). meaningful information that is not consciously perceived..D.1 For clinical purposes. 6 months from the cover date of the issue.1% vs. Only patients in the BIS group selected targets more often than distractors (37.5. or a standard practice group in which BIS was recorded but did not guide drug administration. (Norwood. but patients with consistently high BIS values are rarely encountered or left untreated. Sep 2009 . the American Society of Anesthesiologists. Kerssens: Department of Anesthesiology.. MA) as a measure of hypnotic state to address the question of memory function under anesthesia. provided that BIS monitoring explicitly avoided light hypnosis. 2009. Dr. to verbal commands or * Assistant Professor.B. anesthesiology. Address correspondence to Dr. Chantal Kerssens received an educational grant in support of her salary within the past 3 years from Aspect Medical Systems. Conclusions: BIS titration to BIS 50 – 60 does not necessarily curb memory function under anesthesia when BIS values higher than 60 occur. Received from the Department of Anesthesiology.. B. M. Norwood. Information on purchasing reprints may be found at www. Emory University School of Medicine. Preoperatively. Emory University School of Medicine.edu. 2008..5–7 This is consistent with the notion that memory function depends on attentional resources.B. 111:518 –24 Copyright © 2009.* Julie R. BIS below 60).e.A. 128 patients scheduled for joint replacement surgery under general anesthesia with sevoflurane were randomly assigned to BIS-guided anesthesia. 167 patients gave written informed consent to participate in this study that was part 518 Anesthesiology.11–13 In addition to memory function.01). ckersse@emory. The bispectral index (BIS. WE have limited understanding of the brain’s ability to process complex. memory for verbal stimuli presented during general anesthesia as measured by BIS Ͻ 60 has been reported. for personal use only.5% hit rate.01) and pain management technique (P < 0. Inc. all were interviewed about recall and completed a recognition memory test containing the presented words (targets. but were associated with the amount of fentanyl received preoperatively (P ‫ ؍‬0. especially when the patient is deemed to be unconscious (i. as evident from neuroimaging4 and impaired memory performance for words presented at lower versus higher BIS levels in human surgical patients. This raises the question whether patients under general anesthesia form memories. M.. Georgia. R. Results: BIS values above 60 were recorded in both groups.9 Materials and Methods After institutional review board approval (Emory University. Ph.. M. We have used electroencephalogram bispectral index (BIS. 31.H.S. ‡ Professor and Vice Chair.3 Anesthesia clearly impairs basic elements of memory function. Target hit rates correlated poorly to stress scores (P > 0. Aspect Medical Systems. titrating drugs to BIS 50 – 60 (BIS group). Aspect Medical Systems. Department of Anesthesiology. Submitted for publication November 10. and stress-induced learning mechanisms supported the formation of memory during unconsciousness. ANESTHESIOLOGY’s articles are made freely accessible to all readers. which falter rapidly when anesthesia is given. Preoperative analgesia attenuated the likelihood of memory function under anesthesia.‡ Background: Memory function under anesthesia is undesired but may arise from light hypnosis as well as stress-enhanced learning during surgery. Florida. 33. Massachusetts). but no patient recalled the presented words postoperatively. other forms of stimulation.e. We compared memory function in these patients to a group in which BIS did not guide anesthetic management (standard practice [SP]) and hypothesized less memory in the BIS-guided group. Atlanta. given that BIS is typically low during routine care.org or on the masthead page at the beginning of this issue. Atlanta. Two explanations are commonly given for spared memory function under anesthesia: The anesthetic was not as deep as it appeared.. This study tested the hypothesis that BIS-guided anesthesia maintaining BIS 50 – 60 reduces the likelihood of memory function under anesthesia.D. Georgia 30303. patients’ subjective stress levels were assessed and perioperative fentanyl doses recorded to address claims that stress and analgesic interventions affect memory function by altering the physiologic stress response to surgery. patients filled out a stress questionnaire (Spielberger State-Trait Anxiety Inventory). 2008. † Research Nurse. which is not uncommon. Orlando. or did not respond. Ph. BIS above 60). all patients were repeatedly played a list of 15 words.N.P.10 This study intended to address the controversy over memory function under anesthesia by investigating the occurrence of memory function in a group of surgical patients in whom hypnotic state was controlled within a narrow range as measured by BIS 50 – 60.8 –11 and suggests that the human brain processes and stores information unconsciously. Presented at the meeting of the American Society of Anesthesiologists (Abstract A-487). V 111. Sebel. Inc. Peter Sebel is a paid consultant to Aspect Medical Systems. Inc.. Inc. After induction. The question is not easily answered in the absence of a gold standard for consciousness. Gaither. 49 Jesse Hill Jr. Methods: After obtaining informed consent. Atlanta. Aspect Medical Systems.9). Preserved Memory Function during Bispectral Index–guided Anesthesia with Sevoflurane for Major Orthopedic Surgery Chantal Kerssens. did not financially support the study.

upenn. No 3. audio files of individual words were uploaded in a sound editorʈ and separated by short periods of silence (2 s) to create a digital audio sequence.5 mg/kg esmolol for hypertension. V 111. Within test items. Accessed May 18. To further eliminate possible neurologic dysfunction. Memory Assessments Outcome assessors (JRG and CK) were blinded to study group allocation and tested patients postoperatively for recall and recognition memory. Word presentation typically started 15 min after induction and lasted approximately 42 min in all. The average (ϮSD) Kucera-Francis word frequency for this set was 40. head trauma resulting in the loss of consciousness. For instance. planet. Specific exclusion criteria were a history of illicit drug abuse.3 (15. the patients were instructed to listen to each test sequence and select the word played during surgery.9). Physiologic parameters were automatically recorded to a computer throughout the study using Rugloop (Demed. sister. or to guess if necessary (three-alternative forced choice). one of which was played to patients during surgery in a counterbalanced fashion. For induction. Lastly. patients with a medical history or status that could compromise or skew electroencephalogram recordings were excluded from participation. Sep 2009 . During anesthesia maintenance. primary or revision. under general anesthesia were eligible to participate.2 (1. sevoflurane in oxygen was given using standard ventilation parameters in addition to 50 –100 ␮g fentanyl for analgesia. painting).15 administered preoperatively. audio files of individual words were uploaded in the sound editor and separated by 1 s of silence. 2009. Psychological Stress Assessments Patient completed the State-Trait Anxiety Inventory (STAI) to assess subjective psychological stress levels. 45 words had been selected from the Toronto Noun Pool§ to create a homogenous set of words with comparable lexical word frequency and other language characteristics that affect memory. Vecuronium bromide (0. For this part of the study. end-tidal gas concentrations (every 5 s) and vital signs (every 3 min). including BIS. To create the items. antipsychotic medication treatment. None of the patients received benzodiazepines pre. Words were emotionally bland (e. The sequence was recorded 60 times onto compact disc and played to patients during anesthesia at a set volume using a compact disc player and headphones. with additional doses as necessary. all patients were given 2 mg/kg propofol and 3 ␮g/kg fentanyl. Instead.net. In the other group.14 The sample size was arbitrarily determined to yield at least 100 analyzable cases overall (roughly 50 data points per treatment group).g.sourceforge.edu/wordpools.. The recognition memory test was administered after the recall assessment and consisted of an auditory test. the word frequency was matched. The sequence was then repeated to enhance stimulus audibility and understanding. 15 test items were created. Recall was assessed approximately 6 h after surgery with five questions16. algorithm 3. ࿣ Available at http://audacity.php. a BIS monitor (XP.psych. For the recognition test. The set was split into three 15-word lists of comparable word frequency and concreteness. individuals with severe visual or auditory handicaps and illiterate individuals or nonfluent English speakers were excluded from participation.4) was used to guide anesthetic administration and titrate drugs to values between 50 and 60 (BIS-guided group). Upon testing.or intraoperatively.4). Items were recorded onto compact disc in three different orders to create test versions that were counterbalanced between patients. Accessed July 20. were excluded. Patients 18 yr of age or older scheduled for hip or knee replacement surgery.g. 0. In one group. 2009. BIS was recorded but not available to the attending clinician for drug dosing. For this presentation. Belgium).17: What is the last thing you remember before falling asleep? What is the first thing you remember after waking up? Do you remember anything in between? Did you dream? What is the worst thing about your operation? As necessary.1 mg/kg) was given to facilitate tracheal intubation. and 100 ␮g phenylephrine for hypotension on an as-needed basis. Because our primary intervention involved brain function (electroencephalogram) monitoring. but fentanyl (50 –100 ␮g) was given at the discretion of the anesthesiologist/pain service to ease discomfort or anxiety over epidural or patient-controlled analgesia (PCA) placement. or central nervous system disorders (e. Postoperative pain was managed with epidural (with meper§ Available at http://memory. standard clinical signs such as heart rate and blood pressure guided anesthetic management in this group (standard practice). he or she was asked to describe the event. each consisting of 1 word played during anesthesia (target) and 2 new words not played earlier (distractors). persons scoring below 24 on the Mini-Mental State Examination. The position of targets was counterbalanced across items.18 Anesthesiology. and concreteness was 5..MEMORY FUNCTION DURING BIS-GUIDED ANESTHESIA 519 of a larger project investigating inflammatory outcome after major orthopedic surgery under general anesthesia with and without BIS monitoring. epilepsy). additional questions were asked. when a patient reported recall for events that occurred between falling asleep and waking up from anesthesia. idine/bupivacaine or liposomal morphine) or PCA (with hydromorphone or morphine) based on individual patient demands. Anesthetic Management Patients were randomly assigned to one of two anesthetic management groups using a computer-generated list linking subject study numbers to group assignment.

BIS ϭ bispectral index.5 Ϯ 1. which rendered the auditory stimulus presentation unreliable (n ϭ 10). based on the assumption that surgical stress Anesthesiology.9 Ϯ 11. Data were statistically analyzed using SPSS 14.29 1. The distractor hit rate established chance performance. Differences in recognition memory performance were statistically tested by comparing observed hit rates in the two study groups. Secondary analyses explored recognition memory performance in relation to stress mechanisms by relating individual hit probabilities to individual baseline STAI scores using a nonparametric correlation measure.83 Ϯ 1. A similar comparison was made using the distractor hit rate observed over all patients. defined as the period between 10 min after intubation and 10 min before extubation.4 Ϯ 13.7 28. based on the assumption that analgesic interventions suppress the stress response and. PCA).2 Ϯ 5. or the patient was lost to follow-up (n ϭ 5).7 Ϯ 5. Given the low incidence of explicit recall (awareness) after general anesthesia.29 1. chi-square tests.7 44. data were extracted for the time period during which words were presented. and may range from 20 (minimum) to 80 (maximum).1 63. Redmond. by relating observed hit probabilities to the extent of surgical stimulation during word presentation.12 PCA ϭ patient-controlled analgesia.2 Ϯ 1.2 Data are mean Ϯ SD unless otherwise noted. as well as the results of a depression questionnaire that was filled out at similar intervals.001 between-group comparisons. Results Of 167 consented patients.04 0. WA).17 this study was not powered to detect differences between study groups in explicit recall. Demographics and treatment characteristics were compared between groups using independent sample t tests. rather than within treatment groups. inclusion criteria were not met (n ϭ 7). Both forms of the STAI were administered to obtain transient (state) as well as more permanent (trait) anxiety estimates.55 Ϯ 1.05 was considered statistically significant. From this latter data set. The remaining 128 patients were interviewed for recall after recovery from anesthesia. The results of the baseline assessment are reported here.16. and by relating observed hit probabilities and the incidence of memory to fentanyl administration.4 34 (55) 87. n (%) Days in hospital (recovery) (n) 61. thereby.0 1. BMI ϭ body mass index. the surgery or anesthetic was cancelled or changed (n ϭ 10).47 Ϯ 0. 39 were excluded because intraoperative monitoring could not be accomplished (n ϭ 17). IL) and Microsoft Excel 2000 (Microsoft Corp.4 Ϯ 14. The prevalence of explicit recall was therefore not statistically addressed. The main analyses focused on an effect of study group assignment on recognition memory test performance.0 (SPSS. Characteristics of Patients Assessed for Recognition Memory BIS Group (n ϭ 62) SP Group (n ϭ 47) Age (y) Female.9 Ϯ 18.56 Ϯ 0. the likelihood of memory function. Composite scores are obtained similarly for both forms.37 112 Ϯ 48 0. the probability of selecting a word at test when it had been presented during anesthesia (target hit rate) could be compared to the probability of selecting the same word when it had not been presented during anesthesia (distractor hit rate).27 Ϯ 0.3 33 Ϯ 9 32 Ϯ 8 45. as expressed in the number of surgical minutes and tested parametrically using Pearson’s r measure of correlation.8 36 Ϯ 11 32 Ϯ 9 52. the responses of 19 patients were excluded for one of the following reasons: The patient was wearing a hearing aid that was removed during surgery. using ANOVA and chi-square tests.9 1. and any upward deviation from this probability in the absence of word recall suggests evidence of implicit memory for words presented during anesthesia.9 30. The results of the two other measurements can be found elsewhere. it could not be Table 1. P Ͻ 0.4 8.520 KERSSENS ET AL. n (%) Weight (kg) BMI MMSE score STAI state score STAI trait score BIS maintenance* BIS word presentation* BIS higher than 60 (% word presentation) End-tidal gas maintenance (%)* End-tidal gas word presentation (%)* Duration of anesthesia (min) Fentanyl preoperative (␮g/kg) Fentanyl intraoperative (␮g · kgϪ1· hrϪ1)† Fentanyl postoperative (␮g/kg) Epidurals (vs.10 17 (37) 4.70 Ϯ 1. Specifically. Maintenance ϭ time period between 10 min after intubation to 10 min before extubation. Statistical Analysis Physiologic data recorded intraoperatively were extracted to obtain individual data for steady-state anesthesia.31 Ϯ 0.3 Ϯ 16.0 Ϯ 1. SP ϭ standard practice group. Chicago.9 Ϯ 3.5 13.31 126 Ϯ 51 0. Target hit rates were compared within groups to distractor hit rates using one-sample t tests.30 Ϯ 0.60 Ϯ 0. No 3. STAIϭ Spielberger State-Trait Anxiety Inventory.8 28.43 2. MMSE ϭ Mini-Mental State Examination.18 0.40 Ϯ 0.6 28.1 Ϯ 1.2 Ϯ 11.1 Ϯ 8.0 50. and all reported P values are for two-sided tests (uncorrected for multiple comparisons).66 19 (31) 4.8 31 (66) 84. The inventory was administered once preoperatively (baseline) and twice postoperatively (48 h and 1 month).8 Ϯ 5.0 Ϯ 8. * P Ͻ 0. Because stimuli had been presented during anesthesia in a counterbalanced fashion.. meaning that some patients were exposed to a set of words while others were not. Sep 2009 creates a neuromodulatory response that facilitates memory function. .17 Word Presentation ϭ time period during which an audio compact disc with words was played. or Fisher exact tests. Spearman’s rho.47 2. † Includes the induction dose. V 111. and were presented with a recognition test to assess memory for words played during anesthesia.

76. mean (max–min) BIS @ maintenance. which was correct (true memory) 9 (60) 48. patients in the SP group received more hypnotic agent and their BIS was on average lower than in patients in the BIS-guided group (table 1. a particular song (Not independently confirmed) No recollection 10 (67) 51. Recall and Dreaming Characteristics of the larger sample assessed for recall (n ϭ 128) were similar to those reported in table 1. three patients (2. while the percentage of BIS exceeding 60 was smaller (table 1). P ϭ 0. Coinciding with a lower BIS average. 53. BIS) Verbatim recollection* Word recollection† Recognition Target Hit Score (% correct)‡ BIS @ words. or 33%). all three reported medical events such as drug-induced nausea. which precluded extraction of physiologic data during that time (n ϭ 6). included data of 109 patients. As table 3 shows. SP ϭ standard practice group.2 (61.0) 52. Anesthesiology. These patients did not report dreaming.2 0.371) than words not presented during anesthesia (distractor hit rate ϭ 0.05). The overall target and distractor hit probabilities (0.3 (70.1) 9 8 0.8) 53. In three patients in the SP group. M ϭ male. when tested postoperatively. F ϭ female. age.0) 1.9 (70.41 72 No complications reported Woke up and heard hammering. P Ͻ 0. Their recollections and other pertinent data are reported in table 2.81 77 No complications reported Patients’ sex. When interviewed postoperatively.0 (70. dry mouth. the average BIS during word presentation was lower in the SP than in the BIS-guided group (table 1). SP) Patient 2 (F. Data of Patients Reporting Postoperative Recall Patient 1 (F. Demographics and other characteristics of patients tested for recognition memory are presented in table 1. mean (max–min)§ BIS Ͼ 60 during words (% of time) BIS Ͼ 60 during maintenance (% of time)§ End-tidal gas concentration (mean %)࿣ Duration of anesthesia (min) Anesthesia records Heard clanging of pots and pans after being put to sleep Believes she heard one particular test word during anesthesia. to select words presented during anesthesia (target hit rate ϭ 0.1 (61. 59. which were generally vague but pleasant (e.3%) reported recall of the time period between falling asleep and waking up from anesthesia. whereas such averages were not recorded in BIS-guided patients.5–41.g. ࿣ End-tidal concentrations are shown for the maintenance period. therefore. BIS averaged above 60 during anesthesia maintenance. which was incorrect (false memory) 4 (27) 55. Seven patients (5.4 1.6) 21 14 1. as the standard deviations for BIS measurements in table 1 demonstrate. this effect should be attributed to patients in the BIS group who were more likely.0–39. No 3. chance performance ϭ 5. * Elicited during the postoperative recall interview.5–41.2–37. BIS ϭ bispectral index–guided group. Recognition Memory Consistent with the trend seen during anesthetic maintenance. and group assignment are shown in brackets at the top. 0. However.3 (92. felt pain during surgery Believes she heard one particular test word during anesthesia. Observed hit probabilities for words presented during anesthesia are shown in table 3. Sep 2009 Sixty-seven patients were randomly assigned to the BISguided group and 61 to the SP group.350 vs. ‡ The number of items presented during anesthesia that were correctly recognized at test (maximum ϭ 15.99 88 Difficulty controlling BIS noted Heard music. Nothing in the reports alluded to possible awareness episodes. The . About 50% of patients were classified as American Society of Anesthesiologists Class I-II and 50% as American Society of Anesthesiologists Class III. when patients volunteered information based on hearing test items. During anesthesia maintenance.3) 48. suggesting memory of words presented during anesthesia. § Maintenance was defined as the time period between 10 min after intubation and 10 min before extubation. playing golf.001).. the percentage of BIS below 45 was significantly larger in the SP group. or chills.MEMORY FUNCTION DURING BIS-GUIDED ANESTHESIA 521 Table 2.315. The recognition memory part of this study. being with family).325) differed significantly (P Ͻ 0. BIS) Patient 3 (M. V 111. or the patient heard more or fewer cycles of critical stimuli than the protocol stipulated (n ϭ 3).001). When asked what had been worst thing about their operation. Sixty-two patients were randomly assigned to the BIS-guided group and 47 to the SP group. nor did their recollection prompt an emotional response. with no differences between study groups. however. determined when stimuli had been presented.3–39. and were largely the same during the period of word presentation. † Established during or after the recognition memory test.5%) reported dreams.5–32. BIS values and averages varied more in the SP group.

Observed hit probabilities correlated poorly to scores on either STAI measure (n ϭ 101.. for that matter). P ϭ 0. The incidence (nor dose) of preoperative fentanyl administration or postoperative pain management techniques did not differ between anesthesia treatment groups (table 1).12 They observed implicit memory in the SP group alongside a wider range of BIS values that included a significant portion above BIS 60. word presentation started before surgery. P ϭ 0. This latter finding is instructive and may help to explain why priming-related memory for meaningful stimuli presented at BIS planes below 60 (but not 50) occurs. reached a similar conclusion when comparing BISguided anesthesia to SP not using BIS. related to the amount of fentanyl received in preoperative holding but not to intraoperative or postoperative fentanyl interventions. SP-groups. they had a higher incidence of PCA as opposed to epidural pain management (80% vs.119 0.79). but the two Anesthesiology. r ϭ 0. the target hit probability related poorly to the percentage of recorded BIS values above 60 (Pearson correlation. Trait-related anxiety was less common but likewise comparable between groups (16% vs. * P ϭ 0.21.24). Contrary to our hypothesis. the evidence for implicit memory function in trauma patients5 was not replicated when drugs were titrated to maintain BIS values between 50 and 55.11 In addition.522 Table 3.27). or end-tidal gas concentration during word presentation. arterial blood pressure. P ϭ 0. P ϭ 0.117 0. P ϭ 0. BIS values above 50 were identified as a significant predictor of memory. respectively. as we and others have noted.95). In the current study.17). or other measures such as mean heart rate.371 Ϯ 0. Patients with significant recognition memory were less likely to having received fentanyl preoperatively (49%) than patients not showing evidence of memory (74%) (Fisher exact test.008). the mean BIS during word presentation (r ϭ 0.58). No 3.09.132 0.133 0.19.118 analgesic techniques were not associated with systematic differences in preoperative fentanyl dosing (or intraand postoperative differences.20 BIS-guided anesthetic management to BIS 40 – 60 failed to induce priming of category exemplars that was observed repeatedly in the absence of hypnotic state monitoring.01). 48% BIS group vs. BIS during critical word presentation averaged above 50 in the BIS-guided group. n ϭ 46. SP ϭ standard practice (not bispectral-indexguided). r ϭ 0. rhoSTAI-trait ϭ Ϫ0. V 111.81). as we have argued. Discussion This study demonstrated reliable implicit memory for words presented on average during adequate general anesthesia as measured by BIS Ͻ 60.132 0. Sep 2009 . priming was observed in the BIS-guided rather than SP group. These early studies indicated that hypnotic state titration to adequate levels curbed memory function. Memory took the form of a priming effect that facilitated patients to pick words presented during anesthesia rather than words not presented during anesthesia when tested postoperatively.19 In another. The number of surgical minutes during word presentation correlated positively with observed target hit probabilities.009.e.5. and overall showed no evidence of memory function. SP group performed no better than chance. 56% PCA incidence in memory vs. defined as a target hit probability higher than chance (i. Stress Modulation of Memory Baseline questionnaires suggested that groups experienced comparable and appropriate levels of anxiety in anticipation of major surgery (table 1). Struys et al.006. P ϭ 0. BIS ϭ bispectral index-guided. BIS group (n ϭ 62)* SP group (n ϭ 47) Overall (n ϭ 109)† 0.18 above-average state anxiety was noted in 31% of patients in the BIS group versus 21% of patients in the SP group (P ϭ 0. Overall. titrated anesthetics to BIS 55– 60. and found reliable implicit memory for a word series presented around BIS 50 on average. but nobody heard the entire set before surgical incision. but not significantly (n ϭ 107.05 for within-group comparisons of target versus distractor hit probabilities.323 Ϯ 0.22 The null findings in the BIS-titrated replication studies confirmed the hypothesis that inadequate hypnosis contributed to memory function under anesthesia.325 Ϯ 0. Compared with normative data. This seems to contradict the notion that tight control of hypnotic state obliterates memory function. More recently.93.001 and † P Ͻ 0. P ϭ 0. Significant recognition memory. Words were presented exclusively during surgery in 26% of patients in both study groups. None of the patients explicitly recalled presented words when first interviewed after surgery. In addition. Ն 40% correct. 13% BIS-guided vs.14.05.19 Two of our early BIS titration studies did not find evidence of memory function when depth of hypnosis was tightly controlled and moments of light anesthesia were avoided. Stonell et al. In the remaining patients. P ϭ 0.8 The authors related levels of anesthesia (categorized BIS) to subsequent memory performance and confirmed lack of evidence for memory function below BIS 40. rhoSTAI-state ϭ Ϫ0.315 Ϯ 0.338 Ϯ 0. Observed Mean ؎ SD Hit Probabilities for Target and Distractor Words per Treatment Group and the Overall Sample Target Distractor KERSSENS ET AL. 36% SP group.33). including the three patients who reported recall of other events.350 Ϯ 0. P ϭ 0.20 In one study. no memory groups. and in each treatment group. This time index did not differ between study groups (P ϭ 0. however.

This translates to at least 5 min of recorded case time. M. it remains to be seen how the relatively small doses of fentanyl (50 –100 ␮g) patients received in this study before surgery could subsequently affect the physiologic stress response to surgery or intraoperative memory function.D. Kerssens C.19. We conclude that BIS-guided anesthesia.D. Consistent with the notion that BIS Ͼ 50 facilitates memory function. Physician Assistant in Anesthesia (all affiliated with the Department of Anesthesiology. our early titration studies averaged BIS Ͻ 50 during word presentation (closer to the SP group in the current investigation) and did not observe memory. Professor/Chairman of Orthopaedics. the likelihood of memory function during surgery. BIS was above 60 more than 13% of recorded case time in the BIS-guided group on average (table 1). and Nevin Kreisler.10 We were unable to replicate this finding in the present study but note that all our patients. Johnsrude IS. 93:1336–44 3.D. We are also grateful to Suzan Banks (P.MEMORY FUNCTION DURING BIS-GUIDED ANESTHESIA 523 whereas it remained well below 50 in the SP group.. Kerssens C.. M. in addition to Robin Jones. Emory University School of Medicine. and Greg Erens M. Conversely. Preoperative fentanyl.D. therefore. Fredric Weitz. Proc Natl Acad Sci U S A 2007. facilitates memory function under anesthesia. Atlanta. Emory University School of Medicine.. In 2005. However. Preoperative fentanyl may curb the stress response to surgery. Sebel PS: Development and clinical application of electroencephalographic bispectrum monitoring. The authors wish to thank Steven Helfman.. ANESTHESIOLOGY 2000. 99:570–5 7. Georgia). 104:16032–7 5.D. Rodd JM. Johansen JW.9 our findings suggest that a benefit may be found at an earlier. William Dozier. for their contributions. but not below. 97:382–9 . Bonke B: Awareness: Monitoring versus remembering what happened. Merely excluding lighter levels from the analyses or categorizing hypnotic states into deeper versus lighter levels may prove instructive. This divide provides one possible explanation why we observed reliable implicit memory in BIS-guided patients.D. In the present study. Neither study established evidence of memory function. which is uncommon but occasionally occurs between BIS 55– 60. M.. With these stringent criteria in mind. Student.20 BIS averaged between 60 and 70 in less than a handful of patients (5%) at some point during word presentation. Emory University School of Medicine. We note that the difference in memory performance between pain management techniques (PCA vs. In addition to a higher BIS average. Coleman MR. Variation in BIS is reduced by BISguided anesthesia. Absalom AR. Hudetz AG: Suppressing consciousness: Mechanisms of general anesthesia. but would not suffice.D.19. Lubke GH. using a similar approach to hypnotic adequacy as well as probing memory. Assistant Professor of Orthopaedics (Department of Orthopedics. ANESTHESIOLOGY 1999. were surgically stimulated to some degree.. as compared with not using BIS to guide anesthetic management.10 and reported tentative evidence for an effect of surgical stimulation on implicit memory. and James Roberson. in contrast to prior studies that focused on intraoperative analgesic interventions. ANESTHESIOLOGY 2002. van der Woerd A. Georgia). Matta BF. Klein J. Sep 2009 Andrade et al. To test this hypothesis. Atlanta.20 Anesthesiology. Semin Anesth 2006.9. (all Assistant Professors). and in 2001. and consequently. Bonke B: Memory function during propofol and alfentanil anesthesia: Predictive value of individual differences. Sigl JC: Clinical impact of hypnotic-titration guidelines based on EEG bispectral index (BIS) monitoring during routine anesthetic care. BIS averaged above 50 (54 Ϯ 14) during word presentation in the trauma study referenced earlier5 and in a significant portion of patients in the Stonell study discussed above..9 However. Klein J. J Clin Anesth 2000. was associated with a lower incidence of memory function. It may coincide with an increased probability of return of higher cognitive function (i. M. Although this count reflects instances of elevated BIS (5 s epochs) and does not imply that BIS was elevated for more than 5 min consecutively. James Beatty. Owen AM. Lubke GH.20 Each of these findings is consistent with the notion that BIS above 50.A. on the other hand. Davis MH. 25:196–204 2. memory function may be preserved. but not the SP group. Sebel PS: Dependence of explicit and implicit memory on hypnotic state in trauma patients. but if BIS values higher than 60 occur. have argued that the physiologic stress response to surgery is an important modulator of memory function under anesthesia.. This finding is consistent with the hypothesis that analgesics indirectly attenuate memory function by suppressing the stress response. reduced nociception in this group of patients. we did not observe memory function at comparable BIS levels in the two early titration studies already mentioned. only one study to date demonstrated memory for words presented at low BIS (Ͻ 50) levels. and therefore.19 we registered a handful of words (1%) presented at BIS above 60.e.19.Msc.6 Another explanation for memory function under anesthesia is the actual control of hypnotic state attained. response to verbal command). M. yet observed a small priming effect for seven words repeatedly presented to patients during orthopedic same-day surgery.9 These investigators altogether excluded 25 patients with BIS values above 60 from data analyses. M. V 111. is not necessarily associated with a lower probability of memory function. Menon DK: Dissociating speech perception and comprehension at reduced levels of awareness. preoperative stage. The implication is that BIS values above 60 affect memory function. M. it would be critical to avoid BIS over 60 altogether and keep hypnotic variation at a minimum. At the same time. Atlanta. Johansen JW. Georgia) for assistance with data extraction. 90:670–80 6. titrating drugs to maintain BIS values between 50 and 60. Sebel PS. Contrary to our early titration studies. Phaf H. unlike Andrade’s. epidural) might be the result of using an anesthetic test dose in patients with epidurals.20 we were less successful in maintaining BIS below 60 during word presentation this time. Kerssens C. the higher percentage of BIS above 60 in BIS-guided patients may also explain why reliable memory was observed in this. No 3. References 1. 12:433–43 4.8 Both these studies reported evidence of memory function. hypnotic state as measured by BIS was less tightly controlled in the current investigation. ANESTHESIOLOGY 2003.

Manual. Rampil IJ. 105:920–6 9. 1990. Ghoneim MM. Spielberger CD: State-Trait Anxiety Inventory (Form Y). Moerman A. ANESTHESIOLOGY 2005. Wolters G.524 KERSSENS ET AL. Stonell CA. Andrade J. Folstein MF. Bonke B. ANESTHESIOLOGY 2005. Amsterdam. 92:1210–4 21. Edited by Gorsuch RL. Fitch W. Iselin-Chaves IA. Jelicic M. Versichelen L. Jacobs GA. Anesth Analg 2004. Memory and Awareness in Anaesthesia. Kerssens C. 1983 19. demonstrated by an implicit memory task. Lancet 2000. Br J Anaesth 2005. Mortier E. Padilla RE. Sandin RH. V 111. Varma S. Forster A. 12:189–98 16. Andrade J. Sebel PS: No evidence of memory function during anesthesia with propofol or isoflurane with close control of hypnotic state. Van der Linden M: Investigation of implicit memory during isoflurane anesthesia for elective surgery using the process dissociation procedure. ANESTHESIOLOGY 2007. McHugh PR: “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Swets & Zeitlinger Publishers. Redwood City. Lushene R. Domino KB: The incidence of awareness during anesthesia: A multicenter United States study. Eur J Cogn Psychol 1992. Sample Set. Rolly G: Clinical usefulness of the bispectral index for titrating propofol target effect-site concentration. Vagg PR. Harrison D. Sebel PS: Hypnotic Depth and Postoperative Inflammatory Response (abstract). No 3. Sebel PS. Millar K. 53:4–12 13. Anesth Analg 2001. Wolters G. Byttebier G. Struys M. Bonke B. ANESTHESIOLOGY 2006. Punjasawadwong Y. 4:71–80 22. Edited by Bonke B. Klein J. Mind Garden. Deeprose C. 107:A1860 15. Boonjeungmonkol N. Bonke B: Auditory information processing during adequate propofol anesthesia monitored by electroencephalogram bispectral index. pp 151–5 Anesthesiology. 99:833–9 18. Gaither JR. Willems SJ. Br J Anaesth 2004. Bowdle TA. Scoring Key. He C. 17:CD003843 14. 102:57–62 20. Ouchi T. Deeprose C. Anaesthesia 1998. Gan TJ. Cochrane Database Syst Rev 2007. Jermann FC. Phaf RH: Unconscious perception during general anaesthesia. Adam SR. Enlund G. Edwards N: Unconscious learning during surgery with propofol anaesthesia. 103:925–33 12. Edwards N: Unconscious auditory priming during surgery with propofol and nitrous oxide anaesthesia: A replication. Roorda-Hrdlickova ´ V. Test. 8. 355:707–11 17. Phaf R: Implicit memory for words presented during anaesthesia. Lee L: No sex differences in memory formation during general anesthesia. Folstein SE. Lennmarken C: Awareness during anaesthesia: A prospective case study. Leslie K. CA. Kerssens C. Kerssens C. Samuelsson P. 92:171–7 11. Phongchiewboon A: Bispectral index for improving anaesthetic delivery and postoperative recovery. J Psychiatr Res 1975. Sep 2009 . van der Woerd A. 94:57–62 10.

which can either be achieved by either single nerve blocks or by a posterior lumbar plexus (psoas compartment) block. M. the necessity of an obturator nerve block is a subject of debate in total knee arthroplasty. Conclusion: Improvement of both the proximity and the margin of error is possible by using diagonal landmark vectors. Germany. nausea. ᭛ This article is featured in “This Month in Anesthesiology.22 Traditional methods for determining the insertion site rely on surface landmarks. Instead new problems arose.19. and urinary retention...heller@mailbox. 167 ؎ 6 cm. the spinous processes. Heller: Klinik und Poliklinik fu ¨ r Anaesthesiologie und Intensivmedizin. Methods: The lumbar plexus region of 48 cadavers (78 ؎ 7 yr. Received from the Medical Faculty. Further.3 mm was reached. § Resident. Clinic of Anesthesiology and Intensive Care Medicine. e.7 The obturator nerve has a cutaneous distribution at the mediodorsal aspect of the lower thigh in 43% of patients.de. Sep 2009 . Needle proximity curves were obtained by triangulation for the five traditional approaches and for vectors from the posterior superior iliac spine directed towards the lumbar spinous processes of L3 and towards L4. M. M. Using the vector posterior superior iliac spine-L3 with a length between 1/6 –1/3 (‫ ؍‬16 –22 mm) of the distance posterior superior iliac spine-L3. Chayen (8 ؎ 5 mm). www. and Dekrey (17 ؎ 6 mm). M.1 Intraoperative pain scores were lower and patient satisfaction was higher when using posterior lumbar plexus blocks as opposed to “3-in-1 blocks” during knee arthroscopy.‡ Oliver Vicent. The aim of this study was to determine the accuracy of these traditional approaches and determine if modifications could increase their accuracy. adopting a meaningful method that creates a line much closer to the axis 525 Anesthesiology. ࿣ Full Professor and Chair of Department. Universita ¨tsklinikum Carl Gustav Carus. 01307 Dresden.6.§ Richard H. V 111.1. with these new approaches the success rates did not increase.. Carl Gustav Carus University Hospital. the curves had a narrow parabolic shape and thus a narrow margin of error.anesthesiology. M. Dresden. Presented at the Annual Congress of the European Society of Regional Anesthesia. a proximity to the lumbar plexus < 5. M.A. all others were too lateral: Winnie (17 ؎ 8 mm).D.1– 4 For sufficient intraoperative analgesia besides a sciatic nerve block. Relying on the position of the posterior superior iliac spine eliminates the sex and sided differences and individual body size. page 9A.D. Germany. Dresden.‡ Background: Traditional methods for approaching the lumbar plexus from the posterior rely on finding the intersection of lines that are drawn based on surface landmarks. Lippincott Williams & Wilkins.8 Thus.anesthesiology.‡ Diana Wiessner. men/women: 29/19) was dissected. Results: Proximity curves (mean ؎ SD) showed that except Pandin’s approach (13 ؎ 5 mm too medial). TOTAL knee arthroplasty is one of the most commonly performed orthopedic procedures in elderly and obese patients.D.D. Address correspondence to Dr.D. Italy. Peripheral nerve blocks offer potential advantages such as earlier hospital discharge and less postoperative pain.org). It has been recognized that the formerly termed “3-in-1 block”5 is rather a femoral nerve block and usually spares the obturator nerve. 1) to improve the quality of blocks. hypotension. University of Technology. Heller. These methods may be inaccurate in many cases. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www..org. D. M. regardless of the use of catheter techniques.” Please see this issue of ANESTHESIOLOGY.. Inc. even with the posterior lumbar plexus block. September 25.21 or even catheter placement. 111:525–32 Copyright © 2009.20 subarachnoid puncture. 2008.g. Genoa.tu-dresden. University of Technology. Germany. axel.* Alexander Fuchs. such as retroperitoneal hematoma17 or accidental renal puncture18 caused by too lateral or cranial puncture. Litz. morphine consumption was significantly lower if an obturator block had been added to a femoral nerve block. the obturator nerve is not consistently blocked.D.† Thomas Ro ¨ ssel. the American Society of Anesthesiologists. Support was provided solely from institutional and/or departmental sources.10 However. Clinic of Trauma and Reconstructive Surgery. * Senior Anesthetist and Associate Professor. Fetscherstrasse 74. small deviations in the needle insertion point from medial to lateral will result in large deviations between the needle tip and the actual plexus location. Accepted for publication May 4.E. M. Both diagonal vectors had a significantly higher proximity to the lumbar plexus as compared with traditional approaches with a wide parabola. 2008.9 In the postoperative setting. 60 ؎ 13 kg. # Full Professor and Chair of Department. Thus..B.Anesthesiology 2009.. Inc. which can be problematic if firm metric distances are used in determining the entry point. W. 2009.. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. indicating more error tolerance.A..12–16 These construction lines intersect at one precise location. a block of the femoral and the obturator nerve is mandatory. This article may be accessed for personal use at no charge through the Journal Web site. Institute of Anatomy. emesis.D.0 ؎ 0.12–16 In fact. and the proximity of this intersection is not always a good reflection of the actual location of the lumbar plexus. Carl Gustav Carus University Hospital. Submitted for publication November 13. a number of slightly different approaches for posterior lumbar plexus block have been described (fig. and the posterior superior iliac spine (PSIS) from which “construction lines” are made to determine the point of needle entry.11 Thus. Supplemental digital content is available for this article.A.D. No 3. Funk. and relevant anatomic structures were marked. † Resident.. Precision of Traditional Approaches for Lumbar Plexus Block Impact and Management of Interindividual Anatomic Variability Axel R. iliac crests. M. Capdevila (6 ؎ 4 mm).࿣ Thea Koch. An injection of local anesthetics that is too medial increases the risk of their epidural spread.# Rainer J. However. ‡ Staff Anesthetist.

which contains an in-depth description. 2. Fig. V 111. In each cadaver the intercrestal line was taken as x-axis.lww. Optimizing Traditional Landmarks In all subjects. data of all subjects were gathered in one virtual map of the lumbar plexus region containing the average positions of the relevant anatomic structures. body mass index 21. and relevant internal landmarks were marked. 1) were analyzed in 2. of the nerve will allow for larger deviations along the course of that same line. men/women 29/19) was dissected. Sep 2009 dix. and diagonal construction lines were tested regarding their suitability and error tolerance in predicting the actual location of the lumbar plexus. . Traditional landmarks for posterior lumbar plexus block. PSIS ‫ ؍‬posterior superior iliac spine. Fig. In this manner all spots on horizontal construction lines defined by the five original describers12–16 (fig. spinous processes L3–L5. minima of the obtained polynomial curves were calculated by algebraic standard procedure.and y. 1) were screened for their proximity to the lumbar plexus. L3–L5 ‫؍‬ spinous processes of the respective lumbar vertebrae. Details on trigonometric model development can be found in Supplemental Digital Content 1. L3–L5 ‫ ؍‬spinous processes of the respective lumbar vertebrae. lateral and medial borders of the major psoas muscle at the mid-levels of L3–L5. Further.) In addition to generating mathematical models for the individual lumbar plexus position in each subject (fig. Germany). Trigonometric procedure for needle proximity assessment. as well as for the PSIS. posterior superior iliac spine (PSIS).com/ALN/A536. Supplemental Digital Content 1. Subsequently. see appenAnesthesiology.. optimized traditional landmarks. and approval of the Institutional Review Board of the Medical Faculty of Dresden exists. without the tip of the needle ending up too far away from the plexus. 4 parts water. the distance between the needle inserted at any given point (traditional landmarks. Cubic polynomial models fitted considerably better with the data obtained from the cadavers than quadratic models in terms of R2 and their ability to predict the true highest proximity of needle and nerve (represented by the curve minima). Subsequently. 1. Coordinates (x.12 cross 2 in fig.g.lww. No 3. polynomic regression analysis was performed (Excel. or new landmarks) and the lumbar plexus was calculated.axis) were calculated for the upper and lower border of the lumbar vertebral bodies L3–L5. optimizing these traditional landmarks was attempted. 3 parts glycerin. The aim of this study was to evaluate the traditional surface landmarks regarding their precision to predict the lumbar plexus position. Digital images.2. 167 Ϯ 6 cm. 60 Ϯ 13kg. Needle approach curves were obtained for each traditional technique. and a craniocaudal line through the center of the vertebral column was taken as y-axis. In all cases.4 Ϯ 4. the parallel line 10 mm cephalad to the intercrestal line for Capdevila’s approach. were taken and were mapped offline. The cadavers had been fixed with a mix of 5 parts ethanol. Mapping of all relevant structures in a frontal plane enabled the calculation of the vicinity of a virtual needle perpendicularly advanced from traditional insertion points towards the lumbar plexus. Construction lines are at right angles to the body planes. spots on the body surface being located on the horizontal construction lines for the traditional entry points (e. http://links. Berlin. Depiction of the determination of the proximity (Pt) of any given point (AP) to the lumbar plexus from measured (black circles) and computed (white marks) coordinates to the level L4/5. Microsoft. Trigonometric Mapping of the Lumbar Plexus The trigonometric procedure is briefly described.526 HELLER ET AL. and 3 parts formalin. (For detailed explanation of the mathematic models. and nerve crossing points (NCP). All cadavers were the legal property of the Institute of Anatomy of the Medical Faculty of Dresden. Materials and Methods The lumbar plexus region of 48 human cadavers (78 Ϯ 7 yr.com/ALN/A536. 2).to 5-mm steps from the midline onwards laterally for their proximity to the individual course of the lumbar plexus. including a centimeter scale. http://links.

5) resulted in significant higher accuracy of needle placement (fig. All statistical comparisons were done with SPSS for Windows version 15. Chayen (8 Ϯ 5 mm). Chicago. To enable proper visibility within the proximity curves. only lateral position is variable on the predefined craniocaudal levels12–16). Highest approximation is gained within the course of the groove. iliac bone will regularly impede successful puncture. Polynomial fit procedures were performed to find insertion points on the skin at the predefined craniocaudal levels. 5A–E): Winnie (17 Ϯ 8 mm). This was chosen for practical reasons: Within the area of 8 mm medially and 10 mm cranially from the PSIS. paired t tests were performed and the 95% CIs are depicted. 4) were respectively screened for the length producing the highest proximity to the lumbar plexus. Location of the lumbar plexus within the major psoas muscle (closed line) and evaluated vectors from the posterior superior iliac spine (PSIS) to the spinous processes of L3 and L4 (dotted arrows). and from 10 to 22 mm cranially of the PSIS. The screened rectangle extended from 8 to 16 mm medially. Statistical significance was accepted at P Ͻ 0. 4. Mapping the PSIS Region and Diagonal Vectors In addition to the construction line– derived mapping (one-dimensional. 3).12–16 showing closest proximity to the nerve as represented at the respective curve minima.05. For comparison of the original approaches with Anesthesiology. . and Dekrey (17 Ϯ 6 mm). reflecting the respectively increasing degree of interindividual variation and thus lower predictability when using direct metric measures. Thus. The mediocranial boundary of the rectangle was defined with respect to the ascending bottom of the proximity groove shown in the three-dimensional proximity graph (fig. the two vectors from the PSIS directed towards the spinous processes of L3 and towards L4 (fig. Changing the insertion points for each of the traditional landmarks to the very spots of nearest proximity within the respective approximation curves (fig. Increasing distance from the PSIS is associated with a rising ground of the groove. the whole area around the PSIS was two-dimensionally mapped (both lateral position and craniocaudal level are variable) in millimeter steps for its proximity to the lumbar plexus. Sep 2009 Fig. The curves further had a narrow parabolic shape. Capdevila (6 Ϯ 4 mm). The mediocranial direction of this proximity groove gave the idea of a vector ideally being located above the groove in a long common course with the lumbar plexus. V 111. Proximity map of the region medial and cephalad of the posterior superior iliac spine (PSIS). and thus narrow error margins. Proximity curves of the traditional approaches showed that except Pandin’s approach. unpaired t test. two-tailed.0 (SPSS. their optimization and with the new diagonal vectors. (13 Ϯ 5 mm too medial) all others were too lateral (fig. respectively. SEM is here given as the measure of variability. 3. IL).IMPROVING PRECISION IN PCB 527 Fig. Sex-related effects were checked with a two-tailed. Linear regression analysis was performed to assess the effect of age and sex on the cross-sectional diameter of the major psoas muscle. Results Anatomic coordinates relevant for a lumbar plexus block can be taken from table 1. Statistical Analyses All data within the text and the tables are given as mean Ϯ SD. The L2 and L5 vectors (thin dotted arrows) were not considered. No 3.

Table 1. As compared with the original approaches.15 and (E) Pandin. indicating high error tolerance. Anatomic Coordinates X/Y Axis Anatomic Structure Mean (mm) Y Y Y Y Y Y Y Y Y Y Y X X X X X X X X Upper edge vertebral body L3 Spinous process L3 Lower edge vertebral body L3 Upper edge vertebral body L4 Spinous process L4 Lower edge vertebral body L4 Upper edge vertebral body L5 Chayen´s puncture level Spinous process L5 Lower edge vertebral body L5 Posterior superior iliac spine Posterior superior iliac spine Lateral margin of psoas L3 mid Lateral margin of psoas L4 mid Medial margin of psoas L4 mid Lateral margin of psoas L5 mid Medial margin of psoas L5 mid Diameter of psoas muscle L4 Diameter of psoas muscle L5 Distance: Posterior superior iliac spine to spinous process of L4 Distance: Posterior superior iliac spine to spinous process of L3 52 Ϯ 14 40 Ϯ 14 28 Ϯ 14 17 Ϯ 14 4 Ϯ 13 Ϫ9 Ϯ 13 Ϫ19 Ϯ 12 Ϫ26 Ϯ 13 Ϫ32 Ϯ 11 Ϫ43 Ϯ 15 Ϫ40 Ϯ 11 52 Ϯ 10 41 Ϯ 5 51 Ϯ 7 24 Ϯ 5 62 Ϯ 7 35 Ϯ 7 27 Ϯ 7 27 Ϯ 6 69 Ϯ 16 95 Ϯ 16 Obtained anatomic coordinates (mean Ϯ SD [mm]) in a coordinate system with the intercrestal line representing the x-axis and the vertebral column standing for the y-axis. offering direct approaches to the lumbar plexus.0 Ϯ 0. Positive Y values represent structures above the intercrestal line. While the diameters of the psoas muscle on the measured vertebral levels did not differ with regard to the right or left side.16 (D) Chayen. 9). 8) had a significantly higher proximity to the lumbar plexus versus traditional approaches with a wide parabola. Correspondingly. Using the vector PSIS–L3 with a length between 1/6 –1/3 (ϭ 16 –22 mm) of the distance PSIS–L3. Proximity curves of the traditional approaches to the lumbar plexus (in craniocaudal order). the lateral position of the PSIS was found on the left side at 49 Ϯ 9 mm. The vector PSIS–L4 with a length between 1/10 –1/4 (ϭ 7–15 mm) of the distance PSIS–L4 approached the lumbar plexus Ͻ 5 Ϯ 0. Dekrey.14 insinuating perpendicular needle advancement (mean ؎ SEM). the PSIS– based diagonal vectors had significantly closer proximities (fig.528 HELLER ET AL. Pandin correlated better (P Ͻ 0.001) on the left side (3 mm closer). No 3.028) without significant differences in the craniocaudal position. Further. a proximity to the lumbar plexus Ͻ 5. The vectors PSIS–L3 (fig.13 (B) Capdevila. 7) and PSIS–L4 (fig.01– 0. negative values below it. A proximity map of the region mediocranially of the PSIS is given in figure 3. 6).White marks indicate the proximity obtained by original access.4 mm. Sep 2009 Fig. the insertion sites of Pandin.05) results on the right side.12 (C) Winnie. The accesses based on the PSIS landmark by Winnie and Anesthesiology. . and Chayen showed significant side dependence. as opposed to the right side with 54 Ϯ 10 mm (P ϭ 0. X values give the lateral deviation from the center of the vertebral column (median line). Xmin gives the calculated lateral entry position with the closest proximity of the needle tip to the lumbar plexus. 5. (A) Dekrey. on the right side the complete muscle was shifted significantly laterally by 3 Ϯ 5 mm (P Ͻ 0.05). while Dekrey (2 mm closer) and Chayen (3 mm closer) had better (P Ͻ 0. The lateral distance of the insertion site from the center of the vertebral column (x-axis) is given in millimeters or in proportions of the horizontal distance of the posterior superior iliac spine (PSIS) (as originally published). V 111.3 mm was reached.

Regression analysis revealed a loss of muscle diameter by 0. Comparison of the diagonal construction line effect on proximity to the lumbar plexus (mean ؎ 95% CIs) versus the traditional approaches by Dekrey. PSIS ‫ ؍‬posterior superior iliac spine. but with a higher variability in women. Sex differences were found. Dekrey’s.05 versus Capdevila’s approach (paired t tests).14 Chayen. 8. indicating higher psoas diameters by 5 Ϯ 6 mm in men (P ϭ 0. 5 Ϯ 6 mm (P ϭ 0. Anesthesiology.001 versus respective traditional access (paired t test). Sep 2009 Fig. Proximity curves to the lumbar plexus for perpendicular needle advancement for all lengths of vectors (mean ؎ SEM) directed from the posterior superior iliac spine (PSIS) towards the spinous process of L4.IMPROVING PRECISION IN PCB 529 Fig. *** P < 0.15 Capdevila.03) associated with a lateral shifting of the muscles’ lateral margin by Fig.16 Pandin. (A) Vector length given in millimeters. (B) Vector length given in portions of the distance from the PSIS to the L3 spinous process. Discussion Traditional insertion points for lumbar plexus block rely on surface landmarks and lines derived from them Fig. # P < 0. the lower edge of the fifth lumbar vertebral body was found to be 9 mm more caudally in men (women/men Ϫ37 Ϯ 22 mm/Ϫ46 Ϯ 10 mm). in relation to the intercrestal line.14 Chayen.4 mm per year (R2 ϭ 0. Further.13 Winnie. 9.12 *** P < 0.01). Proximity curves to the lumbar plexus for perpendicular needle advancement for all lengths of vectors (mean ؎ SEM) directed from the posterior superior iliac spine (PSIS) towards the spinous process of L3.001 versus Chayen’s. and Winnie’s approaches.16 Pandin. (B) Vector length given in portions of the distance from the PSIS to the L4 spinous process. . A significant (P Ͻ 0. Comparison of the optimization effect on proximity to the lumbar plexus (mean ؎ 95% CI) of traditional approaches by Dekrey. (A) Vector length given in millimeters. Capdevila as well as the diagonal vectors all showed no side dependence.15 and Capdevila. No 3. V 111.001) correlation between age and cross-sectional diameter of the psoas muscle was found. Pandin’s. 7.13 Winnie.12 and the respective optimized accesses.19) in our cohort. 6.

These vectors intersecting the course of the lumbar plexus in an obtuse angle result in wide needle approach curves indicating a minimum effect of variations in the entry point on needle tip proximity to the mean nerve location. Vectors directed from the PSIS to the spinous process of L3 (fig.14 and Chayen15 may not fit to the individual patient and are. This may be because of the fact that both Winnie’s16 and Capdevila’s12 insertion sites are.530 HELLER ET AL. the narrow shape of the curves of the traditional approaches in figure 5 indicates that small variations of the insertion point result in higher distances of the needle from the average location of the nerve. but still places the entry point. 5E).19.16 hypothetically are prone to deviations from the target structure. V 111. 7) and L4 (fig. 3) starts medially and cephalad of the PSIS. 5A) and Chayen’s15 (fig. The significant sex difference in the Y level of the lower edge of the vertebral body of L5 in relation to the intercrestal line (women/ men –37 Ϯ 22 mm/– 46 Ϯ 10 mm) indicates a broader pelvis in women. 4). no sex differences could be shown for either accesses. where the PSIS and the major psoas muscle are located more medially than on the right side. generally located too laterally. Because its position being in general too medial (fig.g.13 Pandin. Figure 3 gives a first assumption of the lumbar plexus course which then inspired the idea of diagonal vectors. the present dataset underestimates the proximity of Winnie’s approach due to the insinuation of perpendicular needle advancement in the two-dimensional model in the frontal plane. and thus will have a higher margin for deviations from the individually best insertion point.25 These observations are in accordance with the present data and may be explained by the notion that the right lower limb of right-handed individuals has a greater role in propulsion.. In the present dataset. we were seeking a meaningful method that creates a line much closer to the axis of the nerve.25 Considering this sex-related variability. prone to deviation from perpendicular needle direction and thus result in too medial advancement. Sep 2009 fixed metric landmarks is supported by the observed side differences in the calculated needle proximity within our dataset when using these metric accesses. considering that pelvic bone may impair perpendicular needle advancement. which may in parts compensate for the craniocaudal variability. indicating a greater lateral sacral mass on the right side. Pandin’s approach14 is closer to the lumbar plexus on the left side. which is usually 4 –12 min. and thus have a narrow margin of error. likewise. the large width of the needle approach curve (fig. 3). By needle advancement off the perpendicular direction as necessary in Winnies approach. which lie nearly perpendicular to the course of the lumbar plexus. on average. However. 5C) and therefore the problem of Winnie’s technique remains: Small medial or lateral deviations in the entry point will result in large deviations from the needle tip from the lumbar plexus.26 Despite a majority of right-handed specimens being assumed in our study. related to the PSIS in the lateral axis. therefore fit better on the right side. 5). Too medial an injection of local anesthetics favors their epidural spread. 5D) approaches.and left-handed specimens were not available. Besides optimizing traditional surface landmarks. PSIS area mapping (fig.13–15 rather than in the PSIS-oriented traditional12. Figures 7 and 8 are depicting new PSISrelated approaches with constructing lines that fulfill these criteria. In this regard. renal or neuraxial puncture. it does not consider the transverse process of L5. where the major psoas muscle and the PSIS are shifted laterally. e. 6 mm lateral to the course of the nerve.16 and diagonal approaches. accesses to the lumbar plexus relying on the intercrestal line12. Dekrey’s13 (fig. The method described by Capdevila12 is the least problematic.16 a high needle tip deviation results from minimal changes of the advancement angle. definite data on the distribution of right.22 An approach that is too caudal for lumbar plexus block14 in addition may fail to block the femoral nerve because of its variable exit off the major psoas muscle. however. Fixed metric surface landmarks as suggested by Parkinson. Side differences in the anatomical shape of the hip have been shown in electromagnetic three-dimensional studies.23 In addition. No 3.27 Access that is too high and too lateral bears the risk of renal puncture.24 The hypothesis of problematic Anesthesiology. as opposed . 3) was the first step in seeking more precise approaches to the lumbar plexus. A–E. Such landmarks prone to deviation may increase patients’ risk by repetitive attempts and prolong block performance time. 8) were taken because of their relatively parallel course with the axis of the lumbar plexus (fig. Best medial or lateral modifications for improving the accuracy of traditional entry points are represented by the respective minima of the curves in figure 5. in addition. even if the approach curve would be slightly shifted medially during medial needle advancement off the perpendicular direction. 4). By contrast. The idea of evaluating diagonal landmark vectors was derived from the PSIS mapping and the derived needle approach groove (fig. However. thus increasing the risk of puncture complications. The current analysis demonstrates that traditional surface landmarks12–16 place the entry points for a lumbar plexus block significantly away from the average location of the course of the lumbar plexus (fig. The PSIS approximation map (fig. and which will allow for larger deviations along the course of that same line without the needle tip ending up to far away from the plexus.12–16 Small deviations in the needle insertion point from medial to lateral will result in large deviations between the needle tip and the actual plexus. They are more in line with the average location of the nerve (fig.

A line between the PSIS and the spinous process of L3 should be drawn (fig. Greger J. V 111. Unis G. 42:80–4 3. 4). Fallaha M: The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Capdevila X. Winnie AP.12. Fixation artifacts in the present setting may not be completely ruled out. Karaca PE. Schroeder DR. Zuurmond WW. using a line drawn between the PSIS and L3 or L4. Leoni A. Capdevila X. Dermksian J. Guay J. likewise. The assumption made in the present model that the lumbar plexus was located at the medial third border of the major psoas muscle was driven by own observations in line with previous literature. 52:989–96 6. 94:1001–6 7. Hebl JR. 4). Lang SA. so that failure of obturator block may occur. References 1. the higher the vertebral level aimed at. Practical implications for block performance derived from this study include identification of the iliac crests. the entry point can be moved further cephalad and medially along the line without deviating too far from the course of the nerve or changing the axis of needle advancement after skin penetration from perpendicular to the skin’s surface in all planes. Fanelli G. if the needle contacts bone. Horlocker TT: Lowerextremity peripheral nerve blockade: Essentials of our current understanding. Heck M. traditional landmarks should be considered to be adapted as reported to bring the needle tip closer to the average course of the lumbar plexus. around 1/5 of the distance of PSIS-spinous process to L3 or to L4. Anesth Analg 2003. Anesth Analg 2005. Aldegheri G. Ouologuem S.24 thus being sufficient for model generation. Laxenaire MC: An evaluation of the cutaneous distribution after obturator nerve block. No 3. Casati A.23. Heck M. Bouaziz H: Postoperative analgesia after total knee replacement: The effect of an obturator nerve block added to the femoral 3-in-1 nerve block.27. Touray ST. 19:591–5 10. Spinous process of L4 will be found 4 Ϯ 13 mm cephalad of the intercrestal line. Yufa M. Enneking FK. where neuraxial spread is less likely. Deschodt J. Thys DM: Peripheral nerve blocks result in superior recovery profile compared with general anesthesia in outpatient knee arthroscopy. Acta Anaesthesiol Scand 1998. Rock MG. Macalou D. The entry point for lumbar plexus block is at 1/5 of the PSIS-L3 distance counted from the PSIS (fig. The lumbar plexus may not shift laterally to the same extent because of fixation of nerve roots within the intervertebral spaces. and the spinous process of L3 40 Ϯ 14 mm. Biboulet P. nevertheless taking 1/5 of the distance from the PSIS to the identified spinous process (actually L4) would. Hadzic A. Vial F. In addition. Lopez S. Ramamurthy S. Durrani Z: The inguinal paravascular technic of lumbar plexus anesthesia: The “3-in-1 block. produce a close proximity (fig. Vloka JD. respectively (table 1). 51: 45–51 8. Improvement of both the proximity of traditional accesses and increasing error tolerance of needle advancement by diagonal landmark vectors was possible within our anatomic model. d’Athis F: Continuous three-in-one block for postoperative pain after lower limb orthopedic surgery: Where do the catheters go? Anesth Analg 2002. Atim A. Virion JM. 94:445–9 9. either with the iliac bone or the sacrum. Kurt E. as described. Cote ´ C.” Anesth Analg 1973. Guzeldemir E: Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy.29 and own regression analysis revealed that major psoas muscle diameter in typical total knee arthroplasty patients can be expected to be 4 mm broader. Pagnano MW. Vial F. “Broadbent’s error” may not reduce the success of reaching the lumbar plexus even when L3 and L4 are mixed up by the anesthetist. Ergin A. insinuating the same problems as the traditionally used landmarks. Can J Anaesth 2004. Trueck S.12. 7). By means of this new vector localization technique. 100:976–81 4. Claudio R. Beighley CM. Perez RS: Psoas compartment . Kaloul I. Clinical use in terms of safety and ease of access. Anesth Analg 2004. Anesthesiology. as indicated by the sex difference in major psoas muscle thickness and lateral extent. Stuart MJ. Torri G: Cardiovascular effects of two different regional anaesthetic techniques for unilateral leg surgery. Chan V. Sep 2009 comparisons between the different techniques are still valid and of relevance. Braun M. Broadening of the major psoas muscle in younger individuals because of the solid vertebral column may merely be achieved laterally. Hobeika P. 30:4–35 2. Thus.related diagonal approaches have a long close course to the lumbar plexus. Bernard N. without having considered artifacts caused by fixation. Vectors in the direction PSIS-L5 and PSIS-L2 were not considered for several reasons: The first one is located almost horizontally. Meuret P. Further. the fact that both PSIS. must be evaluated in a relevant cohort of patients. 97:1003–9 5.7. in the present analysis all techniques for identifying entry points to the lumbar plexus12–16 were challenged within the same model. 8). Berti M. From the studied specimens. Santos AC. Morau D. On the other hand. From the current data all distances on a vector from the PSIS to L5 will produce bony contact throughout. that can be problematic if firm metric distances from the midline are used in determining the entry point. In this regard. Macalou D. Hadzic ´ A. Anesth Analg 2002.IMPROVING PRECISION IN PCB 531 to the traditional approaches (fig. the higher the probability of error. however. this vector intersects the lumbar plexus rather cephalad (fig. Horlocker TT: A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy. Jankowski CJ. PSIS may be found 40 Ϯ 11 mm below the intercrestal line in a lateral distance of 52 Ϯ 14 mm from the midline. Keeping in mind Broadbent’s findings28 that anesthetists frequently fail to identify the intended vertebral level by using the intercrestal line for orientation. Beccaria P. de Leeuw MA. In case of erring by one vertebral level aiming at L3 and reaching L4. Meuret P. and shrinking. The mean age of the cadavers was 10 yr older than patients from recent literature on lumbar plexus block in total knee arthroplasty. using the PSIS-based entry points places the course of the needle to the lumbar plexus. However. Reg Anesth Pain Med 2005. 5). The PSIS-L2 vector may be prone to age-related variations such as lowered height of vertebral bodies or intervertebral discs. as well as individual body size. Jochum D. Bouaziz H. Ozdemiroglu Y. 99:251–4 11. relying on the position of the PSIS eliminates the sex and sided differences. J Clin Anesth 2007.

Shorten GD: In with the new. Legaye J.v. Matziolis G. Nathan H. Reg Anesth Pain Med 2003. d’Hollander AA: Lumbar plexus posterior approach: A catheter placement description using electrical nerve stimulation. and the combination of a continuous femoral and sciatic nerve block. Anesth Analg 1989. Geldner G. Ferrie R. Little WL. 208:21–33 26. Dirkmorfeld LM. opioid analgesia: A prospective study of 63 patients. and clinical evaluation. Choquet O: Le bloc du plexus lombaire est-il ´ valuation et traitment de la doleur. Aveline C. Choquet O. Mitterschiffthaler G. Vandesteene A. Winnie AP. Morin AM. Gaertner E: Continuous lumbar plexus block: Use of radiography to determine catheter tip location. Aida S. Bonnet F: Delayed retroperitoneal haematoma after failed lumbar plexus block. Dinges G. Russell R: Ability of anaesthetists to identify a marked lumbar interspace. Vicent O. Be ´naim C. Kirchmair L. Wulf H: Postoperative analgesia and functional recovery after total-knee replacement: Comparison of a continuous posterior lumbar plexus (psoas compartment) block. Heider E. Durrani Z. Priem K. 101: 750–60 12. Anesth Analg 2005. Pandin PC. Hecquet J. Can J Anaesth 2004. 33:109–14 25. Capdevila X. Dadure C. Ryckwaert Y. out with the old? Comparison of two approaches for psoas compartment block. block for lower extremity surgery: A meta-analysis. Lupescu R. 45:95–9 16. Gawne-Cain M. 2002. a continuous femoral nerve block. Volk T: Continuous psoas and sciatic block after knee arthroplasty: Good effects compared to epidural analgesia or i. Maxwell WB. ANESTHESIOLOGY 1996. 68:243–8 14. Sadeghi H. 95:1428–31 15. 93:589–91 18. Shimoji K: Renal subcapsular hematoma after lumbar plexus block. De Biasi P. technical guidelines. Br J Anaesth 2004. Bailey SL: Extent of blockade with various approaches to the lumbar plexus. and three-dimensional gait analysis of elderly people without impairments. Lirk P. O’Callaghan S. Parkinson SK. Marty C. 94:1606–13 13. 1:11–6 17. Broadbent CR. Kratz CD. Am J Phys Med Rehabil 2004. Mannion S: Epidural spread depends on the approach used for posterior lumbar plexus block. Ramamurthy S. V 111. Eisenhardt G. Colvin J. Wiese AA. Murphy DB. Chayen D. Labelle H: Simultaneous. Anaesthesia 2000. Reg Anesth Pain Med 2004. Edited by SFAR. Reg Anesth Pain Med 2008. Anesth Analg 2002. Reg Anesth Pain Med 2005. Perka C. 78:193–200 Anesthesiology. Heller AR: Misplacement of a psoas com- partment catheter in the subarachnoid space. Acta Orthop 2007. 29: 60–4 23. Macaire P. Wiessner D. 28:135–9 20. Elsevier & dangereux? E SFAR. Pe ´lissier J: Three-dimensional study of pelvic asymmetry on anatomical specimens and its clinical perspectives. Walsh M. Biboulet P. Sep 2009 .532 HELLER ET AL. ANESTHESIOLOGY 1976. Anesth Analg 2002. Mueller JB. Moriggl B: Lumbar plexus and psoas major muscle: Not always as expected. Eberhart LH. J Anat 2006. 83:112–23 27. Br J Anaesth 2008. Lascurain P. Duval-Beaupe `re G. 51:516–7 21. Macaire P. Wilson DJ. pp 37–50 22. Birnbaum J. No 3. Paris. Raimer C. 84:452–5 19. Boulay C. Litz RJ. Mossner A. Radonjic R: Plexus blocks for lower extremity surgery. 30:434–45 24. Schwarz N. Anesthesiol Rev 1974. Tardieu C. Takahashi H. Zabjek KF. Prat-Pradal D. D’Athis F: Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: New landmarks. 55:1122–6 29. Burgun G. Gaertner E. bilateral. Prince F. 101:259–64 28. Chayen M: The psoas compartment block. Mannion S.

however.org or on the masthead page at the beginning of this issue. Conclusions: Volatile agent preconditioning partially protects perirhinal cortex and striatal dependent functions against moderate to severe neonatal hypoxia-ischemia. Submitted for publication January 28. V 111. Ohio.mcauliffe@cchmc. and Sevoflurane Provide Limited Neuroprotection against Neonatal Hypoxia-Ischemia in a Delayed Preconditioning Paradigm John J. M.org. Support was provided solely from institutional and/or departmental sources. Inc. University of Cincinnati College of Medicine. there are no data indicating durable protection after desflurane preconditioning using long-term functional outcomes. Lippincott Williams & Wilkins.D. rotorod. † Assistant Professor. Results: Mice in Groups D. Methods: Institutional Animal Care and Use Committee approval was obtained.. B.. No 3.. D. ‡ Research Assistant. Twenty-four hours later.anesthesiology. Address correspondence to Dr.. 3333 Burnet Avenue.‡ Charles V. McAuliffe: Department of Anesthesia. acoustic startle. Isoflurane has also been shown to improve long-term outcome when used in a delayed preconditioning paradigm in neonatal rats. there may be an advantage to their use for a defined period during the operative procedure. or 3.4% desflurane in 40% oxygen (Group D). isofluorane.3 rat global ischemia using both immediate and delayed preconditioning. 111:533– 46 Copyright © 2009. M. the American Society of Anesthesiologists.D. right com533 Anesthesiology. Ph. The authors used these agents in a delayed preconditioning model to test the hypothesis that they could provide neuroprotection against neonatal hypoxiaischemia as assessed by a battery of behavioral tests. I. C57-129T2 F1 hybrid 9-dayold mice were randomized to 3 h of preconditioning with room air (Group Sham and Group HI). Ph. A total of 140 129T2 ϫ C57 Bl/6 F1 hybrid mice were used for the long-term outcome experiments. Cincinnati Children’s Hospital Medical Center. M.* Lili Miles. Histologic analysis was also performed. Anesthesia and Pediatrics. We tested the hypothesis that the volatile anesthetic agents isoflurane. Received from the Department of Anesthesia. B. john. Cincinnati. and Group Sham had 60 min of sham HI. The effectiveness of isoflurane. tection of the hippocampus. Ischemic periods can occur as a consequence. and S performed better than Group HI and similarly to Group Sham on novel object recognition and apomorphine challenge and better than Group HI but not as well as Group Sham on cued maze testing.. 2009. In all cases. no long-term functional outcomes were evaluated. Histologic sections did not show any significant effect of preconditioning on injury scores. Loepke. reduction in the extent of injury was noted. performance on the spatial memory-dependent phases of the Morris water mazes was not improved. 2009. sevoflurane.§ Background: The volatile anesthetics desflurane.8 Briefly. it was not possible to assess the effectiveness of isoflurane preconditioning on protecting working memory because the hypoxic-ischemic insult was relatively mild.. Pathology and Pediatrics.Anesthesiology 2009.5 and mixed neuron-glial cell culture6 for neuroprotective properties. 8. prepulse inhibition. Cincinnati.1 Improved performance in striatal dependent functions was noted. I. ANESTHESIOLOGY’s articles are made freely accessible to all readers. Cincinnati Children’s Hospital Medical Center. and sevoflurane have been found to produce neuroprotection in various paradigms. McAuliffe. 6 months from the cover date of the issue.B. Sevoflurane has been tested in various models. Cincinnati Children’s Hospital Medical Center and the University of Cincinnati. Specifically. and S mice had 60 min of hypoxia-ischemia. for personal use only.7 Immediate functional outcome and histologic injury score were improved in the desflurane-treated groups in a dose-dependent manner. however.4 rat cerebellar slices. Consequently. has been demonstrated by testing adult mice that were subjected to a moderate to severe hypoxic-ischemic (HI) insult on day 10 of life. 1. Isoflurane. Information on purchasing reprints may be found at www. water mazes. Thirty-five mice from each of four mating pairs were randomized within the pair to one of five treatments..A.‡ Elizabeth Hughes. The groups are shown in table 1. the Group HI.† Bernadin Joseph. the behavioral performance of anesthesia-preconditioned animals that had hypoxia–ischemia on day 10 of life was hypothesized to be (1) no different from sham control animals and (2) better than sham preconditioned animals subjected to 60 min of hypoxia–ischemia on day 10 of life. Materials and Methods Cincinnati Children’s Hospital Medical Center Institutional Animal Care and Use Committee approval was obtained for all procedures involving the use of live animals. Desflurane has been shown to confer neuroprotection in a low-flow bypass model using piglets. § Professor. All mice exposed to hypoxia-ischemia performed worse than Group Sham on the spatially oriented water mazes with no difference among groups.1% sevoflurane (Group S). Inc. If volatile anesthetic agents are able to provide delayed neuroprotection. including open field activity.Sc. and desflurane would confer neuroprotection when used in a delayed preconditioning paradigm 24 h before hypoxia-ischemia in a neonatal mouse model. Vorhees. Sep 2009 .8% isoflurane (Group I). The surgical procedure and hypoxia-ischemia treatment are as described previously. The animals were evaluated as adolescents and adults by using a series of behavioral tests to assess functional outcomes. and the Department of Anesthesia. when used in a delayed preconditioning paradigm in neonatal mice. novel object recognition. including adult mouse focal ischemia.Sc.* Andreas W. A total of 140. there was no pro* Associate Professor. Neurology and Pediatrics. Desflurane.1. Accepted for publication April 22.D. Cincinnati.7 As in the case of sevoflurane.D. Ohio.D.2 However. Ohio 45229-3036. INFANTS undergoing cardiac and other types of surgery are at risk for hemodynamic instability many hours after surgery. and apomorphine challenge. M. Surviving animals had behavioral testing.

and prepulse inhibition on day 4. MA) in 5% horse and 5% goat serum overnight at room temperature. RCCAL ϭ right common carotid artey ligation. TX) using data from previous trials to calculate the means and variance parameters.or 633-nm Helium-Neon laser. rotorod on day 2. Carlsbad. sections were incubated with 1:200 Alexa-fluor 488 conjugated goat antirabbit IgG (Molecular Probes A11034. Sep 2009 activated caspase-3 (Cell Signaling 9661S. Beverly. The mice in this group were anesthetized and transcardially perfused by using heparinized phosphate-buffered saline followed by 4% paraformaldehyde. Molecular Probes A21424. and the 2-week-delayed probe trial and apomorphine challenge during week 6. Whole brain weights were obtained when the brains were removed after perfusion and before postfixation. n ϭ number of animals assigned to each group. Millipore. CA).5 and ␮2 ϭ 13. cued water maze during week 2. and P16 to track early somatic growth. STATA Corporation.8% isoflurane in 40% O2 for 3 h 3. The anesthetic agents were administered in 40% oxygen. Billerica. East Windsor. and 5% sucrose in phosphate-buffered saline. IL) with a 488-nm Argon laser and a 543. Slides were mounted with antifade mounting media. the mice were placed in temperature-controlled chambers with 10% O2 in 90% N2 for 60 min. The computed sample size was 28 per group if data analysis was performed using analysis of variance/covariance. Experimental Groups Group n Preconditioning on P9 Treatment on P10 Sham HI D I S 28 28 28 28 28 Room air for 3 h Room air for 3 h 8. The sample size was determined by using a sample size calculator for means with repeated measures (STATA. hypoxia-ischemia. the correlation between day-to-day measurements was 0.7°C. P14. The inputs into the calculator were a ␮1 ϭ 9. NJ) with CG-8 cartridges as previously described. Table 1. Long-term Effects of Preconditioning The animals assigned to the long-term groups were weighed on days of life or postnatal day (P)9. hypoxia-ischemia.4% desflurane in 40% O2 for 3 h 1. S ϭ sevoflurane preconditioning. The remainder of the behavioral tests began the Monday after P49. reduced water maze during week 4.534 MCAULIFFE ET AL.63. D ϭ desflurane preconditioning. The blood samples for two of the Group S animals did not give results due to cartridge errors. Two hours later. Weights were also obtained on days P50 and at the time of apomorphine challenge (P94). sham hypoxia-ischemia. After wash steps.1% sevoflurane in 40% O2 for 3 h Sham ligation/room RCCAL/10% O2 for RCCAL/10% O2 for RCCAL/10% O2 for RCCAL/10% O2 for air 60 60 60 60 for 60 min min min min min P9 and P10 denote postnatal day 9 and 10. hypoxia-ischemia. Groups: Sham ϭ sham preconditioning. The brains were cryopreserved in 35% sucrose in phosphate-buffered saline 3 h after the completion of the preconditioning period. I ϭ isoflurane preconditioning. Invitrogen) and 1:250 Alexa-fluor 633 conjugated goat antichicken IgG (Molecular Probes A21103. Imaging was acquired by using a Leica TSC SP5 confocal microscope (Leica Microsystems Inc. hypoxia-ischemia. Another cohort of 20 mice (5 per preconditioning protocol) was preconditioned by using the same protocol as the study animals. Preconditioning was performed in incubators set to an ambient temperature of 34. Measurements were made by using the I-Stat blood gas analyzer (Abbott Point of Care. The bandwidth of the photodetectors was set to minimize acquisition of energy emitted by fluors other than the fluor to be acquired by a specific channel. P10. Behavioral testing began on the first Monday after P34. acoustic startle on day 3. the mice were deeply anesthetized. V 111. HI ϭ sham preconditioning. and the heart was exposed and perfused with 4% paraformalde- .1 and ␴1 ϭ 6. Immediate Effects of Preconditioning A separate group of animals (n ϭ 24) were used to measure blood gases and metabolic parameters at the end of the preconditioning period. mon carotid artery ligation was accomplished under isoflurane anesthesia (5 min) using a double ligation and division technique. Cell Signaling Technology. The testing sequence was novel object recognition during week 1. No 3. respectively. College Station. MA) and 1:100 mouse anti-NeuN (Chemicon MAB 377. hidden water maze during week 3.1 Blood samples were obtained from the right common carotid artery directly into heparinized syringes. 15% glycerol. P12. The testing sequence for the first week was locomotor activity on day 1. The tissue was postfixed in the same solution overnight before treatment with increasing concentrations of sucrose in phosphate-buffered saline. 40% oxygen in nitrogen used for carrier gas for anesthetics. After all behavioral tests were completed. Invitrogen. Sequential scanning with line averaging was used to further reduce crosstalk between channels and to enhance signal-noise ratio.3 and ␴2 ϭ 10. The anesthetic concentrations used are equipotent in neonatal mice based on previous studies conducted in our lab. 1:250 Alexa fluor 555 conjugated goat antimouse IgG (highly cross absorbed. Sections (40 ␮m) were cut from dorsal striatum and dorsal hippocampus and were stained by using primary antibodies 1:100 rabbit antiAnesthesiology.. Bannockburn. Invitrogen) for 2 h at room temperature.

the mice were tested for prepulse inhibition response. The acoustic startle response of the mice was tested at 35 days of age. The animals were given a 1 h rest period before the second test trial. time to peak. This effect is prepulse inhibition.8. the velocity increased 1 rotation per minute every 15 s until the animals fell off or the maximum velocity of 20 rotations per minute was reached. No 3.23 The behavioral testing protocols for locomotor activity. After a 5-min acclamation period. Gross motor impairments or poor coordination impair the animal’s ability to remain on a rotating rod as angular velocity is increased. The 2-week delayed probe trial is a test of long-term spatial memory. the locomotor activity test is conducted in a 41 cm ϫ 41 cm acrylic chamber with photo-beams placed a 2. V 111. Behavioral Testing Each behavioral assay is designed to assess the functional state of neural circuits or systems in the brain of the experimental animals. After acclamation trials. San Diego. and interpulse voltages were recorded.22.13–16 The cued water maze assesses visual navigation as well as dorsomedial but not dorsolateral striatal function. hidden maze performance relies on an intact dorsal hippocampus. Rodents will spend more time exploring a nonfamiliar or novel object than a familiar object. The device is equipped with a set of sensors that marks the time the mice fall off the cylinder. unilateral lesions created in the neonatal period are sufficient to produce the effect. Acoustic startle is a reflex that is dependent on an intact cochlear nucleus and caudal pontine reticular nucleus.17 An animal must track to a platform with a visible cue. Anesthesiology.11 Novel object recognition tests the innate ability of a rodent to remember a familiar object. and apomorphine challenge have been previously described.000 data points of 1-ms duration. The maximum voltage. the 2-weekdelayed probe trial. a series of 11 120-dB white noise pulses (20 ms duration) were administered with a random interpulse interval of between 8 and 16 s.18. cued. and basolateral amygdala.10. the mice were placed on the cylinder for 10 s before the first test trial. dorsal hippocampus.20 and entorhinal cortex. CA) consists of a rotating cylinder. Background noise level was set to 70-dB white noise via a speaker placed 24 cm above the acrylic cylinder in which the animal was placed. Intact motor systems are also required for the animals to swim to the platform.24 Briefly. medial prefrontal cortex. Sep 2009 The apomorphine challenge assesses the competence of dopaminergic inputs to motor pathways. Damage to any of these structures can result in a diminished prepulse inhibition response. The mice are allowed to move freely in the chambers for a period of 1h. San Diego Instruments) equipped with a piezoelectric transducer to sense small forces. but the entry point moves with each trial. The test animal must find a submerged platform by using distant visual cues. In adult mice. All acoustic . The initial angular velocity of the cylinder was 1 rotation per minute. The mice were allowed to acclimate to the device for three trials. The platform location is fixed. the angular velocity of the cylinder is controlled by a servomotor driven by a computer. peak amplitude.8. The delivery of all pulses and data recording was controlled by a microcomputer equipped with SR-Lab software. bilateral but not unilateral lesions of dorsal hippocampus21 or bilateral dorsomedial striatal lesions17 result in prolonged hidden maze latencies compared to control (uninjured) animals.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 535 hyde. The rotorod (San Diego Instruments. The day after acoustic startle response. The hidden maze is a test of spatial navigation that uses distant visual clues as reference points. The peak amplitude for each pulse was used as the measure of startle response. Rotorod performance is a measure of motor coordination. The circuitry mediating prepulse inhibition converges on the caudal pontine reticular nucleus and involves the nucleus accumbens. Both the platform location and the entry point are moved with each trial. This test was performed to assess the presence of gross motor abnormalities that could affect the results of other behavioral tests. The chambers were calibrated each day to assure uniformity of output.5-cm interval on both axes. hidden and reduced water maze. Increased locomotor activity results from lesions to the ventral hippocampus. the first value was discarded and the remaining 10 were averaged. A low-intensity acoustic pulse (3–12 dB above background) presented before a startle pulse can reduce the startle response.9 The rotorod test is used to assess cerebellar function and gross motor function. The brains were removed and postfixed in 4% paraformaldehyde overnight and then cryopreserved. as the platform size is one-quarter the size of the hidden maze platform. The integral of time-rotations per minute was used as the measure of rotorod performance. The reduced maze tests the ability of an animal to “unlearn” cues previously learned and learn a new set of cues to a higher degree of precision. In addition to visual acuity. especially in the presence of dopaminergic overstimulation.19 dorsomedial striatum. Performance on tests of novel-object recognition are dependent on the hippocampus for acquisition of object memory12 and on the integrity of the perirhinal cortex for retrieval of those memories. Animals with unilateral damage to these dopaminergic circuits in the striatum and structures projecting to the striatum will circle repeatedly to the side of the lesion in response to the dopamine agonist apomorphine. The response was measured by sampling 1. They were placed in an acrylic cylinder within one of two acoustic chambers (SR-Lab. The rotorod test was performed on the day after locomotor activity testing.

curtains were opened.29 Latency was recorded by hand for the cued maze. (2) no acoustic pulse. Games-Howell otherwise based on Bartlett’s test). Thus. dorsal hippocampus and ventral hippocampus were Nissl stained for examination by a neuropathologist blinded to treatment group. The relationship between the extent of striatal injury and the response to apomorphine challenge was determined by examining the correlation between number of circles made by the animals after apomorphine injection and the striatal area ratio.05 divided equally between two null hypotheses. The use of low-intensity (above background) prepulses has been shown to be a more sensitive way to detect subtle loss of prepulse inhibition compared to use of high-intensity prepulses. The software was used to extract the selected data parameters such as latency to reach the platform. Experiment-wise error ϭ 0. The goal location was marked by a visible cue on the platform. The five acoustic pulse sequences were (1) a 120-dB pulse of 20 ms duration. The animals were tested on the fifth day. The Nissl-stained sections were used to estimate cell loss by comparing the layers and arrangement of neurons in the different regions of the hippocampus. path length. The total chamber time required for a mouse to acquire a total of 30 s of object exploration time was recorded for each phase as well as the time spent exploring the right and left sided objects for both phases of the test. metric for Group I. San Diego Instruments). the critical P value for this comparison was set to keep experiment-wise error at 0. Each mouse was allowed four trials per day for six days. Mice were habituated to the testing chamber for 10 min/d for 4 consecutive days with two identical objects in the test chamber (tinted glass cylinders) on days 3 and 4. mice were placed in one of the locomotor chambers for a period of 10 min to count baseline circling activity. Normally distributed continuous variables were analyzed by using analysis of variance with corrections for multiple post hoc comparisons (Bonferroni if variances equal. and average swim speed. The water maze tests were performed in a tank of 122 cm diameter. whereas the other object was an identical copy of the one used during familiar-object phase. The pulse sequences were randomized by using a 5 ϫ 5 Latin-squares design25 with three repeats of the block. No 3. striatum and cortex of the injured to the noninjured sides. for the familiar-object phase. For the apomorphine challenge. The total number of clockwise circles made by a mouse during a 20-min epoch after apomorphine was tallied. Sep 2009 cue on the platform was removed. metric for Group S. Statistical Analyses All data were analyzed using STATA 10. metric for Group S. pulses were white noise. with the water temperature maintained at 21°C as previously described.. Hypothesis testing proceeded as follows. A positive correlation between prepulse intensity and reduction of startle intensity demonstrates intact prepulse inhibition circuitry. Sections from striatum.05. 1. CA). Histology After all behavioral tests were completed. H01: metric for Group Sham ϭ metric for Group D. and (5) a 20-ms pulse 12 dB above background followed 70 ms later by a 120-dB pulse.) for Mac (Apple Computer Corp. All other testing was performed with automated tracking and data analysis (Smart. the mice were returned to the chamber for the novel-object phase. One hour later. The platform location and entry point were varied according to a preset randomization scheme for the cued phase. with a maximum of 60 s per trial and intertrial interval of 15 s. A 5-cm ϫ 5-cm platform was used for the reduced maze trials.2 mg/kg apomorphine was given intraperitoneally. If the mouse failed to find the goal within the allotted time. mice were placed in the chamber with two identical brown ellipsoidal objects positioned 41 cm apart and 25 cm from the wall and observed until they accumulated a total of 30 s exploring the objects or 5 min of time accumulated. (4) a 20-ms pulse 6 dB above background followed 70 ms later by a 120-dB pulse. metric for Group I.27 The novel object recognition protocol was performed in a circular chamber of 91 cm diameter by using the method of Clark12 with minor modifications.0 (SATA Corp. If Group Sham and Group HI were compared within a behavior. Cupertino. the mice were deeply anesthetized and then perfused transcardially as described in the section immediate effects of preconditioning. Testing consisted of two phases.28 The water was tinted with white tempura paint to obscure the platform. The average of the 15 repetitions of a pulse sequence was used as the response for the sequence. After acquisition of the baseline data. For hidden (and reduced) platform trials.26. (3) a 20-ms pulse 3 dB above background followed 70 ms later by a 120-dB pulse.536 MCAULIFFE ET AL. and H02: metric for Group HI Control ϭ metric for Group D. The locomotor activity data and the water maze data were transformed by using a zero-skew ln transform . and curtains were closed around the maze to reduce distal cues. the values for H01 and H02 were adjusted so that the sum ϭ 1 Ϫ P for Group sham versus Group C. Mice were again allowed to explore the objects until a total of 30 s of exploration of the objects was accumulated or 5 min of time accumulated. it was placed on the platform for a period of 15 s. V 111. The chamber and objects were cleaned with alcohol between trials. A 10-cm ϫ 10-cm platform was used as the goal for cued and hidden platform testing. and the platform remained in a fixed location while entry point varied. The left-side object was replaced with a novel object (clear glass cylinder with marbles inside). The visible Anesthesiology.

23 (0. The highpower view shows that some of the caspase-positive cells are colocalized with NeuN-positive cells.11) 58 (7) 58 (13) 85 (7)*† 63 (7) 4.7)* 1. Very few caspase-positive cells are seen in the overlying retrosplenial cortex (compare to Panel A).3) 6. (D) Low-power view (with high-power inset) of subiculum at level of dorsal hippocampus after 3 h of desflurane exposure. The left edge of the slide is medial. normally distributed with a mean of zero.3 (0. No transformation met all criteria.7 (0.1 (SAS Corp. iCa ϭ ionized calcium.2)* 1. 1. Preconditioning Blood Gas and Metabolic Parameters Group pH Pco2 mmHg BE Kϩ. hypoxia-ischemia. (F) High-power (63؋ oil objective) view of the superficial layers of the primary motor cortex at the level of the dorsal striatum after 3 h of sevoflurane exposure. D ϭ desflurane preconditioning. HI ϭ sham preconditioning.09 (0.26 (0. The first deals with the early effects of preconditioning on the animals.8)* 6. The merged channel shows both the activated caspase-3–positive cells (green) and NeuN-positive cells (red). hypoxia-ischemia. hypoxia-ischemia.7 (0. was set to 0.. Results The Results are presented in two sections: early preconditioning effects and late preconditioning effects.0) 1. Anesthesiology. NC) using the Proc Mixed procedure with group as the fixed effect. No 3. V 111.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 537 before analysis using repeated measures ANOVA to determine significant between-subject variables within a day. Results were accepted only if the data within individual cells were normally distributed and residual analysis proved the residuals to be independent. (C) High-power (63؋ oil objective) view if the cortex overlying CA-1 after 6 h of isoflurane exposure. I ϭ isoflurane preconditioning.3 of the Conover and Iman reference. Activated caspase-3– positive cells are also present in corpus callosum and the fasciola ceruneum.6 (0.18) 1.05) 7. A few caspase-3–positive cells are seen after 3 h of isoflurane in the retrosplenial cortex but far fewer than after 6 h of exposure. indicating this cell is probably an astrocyte or reactive microglial cell in which caspase-3 has been activated. Binary variables were analyzed using chi-square contingency tables. (B) Low-power (10؋ objective) view of the cingulate cortex 6 h of isoflurane exposure. These data were obtained from animals sacrificed either at the end of the preconditioning period Table 2.05.3)* Values are mean Ϯ SD. The somatic weight data were subjected to linear regression to compare rates of growth among groups. on an experiment-wise basis. Novel object and prepulse inhibition data were analyzed by using the Wilcoxon matched-pairs signed rank test with correction for multiple tests.3)* 1. Fig. † value for this group is significantly different from that of Group D. Sep 2009 . There is also evidence of nodular staining along dendritic branches throughout the image. The green cells are activated caspase-3–positive cells in CA-1 and the overlying cortex.26 (0. Cells with an orange to yellow hue are positive for both signals and represent mature neurons that are caspase-positive.07) 1. Caspase-3 activation after volatile agent exposure. mmol/L Sham D I S 6 6 6 4 7. Groups: Sham ϭ sham preconditioning. and these have a morphology suggestive of mature neurons that have degenerated. and an F-statistic was calculated according to equation 5. The apomorphine challenge data were analyzed as both continuous and binary variables. Nonnormally distributed continuous data were analyzed by using the KruskalWallis rank sum comparison with Dunn testing for post hoc comparisons among groups. A dendritic caspase-3–positive cell is seen in detail as well as some other slightly out of the plane of focus.33 (0. K ϭ potassium.21 (0. PCO2 ϭ partial pressure of carbon dioxide.30 The ranks were assigned for each time block. The channel acquiring signal from the Alexa-fluor 488 is shown. BE ϭ base excess. S ϭ sevoflurane preconditioning. In addition.7 (0.03)* 7. Statistical significance. a blood vessel with stained nucleated red blood cells is visible on the righthand side of the inset. 9.1 (0. meq/L iCa. Carey. merged channel.27 (0.7 (1. and the top edge isdorsal. Several activated caspase-3–positive cells are seen.08) 7. Therefore. The findings were corroborated by using repeated measures analysis.08) 4. The cell shown did not colocalize with the NeuN signal in any of the 10 optical planes in the z-stack. Linear regression was used to determine if a significant relationship exists between prepulse intensity and prepulse inhibition.7 (0. repeated measures data (locomotor activity and water mazes) were analyzed by using the rank transformation type 2 method described by Conover and Iman. sham hypoxia-ischemia. (E) Low-power (10؋ objective with 2؋ zoom) view of the retrosplenial cortex and medial portion of CA1 after 3 h of isoflurane exposure. Activated caspase-3–positive cells are seen in the subiculum on the lowpower view. * Value for this group is significantly different from that of Group Sham.08) 1. The cued maze data were also analyzed by using SAS Ver. mmo/L Glucose. hypoxia-ischemia.6)* 6.19 (0. (A) Low-power (10؋ objective) view of the dorsal hippocampus and overlying cortex after 6 h of isoflurane exposure.

‡ Group Sham brain weights significantly greater than Groups HI.9 (2. some of the caspase signal (green) colocalizes with NeuN (red).0905). HI ϭ sham preconditioning.5% isoflurane in 30% oxygen.45 (0. Groups C. P9 (table 3).331 (0. i. Sep 2009 . † Group Sham body weights are significantly greater than mice in Groups HI.47) 5.3) 20.028) 0.31) 5. The Group Sham mice had significantly more rapid growth from P9 to P16. but at two orders of magnitude lesser frequency.2) 21. hypoxiaischemia.39) 5.75) 22. However. and subiculum. sham hypoxia-ischemia. D. hypoxia-ischemia. Caspase is seen in the cell body and nucleus as well as along the dendritic tree. To rule out such injury in the preconditioned mice.57) 5.49) 5. The brain weights of the HI groups (C. (metabolic data) or 3 h later (histology data). I.37 (0. Panels A and B show low-power views of sections from cingulate cortex (A) and retrosplenial cortex and subiculum (B) from P7 mice exposed to 6 h of 1. S ϭ sevoflurane preconditioning. df ϭ 4.538 MCAULIFFE ET AL.71) 6. There were three deaths in each of Groups C.218) or at P94 (K-W chi-square ϭ 1.e. hypoxia-ischemia. D ϭ desflurane preconditioning.26 (0.52) 6. Isoflurane produced caspase-3 activation in the cortex (panel E) and sevoflurane in the corpus callosum (panel F). P ϭ 0.396 (0. The data obtained from the large cohort of mice that completed the long-term study are presented in the section on late preconditioning effects.9) 26.022) 0.3) 0. A high-power (63ϫ oil immersion objective) view of retrosplenial cortex is shown in panel C. hypoxia-ischemia.58) 5.069 using Dunn’s test for post hoc test of H02 with ␣ ϭ 0. the Group D mice showed a trend toward greater brain weight than the Group HI (P ϭ 0.118 – 0.9) 26. The base excess and blood glucose values were significantly lower.761.174 (99% confidence interval 0. S. the body weights did not differ among groups at P50 (Kruskal-Wallis [K-W] chi-square ϭ 5. The cells had the morphologic characteristics of oligodendrocytes. Caspase-3 activation is assumed to be evidence for commitment to cell death or irreversible cell injury. Early Effects of Preconditioning Blood Gas and Metabolic Data. such as hippocampus. retrosplenial cortex.73) 7. Groups: Sham ϭ sham preconditioning. D.62) 6. df ϭ 4.286 – 0.340 (0.6 (3.026) Values are mean (SD). I ϭ isoflurane preconditioning.43 (0. P ϭ postnatal age in days.9) 26.069).24 (0. Anesthesiology.74 (0.209. P ϭ 0.41 (0. No 3. D.001). df ϭ 3.38) 5.244) for the HI mice.4) 26.03 (0.49 (0. V 111. Somatic weights and brain weights are shown in table 3. potassium.6 (2. Only isolated caspase3–positive cells were seen in sham-preconditioned P9 mice (data not shown). The pH of the isofluranetreated mice was significantly lower than the Group Sham mice. df ϭ 4.27 (0.2 (2.4 (2.05 (0. the differences among the groups were not significant.28 (0. I.025). § Group D brain weights trend to greater than Group HI (P ϭ 0.64) 6.05). P ϭ 0.400) versus 0. the linear regression coefficient for growth was 0.82 (0.46) 6. Locomotor Activity.99 (0. Ionized calcium did not differ significantly among the groups.55) 6.53 (0.45 (0.64) 7.4 (3. and S (all P values were Ͻ 0. The isoflurane-preconditioned mice exhibited elevated PCO2 compared to the sham-preconditioned and desflurane-treated mice. Desfluane produced caspase-3 activaTable 3.63) 6. none of the affected cells were also NeuN positive (no colocalization of caspase-3 signal and NeuN signal) in the sevofluranepreconditioned mice.001).34 g/d for the Group Sham mice (99% confidence interval 0.018) 0. P ϭ 0. and sevoflurane-preconditioned mice compared with sham-preconditioned mice. There was no difference among the groups in body weight at the time of entry into the study.9) 21. PCO2. individual comparisons all P values Ͻ 0. Somatic Weights and Brain Weights tion in the subiculum (panel D). and glucose values at the end of the 3-h preconditioning period are shown in table 2 for the 22 mice used to measure the effects of the preconditioning protocol.28 (0..32 (0. Numerous cells exhibit evidence of activated caspase-3 are seen in both sections.2 (2. and D) were all significantly less than those of the Group Sham mice (K-W chi-square ϭ 61. ionized calcium.37) 5.334 (0.877). base excess.63) 5. Representative sections of hippocampus from the mice sacrificed 3 h after preconditioning are shown in figure 1.3) 26.025).0001.38) 5. and potassium concentrations were significantly greater among desflurane-. The total distance traveled by each group of mice during each of the 5-min intervals. I.59) 5. a cohort of preconditioned mice were examined for the presence of activated caspase-3 in vulnerable regions.1 (2.45) 5.03 (0. making up the 1-h observation period was used as the Body Weights (g) at Postnatal Age Group n P9* P10* P12† P14† P16† P50* P94* Brain Weight P94‡§ Sham HI D I S 28 23 27 25 25 5.322 (0.27 (0. and S. isoflurane-. No animals in Group Sham or Group D died.54) 5. Long-term Effects of Preconditioning Mortality and Somatic Growth.001 using Dunn’s test with ␣ ϭ 0. A few caspase-3–positive cells were seen in sections from the preconditioned mice.1 (2. (All P values were Ͻ 0.00 (0. * No significant differences in body weights among groups (P Ͼ 0. and S.62) 5. I.51) 5.45 (0. indicating that mature neurons are affected.478. and S.8) 21.036) 0.46 (0.8 (2.99 (0. The pH. I.60 (0.44. H02 was tested by using K-W test (K-W chi-square ϭ 6.

df ϭ 4.0234 Ϯ 0. In all cases.2 (16) 31. The acoustic startle response and prepulse inhibition data are summarized in table 4. P Յ 0.321 3. ANOVA p is the probability of a difference existing between two of the groups being compared. hypoxia-ischemia. Groups: Sham ϭ sham preconditioning.8 Ϯ 8. There were no differences among groups for distance traveled (F 4. Group Sham had the greatest mean coefficient for the prepulse intensity (a ϭ 0. P Ͻ 0. The Anesthesiology.1 (15) 3. neither H01 nor H02 were rejected). (n) mean ϩ SD Group r-squared Sham HI D I S Statistics Shapiro-Wilk W P (normal) ANOVA F ANOVA P Bartlett’s Test ␹2 P (equal var) value (14) 952 Ϯ 263 (14) 1002 Ϯ 300 (19) 1070 Ϯ 212 (17) 1086 Ϯ 293 (15) 950 Ϯ 339 0. (n) Mean Ϯ SD Regression Equation (1) Slope.6 Ϯ 6. Collectively. P ϭ 0.5 Ϯ 9.8 0.677 0.346 for the second trial).485 (18) 3.127 0.6 (20) 8. hypoxiaischemia. (n) Mean Ϯ SD ϩ3 dB Prepulse. (n) Mean Ϯ SD ϩ6 dB Prepulse.259 ϭ 286.32. I ϭ isoflurane preconditioning. Rotorod. Identical amonggroup comparisons were obtained using the Hollander and the Potthoff distribution-free tests for parallelism of two regression lines.509). I ‫ ؍‬isoflurane preconditioning.8 (15) 16. There were no significant differences among groups for startle response or percentage of startle inhibition at any prepulse intensity.454. hypoxia-ischemia.0292 Ϯ 0.4 (16) 15.365 0.19 0.393. whereas Group S had the smallest (0. respectively after correction for multiple comparisons). sham hypoxia-ischemia.0229 (60) 0.1 (20) 16.0032 SE). the mice exhibited reduction in startle as the prepulse intensity increased.2 5.3 Ϯ 8. whereas the slope for Group HI was not significantly different from Group Sham (t ϭ 1.405 ANOVA F is the F-statistic for the ANOVA table comparing the groups. r2adj ϭ 0. P ϭ 0.7 (20) 29. P ϭ 0. HI ϭ sham preconditioning.389 (18) 37.1 Ϯ 7.523). P ϭ 0.1 0.667 1.0235 (48) 0. sham hypoxia-ischemia.625 0.26 0. hypoxia-ischemia. Groups: Sham ‫؍‬ sham preconditioning. Points that lie above the line of identity favor novel object recognition. .7 0. hypoxia-ischemia.0376 Ϯ 0. P ϭ 0.0001. D ϭ desflurane preconditioning.455 0.2 Ϯ 13. HI ‫ ؍‬sham preconditioning. Novel Object Recognition.31. and S were significantly different from the slope for Group Sham (t ϭ 4.8 Ϯ 7. * Significantly different from Group Sham. V 111. linear regression analysis was performed for each group (table 3). df ϭ 4. P ϭ 0.982.53 0.7 Ϯ 9. P ϭ 0.2 Ϯ 9.418 0. (n) Mean Ϯ SD ϩ12 dB Prepulse.0376 Ϯ 0.298.225 (54) 0.3 (18) 3.0228 Ϯ 0.04. df ϭ 4. hypoxia-ischemia. The metric used for rotorod performance was the integral of time on the device and the speed in revolutions per minute at which it turned.715 0.6 Ϯ 14. There were no significant differences among the groups for either test trial (K-W chi-square ϭ 5. Acoustic Startle and Prepulse Inhibition.46 0. z ϭ 4.0041 SE). In all cases. z ϭ 3.253 after correction for multiple comparisons).003.257 for the first trial.32 There was no difference Fig.4 (18) 12.67 ϭ 1. No 3. Sep 2009 slopes for Groups D.499 (18) 14.456 0.0275 Ϯ 0.763 4.1 Ϯ 6. K-W chi-square ϭ 4.699 1.1 (16) 5.237.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 539 Table 4. hypoxia-ischemia. Acoustic Startle and Prepulse Inhibition Data Summary Percent Startle Inhibition Response Startle.0323* (45) 0. S ‫ ؍‬sevoflurane preconditioning. Similarly.761 0.0275* 0.8 0.0001.0256* (54) 0. D ‫ ؍‬desflurane preconditioning.88. I. Only Group HI is different from the others (fails novel-object recognition) using the Wilcoxon matched-pairs signed-ranks sign test.8 (15) 28.8 Ϯ 13.0228 Ϯ 0. startle inhibition was linearly related to the prepulse intensity (F 1. metric for locomotor activity (data not shown). There was no difference among the groups in the fraction of mice with improved performance on trial 5 compared to trial 1 (Pearson chi-square ϭ 3.5 (18) 29.8 Ϯ 8.5 Ϯ 11.087.8 Ϯ 8.0001. significant correlations existed between fractional inhibition of startle and prepulse intensity (fractional inhibition of startle ϭ a ϫ prepulse intensity ϩ b). The left-side object time during the novel object phase is plotted against the left-side object time during the familiar phase for all groups. 2. the data were distributed normally as assessed by the Shapiro-Wilk W-test (table 4). The data were analyzed by using the rank transformation method (RT-2) of Conover and Iman30 with interval as the repeated block. hypoxia-ischemia.529 3. S ϭ sevoflurane preconditioning.

0045. (D) The distribution of latencies to first platform crossing is shown for all groups. The distribution of latencies is shown for days 1–5 for each group using box plots. There were no differences among Groups HI (H).0195). among the slopes for Groups HI. and S (P ϭ 0. 3. There were no differences among Groups HI (H). Fig. The difference between the familiar-object and novel-object time was significantly different for Groups Sham.027 (all P values Bonferroni corrected for multiple tests) exhibited an increase in the fraction of time spent with the object on the left side of the test chamber when the familiar object was replaced with a novel object. HI ‫ ؍‬sham preconditioning. The time spent exploring the left side object during the novel object phase is plotted against the time spent exploring the left side object during the familiarization phase by group. V 111. The fraction of time spent exploring the left-side object during the familiar-object phase was compared to the same fraction for the novel-object phase using the paired-sample Wilcoxon sign-rank test. (B) Hidden Maze. I (P ϭ 0. and the 25th percentile for Group D is 30 s. respectively) but not for Group HI (P ϭ 0. D. hypoxia-ischemia. All performed significantly worse than Group Sham. D ‫ ؍‬desflurane preconditioning. hypoxia-ischemia. Morris Water Maze Data. (C) Reduced Maze.720).008. The time with the left-side object during the familiar-object phase and the novelobject phase was compared by using the paired Wilcoxon signed-ranks test. and S (H02 not rejected). and S (P ϭ 0. Anesthesiology.005) and Groups D (P ϭ 0. Novel Object Recognition. sham hypoxia-ischemia. I. The group HI mice did not show a significant increase in fraction of time with the left object when the familiar object was replaced with a novel object (P ϭ 0. Sep 2009 . I. No 3. I. Groups D. and S are different from both Group Sham (GS) and Group HI (H). D. D. 0. (A) Cued Maze Data. and S. The distribution of latencies is shown for days 1– 6 for each group using box plots. I ‫ ؍‬isoflurane preconditioning. and S.846) after correction for multiple tests from same data set. Data points above the identity line represent animals that exhibited novel object recognition.0005. hypoxia-ischemia. The median value for Groups I and S is 30 s. and 0. The novel object recognition data are summarized in figure 2. The test is right-truncated at 30 s. Groups: Sham ‫ ؍‬sham preconditioning. Group Sham (P ϭ 0.0015. S ‫؍‬ sevoflurane preconditioning. All performed significantly worse than Group Sham. 0.0035). The line of identity appears in each panel. hypoxia-ischemia. D. The distribution of latencies is shown for days 1–5 for each group using box plots.540 MCAULIFFE ET AL. I. I.

45. 4. Learning can be estimated using the fractional change in latency and fractional change in path length.44. isoflurane-.001 compared to Group HI.01 compared to Group HI. The distributions for the number of clockwise rotations after apomorphine injection are shown for each treatment group in figure 4. All animals exhibited a learning curve during the cued maze testing (fig. the fractional change in path length for the HI mice was 0. the group effect was highly significant (F 4. P Յ 0. the fractional change in latency for all HI mice was 0. V 111. D. HI ‫ ؍‬sham preconditioning. the critical P value for each of these comparisons is P ϭ 0. D ‫ ؍‬desflurane preconditioning.200).01.62. and K-W chi-square ϭ 17.0013. # P < 0. No 3. respectively). and sevoflurane-preconditioned mice all exhibited evidence of impaired spatial learning and memory. 4. Group D for days 3–5.59 (K-W chi-square ϭ 19. This apparent discrepancy is explained by the fact that the swim speed of the Group Sham mice was significantly greater than Group HI for days 2–5. P ϭ 0. as can be seen by examining the distributions of the latency to first platform crossing (fig. . which is the critical value for P Ͻ 0. Apomorphine Challenge. Group I for days 4 –5.0019.14). These data were analyzed by nonparametric methods using Kruskal-Wallis tests with Dunn’s post hoc for multiple comparisons. and 5 of the reduced maze compared to Groups C.32 compared to 0.00). P Ͻ 0. The ranks were then used in a repeated measures ANOVA to calculate the F-statistic according to Conover and Iman. Clockwise rotations after apomorphine results from damage to rightsided striatal structures. Analysis of orthogonal contrasts revealed Groups D. The raw latency data for the hidden maze are shown in figure 3B. There were no significant comparisons among the HI groups. Group Sham had significantly shorter latencies on days 3.33 The SAS Proc Mixed results were similar using rank as the dependent-variable. 9.91. The path lengths were not different for any day among the groups. The Group Sham mice performed better than all other groups on all three mazes during both the acquisition phases and the probe trials (not used in cued maze). Anesthesiology. hypoxia-ischemia. Box’s conservative ␧ ϭ 0. For Groups Sham. Nonparametric analysis was performed by using rank transformation of the data on a day-by-day basis. Neither the latency nor the path length data for the hidden and reduced maze could be transformed with a zero-skew transform to yield normally distributed values. hypoxia-ischemia. and day was insignificant (F 1. and 5 of the hidden maze compared to Groups C.361.0004). The Group Sham mice performed better than all other groups in terms of latency and number of crossings (K-W chi-square ϭ 17.0792). and the data were found to be spherical (Huynh-Feldt ␧ ϭ 0. D. I.22 compared to 0. vs. hypoxia-ischemia.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 541 Morris Water Mazes. 0. and Group S for days 1–5 using Dunn’s test. The within-block correlation was essentially zero among groups as required by Kepner and Robinson for application of the F-statistic to RT type data. and 0. df ϭ 4. and S.22 None of Groups D. P ϭ 0.512 ϭ 29.05 using Dunn’s test). Delayed Probe Trial. I. the median value for number of rotations is zero. as there was a blunted learning curve on the hidden maze among all HI groups compared to the Group Sham mice. I. and S. Group HI. For the hidden maze. df ϭ 4. df ϭ 4. The raw latency data for the reduced maze are shown in figure 3C.10.1.51 for the Group Sham mice (K-W chi-square ϭ 20. hidden. and S.001). Group Sham had significantly shorter latencies and path lengths on days 2. Sep 2009 3D). and S made Fig. Hidden Maze.83.00625).05 compared to Group HI.29.8 The fractional change in latency is (day 1 latency Ϫ the day 5 latency)/day 1 latency. P ϭ 0.0020 for Groups D. I ‫ ؍‬isoflurane preconditioning. I. respectively. ### P < 0. 3A). The desflurane-. This measure partially removes the effect of differences in swim speed among groups. P ϭ 0.30 Group was highly significant (F 4.52.41. The raw data for the cued. Groups: Sham ‫ ؍‬sham preconditioning.0027. ## P < 0. P ϭ 0. and reduced maze acquisition phase testing as well as the delayed probe trial are shown in figure 3.512 ϭ 9. There was no block-treatment interaction using rank (F 5. Reduced Maze. hypoxiaischemia. All groups had difficulty with the delayed probe trial. the difference between Group Sham and all other groups contributed most to the F-statistic. Cued Maze. P ϭ 0. and 9.001). There was no difference among groups in swim speed on day 5 of the hidden maze (K-W chi-square ϭ 8.635 ϭ 0.0006) for the Group Sham mice.969. S ‫؍‬ sevoflurane preconditioning. 4. and S (all differences in mean rank Ͼ 29. 3.127 ϭ 0.123 ϭ 28. Apomorphine Challenge. and S were significantly different from Group HI (F 1.0017. D. sham hypoxia-ischemia. Box plots are presented showing the number of clockwise rotations over 20 min made by animals in each group after apomorphine injection. I.

and S but not compared to Group I (chi-square ϭ 21.001. hypoxia-ischemia.38. 100) 100 (90. ͉͉ Cortex overlying right (ipsilateral) hippocampus. Histology Summary. P ϭ 0. I.51 0. with ties).054 Entries are the median (5th percentile. 0) 100 (0. P Ͻ 0. striatum. respectively. P ϭ 0.0081. 100) DG t 0 (0. V 111. 50) Cortex͉͉# 0 (0. Anesthesiology. One or more of Groups D.139.025 with four groups). 100) 50 (0.01. Sep 2009 The numbers of circles after apomorphine injection were correlated with the day-5 latency on the cued maze (Spearman ␳ ϭ 0. chi-square ϭ 5. # No significant difference in injury scores among groups (Kruskal-Wallis ␹2 for dof ϭ 4 Ͻ 9.79 0.34.63 0. 100) 0 (0. P ϭ 0. Dunn§ 0 (0. Using Dunn’s test. df ϭ 3. and S compared to Group Sham (chi-square ϭ 3.49. I.49). 100) 100 (90. Some sections from individual brains were not usable for analysis. HI ϭ sham preconditioning. Dorsal hippocampus and striatum were examined for evidence of neurogenesis and gliogenesis. § P values for comparison to Group Sham using Kruskal-Wallis (K-W) followed by Dunn test. 1. 60) 0 (0.072 0. I.080. 100) 100 (90. 100) 0 (0. suggesting both reflect the integrity of common striatal circuits. 100) 0 (0. Severe injury to the dorsal hippocampus was defined as a score of 100 or greater for the sum of CA1–3 plus .975 0. chi-square ϭ 6. 100) 100 (90.09.16. 90) 0 (0. respectively. chi-square ϭ 3. 0.581. 95th percentile) injury scores for the group. 100) 100 (90. D.100) 50 (10. P ϭ 4. and S made significantly fewer circles than Group HI (K-W chi-square ϭ 11.61 0.59 0. 0. These groups did not differ from Group Sham in CA1 injury score in ventral hippocampus.03. 95th Percentile) Injury Scores for the Group n CA1* CA2–3* DG† Cortex͉͉# Dorsal hippocampus Group Sham Group HI Group D Group I Group S 6 7 8 7 10 n 0 (0. † Group Sham had significantly less injury than Groups HI and D (PϽ 0. * Group Sham had significantly less injury than all other groups (P Ͻ 0.001). 100) 30 (10. I ϭ isoflurane preconditioning. P-critical ϭ 0. ␣ ϭ 0. P Ͻ 0. 0) 100 (20. 100) 85 (0. 100) 0 (0. dorsal. Dunn test). sham hypoxia-ischemia.22.09 0.2E-06.00625. hypoxia-ischemia. D ϭ desflurane preconditioning.321. 0) 100 (0. 100) K-W. DG ϭ dentate gyrus. 0. 100) 5%. 100) Median 0 (0.001 with continuity correction).025 with 5 groups). and S as well as between Group HI and Groups D. Post hoc power analysis revealed that a total of 50 – 60 mice would be needed to establish significant differences among the groups if the observed pattern is representative of the population. 100) 0 (0. The incidence of circling. 100) 15 (0. 100) 0 (0. The brain injury scores are shown in table 5. P Ͻ 0. 100) Ventral hippocampus Group Sham Group HI Group D Group I Group S 6 7 6 7 8 n Striatum: ratio of ipsilateral/contralateral area Group Sham Group HI Group D Group I Group S 6 5 7 5 9 0. 0) 0 (0.0018.0179. chi-square ϭ 9.021). Dunn test). 0) 100 (80. Histology. df ϭ 3.062.91 0.01. D. hypoxia-ischemia. D.013. A total of 35 brains were analyzed for injury score in cortex. 100) 100 (90.60. whereas the differences between Group HI and Groups I and S were marginally nonsignificant (P ϭ 0. and ventral hippocampus.07. Groups: Sham ϭ sham preconditioning.005. respectively). defined as more than 16 circles in 20 min (mean ϩ 2 SD for Group Sham) was determined and analyzed by using chi-square tables.41.12. 0) 100 (80. df ϭ 4. S ϭ sevoflurane preconditioning.100) 100 (70. Kendall’s ␶-b ϭ 0. Injury Score in Dorsal and Ventral Hippocampus and Striatum Area Ratios Entries are the Median (5th Percentile. I. The injury scores in the ventral hippocampus were lower than in dorsal hippocampus for Groups I and D. and V) without differences in injury score among the HI animals. chi-square ϭ 9. As expected. There was a highly significant difference among groups (K-W chi-square ϭ 22. 0. P ϭ 0.4370. Table 5. 100) 95 (0.74. 100) CA2–3‡ 0 (0. hypoxia-ischemia. and S. significantly more circles than Group Sham (K-W chisquare ϭ 5. Cystic degeneration of the dorsal hippocampus (100% injury) after hypoxia-ischemia on P10 was noted in mice from all HI groups (C. 90) 45 (15. P Ͻ 0. 100) 100 (90. 100) 100 (90. No 3. I. ␣ ϭ 0. P ϭ 0. 0) 100 (80.155 0. Group D made significantly fewer circles than Group HI (P ϭ 0. 95% 0 (0. P Ͻ 0. ‡ Group Sham had significantly less injury than Group D (PϽ 0.40. The incidence of circling was not significantly greater among Groups D. Comparisons were done between Group Sham and Groups HI. given the numbers of sections in table 5. P ϭ 0. with ties).76 0. 100) CA1† 0 (0.100) 100 (70.067. no injury was noted in the Group Sham mice.71. Dunn test). Group HI mice had a significantly higher incidence of circling compared to Groups Sham. so the number per group differed by brain region (see table 5).803.542 MCAULIFFE ET AL. P-critical ϭ 0.0025.98 Reference group 0.002 0.075 and 0.

7 was defined as significant injury. Short periods of hypoglycemia induce immediate preconditioning in myocardium.6 s versus a median day-5 latency of 17.1 suggesting that the 3-h period may have been past optimal. Of 32 animals. a compound that can contribute to preconditioning as well as cell death39 (fig. metallothionein deficient mice do not incur significantly greater behavioral deficits than wild-type mice after perinatal HI.34. No 3.7 was 8. peroxynitrite can activate the c-Jun-N-terminal kinase pathway (JNK) and p38 directly. 14 had a score of 100 or greater. The difference was significant (Mann–Whitney z ϭ Ϫ2.0043).852. Akt activation is associated with cell survival. 39). P ϭ 0.80.0296). respectively. P ϭ 0. Short-duration activation of ERK1/2 is protective.2 thase activity was required for the delayed preconditioning effect of isoflurane using infarct size as a metric.6 s for the nonsevere injury group. Role of peroxynitrite and nitrotyrosine in preconditioning and cell death (after Klotz et al. I. and prolonged activation leads to cell death. The median day-5 latency for this group was 38. Sep 2009 Fig.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 543 dentate gyrus (table 5). Alternatively. Post hoc power analysis indicated that 33 animals per group would be needed to detect a difference between Group D and Group HI (␣ ϭ 0. the median number of circles after apomorphine for the group with area ratio greater than 0. The area ratio for Group Sham is significantly greater than that of Groups D. A striatal area ratio of less than 0. Kawano et al. These effects are not seen in the human neonate. The median number of circles after apomorphine for this group was 36.35 The activation of caspase-3 seen may be the result of hypoglycemia or the effects of prolonged volatile agent exposure. 20 had significant striatal injury by this criterion. The reaction of superoxide (O2*) with inducible nitric oxide synthase (iNOS) formed nitric oxide (NO) to form peroxynitrite (ONOO؊) occurs in the mitochondria. ␤ ϭ 0. this was not true after 2 h of isoflurane preconditioning. these are proapoptotic signaling pathways. The ratio of the area of dorsal striatum on the side ipsilateral to the carotid ligation to the side contralateral to the ligation is shown in table 5 for the five groups.01. This would result in a reversible acidosis and hypoglycemia. and the absolute number of circles was not correlated. The incidence of circling was correlated with the striatal area ratio (Kendall’s ␶-a Ϫ0. Of 34 mice. Electrons (e؊) from the electron transport chain (ETC) can be react with oxygen (O2) in the presence of the nox-2 subunit of nicotinamide adenine dinucleotide phosphate oxide (Nox2) to form superoxide. This suggests that Groups D and HI may be biologically different. the area ratio is not different among the groups that had hypoxia-ischemia on P10 based on the number of brains examined.0192 with continuity correction). More recent evidence suggests that induction of metallothioneins may play a role in anesthesia preconditioning40. suggesting a relationship between hidden maze performance and dorsal hippocampal injury.39 This scheme also provides a rationale for why blockade of iNOS during preconditioning with isoflurane blocked the preconditioning effect. and S and Group C. Previously published studies indicate that severe hypoglycemia will produce caspase-3 activation in brain 3 h after reintroduction of normoglycemia. The brains of mice subjected to the 3-h preconditioning paradigm showed some activation of caspase-3 at 3 h after preconditioning. Discussion The short-term effects of preconditioning in the mice studied include significant metabolic changes.24 The choice of a 3-h preconditioning period versus the 2-h period in the previous study was based on proteomic data obtained after 3 h of desflurane exposure. 5). These intermediates in turn activate Akt (also called phosphorylase kinase B) and extracellular-signal-regulated kinase 1 and 2 (ERK1/2). Peroxynitrite may react with cell surface receptors platelet-derived growth factor receptor (PDGFR) and/or epithelial growth factor receptor (EGFR) to activate phosphoinositide 3-kinase (PI3°K) and/or mitogen-activated protein kinase kinase (MEKK). however. V 111. particularly hypoglycemia and acidosis. We postulate that both are the result of inhibition of the electron transport chain with a subsequent increase in glycolysis for adenosine triphosphate production.36 Zhao and Zuo37 previously found that inducible nitric oxide synAnesthesiology. The same stresses may also participate in the development of preconditioning.41 The 3-h time would allow ample time for the mediators of the . P ϭ 0. Peroxynitrite works both directly and through nitrotyrosine formation to produce its effects.240. two-sided comparison).38 have found that both inducible nitric oxide synthase and nox-2 activity are required for ischemic preconditioning in adult mice. 5.175. This difference is significant (Mann–Whitney z ϭ Ϫ2. Nitric oxide and oxygen free radicals combine to form peroxynitrite. However.

and apomorphine challenge compared with sham-preconditioned animals.3. Additional behavioral tests were used in this study to examine the effects of preconditioning neural circuits not examined in the previously published study. S D. ϭ HI§ Locomotor activity Rotorod Acoustic startle Prepulse inhibition Novel object recognition Cued water maze Hidden water maze Reduced water maze Delayed probe trial Apomorphine challenge Distance Speed-time integral Response Regression slope Left-object time number Latency Latency Latency Latency Number of circles͉͉ Incidence of circling͉͉ D. S D. but not for Group HI. I. The lack of gross motor impairment in any group implicates cognitive impairment as the likely cause of long latencies on the water maze tests. S ϭ sevoflurane. S I D. S I * These tests did not discriminate between sham HI animals (Group Sham) and hypoxia-ischemia control animals (Group HI). Similar results for each group on the acoustic startle response indicates that the startle mechanism is intact and that differences in prepulse inhibition are a result of the function of the inhibition circuitry rather than blunted startle response. I. Ͼ HI‡ Ͻ Sham. No 3. and S) sustained the same degree of injury to the ipsilateral hippocampus. D ϭ desflurane. This provides a second and different assessment of hippocampal function from the Morris water maze. The novel object recognition paradigm was added to test hippocampal and perirhinal-cortical circuits.I or S different from Group Sham.544 MCAULIFFE ET AL.37 and we observed early caspase-3 activation with 3 h of anesthetic exposure. The optimal preconditioning time remains to be determined. In addition.11 The damage to the hippocampus appears to be dominant. S D. improved performance on cued maze performance. The lack of differences among groups in performance metrics for the rotorod test and the acoustic startle response provide important internal controls for analyzing the results of other tests such as the cued maze and Anesthesiology. and therefore. isoflurane. hypoxia-ischemia. ‡ implies that animals performed worse than Group Sham but better than Group HI. Data Analysis Summary By Behavioral Test Volatile Agent Preconditioned Group Falls Into Category Behavioral Test Metric ϭ Sham. hypoxia-ischemia. † implies that animals performed as well as Group Sham and better than Group HI. I. given the results of the apomorphine challenge. ϭ HI * ϭ Sham. I ϭ isoflurane. Table 6. sham hypoxia-ischemia. as protective genes may be activated early. delayed preconditioning effect to be activated.46.48. Groups: Sham ϭ sham preconditioning. I. I. § implies that animals performed worse than Group Sham and equal to Group HI. when used in the delayed preconditioning paradigm before a moderate hypoxic-ischemic insult on P10. Acoustic startle and prepulse inhibition test sensory-motor modulation circuits. The current study extends the results of our previous report showing a durable but selective neuroprotective effect of isoflurane when used in a delayed preconditioning paradigm before moderate-severe neonatal hypoxiaischemia. S D D. and S mice would be expected to have greater dopaminergic input than Group HI on the ipsilateral side. isoflu- . The comparisons of performance after preconditioning with the three agents for all behavioral tests are shown in table 6. relative to Group Sham is a paradoxical result of improved protection of dopaminergic circuits in Groups D. I ϭ isoflurane preconditioning. S I. S D.47 The effect can be influenced by dopaminergic inputs. D. I. ͉͉ None of D.49 The results of this study suggest that reconditioning with desflurane. As in our previously published study with isoflurane. D. isoflurane. and sevoflurane. S D. I. and its projections to the nucleus accumbens and the medial prefrontal cortex42– 44 as well as cholenergic projections from the nucleus basalis magnocellularis.21 This suggests that unilateral injury in the neonatal period has a detrimental effect on the development of the contralateral hippocampus that produces longterm deficits in spatial learning. D ϭ desflurane preconditioning. I. I.45 The data indicate that desflurane. novel object recognition testing. The current data suggest that the optimal preconditioning period is less than 3 h. S D. I. S D. there is no significant difference between the prepulse inhibition slopes of the HI groups (Groups HI. I. The decreased prepulse inhibition response slope noted for Groups D. there was no improvement in spatial reference learning and memory resulting from preconditioning with desflurane. Groups D. Neonatal hippocampal lesions have been found to disrupt prepulse inhibition. only Group D better than Group HI. and S). All HI groups (HI. I. hypoxia-ischemia. Unilateral neonatal hypoxia-ischemia has been shown to produce spatial learning deficits in adult animals equivalent to those seen in animals with bilateral hippocampal lesions made as adults. HI ϭ sham preconditioning. a reduced prepulse inhibition effect. and sevoflurane. which engage the basolateral amygdale. Sep 2009 prepulse inhibition. hypoxia-ischemia. S ϭ sevoflurane preconditioning. and S relative to HI and not the result of more severe injury during preconditioning. Ͼ HI† Ͻ Sham. mice preconditioned with isoflurane (Group I mice) did not exhibit a significantly reduced prepulse inhibition response compared with sham controls. I. V 111. and S.

107:963–70 3. Ohio (current of the Department of Pediatrics. isoflurane-. The authors thank Todd Nick. J Neurosci 2004. Vorhees CV: Adult neurological function following neonatal hypoxia-ischemia in a mouse model of the term neonate: Water maze performance is dependent on separable cognitive and motor components. Masmejean FM. McAuliffe JJ. reduced cell injury in rat cerebellar slices after an in vitro simulated ischemia.24.. Psychopharmacology (Berl) 2001. Kurth CD: Desflurane improves neurologic outcome after low-flow cardiopulmonary bypass in newborn pigs. Department of Anesthesia. and sevoflurane does not alter the process that results in poor spatial learning after unilateral neonatal hypoxia-ischemia. Nieoullon AL. Yeomans JS: Brain stem circuits mediating prepulse inhibition of the startle reflex. Pape M. isoflurane. Guillet BA.to 15-min reduction in HI time for a nonpreconditioned mouse. V 111. and sevoflurane-delayed preconditioning preserves one aspect of murine hippocampal function (novel object recognition) compared to sham preconditioning after neonatal hypoxia-ischemia. Squire LR: Impaired recognition memory in rats after damage to the hippocampus. Kehl F: Sevoflurane-induced preconditioning protects against cerebral ischemic neuronal damage in rats. 97:1521–7 8. and consolidation of object recognition memory. I. 22:2835–42 10. The hypoxic-ischemic insult used in this study may be too severe for any potential protective effect of preconditioning to be seen in the dorsal hippocampus. Schurr A. Division of Epidemiology and Biostatistics. this correlation was also seen in the current study. Hollweck R.. Golden J. Bruder NJ. The model system has been very stable in our hands. 156:216–24 11.2-dichlorohexafluorocyclobutane. Engelhard K. Zhao P. 25:52–61 Conclusions In summary. 1034:147–52 5. Canas PT. 3 h of preconditioning with isoflurane 24 h before unilateral hypoxia-ischemia on P10 improved performance in adult mice on novel object recognition and cued water maze and reduced the number Anesthesiology. Gouin FM. Roewer N. Xu X. and consolidation of object recognition memory. Alternatively.VOLATILE AGENT PRECONDITIONING IN NEONATAL H-I 545 rane. Miles L. Winters BD. Bussey TJ: Transient inactivation of perirhinal cortex disrupts encoding. 105:990–8 7.24 The data presented herein show that novel object recognition is lost after 60 min of neonatal HI. Fendt M. Halim ND. Labrande CN. isoflurane preconditioning has been found to partially protect the hippocampus against milder insults. 156:194–215 12. Cincinnati. retrieval. Zuo Z: Isoflurane preconditioning improves long-term neurologic outcome after hypoxic-ischemic brain injury in neonatal rats. Li L. Performance of novel object recognition is both hippocampal-dependent12 for object memory formation as well as perirhinal cortex-dependent13–16 for object memory retrieval. J Neurosci 2000. 20:8853–60 13. Segal PN. Braff DL: Neural circuit regulation of prepulse inhibition of startle in the rat: Current knowledge and future challenges. Phillips AG: Interaction between perirhinal and medial prefrontal cortex is required for temporal order but not recognition memory for objects in rats. 104:1066–77 2. Jung HH. desflurane. Cincinnati Children’s Hospital Medical Center. Payne RS. 24:4596–604 14. Geyer MA. This conclusion is based on data that were obtained from the same hybrids derived from inbred strains maintained in-house. Weinberger DR: Effects of reversible inactivation of the neonatal ventral hippocampus on behavior in the adult rat. and the reduction in circling after apomorphine challenge as 45 min of neonatal HI are sufficient to produce differences in cued maze performance and circling after apomorphine between sham and HI mice. The improved protection of ipsilateral dopaminergic circuits resulted in a paradoxical decrease in prepulse inhibition response among desflurane. Lipska BK. Cincinnati. isoflurane. Priestley MA. Despite the extensive unilateral injury. Velly LJ. Vorhees CV: Isoflurane-delayed preconditioning reduces immediate mortality and improves striatal function in adult mice after neonatal hypoxia-ischemia. Brain Res 2005. 1152:201–8 6. Brain Res 2007. Bussey TJ: Glutamate receptors in perirhinal cortex mediate encoding. References 1. We estimate the preconditioning effect to be equivalent to a 10.50 The improved performance on novel object recognition testing in Groups D. Pisano PS: Sevoflurane protects rat mixed cerebrocortical neuronal-glial cell cultures against transient oxygen-glucose deprivation: Involvement of glutamate uptake and reactive oxygen species. and sevoflurane preconditioning protect perirhinal cortex relative to sham preconditioning. Ohio. desflurane-. McAuliffe JJ. Little Rock. J Neurosci 2005. J Neurosci 2005. Eberspacher E. Poor performance on day 5 of the hidden maze has been shown previously to be correlated with severe injury to the right (ipsilateral) dorsal hippocampus in our model8. Zuo Z: Pretreatment with volatile anesthetics. Ph. Psychopharmacology (Berl) 2001. No 3. The effect may be greater for the improvement in cued maze performance. Hannesson DK.A. Peng L. Swerdlow NR. ANESTHESIOLOGY 2002. The current data suggest that the pathways involved in novel object recognition do not rely on a bilaterally intact dorsal hippocampus and that desflurane. Zintner S. Previous work in our lab indicates that novel object recognition is preserved after neonatal HI in the absence of preconditioning after 45 min of HI. the effect of preconditioning is equivalent to reducing the HI by about 10-15 min. Kellermann K. of circles after apomorphine compared to sham-preconditioned mice without reducing prepulse inhibition response. 25:4243–51 15. Cincinnati Children’s Hospital Medical Center. Clark RE. for expert assistance in preparing final graphics. Arkansas) for preparation of SAS output for cued water maze data. Akca O. Loepke AW. Li L. Brain Res 2006. retrieval. In slice cultures models. Anesth Analg 2006. Arkansas Children’s Hospital. but not with the nonimmobilizer 1. 103:173–9 4. Sep 2009 . Jin Lee J. Joseph B. Winters BD. ANESTHESIOLOGY 2006.D. There was no protection of spatial learning and memory circuits under the conditions of this study. Wang C. Desflurane and sevoflurane preconditioning also improved performance in adult mice on novel object recognition and cued water maze and reduced the absolute incidence of circling after apomorphine compared to shampreconditioned mice. Sautou-Miranda V. Professor. 1118:208–21 9. Anesth Analg 2007. For this test. Zola SM. They also thank Vicki Bitter. J Neurosci 2002. Applications Specialist. and S occurred despite equally poor performance compared to group HI on the hidden maze. B. and sevoflurane preconditioning prevents the developmental disruption caused by unilateral neonatal HI of the circuits involved in novel object recognition in the contralateral hemisphere. Werner C: The long-term effect of sevoflurane on neuronal cell damage and expression of apoptotic factors after cerebral ischemia and reperfusion in rats. Schultz SE.and sevoflurane-preconditioned mice relative the sham control mice. Hutzler P. ANESTHESIOLOGY 2007. Howland JG. McCann J.

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University of Auckland. F. F. the raw electroencephalogram of propofol patients showed more and faster spindle activity than in desflurane patients (P < 0..N. Dip. we randomized patients to propofol or desflurane-maintained anesthesia and collected raw electroencephalogram from induction of anesthesia until completion of an early postoperative interview....Z.). Perth. broad-band high-frequency activity and lack of sleep spindles). Leslie: Department of Anaesthesia and Pain Management. but dream recall may be associated with more high-frequency activity4 and suppression of ␣ power.Z. and a varying amount of ⌬ (0. when the brain is still affected by sedative concentrations of anesthetic drugs that are sufficient to activate endogenous sleep mechanisms and the patients enter a sleep state.C. Perth. School of Medicine and Pharmacology..B. 17 [7– 86] min. the presence of sleep spindles (waxing and waning oscillations in the ␣ [8 –16 Hz] frequency range). the electroencephalographic patterns associated with anesthetic dreaming are unknown.R.App. M. M.G.. Lippincott Williams & Wilkins.F. University of Auckland.(Hons.A. for personal use only.Z. Royal Perth Hospital. King Edward Memorial Hospital for Women. Australia.C.Sc. the authors quantified the amount of sleep spindle-like activity and high-frequency power in the electroencephalogram. Royal Melbourne Hospital. Department of Pharmacology.A. but this may be due to delayed emergence or more amnesia after longer-acting volatiles. Australia.A. Inc. but bispectral index values at interview were lower (85 [69 –98] vs.B. Results: The incidence of dream recall was similar for propofol (27%) and desflurane (28%) patients.org. REM sleep may be distinguished from the awake state by the presence of low muscle tone. F.. Information on purchasing reprints may be found at www. Address correspondence to Dr. Inc.. K-complexes. Australia. Department of Anaesthesia.14 An alternative explanation is that propofol is associated with more rapid emergence from anesthesia than the older volatile anesthetics. During surgery.. Specifically. M.. Dreaming occurs in both rapid eye movement (REM) and non-REM natural sleep. PATIENTS frequently report that they have been dreaming during anesthesia.Epi. 111:547–55 Copyright © 2009. Victoria.† Michael J.D. Royal Melbourne Hospital. In contrast.N. The authors therefore compared dream recall after propofol. Melbourne.15 allowing patients to report their dreams before they are forgotten. rapid eye movements. B. 6 months from the cover date of the issue.. ‡ Professor of Obstetric Anaesthesia. D. King Edward Memorial Hospital for Women.or desfluranemaintained anesthesia.. Melbourne. Times to interview were similar (median 20 [range 4 –114] vs. Department of Anaesthesia and Pain Medicine.001). V 111.05). the electroencephalogram of REM sleep is very similar to the awake state (i. Department of Anaesthesia and Pain Management. 2009. the American Society of Anesthesiologists. The electroencephalogram of non-REM sleep is characterized by loss of high-frequency electroencephalographic activity. Accepted for publication April 23. 08/005) from the Australian and New Zealand College of Anaesthetists.1–3 If this hypothesis is correct. and Honorary Associate Professor. University of Auckland.Stat. M. § Research Fellow.B.M. Australia. F.9 –12 One explanation is that propofol and volatile anesthetics have different pharmacological effects in the central nervous system. Dreaming and Electroencephalographic Changes during Anesthesia Maintained with Propofol or Desflurane Kate Leslie. Sep 2009 . P < 0. M. Submitted for publication February 25. P ‫؍‬ 0. Ch. The electroencephalographic signs of dreaming during natural sleep are not well described. University of Auckland. Department of Anaesthesia and Pain Medicine. Australia.# Background: Dream recall is reportedly more common after propofol than after volatile anesthesia.D.Anesthesiology 2009. New Zealand. M.G.5– 4 Hz) activity. Melbourne. To investigate these hypotheses further.A..e. the raw electroencephalogram of patients who report dreaming may display characteristics of the raw electroencephalogram of natural sleep. dreaming may actually occur as patients recover from anesthesia..P.C. D.C.. Patients receiving propofol for maintenance of general anesthesia often report higher incidences of dreaming than patients maintained with volatile anesthetics.A. The raw electroencephalogram was recorded from induction until patients were interviewed about dreaming when they became first oriented postoperatively.leslie@mh. 92 [40 –98]. Department of Anaesthesia and Pain Management. No 3.M. we tested the hypotheses that in patients presenting for noncardiac surgery under relaxant general anesthesia (1) propofol maintenance is associated with a higher incidence of dream recall 547 Anesthesiology. However. Royal Melbourne Hospital. Methods: Three hundred patients presenting for noncardiac surgery were randomized to receive propofol.A. Using spectral and ordinal methods.N. * Head of Anaesthesia Research. Department of Pharmacology. kate.* Jamie Sleigh.org or on the masthead page at the beginning of this issue.O.or desflurane-maintained anesthesia and analyzed electroencephalographic patterns in dreamers and nondreamers and in propofol and desflurane patients for similarities to rapid eye movement and non–rapid eye movement sleep. F.‡ Logan Voss.A. B.S. 3050.N.11. The University of Western Australia. School of Medicine and Pharmacology.Sc. Australia. The University of Western Australia. 2009. Victoria.R.13.R. The electroencephalographic signs of dreaming during anesthesia and the differences between propofol and desflurane also are unknown. University of Melbourne.anesthesiology. However. ANESTHESIOLOGY’s articles are made freely accessible to all readers.§ Chiew Woon Lim. and Senior Anaesthetist. ClinicalTrials.N. and ␪ waves.). F.B.A. Visiting Anaesthetist.(Hon. the incidence of dreaming was low (3% overall) because patients were not interviewed until the first postoperative day.D. Waikato.C. M.A.C. Australian Clinical Trials Registry number 012606000279527.5– 8 However. Royal Melbourne Hospital. Supported by a Project Grant (no. Department of Anaesthesia and Pain Medicine. † Professor of Anaesthesia.O. gov identifier NCT00446212. Paech. Received from the Department of Anaesthesia and Pain Management.͉͉ Callum Sleigh. Conclusions: Anesthetic-related dreaming seems to occur just before awakening and is associated with a rapid eye movementlike electroencephalographic pattern.16 compared patients receiving propofol and desflurane (a volatile agent with a more rapid recovery profile) and reported no difference in dream recall between the groups..S..au.1029).0001) in propofol than in desflurane patients. Luginbu ¨ hl et al. Ph.. Department of Anaesthesia and Pain Medicine. University of Melbourne..C. # Research Fellow. ͉͉ Medical Student. Parkville. B. The raw electroencephalogram of dreamers showed fewer spindles and more high-frequency power than in nondreamers in the 5 min before interview (P < 0.Z.A. Australia. Perth.Z. Royal Perth Hospital.

In the desflurane group. and major plexus and neuraxial blockade were prohibited. ketamine. Patients were randomized from a computer-generated list** (block randomized by site). Eligible patients were aged 18 –50 yr. Clinical signs of inadequate anesthesia. Dreaming during anesthesia was defined as any experience that was described by the patient as dreaming and was thought by the patient to have occurred between induction of anesthesia and emergence after anesthesia. dreaming was reported on emergence in 36% of propofol patients and 20% of desflurane patients. or intellectual disability. We therefore planned to recruit 300 patients in total. 3 ϭ almost every morning) and risk factors for awareness. Patients were interviewed as soon as they became oriented to time. Patients with inadequate English comprehension due to a language barrier. At the conclusion of surgery. both with specific patient consent and using research software provided by Aspect Medical Systems (once-per-minute recordings.05). desflurane admin** Available at www. With 300 patients. 12 min. a bispectral index (BIS) sensor (BIS-XP. Anesthesia was induced with 1–2 ␮g/kg fentanyl. MA) was applied to the forehead of all patients. patients were taken to the postanesthesia care unit (PACU). and lacrimation) were recorded. istration commenced after induction with propofol. or taking a benzodiazepine or more than two standard alcoholic drinks on the evening before surgery were excluded. a target-controlled infusion device was used to target desired plasma propofol concentrations. and a muscle relaxant and was maintained with the randomized maintenance agent. and BIS data were downloaded from the monitor at the end of each case. 2006. Perth. Royal Perth Hospital. place. Materials and Methods This randomized. The signal was then bandpass filtered between 1 and 41 Hz by using a ninth order Butterworth filter. and randomization results were concealed until after consent was obtained. including a past history of awareness. a narrative report was collected. Australia. Data Collection Baseline data included demographic and surgical details. paracetamol. Sep 2009 . 1 ϭ less than once a week. place. 20%. After skin preparation. psychotic disorders. Morphine. tramadol. hypertension. propofol. SD ϭ 6 min. and person. In the propofol group. and (3) the raw electroencephalogram distinguishes patients receiving propofol and desflurane. Norwood. including movement and autonomic signs (tachycardia. Intravenous access and routine monitoring were established. after reversal of neuromuscular blockade and tracheal extubation. (2) the raw electroencephalogram distinguishes patients who report dreaming from those who do not. whether or not they could remember the narrative of the dream. Melbourne. midazolam. Electroencephalographic Analysis The raw electroencephalographic signal was digitized at 128/s and 14-bit resolution.com. nitrous oxide. Anesthesia was titrated to BIS 40 –55 during maintenance. Hamilton. but other opioids. In our previous study. Perth. Times to eye opening. than desflurane maintenance. and electroencephalographic recording commenced. cognitive deficit. the power to detect a 2-min difference between the two groups in the secondary endpoint of time to eye opening was 80% (14 min vs. Raw electroencephalographic data were collected in real time. major affective disorders. and/or a 5-hydroxytryptamine3 receptor blocker were allowed. peripheral nerve blocks. heavy alcohol or sedative drug use and anticipated difficult intubation. If dreaming was reported. We used the following standard questionnaire. sweating. Patients were blind to group allocation. All patients who reported dreaming were considered to be dreamers for the purpose of the analyses. nonsteroidal antiinflammatory drugs. Aspect Medical Systems Inc. We hypothesized that recalled dreams would occur close to the time Anesthesiology. and to eligibility for PACU discharge (Aldrete score Ն 918) commenced at time of completion of wound closure. recordings with signal quality below 50 were removed from the analysis). dexamethasone. Segments with a maximum amplitude greater than 200 ␮V were rejected as artifacts.randomization. double-blind controlled trial received prospective ethics committee approval at the Royal Melbourne Hospital. New Zealand. and were scheduled for elective noncardiac surgery under relaxant general anesthesia. home dreaming recall frequency (0 ϭ never. or major drug abuse. Australia. Anesthesia duration was defined as the time from induction of anesthesia to the completion of wound closure. No 3. King Edward Hospital for Women. Australia. were American Society of Anesthesiologists’ physical status I–III. n1 ϭ n2 ϭ 150). and person. and Waikato Hospital. to orientation to time. Written informed consent was obtained from all recruited patients. Interviewers were blind to group allocation and electroencephalographic data. The primary endpoint was the incidence of dreaming reported on emergence from general anesthesia. accessed July 7. smoothing ϭ 15 s for BIS data.17 What was the last thing you remember before going to sleep? What was the first thing you remember when you woke up? Can you recall anything between? Did you have any dreams during your anesthetic? Electroencephalographic recording continued until after the interview was complete. local anesthetic infiltration.1 A sample size of 270 patients (135 patients per group) provides 80% power to detect this difference (36% vs. V 111.548 LESLIE ET AL. ␣ ϭ 0. 2 ϭ several times a week.

The power spectrum is calculated as described in the text. we tried various combinations of different settings for the spindle method (longer spindle sequences [up to 11 peaks and troughs] and different noise thresholds). . We therefore used the ordinal method of analysis to complement (and check) the power spectral methods. The output from this method is the percentage of sampled data points that could be associated with a short ( ⁄ ‫ گ‬⁄ ‫ گ‬⁄ .2 were all included in multivariate logistic regression models. The Mathworks Inc. Sep 2009 .82 Hz. the electroencephalographic spectrum could be described 10 9 8 Log Power 7 6 Intercept = 7. and (4) a sequence of times (Ϫ1 min. Illustration of the method of obtaining parameters from the electrocephalographic power spectrum. up to Ϫ20 min) before the dream interview.02 Hz. Survival data (time to an event) were assessed by using log-rank tests. It applies the Welch method to obtain averaged periodograms (by using a tapered Hamming window of length 64. A major problem with the use of Fourier methods of analysis for nonsinusoidal signals like the electroencephalogram is the presence of harmonics. Statistical Analyses Continuous variables were graphed to assess their distribution. Inter- Fig. The electroencephalographic waveforms were characterized in two different ways: spectral and ordinal.36 Hz). Specifically. but we found no improvement in discriminatory power. No 3. Bispectral analysis is suitable for detection and quantification of higher harmonics and is used in the BIS algorithm for this purpose. This method is useful in the detection of oscillatory spindle-like activity in the electroencephalogram. The regression line describes the underlying broad band activity. and the spindle amplitude (the distance between the ␣ peak and regression line underneath [the length of the vertical dotted line in fig. We used this function because it is the standard nonparametric method. and it makes no assumptions about system linearity or noise inputs. it could be generated by the second harmonic of a more angularly shaped 8-Hz oscillation. 50% overlap.0. The strength of narrow-band oscillations was quantified by finding the peaks in the ␣ and ⌬ wavebands (fig. This method makes no assumptions about the shape or size of the peaks and troughs (as long as they are greater than a preset minimum threshold amplitude). After taking the natural logarithm of the spectral density. (2) completion of wound closure. 1]).72 5 Slope = − 0. To do this. (3) eye opening. Ϫ2 min. and the narrow-band oscillations by the height and frequency of the ␣ and ⌬ peaks. 1). 12. Anesthesiology.12 4 3 2 0 10 20 30 Frequency (Hz) 40 Power Spectrum Regression line Delta peak Alpha peak by seven parameters: the broadband activity by the regression line slope and intercept. and it is fitted to the power at frequencies (5–7 and 17–35 Hz). Predictors of dreaming from univariate analyses with P values less than 0. MA). 1. alternatively. V 111.7. . During the course of the analysis. ␪ oscillations did not interfere with this process. Natick.DREAMING AND THE ELECTROENCEPHALOGRAM 549 of awakening. 16. Another solution is to use an ordinal analysis that simply detects a sequence of peaks and troughs at the prescribed wavelength/“frequency” in the electroencephalographic signal. 2peak-2trough) electroencephalographic pattern at the specific frequencies (10. The power spectral density of the electroencephalographic segment was estimated by using the absolute value of the complex number that is output from the ‘psd. Normally distributed variables were described by using mean and SD and compared using two-tailed Student t tests. we concentrated the analysis on this period. therefore. To minimize the biasing effect of a few outliers. Categorical variables were described by using number (%) and compared by using chi-square or Fisher exact test. In our case. Thus. we used the frequencies that avoided the ⌬ (1– 4 Hz) and ␣ (8 –16 Hz) oscillations – namely the 5–7 Hz and 17–35 Hz ranges. Backwards elimination was used to eliminate nonsignificant predictors and to create parsimonious models. For example. the power spectrum of REM sleep would be expected to show no ␣ or ⌬ oscillations and a flat gradient for the background activity. and 21. We attempted to develop a succinct description of the electroencephalographic power spectrum by using only a few parameters. Skewed variables were described by using median and range and compared by using Wilcoxon rank sum test. this background activity was quantified by fitting a linear regression to the subset of frequencies in which there were no prominent oscillatory peaks. the electroencephalographic parameters are presented as median (interquartile range). it is necessary to separate the narrow-band oscillations in the electroencephalographic signal from the underlying broadband irregular activity. Ϫ3 min . the spectral power at 16 Hz could reflect a pure 16 Hz sinewave oscillation. The power spectrum of natural non-REM sleep would be expected to show strong narrowband oscillations in the ␣ or ⌬ bands and a steep slope for the regression fit to the background activity.68 Hz. we analyzed 30-s segments of the electroencephalogram at the following time points: (1) the middle of the operation.m’ Matlab function (Matlab 7. and 1-Hz frequency resolution). Conversely.

Sep 2009 . actions were tested (none significant – not shown).03). Some patients had more than one risk factor.97 0. 24%. Electroencephalographic Results: Dreamers versus Nondreamers Suitable raw electroencephalographic data were obtained from only 150 patients due to difficulty in down- Results are presented as mean Ϯ standard deviation or number (percent).0) 15 (10) 8 (5) 9 (45) 94 (27–320) 9 (1–80) 17 (7–86) 73 (12–213) 8 (0–57) 43 (29) 39 (91) 150 (50–700) 10 (3–30) 4. Results of these analyses are presented as adjusted odds ratios (OR) and 95% confidence intervals (CI). No patients reported awareness during anesthesia. P ϭ 0.01. and propofol patients had lower BIS values at eye opening and at the postoperative interview (table 3).0001 0.2 (Stata Corporation. work. 58% female at Royal Melbourne Hospital. V 111. P ϭ 0.07). Patients reported simple dreams about family.69 * Autonomics signs ϭ tachycardia. ASA ϭ American Society of Anesthesiologists.47 0.82 — — Ͻ 0. College Station.7. The range of BIS values during anesthesia was greater in propofol patients. PACU ϭ postanesthesia care unit. There was unequal gender distribution between the sites (100% female at King Edward Memorial Hospital for Women.0.45. hypertension. Results A total of 330 patients consented to participation.035). min Time from wound closure to eyes open. Table 1.001).8 (3. heavy alcohol intake or chronic opioid use. min Dream reported Narrative reported by patients reporting a dream Results are presented as median (range) or number (percent). 95% female at Table 2. and 300 were randomized.96.89.36 Ͻ 0. 95% CI 1. Some patients had more than one risk factor. P ϭ 0.5–8.550 LESLIE ET AL. and there were no dreams that were suggestive of intraoperative memory formation.47) or recovery (0% [0 –13%] vs. lacrimation and sweating. Dreaming patients had higher home dream recall (table 4) and higher BIS values at interview (table 5).53–5. anesthesia duration of no more than 100 min (OR 1.05–3.93. No 3. 0% [0 –7%]. and 58% female at Royal Perth Hospital).0) — 46 (31) 12 (8) 37 (68) 97 (25–467) 10 (0–52) 20 (4–114) 69 (10–157) 10 (0–100) 40 (27) 35 (88) 0. Intraoperative and Postoperative Characteristics of Patients Randomized to Propofol or Desflurane Characteristic Desflurane (n ϭ 150) Propofol (n ϭ 150) P Value Fentanyl dose. and BIS greater than 90 at interview (OR 1. Dreaming Results: Propofol versus Desflurane Dreaming was reported on emergence by 27% of propofol patients and 28% of desflurane patients. Anesthesiology. Thirty-five percent of gynecological surgery patients compared with 20% of other surgery patients recalled dreaming (P ϭ 0. The only significant multivariate predictors of dreaming were dream recall greater than 1 per week (OR 3.70 0. friends. P Ͻ 0. 95% CI 1. Statistical analyses were performed using Stata 8. P ϭ 0.10 0. Baseline Characteristics of Patients Randomized to Propofol or Desflurane Characteristic Desflurane (n ϭ 150) Propofol (n ϭ 150) Age. ␮g Morphine dose. min Time from wound closure to PACU discharge.20). * History of awareness.60. Patients randomized to propofol maintenance received higher total fentanyl doses and were more likely to move during anesthesia than patients randomized to desflurane (table 2). mg (n ϭ 117) Propofol target. predicted difficult intubation.07–3. P ϭ 0.05 was accepted as statistically significant. Patients were similar at baseline (table 1). TX) and Matlab 7. 100 (50–700) 10 (3–40) — 5.5 (2.0001 0.16 0. min Time from eyes open to orientation.1–9. Thirty consenting patients were not randomized because their surgery was cancelled or rescheduled or because the anesthetic plan changed. 23%. P ϭ 0. Loss of BIS data because of signal quality less than 50 was not different between the propofol and desflurane groups during maintenance (1% [interquartile range 0 –3%] vs. ␮g/ml Desflurane concentration. yrs Sex. female ASA physical status I II III Home dream recall Ͻ 1 per week Ͼ 1 per week Almost every day At risk of awareness* Operation type Gynecology General Other 36 Ϯ 9 102 (68) 69 (46) 75 (50) 6 (4) 59 (39) 62 (41) 29 (20) 16 (11) 35 (23) 65 (44) 50 (33) 36 Ϯ 9 102 (68) 74 (49) 67 (45) 9 (6) 52 (34) 72 (48) 26 (18) 12 (8) 35 (23) 67 (45) 48 (32) Waikato. and 38%.08). but there were no statistically significant differences in the incidence of dreaming (38%. % Signs suggestive of awareness* Autonomic signs Movement Duration of anesthesia. min Time from wound closure to orientation. 95% CI 1. and recreation.03 0.04 0. 0% [0 – 4%]. respectively.

sleep. % BIS Ͻ 40 during maintenance.8 to 4.70 0.88 — — 0. the black mesh surface lies on top of the colored surface in this part of the figure).0007 Ͻ 0.10 0.09 0.1) ␮V for dreamers versus 4. and sweating. Characteristics of Nondreamers and Dreamers Characteristic Nondreamers (n ϭ 217) Dreamers (n ϭ 83) P Value Median maintenance BIS Minimum maintenance BIS Maximum maintenance BIS Range of maintenance BIS values BIS Ͼ 60 during maintenance. During surgery. Some patients had more than one risk factor.e. We have not reported most of this work because the best discriminatory parameters were simple: the spectral power in the high frequencies (greater than 20 Hz) and the relative amount of spindle activity.5–8. or chronic opioid use. mg Propofol target. and the log spectral power at 30 Hz was 4. when the electroencephalograms of dreamers showed more high-frequency (30 Hz) spectral power and fewer low-frequency (10. median (range). nondreamers and propofol vs. desflurane) could be linked to the underlying neurobiology of anesthesia.9–9. Conversely. Bispectral Index (BIS) Values in Patients Randomized to Propofol and Desflurane Characteristic Desflurane (n ϭ 150) Propofol (n ϭ 150) P Value Table 4. We undertook extensive analysis to characterize the raw electroencephalographic waveforms so that any putative parameter found to discriminate between the groups (dreamers vs.937). predicted difficult intubation. and dream recall was 32% versus 23% (P ϭ 0. except that at wound closure the electroencephalographic slope parameter was less for dreamers than for nondreamers.0) 5.062). 3). An 10-Hz spindle peak was lost as the patients approached the interview time. The differences in electroencephalographic parameters between the patients who reported dreams (n ϭ 34) and those who did not (n ϭ 116) were small. or number (percent).4 (3. minimum and maximum BIS values. ASA ϭ American Society of Anesthesiologists.018 0.1–7. min Time from wound closure to orientation. loading raw electroencephalographic data and in achieving adequate signal quality in the other patients. and dreaming. Sep 2009 Age.45 0. pronounced in the dreamers than in the nondreamers (i. More significant differences were observed just before the interview. ␮g Morphine dose.0001 0. Patients without raw electroencephalographic data were similar to patients with raw electroencephalographic data: mean age was 35 Ϯ 9 versus 37 Ϯ 9 yr (P ϭ 0. female ASA physical status I II III Home dream recall Ͻ 1 per week Ͼ 1 per week Almost every day At risk of awareness* Operation type Gynecology General Other Propofol group Fentanyl dose.8 (3. 68% of patients were female in both groups (P ϭ 0.0 0. % BIS 40–60 during maintenance.0001 Median. A graphical demonstration of the mean changes in spectral power during the 20 min preceding the interview is shown in figure 2. there were no significant differences between dreamers and nondreamers. V 111. % Signs suggestive of awareness† Autonomic responses Movement Duration of anesthesia.22 0.5–7. 4). min Time from wound closure to PACU discharge.8 (4.0) 43 (20) 18 (22) 13 (6) 33 (15) 100 (25–467) 10 (0–49) 19 (4–114) 73 (10–213) 9 (0–100) 7 (8) 13 (16) 88 (28–320) 9 (2–80) 18 (6–86) 66 (12–185) 8 (1–40) Results are presented as mean Ϯ standard deviation.047).9) ␮V for nondreamers (P ϭ 0.18 0. Some patients had more than one risk factor. † Autonomics signs ϭ tachycardia.55 0.68 Hz) spindles (a REM-like pattern) than the nondreamers (fig.2 to 5. but the loss was more Anesthesiology.02 0.40 0.118 0. range) were calculated for each patient. min Time from eyes open to orientation.037).92 0. Dreamers and nondreamers are represented by the colored and black mesh surfaces respectively.01 0.44 — — Ͻ 0. hypertension. Electroencephalographic Results: Propofol versus Desflurane Propofol resulted in a more marked oscillatory peak in the frequency band 8 –16 Hz (which corresponds to sleep spindle-like patterns) than desflurane (fig. No 3. * History of awareness. There were no differences with respect to faster spindle oscillations. and the difference between the minimum and maximum BIS value (i.66 0.e.55 1. lacrimation. American Society of Anesthesiologists status was 2–3 in 46% and 68% of patients (P ϭ 0.15 0.12 0. a more gentle . These two parameters are easily linked to REM and nonREM electroencephalographic patterns. % BIS at wound closure BIS at eye opening BIS at interview 40 Ϯ 6 27 Ϯ 8 55 Ϯ 11 26 (8–79) 0 (0–47) 62 (0–100) 37 (0–100) 44 (25–96) 80 (29–98) 92 (40–98) 38 Ϯ 6 25 Ϯ 5 58 Ϯ 10 32 (11–68) 0 (0–25) 51 (0–100) 45 (0–100) 46 (22–86) 75 (34–97) 85 (69–98) 0.50 0. high-frequency power was greater in the dreamers than the nondreamers close to the interview time. yrs Sex.. Results are presented as mean Ϯ standard deviation or median (range).DREAMING AND THE ELECTROENCEPHALOGRAM 551 Table 3.8 (3. min Time from wound closure to eyes open.5 (2.0) 5. and then summarized within the desflurane and propofol groups. min 36 Ϯ 9 147 (68) 102 (47) 102 (47) 13 (6) 96 (44) 85 (39) 36 (17) 22 (10) 35 Ϯ 8 57 (69) 41 (49) 40 (48) 2 (2) 15 (18) 49 (59) 19 (23) 6 (7) 0. heavy alcohol intake.54 45 (20) 25 (30) 99 (46) 33 (40) 73 (34) 25 (30) 110 (51) 40 (48) 100 (50–700) 137 (50–550) 10 (3–40) 10 (2–30) 4.23 0.0004 0.44 — — 0. ␮g/ml Desflurane concentration.0) 4.5 (2. PACU ϭ postanesthesia care unit.09) (table 6).72 0.

62 0. and (3) more spindle-like waves during maintenance of anesthesia with propofol than with desflurane. range) were calculated for each patient.96) 3. and then summarized within the non-dreamer and dreamer groups.69 to 1.37 0. Our finding of similar incidences of dream recall in patients randomized to propofol or desflurane is consistent with our hypothesis that the patients in the enflurane or isoflurane arm of previous randomized trials may have emerged more slowly from anesthesia and consequently had difficulty remembering any dreams.87 to 11.1) 10.21) 1.82 Hz spindle 16.79 to 10.68 Hz spindle 12. (2) more signs of cortical activation (more high-frequency power.0002).85 0.12 (2.64 (9.20 (5.02 Hz spindle 21.552 LESLIE ET AL.75) 3.18 0. 0. underlying slope. sustained awakening or increased electromyographic activity are unlikely to be the cause of the activated electroencephalogram in our patients who reported dreaming.91 to 1.8 (4.75 0.22) 10.18 (9.68) 9. However.09 0. and the difference between the minimum and maximum BIS value (i. At eye opening. However.9) 10.34) 1.87 Results are presented as median (interquartile range).36 0.51) 11 Hz 2 Hz 0. showing that propofol was associated with increased spindle activity. V 111. % BIS Ͻ 40 during maintenance. Results are presented as mean Ϯ standard deviation or median (range). and larger and faster spindle frequency oscillations than the desflurane electroencephalogram (table 7).18 (Ϫ0. Table 5.07 to 10.86 (1. Anesthesiology.18 to 0. both dreamers and nondream- Median maintenance BIS Minimum maintenance BIS Maximum maintenance BIS Range of maintenance BIS values BIS Ͼ 60 during maintenance.05) 4.72 (9. Bispectral Index (BIS) Values in Nondreamers and Dreamers Characteristic Nondreamers (n ϭ 217) Dreamers (n ϭ 83) P Value Discussion This study found (1) no difference in dream recall between the propofol and desflurane groups.20) 10.78 to 10.15 0. The spindle units are the percentage of electroencephalographic data points that could be associated with a spindle sequence. fewer spindles.53) 9.78 to 1.66] log ␮V.9 –12 Luginbu ¨ hl et al.43 0.15 to Ϫ0. there were no significant differences between the groups.72 0. except that the peak frequency from the spectral analysis was 12 Hz for propofol patients and 9 Hz for desflurane patients (P Ͻ 0.32 (0.33 0.33 to 13.36 Hz spindle Peak frequency of spindle Peak frequency of ⌬ Ϫ0.1 Our finding contrasts with our previous cohort study in which the incidence of dreaming was significantly higher in propofol patients than desflurane patients (36% vs. minimum and maximum BIS values.89) 1.08 to 10.73 0.96 [0. Sep 2009 .46 to 2. The apparent electroencephalographic activation in dreamers could be caused by awakening (responsiveness to external stimuli).27) 4. Raw Electroencephalographic Parameters in Dreamers and Nondreamers Parameter Nondreamers (n ϭ 75) Dreamers (n ϭ 75) P Value Wound closure Slope Intercept ␣ Peak Spindle amplitude ⌬ Peak Log spectral power at 30 Hz Mid-surgery 10.46) 6.62 0.47 (9.99 to 1. P ϭ 0. % BIS 40–60 during maintenance.78) 10. a lower intercept.49 [0.71) 10. There were no differences in the high-frequency components of the electroencephalogram.93 0.85 to 11.2 to 5. their overall incidence of dreaming was low because they did not interview patients immediately upon emergence from anesthesia. or artifact from frontalis electromyographic activity.0001) and the spindle amplitude for propofol was greater than for desflurane (1. These three states are difficult to separate on the basis of electroencephalographic analysis because of the fluctuating levels of alertness and stimulation during emergence from anesthesia.44) 7. Desflurane patients had fewer spindle oscillations and more ⌬ power.69] vs.71 to 4.002 Median. The ordinal analysis of electroencephalographic segments from the middle of surgery provided similar results. REM-like dreaming (internal cognitive activity that is disconnected from external stimuli and associated with reduced responsiveness). particularly in the 10 –12 Hz range (table 7).79 (9. This difference may be attributable to selection bias in the previous study.64 (1. Table 6.29 (0.03 0. % BIS at wound closure BIS at eye opening BIS at interview 39 Ϯ 6 26 Ϯ 7 57 Ϯ 10 30 (3–79) 0 (0–47) 42 (0–100) 56 (0–100) 44 (22–86) 77 (29–98) 88 (40–98) 38 Ϯ 6 25 Ϯ 6 55 Ϯ 10 28 (10–68) 0 (0–10) 42 (0–100) 46 (0–100) 46 (23–96) 77 (35–97) 91 (69–98) 0.52 (7.27 0.58 to 8.20 (Ϫ0. No 3.34 0.15 to 2.4 (3.72 0.e.44 (2.22 (4. The units of spectral power are the natural logarithm with respect to 1 mV.30 to 4.8 to 4.26) 1. 20%1).55 0. which is consistent with our result. and higher BIS values) during recovery in patients reporting dreaming than not reporting dreaming.50) 10 Hz 2 Hz Ϫ0.75 (8.37 0.16 reported similar recovery times and similar incidences of dreaming in the propofol and desflurane arms of their study.27 (9.33 to 12.57 to 8.

Both plots are of the same data. Sep 2009 −15 −10 −5 Time before interview (min) 0 Fig. high-frequency power. suppression of electroencephalographic power in the ␣ band was correlated with dream recall. V 111. and there was no significant difference in the time from eye opening to interview between the two groups (table 4 and fig. the upper surface (which may be either blue mesh or rainbow color surface) hides the lower surface at each point in time and frequency.01 (–1 min).04 (–15 min) and P ‫ ؍‬0. P ‫ ؍‬0. These spindles are generated in both natural sleep and general anesthesia.5.04 (–5 min). and eye opening in the 20 min before interview in dreamers and nondreamers. 3). We therefore conclude that the increased high-frequency power and decreased sleep spindle in patients reporting dreaming was due to a REM-like state.03 (–13 min).0009 (–2 min). During sleep states. ␣ frequency oscillations consist mainly of sleep spindles. No−dream Dream Eye open (%) 60 40 20 0 −20 ers were interviewed as soon as they were oriented. P values were as follows: P ‫ ؍‬0. P ‫ ؍‬0. but they are rotated differently for ease of visualization.05) between the groups at that time point.01 (–1 min). P ‫ ؍‬0. Changes in percentage spindles.68-Hz spindles.03 (–10 min). In the figures. P ‫ ؍‬0. P ‫ ؍‬0. * Significant difference (P < 0. 2. Results are presented as mean (SEM). P ‫ ؍‬0. No 3. . (C) Percentage of patients who had opened their eyes at each time point. P values were as follows: P ‫ ؍‬0.6.03 (–17 min). which are a definitive sign of stage 2 non-REM sleep. Anesthesiology. P values were as follows: P ‫ ؍‬0.005 (–3 min). (B) Log 30-Hz power.02 (–2 min).02 (–9 min). 3. Mean electrocephalographic power spectra of dreamers (colored surfaces) and nondreamers (blue mesh surfaces) in the 20 min before the interview. (A) Changes in 10.DREAMING AND THE ELECTROENCEPHALOGRAM 553 A 12 10 Spindle (%) Log 30Hz power 8 6 4 B 8 7 6 5 4 C 100 80 Fig.8 In these studies. P ‫؍‬ 0. This conclusion is further corroborated by the similarity between our electroencephalographic findings and those of researchers who wake up patients from natural sleep.09 (– 4 min) and P ‫ ؍‬0.

15 to Ϫ0.02) 3.20 to 1.24 which found increased mid-latency cortical evoked potentials during anesthesia in patients who reported dreaming on emergence.77 to 1.21 (9.57) 10 Hz 3 Hz Ϫ0. between the propofol and desflurane groups. different electroencephalographic patterns for different drugs are a potential source of error in depth-of-anesthesia monitors.92) 12. potassium channel opening.39 to 10. Presumably the sleep-spindle-like “oscillatory” electroencephalogram seen in our propofol group is largely the result of the ␥-amino-butyric acid (GABA)-ergic actions of propofol. N-methyl-D-aspartate receptor blockade).67 to 3.09 (0.17) 1.99 to 2.85) 2.36 Hz spindle Peak frequency of spindle Peak frequency of ⌬ Ϫ0.47 to 10.13 to Ϫ0. activation of endogenous cholinergic and aminergic neuromodulator systems results in cortical and thalamic neuronal depolarization.02 Hz spindle 21.05 to 15. Anesthesiology. the most parsimonious explanation is that propofol is a “cleaner” drug than desflurane. V 111. patients in the propofol group opened their eyes at lower BIS values than patients in the desflurane group.0001 Ͻ 0.02 0.47) 1.16 (Ϫ0.46 to 10. Of note. mid-latency evoked potentials contribute to the 20. Sep 2009 . Although the mechanisms of drug-induced spindles are only partially understood.001 Ͻ 0.0001 0.008 Ͻ 0.39 to 4. predominantly slower waves of the electroencephalogram in our desflurane group are caused by the additional (and unknown) receptor and ion-channel effects of volatile anesthetic agents (e.002 Ͻ 0.00 (2.001 Results are presented as median (interquartile range).83 (9.59 (1.48 (8.22 Our results suggest that patients who report dreaming lose their spindles in the recovery period to a greater degree than those who do not report dreaming. but not in BIS values. The propofol patients had larger and faster spindle-like patterns than the desflurane patients.003 Ͻ 0. even when they were still unresponsive.26 to 11. The spindle units are the percentage of electroencephalographic data points that could be associated with a spindle sequence..42 (1.04) 11 Hz 2 Hz 0.49) 10.96) 10.85 (9.84) 7.73 to 1.86 to 10.g..80) 9.45) 5. 4. the differences in raw electroencephalographic pattern may be an indicator of differences in drug mechanisms of action.21 This might be why scopolamine prevents dream recall after anesthesia. hence dreams are more difficult to recall after non-REM than REM sleep.13. Although the contribution of evoked potentials to the raw electroencephalographic signal is small.88 to 6.14 Table 7.22) 10. 11 10 9 Log Power 8 7 6 5 4 3 0 10 20 30 Frequency (Hz) 40 50 Desflurane Propofol Fig. suggesting that the relationship between BIS and the clinical level of consciousness is different for the two drugs.63 (6.19 (Ϫ0.19) 9.66 (10. Raw Electroencephalographic Parameters in Patients Randomized to Desflurane and Propofol Parameter Desflurane (n ϭ 75) Propofol (n ϭ 75) P Value Wound closure Slope Intercept ␣ Peak Spindle amplitude ⌬ Peak Mid-surgery 10.02) 1.82 Hz spindle 16.18) 8.to 40-Hz frequency band.41 to 10. which reduces spindle activity in the electroencephalogram.05 (0. The spindle activity found in stage 2 non-REM sleep is associated with impairment of memory consolidation.0001 0.33 (0.68 Hz spindle 12.61 (10.4.03 (2. Whether the reduction in spindles is a direct electroencephalographic manifestation of the dreaming process itself or is an indication of likely improved dream recall cannot be determined from our data. Mean power spectra of the propofol and desflurane groups at completion of surgical wound closure. Second.35) 1. This is consistent with electroencephalographic findings in dreamers during natural sleep4 and with the study by Aceto et al. when neurons in thalamocortical networks become hyperpolarized and move to a burst-firing mode. whereas the less well-defined.0001 0.83 (6.05) 9.19 –21 On the other hand. We also observed substantial differences in raw electroencephalographic patterns.1 to 10. First.001 Ͻ 0.74 (10. Our findings are of interest for two reasons. No 3.23 Our results support this idea.554 LESLIE ET AL. We also found that the patients who reported dreaming had a consistent tendency to show more high-frequency power (20 – 40 Hz) in their electroencephalogram towards the end of their operation.15 to 12.

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Royal Perth Hospital. Nudleman K. Anesth Analg 1970. Sakima N.. Bertolo H. King Edward Memorial Hospital for Women. 93:294–304 21. Wuthrich S. we used several different analytic approaches (spectral and ordinal). Weindlmayr-Goettel M. Antkowiak B: Anaesthetic drugs: Linking molecular actions to clinical effects Curr Pharm Des 2006. This may be explained by the pharmacodynamic plateau effect that is seen in processed electroencephalographic variables with volatile anesthetics but not with propofol. Australia. Gualtieri E: Dreams recall and auditory evoked potentials during propofol anaesthesia. Acta Anaesthesiol Scand 2003.N. 42:535–42 18. Moffitt A: The electrophysiological correlates of dream recall and nonrecall from stage 2 sleep.N. However. Steriade M: Membrane bistability in thalamic reticular neurons during spindle oscillations J Neurophys 2005. Br J Anaesth 1970. Leslie K. Tschan C. Drexler B. Susan March. we can be confident that our study was adequately powered with respect to finding a difference between the incidence of dreaming in propofol and desflurane patients if one existed. Rudolph U. 47:165–73 17. Conduit R. Antkowiak B: Molecular and neuronal substrates for general anaesthetics. Aceto P. Bruhn J. R. Paech M. 49:924–34 19. Melbourne. Lai C. 52:750–5 11. Bromley L: Dreams. Larsen R. Hetherington R. Brandner B. and Desiree Cavill. Crewther S. J Neurosci 1997. Greher M. Shafer S. Zuckerman R. Wu J.25 In addition. Anesth Analg 2004. Pancaro C. Sep 2009 . Sejnowski T. Stierer T.

or vocal cord paralysis and accidental extubation. Kang: Department of Anesthesiology and Pain Medicine. A and B).6 mg/kg rocuronium IV. neck. M. Department of Anesthesiology. Seoul. patient in the extended position are aligned in an almost straight line (fig. 2008. r2 ‫ ؍‬0. ‡ Fellow. 111:556 – 60 Copyright © 2009. the forward prominence formed by the manubriosternal joint (MSJ). Support was provided solely from institutional and/or departmental sources.1–3 Simple formulas. 6 months from the cover date of the issue. East-West Neo Medical Center. 1. and other methods have been proposed for positioning the endotracheal tube at an adequate depth. Bedside Prediction of Airway Length in Adults and Children Bong-Jae Lee. Sep 2009 . Received from the Department of Anesthesiology. 1. Conclusions: The airway length from the upper incisor to the carina in the neutral position can be predicted by the straight length from the upper incisor to the MSJ in the fully extended position. † Assistant Professor. Patients with anatomical defects of the face.009) ؋ the incisor-MSJ extension length (cm) ؉ 4. informed consent was obtained from each adult patient or parent of pediatric patients.88 (0. the upper airway and trachea of the * Associate Professor. Inc. 3).D.or. 2009.260 (0. Anesthesiology.anesthesiology.5 mg/kg propofol and 0. Therefore.868 (1.. or upper airway were excluded from the study. the endotracheal tube was positioned properly at the upper incisor teeth. Patients were placed on the operating table with the head in the neutral position.* Jae-Woo Yi. Korea 134-090. V 111.† Jun Young Chung..6 mg/kg rocuronium IV. The angle of Louis. The manubriosternal joint (MSJ) is on the same horizontal plane with the tracheal carina. The incisor-MSJ extension length was measured with a specially devised commercial compass after adequate mask ventilation (fig. 149 Sangil-dong Gangdong-Gu. Lippincott Williams & Wilkins. After intubation. The length between both ends of the temporarily fixed commercial compass was measured along the ruler.kr. Kyung Hee University. We compared the incisor-MSJ extension length with the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in the neutral position (incisor-carina neutral length).. Korea.468) with a high coefficient of determination. Seoul. and the incisor-carina neutral length was measured with the fiberoptic bronchoscope at the carina. A formula for the regression line in adults (children) can be obtained as the incisor-carina neutral length (cm) ‫ ؍‬0. Address correspondence to Dr. A and B). The incisor-MSJ extension length was measured after adequate mask ventilation.† Background: Malpositioning of the endotracheal tube within the airway leads to serious complications such as endobronchial intubation. kjm@khnmc. M. Methods: One hundred adults and 50 children were studied..98). M. § Professor.‡ Dong-Ok Kim. the straight length from the upper incisor to the MSJ in the fully extended position (incisor-MSJ extension length) can be expected to be similar to the real airway length from the upper incisor to the carina. East-West Neo Medical Center. One hundred adults (American Society of Anesthesiologists Class 1 or 2) and 50 children presenting for routine elective surgery under general anesthesia were studied between February 2008 and October 2008. 556 MALPOSITIONING of the endotracheal tube within the airway leads to serious complications such as endobronchial intubation.D. Materials and Methods Participants and Anesthesia The study was approved by the Institutional Review Board of the Kyung Hee University Hospital (Seoul.8 With rigid bronchoscopy. Muscle relaxation was obtained with 0. Routine monitors were used.4 –7 Prediction of the correct length of an endotracheal tube is important and should be individualized to each patient. Anesthesia was maintained with sevoflurane (2–3%). a laryngoscopy was performed. Seoul. Information on purchasing reprints may be found at www. Kyung Hee University. Measurements The fully extended position was obtained by having the patient lie on the flat surface of the operating table and by manually extending the head and neck as much as possible (fig. Results: The correlation between the incisor-MSJ extension length and the incisor-carina neutral length is significant (P < 0. Republic of Korea). Ph. Accepted for publication April 29.org or on the masthead page at the beginning of this issue. Inc. In addition.Anesthesiology 2009.5 mg/kg propofol IV. ANESTHESIOLOGY’s articles are made freely accessible to all readers. East-West Neo Medical Center. After loss of all four twitches from the train-of-four obtained by ulnar nerve stimulation. and written. which may cause collapse of the nonventilated lung and barotrauma of the ventilated lung.. is an important landmark in the anatomy of the thorax and on the same horizontal plane with the tracheal carina (fig. Kyung Hee University.D. Induction of anesthesia was achieved with 1. we investigated whether the degree of maximum head extension influences the relationship between the two lengths. Induction of anesthesia was achieved with 1. M. 1). Submitted for publication July 16. M. No 3. the American Society of Anesthesiologists.D. The degree of maximum head extension was measured indirectly with the eye-ear lines’ angle (defined as the angle between the lines from the external ear channel to the superior orbital margin9 in both neutral and extended positions) (fig.001) in both adults and children. 2).D.§ Jong-Man Kang. landmarks.D. Prediction of the correct depth of an endotracheal tube is important and should be individualized. for personal use only. We compared the straight length from the upper incisor to the MSJ in the fully extended position (incisorMSJ extension length) with the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in the neutral position (incisor-carina neutral length). Korea.

3 (3. Neutral position was obtained by having the patient lie on the flat surface of the operating table without head extension or neck flexion. we recruited 100 adults and 50 children for general consistency.5 mm inner diameter tubes. the endotracheal tube was positioned properly at the upper incisor teeth and secured to the upper lip. The correlation between the incisor-MSJ extension length and the incisor-carina neutral length in children is significant (P Ͻ 0. A formula for this regression line can be obtained as the incisor-carina neutral length (cm) ϭ 1. upper incisor. showed a mean (SD) of 23. After intubation. 2.06) and 24. Anesthesiology. Sep 2009 Fig. 3.0 mm inner diameter tubes were used in adult women patients.98). Endotracheal tube size (inner diameter) ϭ Age (yr)/4 ϩ 4. respectively.12 A P value of less than 0. The degree of agreement of the incisor-MSJ extension length and incisor-carina neutral length was assessed by Bland and Altman method.09) in the incisor-MSJ extension length and the incisor-carina neutral length. Fig.468. No 3. with a high coefficient of determination (r2 ϭ 0. The bronchoscopist was blind to the incisor-MSJ extension length. LLC. 4A). Ireland).009 ϫ the incisorMSJ extension length (cm) ϩ 0. The incisor-carina neutral length was measured with the fiberoptic bronchoscope through the endotracheal tube at the carina.260. V 111. A sample size 7 was calculated for a Type I error of 0. An endotracheal tube was chosen using the formula below10 as a guide for children.99 using the PASS 2008 (Trial) Version 08.01 and a power of 0. Statistical Analysis A pilot study of 15 patients.88). including 4 children. a fiberoptic bronchoscope (Olympus LF-GP.BEDSIDE PREDICTION OF AIRWAY LENGTH 557 Fig. Eye-ear lines’ angle. Estimate of the straight length from upper incisor to the angle of Louis in extended position with specially devised commercial compass in a frontal view (A) and a lateral view (B). The correlation between the incisor-MSJ extension length and the incisor-carina neutral length in adults is significant (P Ͻ 0. Straight length from upper incisor to the angle of Louis in extended position (1). UT).001). based on central limit theory.11 With the head in the neutral position. 4B). IL). and measuring the length of bronchoscope took only about 10 s.0 (SPSS. Chicago..7 Windows version (NCSS. Japan) was inserted through a modified right-angle connector (Mallinckrodt Medical. A regression line was derived (fig. The whole procedure of identifying carina.868 ϫ the incisor-MSJ extension length (cm) ϩ 4. Straight length from upper incisor to the carina in extended position (2). Results The details of the patients studied are given in tables 1 and 2. which allowed bronchoscopic examination during manual ventilation. Olympus Optical Co. Adult men were intubated with 7. Linear regression and correlation were used to analyze the relationships among the measured data using SPSS for Windows version 12. Kaysville. Athlone. while 7. Tokyo. Rigid bronchoscopy. * The eye-ear lines’ angle is the angle between the lines from the external ear channel to the superior orbital margin in both neutral and extended positions.4 (3.05 was considered to be significantly different. However. No patient experienced oxygen desaturation. A formula for this regression line can be obtained as the incisor-carina neutral length (cm) ϭ 0. 1.0.001) with a high coefficient of determination (r2 ϭ 0. a regression line was derived (fig. .

C and D). and 0. A and B). We regarded the incisor-carina neutral length as the true airway length.03 cm (95% CI 0.868 ϫ the incisor-MSJ extension length [cm] ϩ 4. these methods cannot be applied to vocal cords that cannot be visualized.7423) (instead of 12. indicating superiority of our prediction formula.6%). The means of the differences between the two lengths were 1.82 (0. It is stated that the plane of division into upper and lower mediastinum traverses the MSJ and the lower surface of the fourth thoracic vertebra.4. Sep 2009 . Bland and Altman plots demonstrated a good agreement between the two lengths. foot length. we found a higher r-squared value and smaller variation in the Bland and Altman plots in our formula using the incisor-MSJ length than those in Cherng et al. 1A).9 cm.18 These methods are definitive but involve additional costs and efforts.21 While performing rigid bronchoscopy.88 in this study. and the cuff palpation method should not be used to verify location within the trachea.59 using our data of adult patients.9. it is difficult to determine superiority of one method to others for prediction of airway length. 0. Child Patient Characteristics Boys (n ϭ 25) Girls (n ϭ 25) Age (yr) Height (cm) Weight (kg) Values are mean (range). including auscultation of bilateral breath sounds. the incisor-MSJ extension length can be expected to be similar to the real airway length (carina to upper incisor).260) with the formula of Cherng et al. farther from the carina. however.14 –16 The second category is prediction of airway length from mouth or nares to carina using age.2) 116 (68–163) 21 (7.8. weight. Flexion of the neck from the neutral position can result in the tip of the endotracheal tube moving as much as 3 cm. We think that the straightened airway length after insertion of the rigid bronchoscope is Anesthesiology. There are several categories of estimating the optimal endotracheal tube length in orotracheally intubated patients. The angle of Louis can be easily palpated near the second rib insertion to the MSJ (fig.9 However. and palpation of the endotracheal tube cuff in the suprasternal notch.14.5–63) seem to have reasonable rationale. 2).5) 121 (65–170) 24 (7.13 (0.4 The fourth category is postintubation confirmation of endotracheal tube placement by chest radiograph or fiberoptic bronchoscopic examination.9 cm. The r-squared values between age (weight.46 ϳ 0. 6. 6. height.28.86 ϳ 1. The first category is using clinical criteria. 5. or arbitrarily determined length.79. 4.19 The correlations between predictor and observation were 0.7–14.20 The tracheal carina was above the MSJ plane in 9 patients (17. symmetric chest expansion. Bland and Altman plots demonstrated the difference of the two formulae (fig.79. We compared our formula (0.9 (0. because those authors estimated the length of the airway from the mouth to 5 cm above the carina) using the data of our adult patients.5 The third category determines how far a certain mark of the endotracheal tube has proceeded beyond the vocal cords. A and B).13 while 0. Adult Patient Characteristics Men (n ϭ 50) Women (n ϭ 50) Age (yr) Height (cm) Weight (kg) Values are mean (range).98 in children of our model.17.1977 ϫ height [cm] Ϫ 7. at the plane in 21 patients (41%). and 0. No 3. may not be always individualized to each patient. Therefore.63 cm (95% CI 0. and 0.85.60) in pediatrics. The fifth category is the method made on topographic measurements and has the advantage of individualization and ease of use.63 of r-squared values in adults in the previous articles.79) in children (fig. auscultation of the chest bilaterally and visualization of symmetrical chest expansion cannot be a reliable method for detecting the endobronchial intubation.17 as compared with 0.7423. while extension can displace the endotracheal tube by as much as 5 cm.20) in adults. 0.22 The incisor-MSJ extension length may not be equal to the real airway length in the extended position because the real airway course is not straight unless it is forcibly aligned in a straight line by the rigid bronchoscope. head circumference) and tracheal length were 0.15 However. with a mean value of 1.1. and that the plane passes horizontally through the sternal angle and also the bifurcation of the trachea.5–69) 5.7–14. 42 (17–75) 171 (155–187) 70 (51–94) 41 (15–76) 158 (143–171) 57 (41–85) The difference between the incisor-MSJ extension length and the incisor-carina neutral length is not linearly correlated with eye-ear lines’ angle (fig. Discussion According to the measured data of the present study.17 However.558 LEE ET AL.5 (0.5. V 111. height.5.’s formula13 using the height. The r-squared value between height and tracheal length was 0. and the correlation coefficients are not high. and below it in 21 patients (41%). and the distance between the tube tip and the carina cannot be optimally predicted. Because of the different study population and methodology among these previous studies.13. the relationship of the incisor-MSJ extension length and the incisor-carina neutral length is significantly correlated. Table 1.9. Using our patient data. these methods do not Table 2. the upper airway and trachea of the patient in extension position are forced into an almost straight line (fig. with a mean value of 1. closer to the carina. 0. foot length.

and since the incisor-MSJ extension length may be similar to the straightened airway length after insertion of rigid bronchoscope.86 ϳ 1. incisor-MSJ extension length must have some relation to the real airway length. this method is very simple and precise.20) in adults. However.6 cm in children to the incisor-MSJ extension length. and Y ‫ ؍‬1. ● ‫ ؍‬female). and out of hospital (e..868 ؋ X ؉ 4. emergency room. and height. associated with the real airway length. the length measured with a fiberoptic bronchoscope was through the endotracheal tube. respectively (P < 0. The incisorMSJ extension length is the straight length from upper incisor to the manubriosternal joint (MSJ) in extended position.79) in children.98.BEDSIDE PREDICTION OF AIRWAY LENGTH 559 Fig.88 and 0. a ruler or endotracheal tube itself (after straightened by force) could be used easily and rapidly in clinical setting only if it is oriented parallel to the line from the upper incisor to the angle of Louis. The means of the differences between the two lengths were 1. Our method can be applied in the operating room. 4. This study has several limitations. we suggest adding 1 cm (the mean difference between the two lengths) in adults and 0. ● ‫ ؍‬female). rather than using the complex formulae. Anesthesiology.63 cm (95% CI 0. intensive care unit. the difference between Fig. for ease of clinical use. Third. Although a special compass was used to measure the incisor-MSJ extension length precisely. The coefficient of determination (r2) is 0.001). V 111.009 ؋ X ؉ 0. Sep 2009 . The incisor-MSJ extension length is the straight length from upper incisor to the manubriosternal joint (MSJ) in extended position. respectively (X ‫ ؍‬male. (A) and (B): The incisor-carina neutral length (Y axis) is plotted against the incisor-MSJ extension length (X axis) for all 100 adults and 50 children. this method cannot be applied to patients with limited head extension. as compared with other methods. (C) and (D): The difference between the incisor-carina neutral length and the incisor-MSJ extension length (Y axis) is plotted against the eyeear lines’ angle (X axis) for all 100 adults and 50 children. respectively. Second.g. The incisor-carina neutral length is the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in neutral position.468 (solid line). Moreover. respectively (X ‫ ؍‬male. The formula of the regression line is Y ‫ ؍‬0. (A) and (B): Bland and Altman plots for all 100 adults and 50 children. age. and may be superior to other methods in that this method gives the whole airway length directly and individually irrespective of sex.03 cm (95% CI 0. We suggest that this method may be the first choice of airway length prediction and combined with previous methods. 5. with emergency services) to avoid endobronchial intubation. The incisor-carina neutral length is the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in neutral position. Moreover. unexpectedly. This is caused by the individual difference of the level of the MSJ compared to the carina and the status of the endotracheal tube curvature within the airway in the neutral position. meaning that the endotracheal tube itself may have straightened the airway path a little bit. No 3. respectively (X ‫ ؍‬male.46 ϳ 0.260 (solid line). First. and the endotracheal tube itself is not flexible enough to follow the airway path. and 0. the difference between the incisor-MSJ extension length and the incisor-carina neutral length is not always regular. ● ‫ ؍‬female).

Owen RL. 20:156–60 6.16 ϳ 0. 1995. 65:886–91 17. Szmuk P. 10:405–8 22. Arch Dis Child Fetal Neonatal Ed 2001. Embleton ND. Singer MM: Alteration of endotracheal tube position. Dietrich KA. 38th Edition. Br J Anaesth 2005. pp 254 21. Morgan GA. Regional and Applied. Clin Anat 1997. Cherng CH. Lainge F. 94:80–7 10. Churchill Livingstone. J Clin Anesth 2002. Scanlan KA: Use of flexible fiberoptic endoscopy for determination of endotracheal tube position in the pediatric patient.’s length ‫ ؍‬0. Dussek JE. Cupa M. Mahajan RP. 46:306–8 5. Schatz E.52) with the formula of Cherng et al. Mehta S: Intubation guide marks for correct tube placement. Williams PL. 57:161–70 3. Wong CS. Bannister LH. Anaesthesia 1991. 29:9–11 11. Gerber AC. Lapostolle F. Further studies about this are needed. Evron S.00 cm (95% CI ؊0. Lapandry C: Study of the “sniffing position” by magnetic resonance imaging. No 3. Flexion and extension of the neck. we could not include neonates because we did not have an ultrathin fiberoptic bronchoscope. ANESTHESIOLOGY 2001. this study demonstrated that the airway length from the upper incisor to the carina with the head placed in the neutral position can be predicted by the straight length from the upper incisor to the MSJ in the fully extended position. ANESTHESIOLOGY 1982. Zwillich CW. Cheney FW. Best CJ: Evaluation of a new method for determining tracheal tube length in children. Goodman LR. Conrardy PA. Dumas JL. Crit Care Med 1976. Collins P. Gavish D. Pollard RJ.81 cm (95% CI ؊1.260. Edinburgh.7423. Churchill Livingstone. Khazin V. Crit Care Med 1988. Sutton FD. Anesth Analg 1995. 67:255–7 2. Currie L. ● ‫؍‬ women). J Clin Anesth 2007. ANESTHESIOLOGY 1987. 19:15–9 20. 14:271–4 14. Wright C. Pierson DJ. Cherng et al. Ezri T: Proper insertion depth of endotracheal tubes in adults by topographic landmarks measurements. Fourth. an accurate predictor of nasotracheal tube length in neonates. Weiss M. Borron SW. Lobato EB: Endotracheal tube location verified reliably by cuff palpation. 16:884–7 19. Anaesth Intensive Care 1992. Birmingham PK.15) with our formula. V 111. Harow E. Sep 2009 . Cabalka AK.13 and 0. Edinburgh.1977 ؋ height (cm) ؊ 7. Milligan DW: Foot length.560 LEE ET AL. Cavo JW Jr: True vocal cord paralysis following intubation. 48:74–5 7. Am J Med 1974. Zimmerman JJ. 1994. 4:7–12 Anesthesiology. 81:135–8 16. Laryngoscope 1985. 57:548–9 15. 95:1352–9 4. Ferguson MW: Gray’s Anatomy.. The incisor-MSJ extension length is the straight length from upper incisor to the manubriosternal joint (MSJ) in extended position. Dyson M. 6. A prospective study of 354 consecutive episodes. Bland JM. Anaesthesia 1995. This may be partly caused by the individual variation of the relationship of the head and cervical vertebrae. Hsu CH. Freeman JA. The means of the differences between the two lengths were ؊0. Anaesthesia 1993. Fredricks BJ. the incisor-MSJ extension length and the incisor-carina neutral length was poorly correlated with the eye-ear lines’ angle. Petty TL: Complications of assisted ventilation. Scott D.10 ϳ ؊0. Creagh CE. References 1. Deshpande SA. McMinn RM: Last’s Anatomy. In conclusion. Berry MM. Dullenkopf A: Appropriate placement of intubation depth marks in a new cuffed paediatric tracheal tube. Fig. Lancet 1986. Ellis H: CT anatomy of the mediastinal structures at the level of the manubriosternal angle. Ho ST: Airway length in adults: Estimation of the optimal endotracheal tube length for orotracheal intubation. Anesth Analg 1986. Triner L: A simple maneuver to verify proper positioning of an endotracheal tube. Ellis FR: Estimation of the correct length of tracheal tubes in adults. Strauss RH. 1:307–10 13. 9th Edition. Chukwuemeka A. A clinical study. 94:83–6 12. Ward RJ: Esophageal intubation: A review of detection techniques. Weisenberg M. 85:F60–4 18. Can Anaesth Soc J 1982. Eagle CC: The relationship between a person’s height and appropriate endotracheal tube length. Cheney FW: Endobronchial intubation: A preventable complication. Lee’s length ‫ ؍‬0. Altman DG: Statistical methods for assessing agreement between two methods of clinical measurement. Adnet F. Patel N. pp 1677 9. (A) and (B): Bland and Altman plots for all 100 adults (X ‫ ؍‬men.868 ؋ the incisor-MSJ extension length (cm) ؉ 4. The incisor-carina neutral length is the length from the upper incisor to the carina after intubation with a flexible fiberoptic bronchoscope through the endotracheal tube in neutral position. 50:1050–2 8. The Anatomical Basis of Medicine and Surgery. Steward DJ: A pre-formed paediatric orotracheal tube designed based on anatomical measurements.

China. gerated release of proinflammatory cytokines in response to endotoxin challenge.D.11.22 and elevated plasma level of atrial natriuretic peptides (ANP). M.D. 111:561–5 Copyright © 2009.3. body mass index Ͼ30 kg/m2 or Ͻ18 kg/m2. Eastern Hepatobiliary Surgery Hospital. atrial natriuretic peptide and nitrate. or renal diseases. we hypothesized that arterial baroreflex function may be compromised in patients with obstructive jaundice. Potential factors that may affect baroreflex sensitivity in jaundice. Baroreflex Sensitivity Is Impaired in Patients with Obstructive Jaundice Jian-gang Song.19 Based on these findings. Ph.§ Xue-wu Xu. V 111. the American Society of Anesthesiologists. Submitted for publication December 31. as compared with the controls (P < 0. sepsis.† Li-qun Yang. Informed consent was obtained from all participating patients.8 subclinical myocardial dysfunction. which may help to explain the enhanced susceptibility to those well-known perioperative complications. Inc. Information on purchasing reprints may be found at www.† Zhi-qiang Liu. which may contribute to their enhanced susceptibility to the well-known perioperative complications.13. M. A modified Oxford pharmacologic technique was used for evaluating baroreflex sensitivity immediately before the surgery. and toxic effects of endotoxin. All participating patients were scheduled for elective surgery for the underlying diseases. Materials and Methods Patients The study was approved by the Institutional Ethics Committee (Eastern Hepatobiliary Surgery Hospital. gastrointestinal bleeding. complication of acute cholangitis. ANESTHESIOLOGY’s articles are made freely accessible to all readers.† Yu-ming Sun.com. Methods: Thirty-five patients with obstructive jaundice scheduled for surgery were included. songjg1993@126.* Yun-fei Cao. 6 months from the cover date of the issue. or ascites. hepatic encephalopathy.7. There was a significant inverse correlation between plasma atrial natriuretic peptide concentration and decreased sympathetic baroreflex sensitivity in the jaundiced group (r ‫ ؍‬؊0. Received from the Department of Anesthesiology. this study aimed to determine whether baroreflex sensitivity was impaired in jaundiced patients.D.24 are frequently observed in patients with obstructive jaundice or in animal models of biliary obstruction.15 A reduction in sympathetic baroreflex sensitivity (BRS) results in greater hemodynamic liability when the patient is challenged with hypotension. Conclusions: Baroreflex sensitivity is impaired in patients with obstructive jaundice. PATIENTS with obstructive jaundice are prone to hypotensive shock. plasma concentrations of methionine-enkephalin. Eastern Hepatobiliary Surgery Hospital. Address correspondence to Dr. ࿣ Associate Professor. Shanghai First Maternity and Infant Health Hospital. The underlying mechanisms for such a change may be associated with an increased level of plasma atrial natriuretic peptide. surgery.1. M. China).21 accumulation of endogenous opioid peptides (methionine-enkephalin).Anesthesiology 2009. and use of medi561 Anesthesiology. Shanghai.18. China. 2008.12 and exag* Assistant Professor.. or neuropathy.D. Besides cholestasis and liver damage. Lippincott Williams & Wilkins.16.17 An intact vagal baroreflex recently has been found to be necessary for improving survival in sepsis. Second Military Medical University.20. acute renal failure. such as anesthesia. P ‫ ؍‬0.01). M.008). Thirty-five consecutive men with obstructive jaundice (serum total bilirubin Ͼ20 ␮M) caused by a tumor in the bile duct or in the head of the pancreas were included in the study. The reflex consists of two parts: A sympathetic and a vagal (parasympathetic) limb. Department of Nuclear Medicine.** Background: Obstructive jaundice is associated with enhanced susceptibility to hypotensive shock. Second Military Medical University. The current study was designed to test this hypothesis. Shanghai. No 3. Thirty men with asymptomatic gallbladder polypus without jaundice were recruited as controls.. Department of Anesthesiology.5. M.10 systemic endotoxemia that frequently accompanies obstructive jaundice. electrolyte or acid-base disturbance. These factors are implicated in the regulation of arterial baroreflex function and/or autonomic nervous system activity. we included these measures in the hope to find some underlying mechanisms for impaired baroreflex in jaundiced patients.org or on the masthead page at the beginning of this issue. Results: Patients with obstructive jaundice had decreased sensitivity in both the sympathetic and vagal components of the baroreflex. Since the normal arterial baroreflex function is necessary for hemodynamic homeostasis and improving survival in sepsis.. which results in high perioperative morbidity and mortality. China. Jian-gang Song and Yun-fei Cao contributed equally to this work. China.D.࿣ Shao-li Song. hemorrhage. for personal use only.D... 2009. Exclusion criteria were as follows: Age Ͼ70 yr or Ͻ50 yr. Department of Anesthesiology. Eastern Hepatobiliary Surgery Hospital. history of diabetes.D. or cachexia defined as weight loss Ն2% in the past 2 months or Ն5% in the past 6 months. renal failure. Shanghai Jiao Tong University. M. Yu: Department of Anesthesiology.4 Reasons for this increased susceptibility are not well characterized at present. or general anesthesia. Sep 2009 . Second Military Medical University.2 Morbidity and mortality in jaundiced patients receiving surgical treatment are higher than in nonjaundiced patients. and 30 nonjaundiced patients served as controls. Renji Hospital... and infection.25–28 Accordingly. hemorrhage. Potential mechanisms include extracellular water depletion. M. China. Department of Anesthesiology.23. ** Professor and Director.44.D. School of Medicine. Tongji University. respiratory. Inc. § Resident. Shanghai. Shanghai.‡ Yan-hu Ge. Shanghai.10.anesthesiology. # Attending Physician.# Wei-feng Yu. cardiovascular. sepsis. † Associate Professor. Accepted for publication April 29. M. Drs. ‡ Assistant Professor. China). and multiple organ failure under a wide range of conditions. Shanghai. Shanghai. were also measured. psychiatric illnesses.. Supported by departmental sources and Shanghai Leading Academic Discipline Project (No. such as liver biochemistry.9. S30203.6 defective vascular reactivity. overproduction of nitric oxide..14 Arterial baroreflex is an important short-term neural control mechanism that maintains cardiovascular stability.D. M.D.

3 65.98 ms/mmHg.3 Ϯ 12. A multivariate analysis was performed to identify factors associated with changes of BRS in the group of jaundiced patients. Samples were centrifuged at 3. respectively. Representative responses to phenylephrine and nitroprusside are shown in figure 1. As for hormonal assays. Sep 2009 Table 1. followed by 100 –250 ␮g sodium nitroprusside to increase/decrease systolic blood pressure by 15–30 mmHg. ␤-blockers. and heart rate (table 1). bile acids. digoxin). Variables with P Ͼ 0. Japan. MO). Sigma Chemical. SBP ϭ systolic blood pressure. The observers were unaware of the study design or the study purpose.001.86 and 5. ionized calcium. The slope of the linear portion of the relationship curve between the pulse interval and the preceding systolic blood pressure was analyzed using a least-square regression as an index for baroreflex sensitivity. body temperature.7 73.80. and albumin. respectively. as compared with controls.3 Ϯ 0.28 Ϯ 2. a blood sample was collected into chilled tubes containing 2 mg/ml EDTA and 400 KIU/ml aprotinin (Trasylol.8% Ϯ 0. Seven to 12 pairs of systolic blood pressure and pulse intervals were used for each test. and assuming a two-sided type I error rate of 0.6 Ϯ 6.05 was considered to be statistically significant. Statistical Analysis Data are presented as mean Ϯ SD. Anesthesiology. I-AR55 Co.4 DBP ϭ diastolic blood pressure. Results The two groups did not differ in age. the formula for normal theory. 30 58. As expected. weight. No arrhythmia was observed during the testing. Tokyo.19 Ϯ 1. Demographic Data Control Obstructive Jaundice n Age (yr) Weight (kg) Temperature (°C) HR (beats/min) SBP (mmHg) DBP (mmHg) Values are mean Ϯ SD. Squared correlation coefficient was greater than 0. P Ͻ 0. 2).7 Ϯ 6. Candidate factors included significantly altered liver biochemistry and/or hormones.21 Ϯ 2.1 Ϯ 0. P Ͻ 0. On arriving at the operating room after an 8 –10 h fast.5 127.562 SONG ET AL. respectively. its production was estimated by measuring the plasma nitrate concentration using a gas chromatography-mass spectrometry method. for the heart rate and systolic blood pressure to return to 95–105% of the pretest level.0 Ϯ 9. bile acids.5 Ϯ 13..14 Ϯ 2.0 35 57.78 and 4. respectively.0 36.2 Ϯ 8. Blood Sampling and Hormonal Assays Before the BRS test. HR ϭ heart rate. and were allowed to rest in a supine position for at least 20 min before the experiment.16 ms/mmHg. Cob. and stored at Ϫ20°C until use. fig.4 74. Acetate Ringer’s solution was administered intravenously at a rate of 2 ml ⅐ kg-1 ⅐ h-1 throughout the entire procedure.0 36. cations that could interfere with cardiovascular function (e.30 Plasma met-enkephalin was determined using a radioimmunoassay kit (Peninsula Laboratories. BRS was 8.8 for all samples. baseline blood pressure. Louis. calcium channel blockers. Inc.1 were excluded from the regression analysis using a stepwise method (SPSS 11 for Windows [SPSS Inc.52 ms/mmHg. Arterial gas analysis was performed using samples of arterial blood collected during the BRS test.4 78.63 and 7. serum concentrations of total bilirubin. CA). A radioimmunoassay kit was used to determine ANP (h-ANP. The patients did not receive any premedication that could otherwise interfere with the subsequent baroreflex testing.98 Ϯ 2. a sample of venous blood was collected. The pressor and the depressor tests were separated by a period of stabilization.05 and a power of 0. The BRS measurements of eight jaundiced patients and eight nonjaundiced patients were taken in the preliminary trial.3 Ϯ 10. Electrocardiogram and blood pressure were continuously monitored.5% Ϯ 0. Plasma concentrations .000 g for 15 min at 4°C.9 128.8 Ϯ 6. alanine transaminase. a central intravenous catheter. reference value: 20 – 60 pg/ml). Patients proceeded to anesthesia and surgery after the BRS experiment was completed. Chicago. A liver function test was carried out using conventional methods and included total bilirubin.68 and 3. Based on the difference between two groups.81 Ϯ 2. usually 5 min. an electrocardiography monitor (lead II). At 50% binding.5% and 6. and an arterial (radial) blood pressure catheter were placed. In control patients. No 3.1 63.10 Because of the extremely short half-life of nitric oxide. potassium. San Carlos.. Baroreflex Sensitivity Measurement Baroreflex sensitivity was measured using a modified Oxford pharmacological method29 before anesthesia on the day of surgery.0 Ϯ 7.7 Ϯ 5.and intraassay variation coefficient was 9. 30 patients in each group were required to reveal a statistically significant difference. Testing was carried out using an intravenous bolus injection of 100 –200 ␮g phenylephrine.g. the inter. respectively.64 Ϯ 2. arterial oxygen and carbon dioxide. Both measures were significantly reduced in patients with jaundice (5.7%. and glucose were all within the normal range in all patients.53 ms/mmHg for the vagal and sympathetic limbs. sodium. and analyzed using an unpaired Student’s t test. and alanine transaminase were significantly higher in patients with jaundice. IL]). The vagal BRS of jaundiced patients and control patients were 5.07 Ϯ 1.. V 111. and the sympathetic BRS were 3. The affinity of the antibody for methionine-enkephalin is 4 ϫ 10Ϫ12 pM. St. Blood pH.6 79.

3). Sympathetic and vagal baroreflex sensitivity in patients with obstructive jaundice versus the controls. Specifically.7 Ϯ 40.1* 38. R2 ‫؍‬ 0. Values are mean ؎ SD. Consequently. Liver Biochemistry and Hormone Levels Control Obstructive Jaundice Total bilirubin (␮M/l) Bile acids (␮M/l) Albumin (g/l) Alanine aminotransferase (U/l) ANP (pg/ml) Met-enkephalin (pg/ml) Plasma nitrate (␮M/l) Values are mean Ϯ SD. The concentrations of plasma nitrate and albumin did not Fig.32 stringent criteria were adopted in the current of methionine-enkephalin and ANP were higher in patients with jaundice as compared with controls. methionine-enkephalin. No 3. (A) Sensitivity of the vagal component of arterial baroreflex in representative subjects. Patients received a bolus nitroprusside injection. plasma total bilirubin. Sep 2009 Fig. pulse interval ‫ ؍‬1.7 Ϯ 4. Pulse interval was plotted against systolic blood pressure (SBP). R2 ‫ ؍‬0. Discussion It is well established that the autonomic function of regulating the cardiovascular system is impaired in primary biliary cirrhosis. P < 0.0 Fig.05 versus the control group.6 Ϯ 7.7 Ϯ 6.6 51. P < 0. pulse interval ‫؍‬ 11. A potential confounding factor in the current study is the presence of tumor in the jaundiced group but not the control group.001.92. a chronic cholestatic liver disease with a probable autoimmune etiology. Anesthesiology. SBP range ‫ ؍‬124 mmHg–103 mmHg. 1.96.OBSTRUCTIVE JAUNDICE AND BAROREFLEX SENSITIVITY 563 Table 2. . V 111.0 243.05 versus the control.0* 121.7 SBP ؊909. (B) Sensitivity of the sympathetic component of arterial baroreflex in representative subjects.3 Ϯ 2.0951– 0. we found significantly decreased sensitivity in both sympathetic and vagal baroreflex as compared with aged match controls. *P < 0.7 28.7 40. Pulse interval was plotted against SBP. alanine transaminase. SBP range ‫ ؍‬137–161 mmHg. Closed circles: Control subject.4 Ϯ 6. Since cachexia caused by neoplasm has been reported to be associated with autonomic dysfunction. ANP ϭ atrial natriuretic peptide.3 209. SBP range ‫ ؍‬126 mmHg–90 mmHg. Patients received a bolus phenylephrine injection. Triangles: Subject with obstructive jaundice.1 Ϯ 6. The slope of the curve reflects the sensitivity of the sympathetic response. R2 ‫ ؍‬0.9* 44. P < 0.4 Ϯ 22.9 Ϯ 42.2 Ϯ 8.65 SBP ؉ 538. SBP range ‫ ؍‬132–158 mmHg. differ between the two groups (table 2). pulse interval ‫ ؍‬6. P < 0. Triangles: Subject with obstructive jaundice.3 22. Pulse interval ‫ ؍‬3. a significant inverse correlation between the plasma ANP concentration and sympathetic BRS in patients with obstructive jaundice was found. 2.92.001.6 4.7* 27.1938 (fig. with R2 of 0.2* 53. and the equation of the regression line was sympathetic BRS (ms/mmHg) ϭ 5.31 Results from the current study for the first time extended these findings to patients with obstructive jaundice.001.008). Closed circles: Control subject. R2 ‫ ؍‬0.91. 10.0 Ϯ 11. and ANP were chosen as possible candidate risk factors associated with impaired BRS of jaundice patients for a multivariate regression analysis.3 Ϯ 126.001. The slope of the curve reflects the sensitivity of the vagal response.4 39. Correlation between the serum atrial natriuretic peptide (ANP) and sympathetic baroreflex sensitivity in patients with obstructive jaundice (P ‫ ؍‬0.0156 ANP (pg/ml). No parameter was associated with vagal BRS. bile acids.31 SBP ؉ 56. * P Ͻ 0.87 SBP ؉ 159. As a result.7 Ϯ 113. 3.7 Ϯ 10.

whereas similar levels of hypotension produced with nitroglycerin provoked an appropriate reflex tachycardic response. which may predispose jaundiced patients to organ hypoperfusion or ischemic events.21 Somewhat surprisingly. Tracey et al. negative correlation between sympathetic BRS and plasma ANP suggested that increased ANP may produce Anesthesiology. in obstructive jaundice. Sep 2009 a relative sympatho-inhibitory action. the changes secondary to liver damage and/or cholestasis may contribute more to autonomic dysfunction than liver damage and/or cholestasis per se. However. endotoxins produce more severe organ damage.41 suggested that abnormalities of heart rate variability and BRS in primary biliary cirrhosis are not specific to advanced disease but associated with fatigue severity. In addition.12 Furthermore. but also minimizes unexplainable or spurious associations. It should be pointed out that the strategy of including only the significant or known variables in the multivariate analysis carries the risk of excluding some potential confounding relations. such as serum alanine transaminase. In fact. sepsis. . in chronic cholestatic liver diseases. This result is consistent with the findings by Padillo et al.11.39 Since endogenous opioids have been implicated in the central inhibition of sympathetic tone and baroreceptor reflexes. The presence of bile products in the blood may diminish cardiac contractility. Consequently.26. mainly through exaggerated release of proinflammatory cytokines. the normal plasma albumin of the jaundiced group indicated a relatively good condition. which in turn may result in increased ANP synthesis through stretching of the atria. recently discovered that an efferent vagus nerve attenuates the development of endotoxin-induced shock by inhibiting the release of proinflammatory cytokines such as tumor necrosis factor. The current study did not confirm the cause-effect relationship between reduced BRS in patients with obstructive jaundice and their susceptibility to hypotensive shock.34 Consistent with previous human and animal studies. bilirubin.20. it is reasonable to attribute impaired BRS in jaundiced patients to extrahepatic biliary obstruction.24 in rabbits with a biliovenous shunt suggests that the passage of bile components to the circulation may be responsible. at least in part. Consequently.35. it is only reasonable to assume that impaired sympathetic BRS would lead to insufficient compensatory responses to hypotension. we were unable to detect a direct correlation between BRS and plasma methionine-enkephalin.37. we hypothesize that decreased vagal BRS in jaundiced patients may.24 we found increased plasma ANP concentration in patients with obstructive jaundice.36 Animal studies have also shown that reflex tachycardia and sympathoexcitation did not occur during hypotension caused by ANP. Newton et al. Decreased vagal BRS may also be a critical contributing factor to the greater susceptibility of these patients to sepsis. a multivariate analysis revealed an inverse relation between plasma ANP and sympathetic BRS in jaundiced patients. The lack of relationship between BRS and liver function in patients with obstructive jaundice suggests that reduced BRS may be the result of pathologic processes (such as increased ANP in circulation) to which obstructive jaundice acts as a permissive factor or cofactor in some way. or multiple organ failure. Keresztes et al. risk factors underpinning the impairment of BRS warrant further study. In other words. acute renal failure. In addition to diuresis and vasodilation. in patients with obstructive jaundice. we also found an increased level of circulating methionine-enkephalin in patients with obstructive jaundice.22. For example. Regarding the cause of increased ANP. However.33 Su et al.27 elevated methionine-enkephalin may have also contributed to observed BRS dysfunction in patients with obstructive jaundice in the current study. at least in part. No 3. a previous study by Martı ´nez-Ro ´ denas et al.13. Indeed. results in impaired sympathetic BRS in jaundiced patients. we did not find changes in plasma nitrate levels in patients with obstructive jaundice.14 Using a rodent model. Endotoxemia is a frequent condition that accompanies obstructive jaundice as a result of increased endotoxin absorption from the intestinal lumen and decreased clearance by the hepatic reticuloendothelial system. Also. result in an endotoxin hypersensitivity state of cholestatic host that eventually leads to multiple organ damage. association between autonomic dysfunction and disease severity has not been confirmed. study to minimize this factor. in jaundiced patients.42 showed that risk factors for autonomic dysfunction include duration and severity of primary biliary cirrhosis but not markers of cholestasis. This hypothesis is consistent with the previous findings that the presence of vagal neuropathy is an independent predictor for reduced survival in patients with chronic liver diseases.40 but not studies using rodent models of acute cholestasis. or other hemodynamic disturbances in the perioperative period. we did not find a significant correlation between impaired BRS and blood biochemical measures indicative of liver damage and/or the degree of jaundice.10 In addition. which. a correlation between subclinical myocardial dysfunction and increased ANP was found in patients with obstructive jaundice.28 Several human studies demonstrated that infusion of exogenous ANP lowers the activity of sympathetic but not parasympathetic nerves.564 SONG ET AL. which is consistent with previous reports in cholestatic rodents and patients.38 Thus. or bile acids. rather than a direct consequence of jaundice itself. and not the systemic effects of the tumors. ANP also influences sympathetic nervous outflow. In addition. V 111.19 Based on these findings.10. blood loss. observed a significant correlation between vagal BRS and survival time in rat models of experimental sepsis induced by lipopolysaccharide18 or cecal ligation and puncture.

O’Neill TP. 297:1241–2 40. pp 3–57 16. Br J Surg 1998. Utkan T. 254:R590–4 36. Ebrahimi F. Dios F. Varga P. Folhoffer A. Reinhart DJ. Allen J. Gubern JM. Nakamura M: alpha-ANP alters reflex control of lumbar and renal sympathetic nerve activity and heart rate. Tanaka M. References 1. 11:447–9 7. Wauer H. Nishikawa T: Moderate hypothermia depresses arterial baroreflex control of heart rate during. 405:458–62 34. Sewnath ME. Lakatos PL. Ann Surg 2002. Martı ´nez-Ro ´ denas F. Sitges-Serra A: Multivariate analysis of factors associated with renal dysfunction in patients with obstructive jaundice. 21: 556–60 19. Shen FM. Clin Exp Pharmacol Physiol 2000. Br J Surg 2005. Support Care Cancer 2002. Pairman J. 164:287–93 4. Borhani AA. Chesterton LJ. Jones EA: Endogenous opioids accumulate in plasma in a rat model of acute cholestasis. 63: 443–9 29. Franch G. Cruz A. Newton JL. Szilagyi JE: Endogenous opiate modulation of baroreflexes in normotensive and hypertensive rats. Shen FM. Van Der Poll T. Nagasaki G. Guan YF. Gallardo JM. ANESTHESIOLOGY 1994. Shock 2004. 31:65–72 31. general anesthesia in humans. Boonyaprapa S. Gubern JM: Body water compartments in patients with obstructive jaundice. Miyawaki T. Gillett DJ: The effect of obstructive jaundice on the blood volume in rats. Neuron 1998. Watkins LR. Finberg JP. Chu ZX. Takeshita A. Am J Physiol 1986. Tavakoli S. the present study demonstrated that both the sympathetic and vagal components of arterial baroreflex are depressed in patients with obstructive jaundice. Morgan DA. Ann Surg 2001. Sep 2009 . Rothman RB. Cowley AW Jr: Atrial natriuretic factor attenuates carotid baroreflex-mediated cardioacceleration in humans. Ebert TJ. Shafaroodi H. Eur Surg Res 1987. Clin Exp Med 2003. 181:567–81 3. Imaizumi T. Eaton JW. Pilowsky PM: Activation of mu-opioid receptors in rat ventrolateral medulla selectively blocks baroreceptor reflexes while activation of delta opioid receptors blocks somato-sympathetic reflexes. Phornphutkul K. 19:207–16 13. Syrop HA. Botchkina GI. Kox WJ: High and low response in relation to nitric oxide formation but not to lipid peroxidation in patients with sepsis. Ivanova S. Nelson KA: Autonomic nervous system dysfunction in advanced cancer. Am J Physiol 1988. Kuppe H. 27:339–44 9. Lumlertgul D. Szalay F: Autonomic and sensory nerve dysfunction in primary biliary cirrhosis. Sewnath ME. Jime ´nez W. Gaskari SA. The underlying mechanisms for such a change may be associated with increased level of plasma ANP. Thanachaikun N. ten Kate FJ. Rege RV: Adverse effects of biliary obstruction: Implications for treatment of patients with obstructive jaundice. 10:523–8 33. Zhang M. V 111. and sepsis in patients with obstructive jaundice during the perioperative period. Rauws EA. Lee HC. Kerr S. Vallejo JA. Ten Kate FJ. Hendrickse MT. Pera-Madrazo C. Bailey ME: Measurement of operative plasma endotoxin levels in jaundiced and non-jaundiced patients. Hepatology 2007. Gouma DJ: A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Polychronidis A. Swain MG. J Am Soc Nephrol 1995. and delays its recovery after. Prins MH. Gouma DJ: Inflammatory and immunologic effects of obstructive jaundice: Pathogenesis and treatment. 80:326–37 18. Schunkert H: Interactions between the sympathetic nervous system and the cardiac natriuretic peptide system. 50:162–7 20. Riazi K. ANESTHESIOLOGY 2001. Csak T. Bates JN. 14:586–91 17. 31:93–100 21. Mani AR. Hepatology 2002. 35:149–58 14.OBSTRUCTIVE JAUNDICE AND BAROREFLEX SENSITIVITY 565 In conclusion. 79:553–6 6. Martin-Malo A. Padillo J. Pitiakoudis M. Sitges-Serra A: Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: Hemodynamic and hormonal assessment. 92:1388–92 41. Lancet 1992. Gouma DJ: Cholestatic interleukin-6-deficient mice succumb to endotoxin-induced liver injury and pulmonary inflammation. Eckberg DL. 95:51–5 30. 103:630–5 23. Ebert TJ: Reflex activation of sympathetic nervous system by ANF in humans. Xu H. Karsten TM. Tachtatzis P. McIntyre CW: The assessment of baroreflex sensitivity in patients with chronic kidney disease: Implications for vasomotor instability. 13:15–22 10. Shi KY. Piera C. Br J Surg 1992. van Noorden CJ. Yang H. 10:3039–43 Anesthesiology. Martı ´nez-Ro ´ denas F. Houshmand G. Liver Int 2006. Xie HH. 234:652–6 11. Cardiovasc Res 2004. AJR Am J Roentgenol 1995. Namiranian K. Papakostas C. Higashi H. Pereira JA. Li Z. Nature 2000. 1992. Am J Physiol 1988. J Am Coll Surg 1995. Van Noorden CJ. Oxford. Keoplung M: The jaundiced heart: Evidence of blunted response to positive inotropic stimulation. 20:1039–49 26. Naranjo A. Rauws EJ. Giesecke AH: Autonomic reflex dysfunction in patients presenting for elective surgery is associated with hypotension after anesthesia induction. Bezirtzoglou E. Ahmadi SH. 255:H685–9 37. Bunnachak D. Min ˜ o G. Sarioglu Y. Reduced BRS may. Go ¨ nu ¨ llu ¨ NN: Effects of experimental obstructive jaundice on contractile responses of dog isolated blood vessels: Role of endothelium and duration of bile duct ligation. Puente J. Abumrad N. Burt JA. Mark AL. Bielefeldt K. Dehpour AR: Contribution of endogenous opioids and nitric oxide to papillary muscle contractile impairment in cholestatic rats. Su DF: The survival time post-cecal ligation and puncture in sinoaortic denervated rats. Schimke I. Sadeghipour H. 109:133–44 28. Gouma DJ: Interleukin-1 receptor type I gene-deficient bile duct-ligated mice are partially protected against endotoxin. Sitges-Serra A: Increased plasma levels of atrial natriuretic peptide and endocrine markers of volume depletion in patients with obstructive jaundice. Homayoun H. Am J Respir Crit Care Med 2004. Pain JA. Istenes I. 5:1853–71 2. 255:H987–91 27. Utkan ZN. Needleman P. Newton JL. Abboud FM: Nitric oxide as an autocrine regulator of sodium currents in baroreceptor neurons. Tracey KJ: Vagus nerve stimulation attenuates the systemic inflammatory response to endotoxin. van Deventer SJ. Wennmalm A. England: Clarendon Press. Su DF: Arterial baroreflex function determines the survival time in lipopolysaccharide-induced shock in rats. Curr Opin Nephrol Hypertens 2005. renal failure. Thore ´n P. Bergasa NV. BMJ 1988. Walsh D. Sitges-Serra A. Carulla X. 253:H1136–40 38. Thuluvath PJ. Pera C. Obertop H. 339:1462–4 35. Latson TW. Bricen ˜ o J. Rohr U. Clin Sci (Lond) 1981. Jones DE: Reduced heart rate variability and baroreflex sensitivity in primary biliary cirrhosis. Sitges-Serra A: Circulating bile is the main factor responsible for atrial natriuretic peptide release in experimental obstructive jaundice. Am J Physiol 1988. Ahmadi H. Thornton JR. Am J Physiol 1987. Hudson M. 85:480–4 25. Go ´ mez M. Martı ´n-Malo A. 45:1496–505 32. Pera C. Ejtemaei-Mehr S. Liu AJ. J Surg Res 1971. No 3. Chapleau MW. Borovikova LV. Triger DR: Natural history of autonomic neuropathy in chronic liver disease. Pereira J. Luchner A. Petersson AS. 26:197–202 42. Cao YL. Vergalla J. 251:H1252–9 39. Goodchild AK. J Cardiovasc Pharmacol 2007. Sutcliffe K. Richter N. 85:28–31 24. World J Gastroenterol 2004. Horvath A. Hajrasouliha AR. van der Poll T. Ren Fail 1991. Eur J Pharmacol 2005. Gastroenterology 1992. Padillo FJ. Praisontarangkul OA. Obertop H. Ashmore TH. Simopoulos C: Endotoxinemia in the portal and the systemic circulation in obstructive jaundice. 169:413–20 15. Green J. 3:124–8 12. Crit Care Med 2003. Br J Surg 1998. 16: 273–9 22. Brody MJ: Activation of vagal depressor reflexes by atriopeptins inhibits renal sympathetic nerve activity. Losowsky MS: Plasma methionine enkephalin concentration and prognosis in primary biliary cirrhosis. Kimmings AN. at least in part. contribute to enhanced susceptibility to hypotensive shock. Dehpour AR: Do endogenous opioids contribute to the bradycardia of rats with obstructive cholestasis? Fundam Clin Pharmacol 2002. Wang H. Neuroscience 2002. Min ˜ o G. Kempler P. 61:535–9 8. Padillo J. Better OS: Systemic hypotension and renal failure in obstructive jaundice-mechanistic and therapeutic aspects. Sleight P: Human Baroreflexes in Health and Disease. Keresztes K. Better OS: Blunted pressor response to angiotensin and sympathomimetic amines in bile-duct ligated dogs. Klein KW. 236:17–27 5. Jones DE: Population prevalence and symptom associations of autonomic dysfunction in primary biliary cirrhosis. Sewnath ME.

Chelerythrine and bisindolylmalemide IX. M. Ph. (Temecula. and ␤-amyloid.D. University of Virginia Health System. 111:566 –73 Copyright © 2009. Epstein Professor. No 3. Maryland (to Dr. were purchased from the American Type Culture Collection (Manassas. Ph. M. Isoflu566 Anesthesiology. coli were purchased from Invitrogen Corporation (Carlsbad. Nitrite production.6 macrophages. Ohio (to Dr. Received from the Department of Anesthesiology.. Submitted for publication September 17. and neurodegenerative diseases. protein kinase C inhibitors. a commonly used combination to simulate clinical situations of endotoxemia and the subsequent inflammation. and by Grant-in-Aid 0755450U from the American Heart Association Mid-Atlantic Affiliate. brain infection. phage-like cells resided in brain and play an important role in brain inflammatory reactions and host defense. Conclusions: These results suggest that delayed isoflurane treatment can reduce lipopolysaccharide and IFN␥-induced activation and injury of microglial cells. Department of Anesthesiology. Drs. For example. † Postdoctoral Research Fellow.Anesthesiology 2009. 2009.8. Charlottesville. but not at 1 or 3%. Delayed Treatment with Isoflurane Attenuates Lipopolysaccharide and Interferon ␥–induced Activation and Injury of Mouse Microglial Cells Jie-Ae Kim.1.‡ Background: Isoflurane pretreatment can induce protection against lipopolysaccharide and interferon ␥ (IFN␥)–induced injury and activation of mouse microglial cells. reduced the lipopolysaccharide and IFN␥-induced nitrite production and decreased cell viability. VA).D.† Zhiyi Zuo.5-diphenyltetrazolium bromide (MTT)-based colorimetric assay kit was obtained from Chemicon International. Sungkyunkwan University. Results: Isoflurane applied 0 and 2 h after the initiation of lipopolysaccharide and IFN␥ stimulation improved cell viability.anesthesiology. These effects may be mediated by protein kinase C. Isoflurane also decreased lipopolysaccharide-induced iNOS expression in mouse brain. CA). Zuo: Department of Anesthesiology. also attenuated this decreased cell viability. Griess Reagent Kit (G7921).10 In this study.D. School of Medicine. Virginia 22908-0710. Inc. INFLAMMATION is an underlying pathophysiological process for almost all of the human diseases acquired later in life. stroke.9 We recently showed that isoflurane applied during reperfusion reduced infarct volumes and improved neurologic functions after brain ischemia in rats. it is recognized that inflammatory process is involved in a broad range of common human brain diseases. a microglial clone isolated from 8-day-old mouse cerebellum. Zuo). the American Society of Anesthesiologists. Bethesda. Charlottesville.. Pretreatment with anesthetics. Ph. Korea.4 This pretreatment-induced protection may be useful if we can predict the occurrence of endotoxemia and severe inflammation.edu. 1 Hospital Drive. Also. The iNOS expression in mouse brain was also studied. can reduce endotoxin-induced lung injury5 and injury of endothelial cells. Charlottesville. Late isoflurane application to microglial cells reduced lipopolysaccharide and IFN␥-induced lactate dehydrogenase release that was not inhibited by aminoguanidine. to produce cytokines and to express inducible nitric oxide synthase (iNOS).. MO). Inc. Zuo).D.7 and microglia. University of Virginia. Aminoguanidine. it has been shown that anesthesia with isoflurane decreases lipopolysaccharide-induced inflammatory responses and improves survival of rats and mice with endotoxic shock... by a grant (2007 Frontiers in Anesthesia Research Award) from the International Anesthesia Research Society. such as isoflurane.8 Materials and Methods Materials C8-B4 cells (CRL-2540). M. This study’s goal was to determine whether delayed isoflurane treatment is protective.5dimethylthiazol-2-yl)-2. Louis.4. Rabbit polyclonal anti-iNOS immunoglobulin G whose epitope is at the C-terminus of iNOS was obtained from Santa Cruz Biotechnology (Santa Cruz. We used mouse microglial cultures and stimulated them by lipopolysaccharide plus interferon-␥ (IFN␥).* Liaoliao Li. catalogue number: sc650). and recombinant rat interferon ␥ (IFN␥) produced from E. Methods: Mouse microglial cells were exposed to various concentrations of isoflurane for 1 h immediately after the initiation of lipopolysaccharide (10 or 1000 ng/ml) and IFN␥ (10 U/ml) stimulation or to 2% isoflurane for 1 h at various times after initiation of the stimulation. Samsung Medical Center.D. Information on purchasing reprints may be found at www. and cell viability measured by 3-(4. Maryland (to Dr. V 111. PO Box 800710. such as brain trauma. Kim and Li contributed equally to the work. University of Virginia. we hypothesize that delayed treatment with isoflurane can induce a protective effect in microglial cells. CA. zz3c@virginia. Baltimore. Zuo). Supported by grants GM065211 and NS045983 from the National Institute of Health. Isoflurane at 2%. an iNOS inhibitor. Lipopolysaccharide from Escherichia coli 0111:B4 and other chemicals except for those described below were obtained from Sigma-Aldrich (St. which then induce inflammatory and host defense reactions that can cause death of brain cells or affect their functions. Sep 2009 . CA). such as bacterial products. lactate dehydrogenase release.D.5-dimethylthiazol-2-yl)-2. 6 months from the cover date of the issue.2– 4 Despite these prominent roles of microglia. Lippincott Williams & Wilkins. for personal use only. ANESTHESIOLOGY’s articles are made freely accessible to all readers.10 This isoflurane posttreatment-induced neuroprotection was also apparent under in vitro conditions. The 3-(4.5-diphenyltetrazolium bromide assay were assessed after stimulation with lipopolysaccharide and IFN␥ for 24 h. Virginia. Address correspondence to Dr. 2008. Inc. Virginia. ‡ Robert M. abolished isoflurane effects on cell viability and iNOS expression after lipopolysaccharide and IFN␥ application. Virginia. Cleveland. and Department of Anesthesiology and Pain Medicine. virus.2 Microglial cells are macro* Visiting Scholar/Postdoctoral Research Fellow. Charlottesville. University of Virginia. Department of Anesthesiology. Seoul.org or on the masthead page at the beginning of this issue.2 These cells can be activated by various agents. Inducible nitric oxide synthase (iNOS) protein expression was quantified by Western blotting. Accepted for publication May 11. Heat inactivated fetal bovine serum. we know very little about how to reduce microglial activation and preserve these cells to provide neuroprotection under various pathologic conditions in the brain.

the culture media (150 ␮l).7 the aqueous isoflurane concentrations at 37°C were 209. Helsinki. Three hours after the cells were plated. Hercules. containing 1 mM EDTA.4 C8-B4 cells were cultured in Dulbecco Modified Eagle’s Medium containing 4 mM L-glutamine. Cells or cerebral cortices of animals after various conditions were harvested and homogenized in 25 mM TRIS hydrochloride. Western Blot Analysis. Nitrite Concentration Measurement.4 N HCl was added and thoroughly mixed in each well. and their brain cortices were harvested for Western blotting. Chelerythrine chloride (2 ␮⌴) or bisindolylmaleimide IX (10 ␮⌴). an iNOS inhibitor. The animals were killed at 6 h after the lipopolysaccharide injection. protein kinase C (PKC) inhibitors. At the end of the 1-h incubation time. 16.000 ng/ml (IFN␥ was still at 10 U/ml) in the LDHrelease experiments because our preliminary study showed that this combination of lipopolysaccharide and IFN␥ induced a significant release of LDH. The culture media collected from 6-well plates with the cells treated with various conditions were centrifuged. equal volumes of N-(1-naphthyl)ethylenediamine and sulfanilic acid were mixed to form Griess reagent immediately before experiments. Cell Viability Assay. The isoflurane concentrations in the gases from outlet of the chambers were monitored with a Datex infrared analyzer (Capnomac. Cell Culture. The values from various treatments were then calculated as percentages of the controls. The cells were plated at a density of 4-5 ϫ 104 cells/ml on 96-well tissue culture plates for viability experiments by MTT assay and LDH release experiments and plated at a density of 2 ϫ 104 cells/ml in 6-well plates for other experiments. 1 mM EGTA. 100 U/ml penicillin. Two-month old C57Bl/6 male mice received intraperitoneal injection of 4 mg/kg lipopolysaccharide or saline (control mice). After formation of black fuzzy crystals. CA). or nitrite measurement at 24 h after the initiation of lipopolysaccharide and IFN␥ stimulation. 2. The cells and/or incubation solution were harvested for viability assay. 8. IL). One hour later. As we described before. Sep 2009 delivered. was added to some cells for 24 h during lipopolysaccharide and IFN␥ application. These cells were not treated with isoflurane. and 100 pg/ml streptomycin in a humidified atmosphere of 95% air–5% CO2 at 37°C. This isoflurane exposure condition was chosen because our preliminary study showed that a higher concentration (2% isoflurane) or a longer incubation (1 h) significantly altered the arterial blood gases (most animals had a PaCO2 greater than 60 mmHg and a PaO2 less than 50 mmHg at the end of the exposure). Cells plated on 96-well plates were gently mixed with 10 ␮l of MTT solution and incubated for 3 h at 37°C. The results of MTT measurements from the controls without any treatments were set as 1. They were then placed immediately or at 2 h after the lipopolysaccharide injection in an airtight chamber that was continuously gassed with air containing 1.5% isoflurane for 30 min.11 The chamber was gassed with 95% air–5% CO2 through or not through an isoflurane vaporizer for 10 min at 37°C. and 23 h after the addition of lipopolysaccharide and IFN␥ to the incubation medium. and 3% isoflurane was Anesthesiology. the absorbance of samples was measured at 570 nm with the reference wavelength of 650 nm by using a microplate reader (Bio-Rad Laboratories.4. 4. 100 ␮l of isopropanol with 0. The absorbance of samples was measured at 570 nm against a standard curve in a spectrophotometry (Bio-Rad Laboratories). and deionized water (130 ␮l) were mixed in 96-well plates and incubated in the dark for 30 min at room temperature. or 3% isoflurane was applied. Isoflurane Exposure and Application of Chemicals. The amounts of lipopolysaccharide and IFN␥ applied were based on our previous experiment. as measured by gas chromatography when 1. and 620 ␮M. respectively. The cells were then removed from the chamber and were kept under isofluorane-free conditions for the rest times of incubation with lipopolysaccharide and IFN␥. Griess reagent (20 ␮l).4. Isoflurane was applied for 1 h immediately after the addition of lipopolysaccharide and IFN␥ to the incubation medium except for the time window experiment that isoflurane was applied at 0. the incubation solutions were replaced with fresh medium not containing these reagents after isoflurane application and before the reexposure to lipopolysaccharide and IFN␥. No 3. Isoflurane exposure was performed in an airtight chamber as we described previously. The medium was changed every 3 days. 415. CA). In these cases. 2. As we described before. Aminoguanidine (10 ␮⌴). 4. To detect the concentrations of nitrite. and 1. PA).1% (vol/vol) ␣-mer- . and the samples were taken for measurements at the end of the 1-h isoflurane incubation.DELAYED ISOFLURANE TREATMENT AND MICROGLIA 567 rane was purchased from Abbott Laboratories (North Chicago. 1 mM sodium pyruvate. 2. Chelerythrine chloride and bisindolylmaleimide IX (R8220) were obtained from Biomol (Plymouth Meeting. Two percent isoflurane was used except for the isoflurane dose-response experiment in which 1. pH 7. Similar procedure (incubation medium changing) was applied to other experimental groups in this set of experiments. they were exposed to 10 ng/ml lipopolysaccharide and 10 U/ml IFN␥ for 24 h.500 mg/l sodium bicarbonate supplemented with 10% heat-inactivated fetal bovine serum. V 111.4 Lipopolysaccharide concentration was increased to 1.500 mg/l glucose. In Vivo Animal Studies. Finland) and reached the target concentrations at 3 min after the onset of gassing. were added to the incubation medium during isoflurane application. a stable oxidation product of nitric oxide. 0. isoflurane concentrations in the gases from outlet of the chamber were confirmed to be at the target concentrations. Lactate dehydrogenase (LDH) activity assay kit was from Clontech Laboratory (La Jolla. LDH activity assay.

568 captoethanol, 1 ␮M phenylmethylsulfonyl fluoride, 2 ␮M leupeptin, and 1 ␮M pepstatin A.2 The homogenates were centrifuged at 14,000 g for 10 min at 4°C. The supernatants were used for Western blotting, and 40 ␮g of proteins were loaded to each lane. After incubation with the anti-iNOS or anti–␤-actin antibody, the protein bands were visualized by the enhanced chemiluminescence reaction. The protein bands were densitometrically analyzed by an ImageQuant 5.0 densitometer (Amersham Biosciences, Piscataway, NJ). The results of iNOS protein bands were normalized by the data of the corresponding ␤-actin. The results of cells treated with various conditions were then normalized by the data of cells exposed to lipopolysaccharide and IFN␥ only. The results of animals treated with various conditions were then normalized by the mean value of control animals. These different normalization procedures were used for cell culture and animal studies because microglial cell cultures without exposure to lipopolysaccharide and IFN␥ did not express iNOS. LDH Activity Assay. Incubation solution of the microglial cells treated with various conditions was centrifuged at 1,000g for 10 min, and the cell-free supernatant was transferred to 96-well plates. The 100 ␮l of supernatant was incubated with the same amount of reaction mixture from the LDH detection kit. LDH activity was determined by a colorimetric assay. The absorbance of samples was measured at 492 nm, with the reference wavelength of 655 nm in a spectrophotometry (Bio-Rad Laboratories). Background absorbance from the cell-free buffer solution was subtracted from all absorbance measurements. After removal of the incubation solution from cells, 1% triton X-100 lysing solution was applied to the cells. The percentage of LDH released to incubation solution in total LDH was calculated: 100 ϫ LDH in the incubation solution/(LDH in the incubation solution ϩ intracellular LDH released by triton X-100). Data Analysis. Each experimental condition was repeated multiple times (n for each condition is described in the figure legends) by using at least three different batches of cells. At least seven animals were used for each experimental condition in the in vivo study. Data are expressed as mean Ϯ SD. Statistical analyses were performed by one-way analysis of variance followed by the Tukey test for post hoc analysis or by Student t test for comparisons between lipopolysaccharide plus IFN␥ alone and the corresponding control in the time course studies involving MTT or LDH release assay. P Ͻ 0.05 was considered as statistically significant.

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Fig. 1. Protective effects of isoflurane and aminoguanidine (AG) on cell viability. (A) Time window of delayed isoflurane treatment. The mouse C8-B4 microglial cells were incubated with 10 ng/ml lipopolysaccharide (LPS) and 10 U/ml interferon ␥ (IFN␥) for 24 h. Cells were exposed to 2% isoflurane for 1 h at 0, 2, 4, 8, 16, and 23 h after the initiation of the lipopolysaccharide and IFN␥ stimulation. Cell viability was measured using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Results are mean ؎ SD (n ‫ ؍‬10 –15). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only. Iso-post ‫ ؍‬2% isoflurane posttreatment. (B) Dose-response of isoflurane effects on cell viability. The mouse C8-B4 microglial cells were incubated with 10 ng/ml lipopolysaccharide and 10 U/ml IFN␥ for 24 h. Cells were exposed to 1, 2, or 3% isoflurane for 1 h immediately after the initiation of the lipopolysaccharide and IFN␥ stimulation. Results are mean ؎ SD (n ‫ ؍‬8). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only. (C) AG effect. The mouse C8-B4 microglial cells were incubated with or without 10 ng/ml lipopolysaccharide and 10 U/ml IFN␥ in the presence or absence of 10 ␮M AG for 24 h. Results are mean ؎ SD (n ‫ ؍‬9). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only.

Results
Delayed Treatment with Isoflurane-induced Time- and Concentration-dependent Protection Lipopolysaccharide and IFN␥ application reduced the cell viability to 70 Ϯ 6% of control as measured by MTT
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assay. Two percent isoflurane applied at 0 and 2 h after the lipopolysaccharide and IFN␥ application enhanced the cell viability to 94 Ϯ 4% and 79 Ϯ 4%, respectively (both P Ͻ 0.05 compared with lipopolysaccharide and IFN␥ alone). However, delayed application of isoflurane at 4 h or longer after the addition of lipopolysaccharide and IFN␥ did not improve the cell viability (fig. 1A). Concentration-response study showed that isoflurane at 2%, but not at 1% or 3%, applied immediately after the initiation of lipopolysaccharide, and IFN␥ stimulation improved cell viability (fig. 1B). Consistent with our previous study,4 the lipopolysaccharide and IFN␥induced reduction of cell viability was abolished by aminoguanidine (fig. 1C), an iNOS inhibitor, suggesting the role of iNOS in this lipopolysaccharide and IFN␥ effect.

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Fig. 2. Inhibition of isoflurane (Iso) protection by protein kinase C inhibition. The mouse C8-B4 microglial cells were incubated with 10 ng/ml lipopolysaccharide (LPS) and 10 U/ml interferon ␥ (IFN␥) for 24 h. Cells were exposed to 2% isoflurane for 1 h immediately after the initiation of the lipopolysaccharide and IFN␥ stimulation. Chelerythrine chloride (Che, 2 ␮⌴) or bisindolylmaleimide IX (Bis IX, 10 ␮⌴) were present during isoflurane exposure. Cell viability was measured using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Results are mean ؎ SD (n ‫ ؍‬15). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only. # P < 0.05 compared with isoflurane and lipopolysaccharide plus IFN␥.

PKC May Mediate the Delayed Isoflurane Treatment-caused Attenuation of Lipopolysaccharide Plus IFN␥-induced Decrease of Microglial Viability Although chelerythrine chloride and bisindolylmaleimide IX, two PKC inhibitors, did not affect cell viability in the presence of lipopolysaccharide and IFN␥, these PKC inhibitors abolished the protective effects of isoflurane on microglial viability after the application of lipopolysaccharide and IFN␥ (fig. 2). PKC May Mediate the Delayed Isoflurane Treatment-caused Attenuation of Lipopolysaccharide Plus IFN␥-induced iNOS Expression The microglial cell cultures did not express iNOS under normal culture conditions (fig. 3A). Lipopolysaccharide and IFN␥ induced a large amount of iNOS expression. This iNOS expression was inhibited by isoflurane applied immediately or at 2 h, but not at 8 h, after the initiation of the lipopolysaccharide and IFN␥ stimulation (fig. 3). Chelerythrine chloride and bisindolylmaleimide IX did not affect the iNOS expression in cells exposed to lipopolysaccharide and IFN␥. However, chelerythrine chloride and bisindolylmaleimide IX abolished the isoflurane-induced inhibition of iNOS expression stimulated by lipopolysaccharide and IFN␥ (fig. 3). Consistent with the results/effects of isoflurane on iNOS protein expression, 2% isoflurane reduced the production of nitrite after lipopolysaccharide and IFN␥ stimulation (fig. 4).
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Fig. 3. Effects of isoflurane (Iso) and protein kinase C inhibition on inducible nitric oxide synthase (iNOS) expression in microglial cells. The mouse C8-B4 microglial cells were incubated with 10 ng/m lipopolysaccharide (LPS) and 10 U/ml interferon ␥ (IFN␥) for 24 h. Cells were exposed to 2% isoflurane for 1 h immediately [Iso(0 h)] (A), 8 h [Iso(8 h)] (A), or 2 h [Iso(2 h)] (B) after the initiation of the lipopolysaccharide and IFN␥ stimulation. Chelerythrine chloride (Che, 2 ␮⌴) or bisindolylmaleimide IX (Bis IX, 10 ␮⌴) was present during isoflurane exposure. These cells and the cells that were not exposed to isoflurane or lipopolysaccharide plus IFN␥ (normal culture) were harvested for Western blotting. Results are mean ؎ SD (n ‫ ؍‬9 for A and 12 for B). * P < 0.05 compared to lipopolysaccharide plus IFN␥ only. ˆ P < 0.05 compared with isoflurane and lipopolysaccharide plus IFN␥.

Delayed Isoflurane Treatment Also Attenuated Lipopolysaccharide Plus IFN␥-induced iNOS Expression in the Mouse Brain To determine the effects of isoflurane on lipopolysaccharide-induced iNOS expression in the mouse brain

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Fig. 4. Dose-response of isoflurane effects on nitrite production. The mouse C8-B4 microglial cells were incubated with 10 ng/ml lipopolysaccharide (LPS) and 10 U/ml of interferon ␥ (IFN␥) for 24 h. Cells were exposed to 1, 2, or 3% isoflurane for 1 h immediately after the initiation of the lipopolysaccharide and IFN␥ stimulation. The culture medium was collected for nitrite measurement. Results are mean ؎ SD (n ‫ ؍‬15). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only.

under in vivo condition, we first identified an isoflurane exposure condition that would not severely alter the arterial blood gases in mice without tracheal intubation and mechanic ventilation. The mouse arterial blood pH, PaCO2 and PaCO2 were 7.26 Ϯ 0.05, 56 Ϯ 13, and 96 Ϯ 27 (n ϭ 5), respectively, at the end of the exposure to 1.5% isoflurane for 30 min. We chose this isoflurane exposure condition for further experiment. Similar to our in vitro experiments, lipopolysaccharide injection significantly increased iNOS expression in the cerebral cortex. This increased iNOS expression was also inhibited by the exposure to 1.5% isoflurane for 30 min applied immediately or 2 h after the lipopolysaccharide injection (fig. 5). Delayed Isoflurane Treatment Attenuated iNOS-independent Microglial Injury after Lipopolysaccharide Plus IFN␥ Application Lipopolysaccharide and IFN␥ caused a significant LDH release from microglial cell cultures (fig. 6A), suggesting that lipopolysaccharide and IFN␥ induced microglial injury. Interestingly, this increased LDH release was abolished by isoflurane applied at later time points (8, 16, and 23 h after the addition of lipopolysaccharide and IFN␥), but it was not affected by isoflurane applied at early time points (fig. 6A). Further study showed that lipopolysaccharide and IFN␥ caused more LDH release than control condition only after application of lipopolysaccharide and IFN␥ for longer than 12 h (fig. 6B). In addition, the lipopolysaccharide and IFN␥-induced LDH release was not affected by aminoguanidine (fig. 6C).

Fig. 5. Effects of isoflurane (Iso) on inducible nitric oxide synthase (iNOS) expression in mice. C57Bl/6 mice received an intraperitoneal injection of 4 mg/kg lipopolysaccharide (LPS) and exposed to 1.5% isoflurane for 30 min immediately [Iso(0 h)] or 2 h [Iso(2 h)] after the injection. Cerebral cortex was harvested at 6 h after lipopolysaccharide injection for Western analysis. Results are mean ؎ SD (n ‫ ؍‬7– 8). * P < 0.05 compared to control. ˆ P < 0.05 compared with lipopolysaccharide alone group.

Discussion
Similar to our previous study,4 the incubation of microglia with lipopolysaccharide and IFN␥ reduced cell
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viability. It has been well-established that lipopolysaccharide and IFN␥ can stimulate/activate microglial cells to express iNOS.3,4,12 We have shown that this increased iNOS expression contributes to microglial damage caused by lipopolysaccharide and IFN␥.4 Consistent with our previous findings, we showed that aminoguanidine, an iNOS inhibitor, abolished the decreased viability of microglial cells after lipopolysaccharide and IFN␥ application. The lipopolysaccharide and IFN␥-reduced microglial viability was dose-dependently attenuated by isoflurane that was applied immediately after the application of lipopolysaccharide and IFN␥. This protection existed when isoflurane was applied even at 2 h after the application of lipopolysaccharide and IFN␥. These results suggest that delayed treatment with isoflurane can induce a protective effect in microglia. Isoflurane exposure immediately or at 2 h after the application of lipopolysaccharide and IFN␥ also decreased the lipopolysaccharide and IFN␥-induced iNOS expression and nitrite production. These results, along with the knowledge that iNOS plays a critical role in damaging microglial cells after stimulation with lipopolysaccharide and IFN␥,4,12 indicate that the mechanisms for protection provided by delayed treatment with isoflurane involve decreasing lipopolysaccharide and IFN␥-induced iNOS expression. Consistent with these in vitro cell culture results, our studies also showed that delayed isoflurane treatment also inhibited lipopolysaccharide-induced iNOS expression in the mouse brain. This finding is significant be-

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Fig. 6. Protective effects of isoflurane on lipopolysaccharide (LPS) and interferon ␥ (IFN␥)-induced cell injury. (A) Time window of delayed isoflurane treatment. The mouse C8-B4 microglial cells were incubated with 1000 ng/ml lipopolysaccharide and 10 U/ml IFN␥ for 24 h. Cells were exposed to 2% isoflurane for 1 h at 0, 2, 4, 8, 16, and 23 h after the initiation of the lipopolysaccharide and IFN␥ stimulation. Cell injury was quantified by lactate dehydrogenase (LDH) release assay. Results are mean ؎ SD (n ‫ ؍‬20 – 42). * P < 0.05 compared to control. ˆ P < 0.05 compared to lipopolysaccharide plus IFN␥ only. Iso-post ‫ ؍‬2% isoflurane posttreatment. (B) Time course of LDH release. The mouse C8-B4 microglial cells were incubated with or without 1,000 ng/ml lipopolysaccharide and 10 U/ml IFN␥ for 0, 2, 4, 8, 16, and 23 h. The incubation solution and the cells were harvested for LDH activity assay. The actual mean values for each time point (n ‫ ؍‬4 – 6) from the experiments and the 95% confidence interval are presented. (C) Aminoguanidine (AG) effect. The mouse C8-B4 microglial cells were incubated with or without 1,000 ng/ml lipopolysaccharide and 10 U/ml IFN␥ in the presence or absence of 10 ␮M AG for 24 h. Results are mean ؎ SD (n ‫ ؍‬18 –24). * P < 0.05 compared to control.

cause volatile anesthetic effects on iNOS expression in the brain under in vivo conditions have not been reported. Although it is not known from our study in which cell types isoflurane treatment decreased iNOS expression, it has been shown that microglial cells are the primary cells expressing iNOS in rodent brains after lipopolysaccharide stimulation.13,14 This knowledge, along with our results, suggests that delayed isoflurane treatment can also decrease lipopolysaccharide-induced iNOS expression in the microglial cells of mouse brain. PKC is a group of important intracellular signaling molecules that are involved in a broad range of biologic functions, such as cell survival.15,16 It has been shown that many isoflurane pharmacological effects may be mediated by PKC.11,17,18 In this study, we showed that
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the isoflurane protective effects were inhibited by chelerythrine and bisindolylmaleimide IX. The isofluranedecreased iNOS expression was also inhibited by chelerythrine and bisindolylmaleimide IX. Chelerythrine and bisindolylmaleimide IX are structurally different. Chelerythrine is a peptide site competitive PKC inhibitor, and bisindolylmaleimide IX is an adenosine triphosphate site competitive PKC inhibitor.19 Our results suggest that PKC mediates the isoflurane protective effects in the microglial cells. Consistent with our results, volatile anesthetics may directly stimulate PKC.20 Also, although activation of PKC has been shown to enhance lipopolysaccharide- and cytokines-induced iNOS expression,21 activation of certain PKC isozymes, such as PKC␧, can inhibit lipopolysaccharide- and cytokines-induced iNOS expression in macrophages and astroglial cells.4,22–24 Although the exact mechanisms for the regulation of lipopolysaccharide-induced iNOS expression by PKC are not fully understood, it has been shown that PKC regulates activation of signal transducer and activator of transcription 1, which can then modulate iNOS expression.21 Isoflurane has been shown to inhibit lipopolysaccharide-induced iNOS expression in J774A.1 cells, a macrophage-like cell line, and this isoflurane effect was attenuated by the calcium ionophore ionomycine.25 These results suggest the role of decreased intracellular free Ca2ϩ in mediating this isoflurane effect. Consistent with this idea, increased intracellular Ca2ϩ has been proposed to mediate lipopolysaccharide- or IFN␥-induced iNOS expression in mouse macrophages,26 although contrary results (increased intracellular Ca2ϩ leads to decreased iNOS expression in mouse macrophages) have also reported.27 Similar to this confusing picture, many studies have reported a decrease of intracellular Ca2ϩ by volatile anesthetics,28,29 and other studies showed that volatile anesthetics induced a slight increase of intracellular Ca2ϩ.30,31 Thus, although lipopolysaccharide has been consistently shown to increase iNOS expression in various cells, including microglial cells, further studies are needed to clarify the role of intracellular Ca2ϩ in iNOS expression and the regulation of volatile anesthetics on this process. We observed a bell-shaped response: 2% isoflurane, but not 1% and 3% isoflurane, reduced lipopolysaccharide and IFN␥-induced decrease of cell viability and nitrite production. The mechanisms for the lost protective effects at a higher concentration of isoflurane are not known. However, activation of different PKC isozymes may increase or decrease iNOS expression in macrophages stimulated by lipopolysaccharide and IFN␥,4,21–24 3% isoflurane may activate PKC isozymes that can increase iNOS expression. This effect may cancel out the inhibitory effects of isoflurane on iNOS expression via other PKC isozymes. Preferential activation of PKC isozymes by various concentrations of isoflurane has been hypothesized to explain the bell-shaped effects of isoflurane on

V 111. Fuentes JM. Mitchell HJ. Zheng B. 35:994–1001 20. Biochem J 1994. Nixon JS. Finally. Moilanen E: Inhibition of classical PKC isoenzymes downregulates STAT1 activation and iNOS expression in LPS-treated murine J774 macrophages. 27:325–55 4. Kumar MK. Newton AC. Dempsey EC. Anesth Analg 1995. Hayes JK. Consistent with this idea. Cerilli LA. may not be the result of the effects of isoflurane on iNOS expression because isoflurane applied at early time points reduced lipopolysaccharide and IFN␥-induced iNOS expression but failed to decrease the lipopolysaccharide and IFN␥-induced LDH release. Plevin R: Differential regulation by protein kinase C isoforms of nitric oxide synthase induction in RAW 264. it appears that more LDH was released from cells incubated with lipopolysaccharide and IFN␥ for longer than 12 h. Rhodes PG. Zuo Z: Isoflurane preconditioning reduces mouse microglial activation and injury induced by lipopolysaccharide and interferon-gamma. ANESTHESIOLOGY 2008. In addition to MTT assay. Future studies are needed to understand the mechanisms for isoflurane to reduce the LDH release under this experimental condition. where isoflurane application only at early time points decreased lipopolysaccharide and IFN␥-induced decrease of MTT metabolism. decreased cell viability. 120:940–6 24. Adamo A. Clin Vaccine Immunol 2006. Sumners C: Angiotensin II-induced decrease in expression of . Sep 2009 all of the human diseases acquired later in their lives. glutamate. Feng J. Fulton WB. J Neurosci 2001. prolonged exposure to high concentrations of isoflurane can induce cell injury. Reyland ME. especially for 1% or 3% isoflurane. 108:1055–62 11. Sando JJ. ANESTHESIOLOGY 2003. Bal-Price A. Gross GJ: Essential activation of PKC-delta in opioid-initiated cardioprotection. Hurst SA. Kopnisky KL. PKC may mediate these isofluorane-protective effects. Ley K: Protective effects of isoflurane pretreatment in endotoxin-induced lung injury. In contrast. ANESTHESIOLOGY 2006. 54:15–36 2. we have shown that delayed treatment with isoflurane can induce a protective effect in microglial cells and reduce iNOS expression. Proc Natl Acad Sci U S A 2005. Sareila O. 98:89–95 7. Neuroscience 1993. 108:643–50 8. Feng X. In conclusion. Microglial cells play a critical role in immune reactions and host defense. Fan LW. Talamini MA. Hanly EJ. Volpe JJ. 279:L429–38 16. Reutershan J. Pfeilschifter J: Possible role of protein kinase C-epsilon isoenzyme in inhibition of interleukin 1 beta induction of nitric oxide synthase in rat renal mesangial cells. Hayes JK. ANESTHESIOLOGY 2008. abolished lipopolysaccharide and IFN␥-induced LDH release. our findings that isoflurane applied after the lipopolysaccharide and IFN␥ administration can reduce microglial activation and injury may have a broad implication. Mol Neurobiol 2003. Insel PA. Doherty K. We used lipopolysaccharide and IFN␥. Hill CH. Fryer RM. Lee JJ. Br J Pharmacol 2006. Messing RO: Protein kinase C isozymes and the regulation of diverse cell responses. Zuo Z: Postconditioning with isoflurane reduced ischemia-induced brain injury in rats. the attenuation of lipopolysaccharide and IFN␥induced decrease of MTT metabolism by isoflurane may be the results of its inhibition of iNOS expression. Surgery 2005. Xu X. Tuominen R. Rich GF: Isoflurane pretreatment inhibits lipopolysaccharide-induced inflammation in rats. the isoflurane-decreased cell injury of the cells exposed to lipopolysaccharide and IFN␥. Jung H-H. Vartanian T. contraction of skinned pulmonary arterial strips and isoflurane preconditioning-induced protection in macrophages. Aurora AR. Substituted bisindolylmaleimides with improved potency and selectivity. Chang D. Mucke L: Molecular profile of reactive astrocytes–Implications for their role in neurologic disease. Rosenberg PA: Peroxynitrite generated by inducible nitric oxide synthase and NADPH oxidase mediates microglial toxicity to oligodendrocytes. but not a later time point. Li J. An increased LDH release may require plasma membrane damage and signify that cells are injured. De Maio A. Talamini MA: Anesthesiaspecific protection from endotoxic shock is not mediated through the vagus nerve. 96:155–61 19. 154:1002–8 5. Fields AP. Xu X. and mitochondria.7 macrophages and rat aortic smooth muscle cells. 68:365–78 15. 280: H1346–53 17. but not at early time points. Keech E. Considering the fact that inflammatory process is involved in almost Anesthesiology. Tien LT. and isoflurane application around and during this period significantly attenuated this lipopolysaccharide and IFN␥-induced LDH release. Dev Neurobiol 2008. Kim JA. Hemmings HJ. 81:1216–22 21. Br J Pharmacol 1997. This finding contrasts sharply with our results from MTT assay. a microglial cell activation indicator. Our results showed that isoflurane application at later time points. Fuentes JM. Aurora AR. Bal-Price A: Inflammatory neurodegeneration mediated by nitric oxide. 67:1522–33 12. Elliott LH. Eddleston M. Brown GC: Inflammatory neurodegeneration mediated by nitric oxide from activated glia-inhibiting neuronal respiration. Zuo Z: Critical role of serine 465 in isofluraneinduced increase of cell-surface redistribution and activity of glutamate transporter type 3. J Biol Chem 2006. Hsu AK. 19:312–8 3. to activate microglial cells.18. Trends Neurosci 1996. Su JY.32 Also. Wilkinson SE: Inhibitors of protein kinase C. Am J Physiol Lung Cell Mol Physiol 2000. Zuo Z: Isoflurane preconditioning reduces the rat NR8383 macrophage injury induced by lipopolysaccharide and interferon gamma. 138:766–71 10. References 1. J Med Chem 1992. after the application of lipopolysaccharide and IFN␥ reduced the lipopolysaccharide and IFN␥-induced iNOS expression. Mochly-Rosen D.572 KIM ET AL. causing glutamate release and excitotoxicity. Kankaanranta H. Pang Y. 13:281–8 9. Molecular Pharmacology 2005. 21:6480–91 13. Paul A. Li L. Brown GC. 104:511–7 6. Muhl H. therefore. 147:790–9 22. Huang Y. 2. Huang Y.33 Exposure to 3% isoflurane for 1 h in the presence of lipopolysaccharide and IFN␥ may be strong enough to cause a detrimental effect. Decreased MTT metabolism suggests a decrease of mitochondrial reduction ability and. 303(Pt 2):607–12 23. which counteracts its protective effect. we used LDH release to measure isoflurane protective effects. Vo AC: Role of PKC in isoflurane-induced biphasic contraction in skinned pulmonary arterial strips. during inflammatory process. Zuo Z: Isoflurane induces a protein kinase C alpha-dependent increase in cell surface protein level and activity of glutamate transporter type 3. 281:38133–8 18. aminoguanidine did not reduce lipopolysaccharide and IFN␥-induced LDH release. ANESTHESIOLOGY 2002. Plachinta RV. They perform active tissue scanning and respond to various endogenous and exogenous stimuli. Hanly EJ. Harris W. Am J Physiol Heart Circ Physiol 2001. No 3. a common in vitro method to simulate endotoxemia and to induce inflammation. Baud O. Thus. Our results showed that the lipopolysaccharide and IFN␥-induced decrease of MTT metabolism was iNOS-dependent and that isoflurane exposure at early time points. Lawton G. Neuroscience 2008. In our study. Hoffman M: Biochemical characterization of the stimulatory effects of halothane and propofol on purified brain protein kinase C. 102:9936–41 14. Kreutzberg GW: Microglia: A sensor for pathological events in the CNS. Salonen T. Wang Y. Cai Z: alpha-Phenyl-n-tert-butyl-nitrone reduces lipopolysaccharide-induced white matter injury in the neonatal rat brain. we exposed microglial cells to various concentrations of isoflurane for 1 h. Jalonen U. De Maio A: General anesthesia delays the inflammatory response and increases survival for mice with endotoxic shock. It is not known whether this length of exposure is optimal for its protective effect. as measured by LDH release. Davis PD.

Bickler PE. isoflurane. Kim HM.. Zhan X.com. (Copyright © the American Society of Anesthesiologists. Kuhn M: Volatile anesthetics differentially affect immunostimulated expression of inducible nitric oxide synthase: Role of intracellular calcium. through a handle. Park Ridge. Kang HS. This image appears in color in the Anesthesiology Reflections online collection available at www. enhances Ca2ϩ-dependent survival signaling in cortical neurons and modulates MAP kinases. Jordan ML. Miao N. Jaquins-Gerstl A. 108:643–50 33. Fahlman CS: Isoflurane preconditions hippocampal neurons against oxygen-glucose deprivation: Role of intracellular Ca2ϩ and mitogen-activated protein kinase signaling. Anesthesiology.118: 138–45. Immunology 1996. Bause. ANESTHESIOLOGY 2000. Neurosci Lett 2007. Anesth Analg 2006. Liang G. 425:59–62 Ⅵ ANESTHESIOLOGY REFLECTIONS The Lennox “Anaesthetic Wand” Several years after attending Philadelphia Dental College. ASA’s Wood Library-Museum of Anesthesiology. 103:532–9 32. In 1891 Parker filed his U. Case Western Reserve University. Lynch C. 92:1093–102 26.anesthesiology. Ohio. After deserting his commission as a Major in the Confederacy in 1864.org. Illinois. Bickler PE.1833– 1898) sided against two of his Union-sympathizing brothers by joining a Confederate regiment that their uncle had mustered in Kentucky. Inc. Charles Parker Lennox (c. Patent application for a “Dental Tool” (pictured above. via a chloroform chamber.H. ANESTHESIOLOGY 1996. courtesy of the Wood Library-Museum). 268:L187–91 29.P.DELAYED ISOFLURANE TREATMENT AND MICROGLIA 573 inducible nitric oxide synthase in rat astroglial cultures: Role of protein kinase C. V 111. Sep 2009 . J Neurochem 2000. Surgery 1995. Hirshman CA. before jetting out a distal aperture into a dental patient’s mouth. M. 85:1147–56 30.. Park YC. Honorary Curator. Chung HT: Role of intracellular calcium as a priming signal for the induction of nitric oxide synthesis in murine peritoneal macrophages. 87:296–302 27. Geller D. Yang H: Isoflurane preconditioning inhibited isofluraneinduced neurotoxicity. 74:613–20 25. No 3. Croxton TL: Volatile anesthetics inhibit voltage-dependent Ca2ϩ channels in porcine tracheal smooth muscle cells. apoptosis proteins and transcription factors during hypoxia. ANESTHESIOLOGY 2005. Jun CD. Feng J. Kim HD.) George S. Schroppel K. Zuo Z: Isoflurane preconditioning reduces the rat NR8383 macrophage injury induced by lipopolysaccharide and interferon-␥ ANESTHESIOLOGY 2008. Xu X. Hoffman RA: Regulation of inducible nitric oxide production by intracellular calcium. discussion 145– 6 28. Tschaikowsky K.S. Dr. Rominski B. Johns RA: Volatile anesthetics affect calcium mobilization in bovine endothelial cells. Parker’s strange “anaesthetic wand” likely worked as a combined inhalational and topical analgesic. and Clinical Associate Professor.D. Cleveland. and around a spiral-grooved warming chamber. which permitted nitrous oxide to pass through a hollow metal wand’s proximal nipple. 3rd. Pajewski TN. Wei H. Am J Physiol 1995. Fahlman CS: The inhaled anesthetic. 103:419–29 31. M. Ritter J. Parker fled to Canada and eventually resumed the civilian practice of dentistry in Toronto. Yamakage M. UJYC@aol.

Finland. Finland. the American Society of Anesthesiologists.oulu.2 In very deep anesthesia.. and from the Finnish Foundation for Economic and Technology Sciences – KAUTE.D. However. Lappeenranta. Information on purchasing reprints may be found at www. University of Oulu.14 This paper studies the effect of the coadministration of remifentanil on the electroencephalogram phenomenon occurring during the induction of propofol anesthesia. Accepted for publication May 5. Inc.10 The changes remifentanil produces in the electroencephalogram are characteristic of ␮-receptor agonists. INCREASING concentrations of anesthetics in the blood produce a continuum of electroencephalographic changes. Ph. ‡ Staff Anesthesiologist. whereas.kortelainen@ee. Submitted for publication November 29. Helsinki University of Technology.‡ Tapio Seppa ¨ nen.§ Background: A high dose of opioids associated with a low dose of propofol has become a popular anesthetic technique. Lappeenranta. Finland. even though the basic propofol-induced frequency progression pattern is left untouched. and desflurane.. First. a decrease of the middle-frequency activity * Research Scientist. by the Department of Anesthesia. the changes obey roughly the following pattern.† Seppo Mustola. Finland. the above-mentioned basic frequency progression pattern has shown to be robust against coadministration of remifentanil. culminating eventually in delta activity at maximal drug effect.D.5 ␮g · kg؊1 · h؊1) or high-dose remifentanil (30 ␮g · kg؊1 · h؊1) during induction of anesthesia with propofol (30 mg · kg؊1 · h؊1).7 Remifentanil is an opioid that is increasingly used in the operating room and in intensive care. the influence of opioids on the electroencephalographic phenomenon related to induction of anesthesia and. thereby. 111:574 – 83 Copyright © 2009. Kortelainen: Department of Electrical and Information Engineering. Inc. Finland. BOX 4500. Finland. Lippincott Williams & Wilkins. on the quantitative parameters used in the depth-ofanesthesia estimation is not well known.5–5 Hz) activity.9 It has analgesic and cardiovascular effects similar to those of alfentanil but with a shorter duration of action. M. Department of Anesthesia. Furthermore. This resulted in statistically significant changes in all 14 quantitative parameters. Finland. the burst suppression pattern (BSP) begins. jukka.8.4 and more complex commercial indices like Bispectral Index (A-2000 BIS® monitor. for personal use only.D.13 However. we examine if the possible changes reflect on the quantitative spectral parameters commonly used in the depth-of-anesthesia estimation. finally. Finland. Department of Electrical and Information Engineering.* Miika Koskinen. Coadministration of opioids therefore challenges the reliability of the spectral properties of electroencephalogram in the depth-of-anesthesia estimation by using a frontal montage. Funding and equipment for data collection and analysis provided by the Graduate School in Electronics. The high-frequency (greater than 14 Hz) activity during light anesthesia was decreased in remifentanil groups. ANESTHESIOLOGY’s articles are made freely accessible to all readers. Finland. Helsinki. Sep 2009 .12 During the induction of propofol anesthesia. Telecommunication and Automation. there is evidence that addition on remifentanil during steady-state propofol anesthesia affects to some extent. and its time-frequency properties in the patient groups were analyzed from the induction of anesthesia to the occurrence of burst suppression pattern. Results: The time-frequency properties of electroencephalogram were different between groups. Finland. Materials and Methods Patients and Clinical Protocol After the study was approved by the institutional Ethics Committee of South Carelia Central Hospital. an increase of the high-frequency (greater than 20 Hz) activity. Aspect Medical Systems Inc. South Carelia Central Hospital. § Professor. Newton. Lappeenranta. With propofol. Furthermore.Anesthesiology 2009. Ph. Finland). the finding has implications for design of opioid coadministration studies. Oulu. Finland.1.11.D. by the Department of Electrical and Information Engineering. bispectral index and SEF95%.Sc. such as sevoflurane. University of Oulu..fi. Ph. South Carelia Central Hospital. Finland. 6 months from the cover date of the issue. Finland. They consist of decreasing frequency and increasing amplitude. Advanced Magnetic Imaging Centre and Brain Research Unit. such as the spectral edge frequency 95% (SEF95%) and median power frequency (MPF). Helsinki. No 3. The effects are examined from the beginning of propofol infusion to the onset of BSP. Address correspondence to Mr. Effects of Remifentanil on the Spectrum and Quantitative Parameters of Electroencephalogram in Propofol Anesthesia Jukka Kortelainen. Received from the Department of Electrical and Information Engineering. follow the same electroencephalographic pattern. increased activity in extended alpha band (7–14 Hz) and decreased activity in delta band (0. next. University of Oulu. Electroencephalogram was recorded from Fz electrode. 2008.anesthesiology. Methods: Twenty-seven patients were divided into three groups to receive saline. V 111. and an increase of the low-frequency (0. Supported in part by grants from the Tauno To ¨ nning Foundation.6 Generally.3 Several measures have been developed for the electroencephalogram-based depth-of-anesthesia estimation. and by the Academy of Finland (National Centers of Excellence Program 2006 –2011).. low-dose remifentanil (7.org or on the masthead page at the beginning of this issue. suggesting some unknown contribution of this opioid to the electroencephalogram. a decrease of the high. isoflurane. 2009.frequency activity and increase of the middle-frequency (10 –20 Hz) activity. MA)5 or State and Response Entropy (M-entropy® module.. FIN-90014 University of Oulu. These include both simple parameters. for example. M. Potent inhaled GABAergic anesthetics. We hypothesize that the opioids result in characteristic changes to the signal’s time-frequency properties. 27 patients (table 1) scheduled for 574 Anesthesiology. Conclusions: The effect of remifentanil on the spectrum and quantitative parameters of electroencephalogram is significant and strongly dependent on the level of anesthesia. in all these measures. Oulu. GE Healthcare Finland Oy. The group differences in 14 quantitative spectral parameters used in the depth-of-anesthesia estimation were examined as well. † Postdoctoral Researcher.5– 4 Hz) was observed during deep anesthesia. first or higher order spectrum is utilized. from the Walter Ahlstro ¨ m Foundation.

17 The method is based on calculation of electroencephalographic activity in eight different frequency bands for each patient and by minimizing the mean squared error between the activity trends of different patients by time scaling.5–90 Hz. patients received saline (R0).5 ␮g · kgϪ1 · hϪ1) or high-dose remifentanil (R2.16 The components that could be related to electrooculographic activity were then manually detected and left out when the electroencephalographic data were reconstructed from the spatial components. R1. low-dose remifentanil (R1.cs. To minimize the signal artifact. Patients having cardiovascular or neurologic diseases. electroencephalogram was recorded from 17 different electrode locations according to the international 10/20 system15 with an Embla polygraphic recorder (Medcare. Both drugs were infused at a fixed rate until the BSP was detected from the electroencephalogram channel of S/5 monitor (GE Healthcare Finland). only the montage Fz with a common average reference was used. MA). 7. and R2. the spectrograms are normalized in time by using the frequency progression phenomenon of electroencephalogram during the induction process. The patients were randomly assigned to one of three groups (9 each): R0.7 38 Ϯ 10. Data Preprocessing All the electroencephalographic signal processing presented in this paper was performed with the Matlab technical computing language (The MathWorks Inc..4 Ϯ 12 73. The effect of amplitude normalization can be seen in figure 1C. The amplitude normalized spectrograms were used only to visualize the changes in the frequency content of electroencephalograms. the electroencephalographic spectral progression phenomenon varies in time between patients. This results in patient-specific time scaling factors that can be applied to the spectrograms. Depending on the group. Demographic Data Age (yr) Weight (kg) Height (cm) ASA Status I/II (n) R0 (n ϭ 9) R1 (n ϭ 9) R2 (n ϭ 9) All (n ϭ 27) 37 Ϯ 11.1 Ϯ 15 72. propofol infusion rate was decreased to 18 mg · kgϪ1 · hϪ1. The recording started several minutes before the induction of anesthesia and continued for at least 5 min after the tracheal intubation. During the induction. Accessed May 6. the patients were told to be quiet and still before the drug infusion began. After the onset of BSP. second order blind identification. The recorder used a sampling rate of 200 Hz and filtered the signals with a bandpass filter of 0. ASA ϭ American Society of Anesthesiologists. In this procedure.8 42 Ϯ 10.tut. due to the interindividual variability in response to the anesthetic agent. The electrooculographic artifacts were removed from the recordings by using the Automatic Artifact Removal toolbox for Matlab. Iceland). The data analyzed in this study was also used in our previous publication. elective surgical procedure gave informed written consent to participate. V 111. To reduce the large difference in the amplitudes of higher and lower frequencies.. However. 2009. ͉͉ Available at: http://www. spectrograms were calculated from the Fz channel of electroencephalograms by using a short-time Fourier transform with a 3-s Hamming window and 2. diabetes. remifentanil does not affect the time normalization. Natick. the spectrograms were amplitude normalized. by which the BSP was sustained for at least 5 min. During the induction process. the electroencephalographic data from 17 channels were decomposed into spatial components by using a blind source separation technique based on second order statistics. the values in a specific frequency were divided by the mean value of all patients in that frequency between the start of the propofol infusion and onset of BSP. They were not used when the quantitative spectral parameters were calculated. Tracheal intubation was facilitated with 0. In other words.7 36 Ϯ 7.e. Because this hinders the comparison. Anesthesiology. 30 ␮g · kgϪ1 · hϪ1) during the induction of anesthesia with propofol (30 mg · kgϪ1 · hϪ1).htm. i.9-s overlap. The window was also long enough for the analysis of the lowest frequencies of interest. The infusion of propofol started 1 min after the start of the saline/remifentanil infusion. This montage was chosen because the modern depth-of-anesthesia monitoring is based on the analysis of frontal electroencephalogram.6 mg · kgϪ1 rocuronium. or a body mass index greater than 30 were excluded as well as the patients using drugs that affect central nervous system. No 3. i. the time scale of the spectrograms was first normalized by using the method presented in our previous study..13 The use of the method in this study is therefore reasonable.13 to which the reader is referred for complete details regarding the clinical protocol. loss of obeying verbal command (LVC) was assessed by asking at 15-s intervals the patient to squeeze the anesthesiologist’s (SM) hand. This window length was selected experimentally because it compromised the time and frequency resolution appropriately. The method has been applied previously to the dataset used in this study.1 Ϯ 13 173 Ϯ 13 170 Ϯ 9 171 Ϯ 9 171 Ϯ 10 8/1 7/2 8/1 23/4 Data are displayed as mean Ϯ SD or observed frequency.9 Ϯ 14 70. An example of a spectrogram with and without electrooculographic artifact is given in figure 1. the spectrograms of different groups need to be compared. Reykjavik.2 72.͉͉ First.EEG SPECTRUM IN PROPOFOL-REMIFENTANIL ANESTHESIA 575 Table 1. In the analysis. Spectrograms After the electrooculographic artifact removal.e. Sep 2009 . and the results showed that the time scaling factors do not differ between groups. To examine the effect of remifentanil on the spectral characteristics of electroencephalograms.fi/ϳgomezher/projects/eeg/aar.

Black and white colors represent high and low activity. and beta). and SEF95%. Total spectral. all spectrograms have their own time scale. theta. (B) The same spectrogram as in A after electrooculographic artifact removal. 1. Spectral Parameters The following 14 spectral parameters were determined as a function of r from the time-normalized (not amplitude-normalized) spectrograms: powers in different frequency bands (total. The burst suppression pattern occurs approximately after 6-min infusion. The time-normalization procedure and determination of r scale is illustrated in figure 2. No 3. theta.e.19 It can be assumed to describe the phase of the electroencephalographic spectral progression phenomenon during induction of anesthesia. and beta powers were determined from the spectrograms. alpha. Electrooculographic low-frequency artifact can be seen during the first minutes of the recording. The relative powers represent classic parameters for depth-of-anesthesia estimation and were therefore included in this study. defined in this paper as light anesthesia) and high r values (1 Ͻ r Ͻ 2. 8 –12 Hz for alpha power. The parameters were chosen on the basis of their common use in the previous research. Instead. and beta). the parameters were determined from the spectrum between 0. Due to the definition of relative beta ratio. i. alpha. It quantifies the flatness of the power spectrum and is calculated as Ϫ SE ϭ Fig. defined in this paper as deep anesthesia).4. were used.20 Relative delta. After the time normalization. These parameters were chosen because the electroencephalographic activity in different frequency bands changes during the induction of anesthesia obeying a characteristic pattern. relative powers in different frequency bands (delta. alpha. delta. the group R0 positions..2. Nf is ͒ the number of frequency components in the range [fl. As r values are determined from the electroencephalograms recorded during continuous infusion of propofol with a fixed rate. relative beta ratio. respectively.. The frequency bands were 0. and 12–25 Hz for beta power. respectively.21.5– 4 Hz for delta power. V 111.5 and 25 Hz. higher frequencies were used exceptionally in the calculation of this parameter. and beta powers were calculated by dividing the power in the corresponding frequency band by the total spectral power. (C) The same spectrogram as in B after amplitude normalization. the occurrence of this clinical end point without coadministration of remifentanil. relative time r is used. and they cannot be given as a function of absolute time anymore. The LVCs of different patients occur also in a slightly different position. MPF. and where Pn is the normalized ͚͑ fh iϭf1 Pn͑i͒ ϭ 1 power spectrum of the signal.18 and its further developed version has been presented recently. and therefore the median of the group R0 LVC points was set to represent the r value 1. The LVC occurs at a different phase of the spectral Anesthesiology. the start of induction of anesthesia and LVC are used as the points of reference: the values 0 and 1 represent the start of propofol infusion and the position in which the LVC occurs. 4 – 8 Hz for theta power.576 KORTELAINEN ET AL. increasing value can be associated with deepening anesthesia. Because some of the signals were contaminated by high-frequency muscle artifact. therefore. theta. theta.13. Sep 2009 iϭf1 ͚ P ͑i͒log P ͑i͒ n n fh log Nf (1) where fl is the lower and fh the higher limit of the used frequency band.5–25 Hz for total spectral power. progression in different groups. The r scale was introduced by Koskinen et al. the spectral properties of electroencephalograms are analyzed continuously as a function of r and also separately during low r values (0 Ͻ r Ͻ 1. spectral entropy (SE). fh] and used for the normalization of the values of SE be- . spectral edge frequency 90% (SEF90%).22 SE is one of the recently proposed measures for the assessment of depth-of-anesthesia. (A) Spectrogram of an electroencephalogram recorded during induction of anesthesia from the beginning of propofol infusion. alpha. 0. In r scale. In this paper. delta.

23 The parameter has been used in the M-Entropy® module (GE Healthcare Finland Oy). To reduce noise in data visualization. the underlying trends of the spectral parameters were approximated with curve fitting.24 It is the logarithm of the ratio of the electroencephalographic spectral power in 30. and SEF95% represent classic parameters measured during anesthesia and have been under active research. (B) The trends after time normalization. The normalization is performed by minimizing the mean squared error between the trends of different patients using patient-specific time scaling factors. the time normalization was performed by using the trends of all 27 patients. Due to the interindividual variability in response to the anesthetic agent. the median curves of smoothed spectral parameters were determined for each group as shown in figure 3B.6 RBR is a subparameter used in the calculation of Bispectral Index. First.to 20-Hz band: RBR ϭ log10 P30Ϫ47 Hz .25 The spline smoothing is illustrated in figure 3A. In this study. Different gray levels are used to represent the data of different patients.4. the spectral progression phenomenon and LVC vary strongly in time between patients. Furthermore. Due to the time scaling. With an appropriate frequency range. Note that.EEG SPECTRUM IN PROPOFOL-REMIFENTANIL ANESTHESIA 577 Fig. the curves and the LVCs have clustered. the values of each spectral parameter were compared between two specific groups continuously in different r values.4. Since the parameters were assumed not to follow any specific pattern. (A) Electroencephalographic activity in eight different frequency bands for three patients. tween 0 and 1. Their scale is in arbitrary units (AU). Statistical Analysis The group differences in the values of 14 spectral parameters were statistically compared with two approaches.21 Spectral edge frequency X% is the frequency below which X% of the power in the specAnesthesiology. which is determined by choosing the median of the LVCs to represent r ‫ ؍‬1.5 Hz and 25 Hz. Sep 2009 . and r ‫؍‬ 1 was determined by using the median of the group R0 LVC points. P11Ϫ20 Hz (2) trum resides. in practice. 2. MPF corresponds to spectral edge frequency 50%. No 3. fl and fh were 0. The curves are given in r scale. The dots on the trends indicate the occurrence of loss of obeying verbal command (LVC). Instead. V 111. respectively.to 47-Hz band to the power in 11. The comparison was per- MPF. the parametric fitting could not be used. The trends are given as a function of time from the beginning of propofol infusion to the onset of burst suppression pattern. SEF90%. a nonparametric cubic smoothing spline was applied to the data. SE has been shown to decrease rather monotonically with increasing depth-of-anesthesia.

the median is calculated from the relative delta power curves of group R0 (dashed lines). formed separately in all r values between 0 and 2 with an interval of 0. The underlying trend (solid line) of. The differences between the median spectrograms of two specific groups are given as well. The median spectrograms differ markedly between groups. only P values less than 0. they were considered not to be related to the administration of remifentanil. (3) decrease of activity in delta band (0. V 111. the activities do not differ statistically significantly between groups in figure 5. In delta band. because all fourteen spectral parameters were compared between groups R0 and R1 and groups R0 and R2 during light and deep anesthesia. The curves are calculated from the time-normalized spectrograms. Spectral Parameters The 14 median spectral parameter curves determined for each group from the time-normalized spectrograms are illustrated in figure 5. The alpha activity is significantly increased in remifentanil groups during deep anesthesia. 3B) were used. the overall effect of remifentanil on the spectral parameters was analyzed separately during light (0 Ͻ r Ͻ 1) and deep (1 Ͻ r Ͻ 2) anesthesia. P Ͻ 0. The spectral parameter median curves of groups R1 and R2 were compared to group R0 curves with Wilcoxon signed-rank test. and the comparison was performed with a nonparametric Mann–Whitney U test.19 the analysis was restricted to that value. Fig. Further inspection of the electroencephalograms showed that this activity was electromyographic artifact that occurred most frequently in group R1. The median spectrogram of group R1 contains relatively strong high-frequency (greater than 30 Hz) activity during very light anesthesia (r Ͻ 0. The following three changes can be clearly related to the increasing dose of remifentanil: (1) decrease of activity in high frequencies (Ͼ 14 Hz) during light anesthesia (0 Ͻ r Ͻ 1). the curves of these two parameters resemble each other. as they appear in a dose-dependent manner. the relative delta power (dashed line) is approximated by using a nonparametric cubic smoothing spline.05. Anesthesiology. the activity decreases when the opioids are coadministered.05 was considered statistically significant.5– 4 Hz) during deep anesthesia (1 Ͻ r Ͻ 2). the median curves were determined from the unsmoothed spectral parameter values (no spline smoothing) to avoid statistical bias. the median curve (solid line) of the specific group is determined. The Bonferroni correction was used to adjust for multiple comparisons so that the overall criterion for rejection of the null hypothesis was P Ͻ 0. (A) An example of the smoothing of spectral parameters. As shown in table 2. The power parameters of different frequency bands follow the changes seen in the spectrograms. the decrease is 26% in R1 and 38% in R2. The figure also shows the results of the statistical comparison of the spectral parameters continuously in different r values. Table 2 shows a decrease of 66%. However. Results Spectrograms Figure 4 illustrates the median spectrograms of different groups from r ϭ 0 to r ϭ 2. In this example.). Because these artifacts were present also before the drug infusion began. The data were not assumed to follow normal distribution. Sep 2009 . Thus. As a result of the dominant effect of delta activity on total spectral power. No 3.578 KORTELAINEN ET AL. even though the beta activity is clearly suppressed in R1 and R2 during light anesthesia. the spectral parameter median curves (fig. due to which they are given as a function of relative time r. In theta and beta bands. The statistical analysis was performed with the statistics toolbox for Matlab® (The Mathworks Inc. Second.5) compared to other groups.05/56 were considered significant. (2) increase of activity in extended alpha band (7–14 Hz) during deep anesthesia (1 Ͻ r Ͻ 2). According to table 2. The values of group R0 and R2 are significantly different in deep anesthesia in figure 5. For this. (B) After smoothing. 3. remifentanil has more than doubled the activity in this band.01. The group differences in spectral parameter median curves analyzed separately during light and deep anesthesia are given in table 2. The median spectrograms are created by choosing the group’s median value at every time-frequency point. in this case. Since the BSP generally occurs approximately when r ϭ 2. These changes can be related to the coadministration of remifentanil.

due to the lack of delta activity. 5). Hence. The median spectrograms are calculated by choosing the group’s median value at every time-frequency point. For example. the delta activity does not differ there between groups. Anesthesiology. No 3. but it does with the relative power. The values of this parameter have decreased 29% (table 2). however. as the changes occur only within a narrow range of r (1–1. the values in R1 and R2 are significantly higher compared to that of R0. 4. in group R2. although remifentanil does not affect the theta activity itself. Therefore. Naturally. as presented in table 2. The power in spectrograms is given in arbitrary units. (Top and middle rows) The difference spectrograms calculated from the median spectrograms of two specific groups. . This can be explained by the fact that. 5). the high-dose remifentanil group shows significantly lower values for relative delta power during deep anesthesia in figure 5. the values are significantly higher in group R1 during very light anesthesia. in figure 5. the change reflected on the values in table 2 are moderate. The parameters MPF. This corresponds to an increase of more than 50%. the relative theta power is significantly higher in remifentanil groups during deep anesthesia. R1. Due to the electromyographic artifact. changing the activity in other frequencies influences the relative power parameter. for example. even though the effects in this case are more complex and require a thorough analysis. However. Again. The median spectrograms are determined from the timenormalized spectrograms and therefore given as a function of relative time r. Sep 2009 during deep anesthesia. and the lower band (11–20 Hz) activity dominates the values of the parameter. and SEF95% show also differences between study groups. respectively. this does not explain why the relative theta power is significantly higher in group R2 during very light anesthesia. figure 5 shows no significant differences between groups during light anesthesia. and R2 calculated from the electroencephalogram during induction of anesthesia. the theta activity did not differ significantly between groups when the spectral power was analyzed. the increased activity in extended alpha band also influences the relative alpha power parameter in remifentanil groups. In SE. This can be explained by the lack of delta activity. The changes in spectrograms also reflect on the relative powers in different frequency bands. SEF90%. V 111. SEF90%.EEG SPECTRUM IN PROPOFOL-REMIFENTANIL ANESTHESIA 579 Fig. although the curve of R2 seems to be slightly decreased. Relative beta ratio was the only parameter in which higher frequencies (greater than 25 Hz) were used. SE has increased 15% (table 2).5). As with the delta power parameter. due to the presence of strong delta activity. For example. due to which the spectrum is more flat in remifentanil groups. The artifact does not explain. At that point. However. (Bottom row) The median spectrograms of the study groups R0. increases from approximately 7 Hz to 12 Hz when the saline is changed to high-dose remifentanil. the activity in the higher band (30 – 47 Hz) has ceased. the lower values in group R2 come from the increased activity in extended alpha band (7–14 Hz) during deep anesthesia. the relative alpha and beta powers are significantly lower in group R0 during deep anesthesia (fig. the decreased values in highdose remifentanil group after r ϭ 1. However. All three parameters indicate consistently also that the electroencephalographic activity in saline group is in significantly lower frequencies during deep anesthesia. The total increase of this parameter is 179% and 293% (table 2) in groups R1 and R2. The suppression of high frequencies during light anesthesia results in a significant decrease of SEF90% and SEF95% in high-dose remifentanil group (fig.

R1. and R2 calculated from the electroencephalogram during induction of anesthesia. resemble somewhat the propofol-induced changes. 3B). Sep 2009 As mentioned in the introduction. However. Discussion The effect of remifentanil on the time-frequency properties of electroencephalogram during propofol-induced anesthesia was studied. Anesthesiology. For example. however.e. The 14 median spectral parameter curves of the study groups R0. V 111. the changes remifentanil solely produces to electroencephalogram. during deep anesthesia. a major decrease was observed. Fig. which may have an impact on the indices using these properties. Coadministration of opioids therefore challenges the reliability of the spectral properties of electroencephalogram in the depth-of-anesthesia estimation by using a frontal montage.. higher SE and lower delta power). but on the other hand a lighter anesthesia in high r values (e. The curves are presented as function of relative time r. SE and SEF90% were clearly increased by remifentanil.g. The positions in which the values of two specific groups differ significantly (P < 0. This easily leads to the hypothesis that the effects of these two drugs on the electroencephalogram would be synergistic. as they are calculated from the time-normalized spectrograms. in delta activity. lower SEF90% and beta power). No 3. i. the coadministered remifentanil suppresses some of them (beta activity during light anesthesia and delta activity during deep anesthesia) and induces some of its own (alpha activity during deep anesthesia). According to the quantitative spectral parameters. progression of activity from high to low frequencies. including decrease of beta activity during light anesthesia as well as decrease of delta and increase of alpha activity during deep anesthesia. The changes were strongly dependent on the level of anesthesia and reflected on the quantitative spectral parameters used in the depth-of-anesthesia estimation. these changes might lead to an impression of a deeper anesthesia in low r values (e. This study deepens our understanding of the total impact of remifentanil on electroencephalogram-based depth-of- . our study shows that instead of increasing the propofol-induced changes. The results show that remifentanil significantly changes the signal’s spectral content in a characteristic manner. The median curves are created by choosing the group’s median value at every point in r scale (see fig..05) are indicated under the curves.580 KORTELAINEN ET AL..g. 5.

In our previous work. the research should Anesthesiology. In future. several improvements were made in this paper. The studies with other opioids (fentanyl. we illustrate the changes induced in the entire spectrum and how these changes reflect on the parameters. Data are expressed as a percentage change compared to the group R0 curve values at the same position (same r value) and displayed as mean (95% confidence interval). MPF ϭ median power frequency. ␮-receptor agonists. therefore. alfentanil. First. making the comparison of the results difficult without an objective control parameter of anesthetic depth.. i. the nature of the electroencephalographic changes remifentanil produces seems to be strongly dependent on the phase of the propofol-induced frequency progression pattern.e. and sufentanil) support this proposition because these drugs have been shown to induce similar electroencephalographic changes with remifentanil during anesthesia. the electroencephalographic changes induced by the drugs . SEF95% ϭ spectral edge frequency 95%. this study shows that also the detailed spectral characteristics are significantly affected by remifentanil and that this phenomenon is strongly dependent on the depth-of-anesthesia. As a result. The results have been controversial. the effects of remifentanil on the electroencephalogram during anesthesia have not been presented adequately before. SE ϭ spectral entropy. In the literature. by applying the time normalization to the spectrograms. remifentanil is considered to be a specific ␮-receptor agonist. Even though it was shown that the propofol-induced basic frequency progression pattern of electroencephalogram is left untouched. Sep 2009 concentrate more on describing the effect of opioids on electroencephalogram throughout the different levels of anesthesia instead of presenting them only for example in a single steady-state condition. This approach clarifies the underlying spectral phenomenon that causes the changes in the parameters. Third. Second. No 3. Differences in Spectral Parameter Median Curves Light Anesthesia (0 Ͻ r Ͻ 1) Spectral Parameter R1 R2 R1 Deep Anesthesia (1 Ͻ r Ͻ 2) R2 Total power Delta power Theta power Alpha power Beta power Relative delta power Relative theta power Relative alpha power Relative beta power SE RBR MPF SEF90% SEF95% –17 (–22 to –11)2 10 (–2 to 22) –21 (–28 to –15)2 12 (1 to 23) –26 (–30 to –21)2 15 (8 to 21) 0 (–6 to 7) 19 (10 to 29) –5 (–9 to 0) –1 (–2 to 0) –36 (–42 to –29)2 –2 (–8 to 5) 1 (0 to 2) 1 (1 to 2)1 –13 (–18 to –9)2 17 (6 to 28) 13 (5 to 21) 21 (10 to 32) –38 (–41 to –35)2 17 (10 to 23) 28 (21 to 36)1 43 (31 to 56)1 –18 (–23 to –13)2 –2 (–3 to –1)2 17 (11 to 24)1 0 (–11 to 11)2 –10 (–12 to –9)2 –7 (–8 to –6)2 –33 (–40 to –27)2 –47 (–53 to –40)2 9 (0 to 18) 118 (93 to 143)1 –5 (–13 to 3)2 –18 (–20 to –16)2 50 (39 to 61)1 179 (148 to 210)1 75 (59 to 91)1 11 (9 to 13)1 4 (2 to 6) 19 (11 to 28)1 47 (37 to 56)1 20 (16 to 24)1 –50 (–54 to –46)2 –66 (–70 to –62)2 –8 (–14 to –1) 114 (96 to 133)1 –12 (–17 to –7)2 –29 (–32 to –27)2 66 (55 to 78)1 293 (252 to 334)1 117 (100 to 134)1 15 (13 to 18)1 7 (5 to 9)1 54 (40 to 69)1 58 (49 to 68)1 27 (23 to 31)1 The spectral parameter median curve values are compared between groups separately during light and deep anesthesia. 1 ϭ curve values are significantly higher compared to group R0 according to Wilcoxon signed-rank test. due to the difference in pharmacokinetic profiles. the effect of the opioid can be seen in different levels of anesthesia and not only in a single steady-state.28 However. V 111. with some studies suggesting the indices to be affected by the coadministration of opioids.EEG SPECTRUM IN PROPOFOL-REMIFENTANIL ANESTHESIA 581 Table 2.12. instead of examining the effects of remifentanil by using only a few quantitative parameters of electroencephalogram. anesthesia estimation. Compared to the previous studies.14 and others failing to find an effect.27 One possible explanation for the controversy is that the effect of remifentanil on electroencephalogram is not stable or stationary during different levels of anesthesia. The median curves were determined for each group from the unsmoothed spectral parameters given as a function of r. the effect of remifentanil on electroencephalogram is presented during the whole process of induction of anesthesia.26. the beginning and duration of the effect may alter significantly. The studies have concentrated on describing the response of the depth-of-anesthesia indices. SEF90% ϭ spectral edge frequency 90%. As presented in this paper. we were able to reduce the interindividual variability in response to the anesthetic agent and made the comparison of the data of different patients reasonable as a function of time.13 we found that the infusion of remifentanil during propofol anesthesia significantly modifies the mutual relations of the electroencephalographic spectral characteristics and the clinical endpoints in a predictable and quantifiable manner. This finding further complicates the reliable usage of spectral properties of electroencephalogram for depth-of-anesthesia estimation when remifentanil is coadministered. It is likely that the effects of remifentanil differ significantly between two steady-states. RBR ϭ relative beta ratio.12. We hypothesize that the effects of remifentanil on the electroencephalogram presented in this study can be generalized to some extent to all drugs with similar pharmacodynamic properties. mostly Bispectral Index. Furthermore. to the coadministration of remifentanil during steady-state anesthesia. 2 ϭ curve values are significantly lower compared to group R0 according to Wilcoxon signed-rank test.

Zhang Y. Steyn-Ross ML. Lately there has been debate about its use during anesthesia. ANESTHESIOLOGY 1993. 4980–3 20. Egan TD.30 These changes. midazolam or sevoflurane. several nonlinear measures. Williams ML. Boylan GB. Koskinen M. ANESTHESIOLOGY 1994. Fuglsang-Frederiksen A. An ideal depth-of-anesthesia monitor accurately relates the electroencephalographic recordings to the clinical state of patient. Kearse L. we can expect this to be possible to some extent. Seppa ¨nen T: EEG spectral changes and onset of burst suppression pattern in propofol/remifentanil anesthesia. Koskinen M. Schuster SV. Mahon P. Br J Anaesth 2001. No 3. Kuizenga K. Pratico ` C. Koskinen M. ANESTHESIOLOGY 1998. Greene BR. Vanluchene A. 86:354–60 21. Vakkuri A. V 111. 81:1365–70 23. Steyn-Ross DA. Acta Anaesthesiol Scand 2004. Pace NL. 84:821–33 12. Acta Anaesthesiol Scand 2008. Albrecht RF: Effects of remifentanil. Glass PS. Cucchiara RF: Neurologic monitoring. Mustola S. 116:2069–76 19. Shafer SL: Remifentanil versus alfentanil: Comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers. Maja V.33.34 –37 In the future. Merila ¨inen P: Description of the Entropy™ algorithm as applied in the Datex-Ohmeda S/5™ Entropy Module. Neurosci Lett 2008. Rampil IJ: A primer for EEG signal processing in anesthesia. Barr J. Abed-Meraim K. tramadol has been shown to induce electroencephalographic changes that can be associated with lightening of anesthesia. Kortelainen J. such as approximate entropy and permutation entropy.29 However. Mustola S. on cerebral blood flow. Furthermore. Shaffer JE: Hemodynamic effects of GI 87084B. are identical to the effects of remifentanil during deep anesthesia reported in this paper. Conf Proc IEEE Eng Med Biol Soc 2007. Br J Anaesth 2001. When coadministered with an anesthetic. ANESTHESIOLOGY 1997. J Pharmacol Exp Ther 1992. Santamaria LB: Remifentanil and the brain. Wong TM: Remifentanil preconditioning protects against ischemic injury in the intact rat heart. Wierda JM. Struys MMRF: Behavior of entropy/complexity measures of the electroencephalogram during propofolinduced sedation: Dose-dependent effects of remifentanil. Philadelphia. 106:259–61 16. Grizzle MK. Voss L. and intracranial pressure in dogs anesthetized with isoflurane and nitrous oxide. Pellegrini M. 101:213–21 22. Edited by Miller R. This is supported by the finding that tramadol does not affect electroencephalogram in the presence of remifentanil. Manberg P: Bispectral analysis measures sedation and memory effects of propofol.582 KORTELAINEN ET AL. Anesthesiology. Manberg P. Talja P. Rosow C. Luccas FJ. 86:50–8 25. and alfentanil in healthy volunteers. Hinrichs H. Tenkanen N. Best Pract Res Clin Anaesthesiol 2007. midazolam. Smith P: Comparison of changes in electroencephalographic measures during induction of general anaesthesia – Influence of the gamma frequency band and electromyogram signal. 45:434–44 17. Fodale V. Clin Neurophysiol 2005. Mustola S. Hoffman WE. Westenskow DR. Ikeda A. Shorten GD: Behaviour of spectral entropy. Formanek V. 446:70–4 3. an ultra-short acting mu-opioid analgesic. International Federation of Clinical Neurophysiology. Emerson R. Numer Math 1967. 1570–3 18. in anesthetized dogs. Interestingly. James MK. John ER. Sa ¨rkela ¨ M. Sebel PS: Remifentanil dose/electroencephalogram bispectral response during combined propofol/regional anesthesia. Tramadol is a centrally acting analgesic occasionally used during operation to prevent postoperative pain. the electroencephalographic changes tramadol induced may in fact be related to increased clinical sedation. 106:696–706 24. this raises the question of whether some other electrode location would be more immune to the coadministration of opioids. Based on the results of this study. Schifilliti D. It would also be of interest to study whether the effects would be similar with other anesthetics. Black S. Koitabashi T. 48:154–61 7. acting also through other receptor may differ in part from that of remifentanil. Mahla ME. have been proposed for the measurement of depth-of-anesthesia. Tolvanen-Laakso H. Mustola S. Electroencephalogr Clin Neurophysiol 1998. Bloom M. the opioids change the electroencephalogram in a rather complex manner that potentially affects the reliability of the indices used in depth-of-anesthesia estimation.32 The drugs acting through the opioid receptors are known to have synergistic effect with anesthetics to the clinical state of the patients26. this paper points out that when coadministered with propofol. the changes resemble closely that of remifentanil. Viertio ¨ -Oja H. tramadol also induces similar electroencephalographic changes as remifentanil during anesthesia. Recently. Comi G. Br J Anaesth 2008. 86:836–47 6. 89:980–1002 5. Gugino LD. Seppa ¨nen T: Remifentanil modifies the relation of electroencephalographic spectral changes and clinical endpoints in propofol anesthesia. including decrease of delta activity and increase of alpha activity and SEF95%. 263:84–91 11. Johansen JW. Rappelsburger P: IFCN standards for digital recording of clinical EEG. However. Koskinen M. Nuwer MR. Sebel P. Anesth Analg 2002. One possibility to overcome this problem would be detection of the presence of opioid from the electroencephalogram. 10:177–83 26. ANESTHESIOLOGY 2007. Belouchrani A. deBros F. 2005. 109:198–205 14. Sep 2009 References 1. spectral edge frequency 90%. isoflurane. Minto CF. Gupta DK. 94:1530–3 15. tramadol appears to have actions on the noradrenergic and serotonergic systems. Hermann DJ.31 It has been suggested that the effect on electroencephalogram results from the ␣-adrenergic activity. Chamoun N. Gue ´rit JM. ANESTHESIOLOGY 1996. Kortelainen J. Sleigh J: Monitoring consciousness – The current status of EEGbased depth of anaesthesia monitors. and alpha and beta power parameters during low-dose propofol infusion. Clergue F. Ferenets R. 6th edition. Moulines E: A blind source separation technique using second-order statistics. Lipping T. Reinsch C: Smoothing by spline functions. Kearse LA Jr. etomidate. Yli-Hankala A. James MK. the observed changes in the signal could more reliably be related to the clinical state of patient. Kortelainen J. therefore. Greene C. Kortelainen J. we therefore speculate that they are induced by opioid receptor activation. Br J Anaesth 2001. Paloheimo M. pp 1511–50 4. Findings from the recent studies propose also new directions for future research. Seppa ¨nen T: Relation of EEG spectrum progression to loss of responsiveness during induction of anesthesia with propofol. Mustola S. In addition to the affinity for opioid receptors. Egan TD: When is a bispectral index of 60 too low? Rational processed electroencephalographic targets are dependent on the sedative-opioid ratio. Heyse B. 79:107–13 13. Dumont L. Seppa ¨nen T: EEG frequency progression during induction of anesthesia – From start of infusion to onset of burst suppression pattern. Johnson KB. Cardoso J-F. Irwin MG. Conf Proc IEEE Eng Med Biol Soc 2008. the effect of remifentanil on these measures should be tested as well. ANESTHESIOLOGY 2008. Seppa ¨nen T: Time-frequency properties of electroencephalogram during induction of anesthesia. Sleigh JW. Zaslavsky A: Bispectral analysis of the electroencephalogram correlates with patient movement to skin incision during propofol/nitrous oxide anesthesia. 101:918–23 9. Baughman VL. we have studied the effect of remifentanil only from the Fz electrode. propofol. Manyam SC. 52:319–26 10. Prichep LS. 21:313–25 8. Vuong A. Tassonyi E: Effects of . Muir KT. Lysakowski C. a new short-acting opioid. 87:421–8 2. Elsevier. 106:472–83 27. Aglio LS: Quantitative EEG changes associated with loss and return of consciousness in healthy adult volunteers anaesthetized with propofol or sevoflurane. IEEE Trans Signal Process 1997. Kalkman CJ: Biphasic EEG changes in relation to loss of consciousness during induction with thiopental.29. ANESTHESIOLOGY 2004. Cunningham F. Chabot RJ. Koskinen M. ANESTHESIOLOGY 2007. This way. Miller’s Anesthesia. The current indices have been developed to fulfill this task with a single anesthetic agent. brain electrical activity. White JL.

such as the Avertin one above (courtesy of the Wood Library-Museum). Rehberg B. Brunner MD: Effect of tramadol on electroencephalographic and auditory-evoked response variables during light anaesthesia. per rectum). Toivonen KJ: Requirements of propofol at different end-points without adjuvant and during two different steady infusions of remifentanil. Bickley. Thakor NV: Monotonicity of approximate entropy during transition from awareness to unresponsiveness due to propofol anesthetic induction. Br J Anaesth 2000. This image appears in color in the Anesthesiology Reflections online collection available at www. Voss LJ: Using permutation entropy to measure the electroencephalographic effects of sevoflurane. Shinner G. 86:523–7 28. When Bickley retired. Sep 2009 . Koskinen M. du Toit JC: Effect of tramadol on depth of anaesthesia. 53:18–24 32. M. Crit Care Med 1999.) George S. Bause. As the bottle label suggests. Seppa ¨nen T. 85:705–7 30. UJYC@aol.. 49:215–21 34. Alliez B. taking with him bottles that he had collected.P. branded Avertin by Winthrop Chemical Company. Pratico ` C. Inc. and Clinical Associate Professor. this “basal anesthetic” was usually administered basally (i. Honorary Curator. 53:669–75 36. Rey M. Park Ridge. Br J Anaesth 1996. 101:810–21 Ⅵ ANESTHESIOLOGY REFLECTIONS Wood. Tong S.org. Drugs 1997. Lucanto T. Dahan A: Permutation entropy of the electroencephalogram – A measure of anaesthetic drug effect. Cleveland. Hoeft A: Electroencephalogram approximate entropy correctly classifies the occurrence of burst suppression pattern as increasing anesthetic drug effect. Illinois. typically to agitated adult and pediatric patients. Case Western Reserve University.anesthesiology. Martin C: Sufentanil. Br J Anaesth 2008. Acta Anaesthesiol Scand 2005. Mustola S. Tescione M. Drs. Desmeules J. Anesthesiology. Maritz JS. IEEE Trans Biomed Eng 2006. (Copyright © the American Society of Anesthesiologists.H.e. Thornton C.. Bruhn J. Potie F. Li X. Mustola ST. Baer GA. Cui S. Sleigh JW. By 1936 Anesthesiologist Wood and Surgeon Bickley had popularized American use of this agent by publishing their “Observations on use of tribromethanol (Avertin)” in the American Journal of Surgery. Collart L: Pharmacology of tramadol. ANESTHESIOLOGY 2008. Br J Anaesth 2001. 93:981–5 35.EEG SPECTRUM IN PROPOFOL-REMIFENTANIL ANESTHESIA 583 fentanyl. 27:407–11 29. Bickley (1885–1957) investigated preliminary sedation and even “basal anesthesia” of patients with tribromethanol. Fodale V. Neuvonen PJ. Santamaria LB: Tramadol does not modify the Bispectral Index during anaesthesia with sevoflurane and remifentanil. Dayer P. Bouillon T. New York. and Avertin To facilitate induction and reduce overall dosage of inhalational anesthetics. Vaughan DJ. Viviand X. and alfentanil in head trauma patients – A study on cerebral hemodynamics.com. Ohio. Ro ¨ pcke H. Paul M. Coetzee JF. 109:448–56 37. 95:212–5 33. Br J Anaesth 2005. Albane `se J. remifentanil and sufentanil on loss of consciousness and bispectral index during propofol induction of anaesthesia.. Wood (1894 –1963) and Robert S. ANESTHESIOLOGY 2000. 76:415–8 31. No 3. Tanania S. fentanyl. M. Olofsen E.D. ASA’s Wood Library-Museum of Anesthesiology. Wood was forced to “semi-retire” to his wife’s family home near West Point. alfentanil. V 111.

Switzerland. 0.10. 2008.11 Next. M.7–9 The aim of the present study was to investigate the in vitro effects of propofol and inhalational anesthetic agents on pharmacologically induced (with 9-anthracenecarboxylic acid [9-AC]) chloride channel myotonia. both of which are considered to originate from decreased chloride conductance. Ph..anesthesiology. Inc. for personal use only. although chloride channel myotonic disorders were shown to be genotypically unrelated to MH. Iaizzo. During continuous 0. † Senior Anesthetist.1.B. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. 111:584 –90 Copyright © 2009. Minnesota. University Hospital. 2008. In Vitro Effects of Propofol and Volatile Agents on Pharmacologically Induced Chloride Channel Myotonia Oliver Bandschapp.3 Another group of myopathies that has been associated with anesthetic complications includes myotonic muscle disorders such as Thomsen’s disease and Becker type myotonia. their tracheae were intubated and lungs mechanically ventilated with an air-oxygen mixture. After anesthesia with 5–7 mg/kg IV thiopental (Gensia Pharmaceuticals. Copenhagen. The authors have. University of Basel.4 (P < 0..Anesthesiology 2009. Results: The myotonic reactions induced by 9-anthracenecarboxylic acid were reversed by high-dose (> 64 ␮M) propofol (P < 0. or sevoflurane each enhanced the myotonic reactions at 5. Departments of Anesthesia and Research. The concentration of propofol in either Intralipid (n ‫ ؍‬11) or dimethyl sulfoxide (n ‫ ؍‬10) was doubled every 10 min (from 4 –512 ␮M). Inc.. 12 castrated male Yorkshire crossbreed swine with a mean weight of 85.† Charles L. the muscle biopsies were dissected into small muscle bundles of intact fibers from tendon to tendon. The concentration of halothane (n ‫ ؍‬8). isoflurane (n ‫ ؍‬8). Inc. chloride channels are essential to stabilize membrane potential and prevent recurring depolarizations. investigated the in vitro effects of various anesthetic agents on pharmacologically induced chloride channel myotonia. Halothane. Denmark. M. temperature-controlled (37 Ϯ 0. Received from the Department of Surgery. Bandschapp: Department of Anesthesia. Sep 2009 . Nevertheless.01).anesthesiology. whereas volatile anesthetics further increased the associated myotonic reactions. # Professor.1-Hz supramaximal electrical stimulation. University of Minnesota. 4031 Basel. in association with various anesthetics that are MH-trigSupplemental digital content is available for this article. M. and 0. 2008. Basel. Irvine. ANESTHETIC choice for patients with various neuromuscular disorders remains in many cases a matter of debate. University of Minnesota.# Background: Anesthetic choice for patients with chloride channel myotonia remains under debate. propofol with its lipid carrier (composed of long-chain fatty acids) has been reported to adversely affect mitochondrial fatty acid oxidation. Methods: Functionally viable (> 10 mN force generation) rectus abdominis muscle preparations obtained from normal swine were investigated using in vitro muscle contracture test baths. Minnesota).D. rectus abdominis muscle biopsies were obtained (within 15 min) and samples placed in preoxygenated Krebs-Ringer solution (gassed with carbogen.‡ Thierry Girard.001). Control muscle bundles were either untreated (n ‫ ؍‬30) or exposed to 9-anthracenecarboxylic acid (n ‫ ؍‬19).6 To date. University of Basel Hospital. 6 months from the cover date of the issue.8 Ϯ 8.D.2 Importantly. respectively. IA). Switzerland. Submitted for publication December 10. Department of Surgery.org or on the masthead page at the beginning of this issue.25 vol% up to the maximum dose according to calibrated vaporizers.8 kg were pretreated with an intramuscular injection of a mixture of 250 mg tiletamine and 250 mg zolazepam (Telazol. 2009.D. propofol elicited a reversal of 9-anthracenecarboxylic acid–induced chloride channel myotonia.S. No 3.org).. In isolated swine skeletal muscle bundles. 95% O2 and 5% CO2) and then immediately transferred to a dissecting dish (with continuous gassing).D. and at the Annual Meeting of the European Society of Anaesthesia. Materials and Methods After approval from the Institutional Animal Care and Use Committee of the University of Minnesota (Minneapolis. Accepted for publication May 14. Address correspondence to Dr. Anesthesiology and Integrative Biology and Physiology. the chloride channel blocker 9-anthracenecarboxylic acid (64 ␮M) was added before the addition of propofol or one of three volatile anesthetics.e. Lund. Presented in part at the European Malignant Hyperthermia Group Annual Meeting. M. May 30. Soule..2. there exist reports of aggravating and improving myotonia associated with the use of either propofol or volatile agents. Furthermore. Support was provided solely from institutional and/or departmental sources. isoflurane. Spitalstrasse 21. Conclusions: The authors’ in vitro data imply that propofol administration for general anesthesia may be better suited for patients with chloride channel myotonia versus volatile anesthetics.4 In skeletal muscle. both central core disease and King-Denborough syndrome have been found to be associated with triggered MH episodes. ࿣ Professor.5 it remains unclear what anesthetic choice is optimal for these patients.. Minneapolis. bandschappo@uhbs. V 111. M. Ginz.D. therefore..21 (P < 0. Sweden. Using a dissecting microscope. ch. Shortly thereafter.05). as complications such as malignant hyperthermia (MH)– like episodes or rhabdomyolysis have been reported (i. they were transferred to in vitro.01).࿣ Paul A. gering agents).1°C) muscle experimental chambers (containing Krebs-Ringer solution bubbled continuously with carbo584 * Resident Anesthetist. June 2. and sevoflurane (n ‫ ؍‬8) was doubled from 0. the American Society of Anesthesiologists. § Associate Professor. Anesthesiology. Fort Dodge Animal Health. ANESTHESIOLOGY’s articles are made freely accessible to all readers.§ Albert Urwyler. CA). Fort Dodge. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www. and thus has been associated with a propofol-infusion syndrome in normal patients as well as those with mitochondrial myopathies.5 minimum alveolar concentrations (P < 0.* Hans F. ‡ Scientist. Lippincott Williams & Wilkins. Information on purchasing reprints may be found at www.

5 mM and 1. and 512 ␮M.8. 16. Investigation Protocols Dose–Response Curves. dimethyl sulfoxide (DMSO.0 mM NaHCO3.5 mM CaCl2(2H2O). and 2. the muscle bundles were exposed to increasing concentrations (every 10 min) of propofol in Intralipid (n ϭ 12) or Intralipid alone (n ϭ 12). areas under the force curves (AUCs). we tested the effects of caffeine (n ϭ 4) at 0. For relative anesthetic comparisons. halothane (SigmaAldrich. To estimate relative changes.4 mM KCl. Investigations of the Effects of Anesthetics and Potential Mechanisms of Myotonia. Switzerland). propofol in Intralipid (n ϭ 5). and 4. length-tension relationships were derived (bundles were stretched) according to the standardized protocol for in vitro contracture testing for MH susceptibility. Aurora. Data Collection and Data Analysis The following variables. and procainamide (Sigma-Aldrich GmbH. Control muscle bundles were either untreated (n ϭ 30) or bathed in 9-AC alone (n ϭ 19).0 mM. were recorded: Peak forces.1 mM NaNO3.0 vol% up Anesthesiology. The Krebs-Ringer solution consisted of 118. 11. sevoflurane (Abbott Laboratories. All data collection was automated employing LabView (ADEPT. Inc. DMSO (n ϭ 10).5. The chloride-free Krebs-Ringer solution consisted of 118.25.16 Pharmacologic Agents The investigated and administered drugs were 9-AC (Sigma-Aldrich GmbH. Fluka. 1. acetazolamide (Bedford Laboratories. DMSO (n ϭ 5) and Intralipid alone (n ϭ 5) were each tested according to the volume used in the groups where they served as the solvent. Plankstadt. The volatile anesthetics halothane (n ϭ 4). AUCs were measured for a period of 9. As such.. Melsungen. St. Next. Hertfordshire. 2.2 mM KH2PO4. 3. PA).13 To identify the optimal muscle lengths. 1). additional muscle bundles were incubated in a chloride-free KrebsRinger solution for 40 min. 0. 8. OH). B.18 followed by a challenge of increasing concentrations of propofol in Intralipid (n ϭ 11). Intralipid (Intralipid 10%. respectively) by a given vaporizer (Dra ¨ger. Buchs. data were analyzed using two-way ANOVA with repeated measures. Braun. Dose–response curves were established for 9-AC in DMSO (n ϭ 5). 256. Steinheim. muscle bundles were incubated in chloride-free Krebs-Ringer solution (n ϭ 12) or normal Krebs-Ringer solution (n ϭ 12). IL). halothane (n ϭ 8). 11. Germany). lidocaine (n ϭ 5). Germany). For the various pharmacologic groups.0. Bonferroni post hoc tests were used to identify intergroup differences. the concentration of the volatile agents was continuously sampled by an inline servo gas monitor (Datex Ohmeda 5530 Agent Monitor. As appropriate controls.0 mM MgSO4-(7H2O).1 mM NaCl. as previously described. Datex-Ohmeda. 25. In addition. Astra Zeneca. Cross-sectional areas were estimated as follows15: Area (mm2) ϭ muscle mass (mg)/(fiber length [mm] ϫ muscle density [mg/mm3]) using 1.4 mM KNO3. muscle bundles were pharmacologically challenged according to the study protocol (see below in the section Investigation Protocols). 1. Each muscle bundle length was measured after optimal lengths had been determined (as the distance between the suture ties that hold the muscle in the tissue bath).5 mM CaSO4-(2H2O).. except the muscle charac- . 3. We waited for 8 min after each treatment to achieve full effects of a given agent and then collected the data during the subsequent 60 s (i. and baseline forces (preloads). 5. Germany). Bedford. United Kingdom). Sep 2009 to the maximum dose allowable (4.0 mM NaHCO3. isoflurane (n ϭ 4). Adept Scientific. V 111.e. 128..13 Before entry into the flowmeters. Germany). isoflurane.0 mM MgSO4-(7H2O). concentrations of the volatile agents were calculated as minimum alveolar concentration (MAC) equivalents. and one-way ANOVA were used for determining differences between drug groups at each time point. contraction times. the specimens were patted dry and weighed immediately.0 vol% for halothane. isoflurane (MINRAD Inc. Dra ¨gerwerk AG. and procainamide (n ϭ 5) at concentrations of 4. acetazolamide (n ϭ 5). Statistical Analysis For measurement with respect to time. Buchs. Muscle mass was determined as the wet weight of the specimen after removing it from the bath and cutting it at the sutures.06 mg/mm3 as the density of skeletal muscle. Stans. six twitch responses per collection period). propofol in Intralipid (Disoprivan 1%. acetazolamide (n ϭ 10). Bethlehem. Louis.5. All data are presented in this report as mean Ϯ SEM. lidocaine (n ϭ 10). or procainamide (n ϭ 10) in the concentrations according to the study protocol. CO).. representing skeletal muscle contractile function. Louisville. Fresenius Kabi. sevoflurane (n ϭ 8). 64. 32. Switzerland). propofol in DMSO (n ϭ 10).EFFECT OF ANESTHETICS ON MYOTONIA 585 gen). each bundle was independently stimulated with supramaximal electrical field stimulation pulses of 1 ms duration at a frequency 0. OH). muscle bundles were pretreated with 9-AC (64 ␮M) for 10 min. a specific voltage-gated chloride channel blocker17. pure propofol (pharmaceutical sample. To investigate a direct effect of chloride.14 An average of 23 Ϯ 8 muscle bundles was obtained from each pig for these experiments. No 3.12.5 s after muscle stimulation (fig. Lu ¨ beck. Intralipid (n ϭ 10). and sevoflurane (n ϭ 4) were tested at 0. Switzerland). lidocaine (ICN Biochemicals Inc. 1. 1.1 Hz.2 mM KH2PO4.0. After maintaining a stable baseline for approximately 10-15 min.0 mM d-glucose. propofol in DMSO (n ϭ 5). all values were normalized to relative baseline forces and then expressed as percents of change. and 2. and 8. isoflurane (n ϭ 8). respectively. Thereafter. 25. 1.0 mM d-glucose. and sevoflurane. North Chicago. MO). the appropriate control groups were used. this data then was used for later analyses. halfrelaxation times.

Illustration of a typical twitch waveform after treatment of the muscle bundles with the chloride channel blocker 9-anthracenecarboxylic acid (9-AC. All statistical analyses were performed using a Prism software package (GraphPad Software. 64 ␮M) (n ‫ ؍‬19) or chloride-free KrebsRinger solution (n ‫ ؍‬12) and time control (n ‫ ؍‬30). Table 1.001). CA).05). at which a significant decrease in the indices of skeletal muscle performance was observed.05 was considered statistically significant. Results Dose–Response Curves Length. contraction time [s]. ** P < 0. The chloride channel blocker 9-AC (64 ␮M) led to significantly increased peak forces for up to 50 min after its administration. Supplemental Digital Content 1.5 Ϯ 4. area under the force curve (AUC) was recorded for 9. 1. the mean values of the muscle bundles’ characteristics were 31. Supplemental Digital Content 1.01. and baseline tension [mN] are provided). All administered drugs led to significantly altered values of peak forces.com/ALN/A537).0 mg. Myotonia induced by the chloride channel blocker 9-anthracenecarboxylic acid (9-AC. and 5.001 versus time control.3 mm2 (see tables 1 and 2.1 MAC)† Concentration (␮M) of the study drugs and minimum alveolar concentration (MAC) of the volatile agents.586 BANDSCHAPP ET AL.0 mm. ( ) ϭ significant increasing effect. La Jolla. Fig.01 and *** P < 0. or cross-sectional areas of the muscle bundles used in the various treatment groups did not differ between groups. the mean values of the muscle bundles’ characteristics were 30. 2. DMSO ϭ dimethyl sulfoxide. as compared with controls (P Ͻ 0.lww.com/ALN/A537.001). a P Ͻ 0.001 vs.5 MAC)† — (16 ␮M)† 512 ␮M‡ 128 ␮M† — 512 ␮M* 32 ␮M† — — 3. * P < 0. and half relaxation times. The same treatment significantly increased AUCs during the entire study period as compared with controls.3 Ϯ 42. which is given in mean Ϯ SD. http://links. V 111. half relaxation time [s]. All control muscle bundles with no treatment elicited both significant decreases in peak forces and AUCs over time (P Ͻ 0. 2. 191. as summarized in table 1. Fig.7 MAC‡ (0. After stimulation. Effects of Study Drugs and Volatile Agents on Skeletal Muscle Performance Peak Force AUC Contraction Time Half Relaxation Time Baseline Tension 9-AC Propofol/intralipid Propofol/DMSO Intralipid DMSO Lidocaine Procainamide Acetazolamide Isoflurane Sevoflurane Halothane (16 ␮M)* 512 ␮M* 128 ␮M† — 512 ␮M‡ 32 ␮M* — — 1.3 MAC† — — — 256 ␮M* — — — 64 ␮M† — — — — — — 512 ␮M* 512 ␮M† — (64 ␮M)† 128 ␮M‡ — — — — — — — — — — — — — — — (6. and 5. including peak force [mN].58 Ϯ 1. AUCs. Forces were recorded in mN.05). The different treatment groups and the indices of skeletal muscle performance. 9-AC led to significantly increased AUCs. starting at 10 min after administration (fig. the dose response curve was sigmoidal in shape (see tables 3–7. 179. Anesthesiology.5 s and analyzed. masses.8 Ϯ 67.9 Ϯ 4.lww. * P Ͻ 0. starting at concentrations of 16 ␮M (P Ͻ 0.0 mg. AUC [g*s]. which are tables providing the entire data set of the dose–response experiments using normal skeletal muscle bundles. Myotonia Induced by Either 9-AC or Chloride-free Krebs-Ringer Solutions In the experiments with induced myotonia.0 mm2. 64 ␮M). and ‡ P Ͻ 0. time control. which list the characteristics of the specific muscle bundles of the various treatment groups used in this study.1 mm. — ϭ no effect. AUC ϭ area under the force curve. As compared to time controls.05. Sep 2009 . Data are mean ؎ SEM. No 3. contraction times.05. teristics data.73 Ϯ 2. http://links. In the dose–response experiments. 9-AC ϭ 9-anthracenecarboxylic acid. P Ͻ 0. † P Ͻ 0.

05). respectively (fig.05). While isoflurane started to decrease myotonia at 0. and (B) sevoflurane (n ‫ ؍‬8). the higher concentrations of the inhalational anesthetic agents appeared to somewhat reverse the elevated myotonic reaction. Similarly. halothane (n ‫ ؍‬8).01). (B) The effects of the chloride channel modulator acetazolamide (n ‫ ؍‬10) and the sodium channel modulators procainamide (n ‫ ؍‬10) and lidocaine (n ‫ ؍‬10) on 9-AC (64 ␮M)–induced myotonia. respectively (fig.) Discussion We have investigated the in vitro effects of propofol and various volatile anesthetics on pharmacologically . MAC ‫ ؍‬minimum alveolar concentration. 4A. This was not the case with either Intralipid or DMSO administration alone. half relaxation times began to increase significantly 80 min after incubation in the chloride-free medium (P Ͻ 0. propofol/Intralipid (n ‫ ؍‬11). 3. Potential mechanisms involved in the effects of the different anesthetic agents on chloride channel–related myotonia. (A) The effects of Intralipid (n ‫ ؍‬12) and propofol/Intralipid (n ‫ ؍‬12) in a chloride-free environment.83 MAC.05). 0.05. and 0. isoflurane.01 and *** P < 0. It was observed that treatment with the chloride channel activator acetazolamide had no effects on the induced myotonia (fig. myotonia induced by chloride-free Krebs-Ringer solution was reversed by the administration of propofol in Intralipid at 128 ␮M (fig. In contrast.05).01).05. Data are mean ؎ SEM. Sep 2009 Fig.EFFECT OF ANESTHETICS ON MYOTONIA 587 Fig. were reversed by the subsequent administrations of either propofol in DMSO or propofol in Intralipid. After incubation in chloride-free Krebs-Ringer solution.05). 4B). Effects of anesthetics on chloride channel–related myotonia. 4.21 (P Ͻ 0. and sevoflurane increased the myotonic reactions. and *** P < 0.0 MAC and 6. Ninety minutes after 9-AC administration (64 ␮M) the baseline force values were significantly higher (P Ͻ 0. Interestingly. * P < 0. Influences of Different Drugs on 9-AC–induced Myotonia The myotonic reactions. In addition. http://links. contraction time [s].01). 4B). caffeine administration significantly increased the myotonic reactions of exposed muscle bundles (P Ͻ 0.4 (P Ͻ 0. Contraction times and baseline force values were not different for muscle samples in either normal or chloride-free Krebs-Ringer solutions.com/ALN/A537. (A) Influence of Intralipid (n ‫ ؍‬10). the muscle bundles showed increased peak forces and AUCs during the entire study period (fig. However. Supplemental Digital Content 1. 9-AC ‫ ؍‬9-anthracenecarboxylic acid.05). The effects of these agents on the contractile features of the 9-AC–pretreated muscles are summarized in table 2.01. Anesthesiology. Data are mean ؎ SEM. P Ͻ 0. including peak force [mN]. the sodium channel blockers lidocaine and procainamide both decreased the myotonic effects significantly at concentrations of 8 ␮M (P Ͻ 0. 3B).001 versus 9-AC single dose. 9-AC ‫ ؍‬9-anthracenecarboxylic acid. Importantly.001). No 3.05) and 128 ␮M (P Ͻ 0. ** P < 0. ** P < 0. 3A).1 MAC) (fig.5 MAC (P Ͻ 0. P Ͻ 0.001 versus chloride free solution or 9-AC single dose. sevoflurane and halothane only did so at their maximum dosages (4. the administration of lidocaine increased peak forces at 128 ␮M and 256 ␮M concentrations in the same setting. 2. starting at 5. The different treatment groups and the indices of skeletal muscle performance. (See tables 8 –12. which are tables listing the entire data set of the dose response experiments using myotonic [9-AC–pretreated] skeletal muscle bundles. Challenges with halothane. * P < 0. There were no differences in contraction times and half relaxation times between the two groups.lww. indicated by the increased values of AUCs after treatments with 9-AC. half relaxation time [s] and baseline tension [mN] are provided. propofol/DMSO (n ‫ ؍‬10). and isoflurane (n ‫ ؍‬8) on 9-AC (64 ␮M)–induced myotonia. starting at 64 ␮M (P Ͻ 0.001) and 256 ␮M (P Ͻ 0. respectively (fig. DMSO ‫ ؍‬dimethyl sulfoxide. DMSO (n ‫ ؍‬10). V 111. AUC [g*s]. 3B).

we tested the relative effects of the voltage-gated chloride channel activator acetazolamide. e. No 3. DMSO ϭ dimethyl sulfoxide.5 mM)† (0. i. i.588 BANDSCHAPP ET AL. Under normal physiologic conditions. there are several previous reports citing the direct myorelaxant effects of propofol on skeletal muscle. isoflurane. This effect was considered part as a result of the activity of propofol itself. in our study. it is considered that human skeletal muscle sodium channels are blocked by propofol in a voltagedependent manner. In general.25. and thus repetitive aftercontractions (myotonia). because neither Intralipid nor DMSO alone altered the relative degrees of induced myotonia. propofol administration resulted in the same efficacies in resolving the myotonic reactions in a chloride-free environment. and ‡ P Ͻ 0.24 We observed that the treatment with Anesthesiology. 64␮M) to induce myotonia. at which a significant decrease in the indices of myotonic skeletal muscle performance was observed.05.23.e. Sep 2009 acetazolamide induced minimal or no such antimyotonic effects in such in vitro experiments. In the experiments presented here.7 MAC)‡ 128 ␮M* 64 ␮M† — — 8 ␮M‡ 256 ␮M† — (0. This phenomenon was supported by our findings that both caffeine and volatile agents were associated with increased myotonic reactions in our experiments. to determine whether voltage-gated chloride channels were primarily involved in these responses. the myogenic production of repetitive action potentials. the influx of chloride is considered to rapidly stabilize the sarcolemmal membrane potential after a depolarization. isoflurane. we also tested the relative effect of the sodium channel inhibitors lidocaine and procainamide. Volatile Agents We observed here that the volatile anesthetic agents halothane. The primary findings of this study were that propofol administration reversed the pharmacologically induced myotonia. Therefore.01. * P Ͻ 0. induced action potential within the muscle fiber membrane.g. induced chloride channel myotonia. it was observed here that propofol dramatically reversed these drug-induced myotonic reactions at concentrations above 64 ␮M.19 Propofol Importantly. Table 2. the sarcoplasmic release of cal- . whereas the volatile agents halothane..4 MAC)‡ 64 ␮M† — — (256 ␮M)* 64 ␮M* (64 ␮M)† (64 ␮M)† (0.5 MAC.20 –22 Thus.. impaired chloride conductance because of altered chloride channels results in membrane hyperexcitability.001 vs. respectively. which in turn prolongs the overall contractions within their skeletal muscles. like caffeine.5 MAC)† (5. AUC ϭ area under the force curve.4 MAC)* — (5. i.26 This action on the voltage-gated sodium channels may have been responsible for the antimyotonic effects of propofol that were observed in the present studies.4 MAC)† 512 ␮M† 128 ␮M† — — — — 512 ␮M† — 3.21 MAC and 0. either by pharmacologically blocking specific chloride conductance with 9-AC18 or by lowering extracellular chloride concentration. V 111.e. these treatments led to disturbed repolarizations with afterdepolarizations.5 mM)‡ 1. Modulation of Myotonic Muscle Performance by Study Drugs and Volatile Agents Peak Force AUC Contraction Time Half Relaxation Time Baseline Tension Propofol/intralipid Propofol/DMSO Intralipid DMSO Lidocaine Procainamide Acetazolamide Caffeine Isoflurane Sevoflurane Halothane — 256 ␮M* — — (128 ␮M)† — (256 ␮M)† (0.28 This may be further evidence that the antimyotonic actions of propofol are mainly a result of modulations of voltage-gated sodium channels within the sarcolemmal membranes of skeletal muscle. volatile anesthetics are known to act agonistically on the skeletal muscle type 1 ryanodine receptor and lead to increased calcium release from the sarcoplasmic reticulum.3 MAC† — — Concentration (␮M or mM) of the study drugs and minimum alveolar concentration (MAC) of the volatile agents.. Consistent with these findings. ( ) ϭ significant increasing effect.27. Clinically.5 mM)‡ (0. Of potential clinical interest was the present observation that both isoflurane and sevoflurane administration induced enhanced myotonic responses at clinically relevant doses: 0. Furthermore. The muscle bundles were treated with the chloride channel blocker 9-anthracenecarboxylic acid (9-AC. This may suggest that chloride anions are not primarily involved in these antimyotonic responses. 9-AC single dose.e. and sevoflurane each significantly increased the myotonia induced by 9-AC. and sevoflurane were associated with aggravated myotonic reactions. in patients with myotonia congenita. As expected..3 MAC)† (0. these two agents were associated with reversals of the myotonic reactions in our experiments as well. — ϭ no effect.5 mM)† — — — 64 ␮M† 128 ␮M† — — 16 ␮M† — — (0. † P Ͻ 0. we observed that in these isolated muscle bundles we could reduce fiber chloride conductances.2 MAC)* (0.29 More specifically.7 MAC* (0. This may in part have been because of the expected increase in the intracellular release of calcium into skeletal muscle cells after exposure to inhalational agents. Interestingly.

35 In our study model. 53:1293–6 8. Ranklev-Twetman E. No 3. Shield J: Impaired fatty acid oxidation in propofol infusion syndrome. Yanagi F. such responses will occur at clinically relevant concentrations. Gronert GA: Failure to induce malignant hyperthermia in myotonic goats. we emphasize that it is difficult to conclude from these in vitro studies employing swine skeletal muscle bundles that one can assume relative safety of these agents in patients. Tashiro M. Furthermore. Moulds RF. First. Driessen JJ: Neuromuscular and mitochondrial disorders: What is relevant to the anaesthesiologist? Curr Opin Anaesthesiol 2008. Stieglitz P. 4:526–8 11. Wolf A. this may even mimic episodes of malignant hyperthermia). Nivoche Y. given that propofol had no effect at clinically relevant concentrations and even showed a reversal of chloride channel–induced myopathy at high concentrations. Chadwick S. Lehmann-Horn F. half relaxation times represent the established marker for myotonia. Hayashida S. Segal SS.32 However. Cozzolino S. However. University of Minnesota. Sep 2009 mances observed in our experimental model. and even precipitation of myotonia reported with its use. Sigurdsson S. adequate oxygenation of centralized fibers may be limited. Nelson TE. isoflurane administration has been associated with decreased peak force values at concentrations above 1. Heiman-Patterson T. Department of Anesthesia. Nevertheless. marked sensitivity to its depressant effects. Faulkner JA: Temperature-dependent physiological stability of rat skeletal muscle in vitro. Lehmann-Horn F.EFFECT OF ANESTHETICS ON MYOTONIA 589 cium through ryanodine receptors may have been at least partially involved in these responses. Weir P. Johnson GW.S. to date there are no comparative clinical or in vivo animal studies on these issues.34. It is less clear whether the results with propofol administration should be interpreted somewhat differently. it has been proposed that in experiments in which volatile anesthetics are administered for the in vitro contracture testing for the determination of MH susceptibility. patients affected by myotonic syndromes may elicit aggravated myotonia causing hypermetabolic events (when extreme. Larach MG: Standardization of the caffeine halothane muscle contracture test. Segar P. propofol was associated with shortening of half relaxation times. Hartopp I: Anaesthesia and myotonia. Lambert EH. we postulate that the concentrations of volatile anesthetics used in this study may also be considered to be clinically relevant. Minnesota) for their editorial assistance and help with manuscript submission.8. Br Med J 1972. Mayo Clin Proc 1991. i.e. 69: 511–5 13. the known abilities of isoflurane to inhibit the voltagegated sodium channels of skeletal muscle could explain the favorable effect of isoflurane on 9-AC–induced myotonia at higher concentrations. Iaizzo PA. 55:57–60 6. Lancet 2001. Tahmoush A: Malignant hyperthermia in myotonia congenita. Martino C. Denborough MA: Procaine in malignant hyperpyrexia. The authors would like to thank Allison Dwileski. In addition. the primary findings would remain the same. University of Basel. Minneapolis. Aerosp Med 1971. Stone J. Kress H. Again.S. Rosenberg H. Pusch M: Myotonia caused by mutations in the muscle chloride channel gene CLCN1. North American Malignant Hyperthermia Group. Regardless of the chosen anesthetic and the likely preferred choices. Wedel DJ. Br J Anaesth 1995.33 There are several potential limitations of our experimental approaches. Therefore. in addition. However. Although 9-AC did not alter half relaxation times. it is not exactly clear how in vitro test bath concentrations of administered agents apply to blood concentrations when employed in vivo. Kinder Ross A: Muscular dystrophy versus mitochondrial myopathy: The dilemma of the undiagnosed hypotonic child. Masui 2004. Halsall PJ. irrespective of dosage. Finally. In addition. Paediatr Anaesth 2007. Wappler F: In vitro contracture test for diagnosis of malignant hyperthermia following the protocol of the European MH Group: Results of testing patients surviving fulminant MH and unrelated low-risk subjects. we have not studied the relative effects of these protocols on muscles of myotonic patients directly. References 1. Snoeck M. Heffron JJ. general anesthesia with propofol seems to be the better choice for use in a patient who may have myotonic activity. if we considered here changes in half relaxation times as the primary measures of elicited myotonia. in some of the aforementioned studies the biggest differences between normal and myotonic patients were in the second half of the relaxation phases. KrivosicHorber R. Fletcher J. University Hospital. Neurology 1988. Br J Anaesth 1977. Austin KL. The European Malignant Hyperthermia Group.30 We consider here that our experiments support the view that in muscles that elicit hyperexcitability. there have been variable responses. 49:169–72 12. volatile anesthetics may secondarily increase overall muscle metabolism and could therefore be potentially dangerous. Denborough MA: Screening for malignant hyperpyrexia. Hum Mutat 2002. 75:113 9. in these isolated muscle bundles there is no vascular perfusion. whereas the volatile agents isoflurane and halothane increased half relaxation times. V 111. Newberg LA. 65:692–7 7. Trezek GJ: Correlation of thermal properties of some human tissue with water content. Department of Surgery. Acta Anaesthesiol Scand 1997. Urwyler A. It may be proposed that higher concentrations of propofol would likely be needed to simulate the situation in vivo.. Cooper TE. Mortier W. and we therefore have to rely on occasional and often anecdotal case reports. 38:810–2 10. Consistent with these results of the indices of skeletal muscle perforAnesthesiology. Terasaki H: [Anesthetic managements of a patient with congenital myotonia (Becker type)].7 MAC. Heytens L. Brancadoro V. according to our in vitro data. Tegazzin V. B. 248:C265–70 16. Gonano EF. It is of interest to note that in some of these reports. we were not able to significantly increase the half relaxation times of the muscle bundles by using 9-AC. Br J Anaesth 1983. Hartung E.31. AUC seemed to be the most sensitive marker for an elicited myotonic reaction. and thus if diameters are too large. Kozak-Ribbens G. Gallagher WJ: In vitro contracture testing for determination of susceptibility to malignant hyperthermia: A methodologic update. propofol in myotonic patients is not without observed side effects. Am J Physiol 1985. 19:423–34 5. 21:350–5 2. Glauber V. B. In conclusion. 357:606–7 4. 42:24–7 . Switzerland) and Monica Mahre. (Administrative Assistant. the anesthesiologist must consider responses in individual patients as the anesthetic proceeds. 66:998–1004 14. Eadsforth P. 41:955–66 15. (Lab Services Coordinator. Ording H. 17:1–6 3. Iaizzo PA: Are myotonias and periodic paralyses associated with susceptibility to malignant hyperthermia? Br J Anaesth 1990. Anesth Analg 1989.19 There are publications describing changes in relaxation times with smaller changes in twitch amplitudes or AUCs in humans with myotonia. Ellis FR.

Sui X. Thonney F. Muscle Nerve 1988. 34:292–7 24.590 BANDSCHAPP ET AL. Barbieri CA. Kwiecin ´ ski H. Codding PW. Dengler R. Lehmann-Horn F. V 111. Shirabe S. Biophys J 1993. Hayashi H. Bass SP: Myotonic dystrophy and paediatric anaesthesia. Nelson TE. OuYang W. 45:417–23 23. Kindler C. Wiegner AW. Lamb GD: Chloride conductance in the transverse tubular system of rat skeletal muscle fibres: Importance in excitation-contraction coupling and fatigue. 34:263–4 25. Kaibara M. Rose E: Malignant hyperthermia and myotonia congenita (Thomsen’s disease). 13: 528–35 32. Tschale `r G. 13:94–102 34. Hecker H. calm on the outside: How acetazolamide may stabilize membrane excitability. Drewe J. Br J Pharmacol 2008. Marsch SC. Haberer JP. ANESTHESIOLOGY 1988. Iaizzo PA. Muscle Nerve 2006. Tomaselli GF. 586:875–87 18. ANESTHESIOLOGY 2007. Stephenson DG. Kress W. Suter PM: Sedation by propofol in tetanus–is it a muscular relaxant? Intensive Care Med 1991. Muscle Nerve 1990. Can J Anaesth 1998. Leuwer M: High-affinity blockade of voltage-operated skeletal muscle and neuronal sodium channels by halogenated propofol analogues. Rochani M. 13:240–6 20. Piepenbrock S. Naϩ channel defect causes myotonia. Marba ´n E. Muscle Nerve 2006. 36:643–50 35. Thornton CA: Computerized hand grip myometry reliably measures myotonia and muscle strength in myotonic dystrophy (DM1). Leuwer M: Propofol blocks human skeletal muscle sodium channels in a voltagedependent manner. Balser JR: Lidocaine induces a slow inactivated state in rat skeletal muscle sodium channels. Kambouris NG. Muscle Nerve 2007. Urwyler A: Propofol reduces succinylcholine induced increase of masseter muscle tone. Anaesthesia 1989. Bufler J. Ru ¨ del R: Drug-induced myotonia in human intercostal muscle. Sep 2009 . French RJ: Dual actions of procainamide on batrachotoxin-activated sodium channels: Open channel block and prevention of inactivation. Spaans F: Schwartz-Jampel syndrome: II. Dessibourg C. White RJ. Anesth Analg 2001. Fontaine B. Muscle Nerve 1990. Iaizzo PA. and cold in differentiating myotonic disorders. Dilek N. Hampl KF. Haeseler G. Paediatr Anaesth 2003. Martens WB. Hemmings HC: Isoform-selective effects of isoflurane on voltage-gated Naϩ channels. 17:427–9 22. 11:576–81 19. J Physiol 2008. 155:265–75 27. Lehmann-Horn F. Fabre F. Michel P. 65:2324–34 29. 49:525–7 21. Pandya S. 69:571–7 30. Kuntzer T: Comparative efficacy of repetitive nerve stimulation. 92:1192–8 26. Muscle Nerve 2007. Logigian EL. J Physiol 2000. 44:166 33. Ruff RL: Sour on the inside. Ong BH. Foadi N. Dengler R. Zamponi GW. Chen Z. Eguchi K: Acetazolamide acts directly on the human skeletal muscle chloride channel. Roeder A. Jeannet PY. Hatt H. 36:320–8 Anesthesiology. Hecker H. Karst M. Franke C. Anaesthesia 1994. Sto ¨ rmer M. Lehmann-Horn F: The correlation between electrical afteractivity and slowed relaxation in myotonia. Moxley RT 3rd. Schaefer HG: External ophthalmoplegia after total intravenous anaesthesia. Ummenhofer WC. Dunand M. exercise. Tsujino A. Dutka TL. Borgeat A. 17. Sternberg D. Murphy RM. 524(Pt 1):37–49 28. Sweo T: Ca2ϩ uptake and Ca2ϩ release by skeletal muscle sarcoplasmic reticulum: Differing sensitivity to inhalational anesthetics. Moxley RT 4th. Fournier E. Haeseler G. No 3. Taniyama K. Gudehus S. 107:91–8 31. Eguchi H. Annis CL.

8 markedly reduce hyperalgesia and allodynia in animals with nerve injury. Germany. Isoflurane produced use-dependent block of Nav1. Nav1.8 and Nav1. † Professor..8 minimum alveolar concentration at 24°C) reduced normalized peak Na؉ current (INa) of Nav1.10 After peripheral nerve damage.14 Halogenated inhaled (volatile) anesthetics inhibit endogenous TTX-s neuronal Naϩ channels.21 Inhibition of presynaptic Naϩ channels contributes to depression of neurotransmitter release by volatile anesthetics. Submitted for publication February 10. Herold. Weill Cornell Medical College. Results: From a holding potential of ؊70 mV. opposite to that of local anesthetics. at a stimulation frequency of 10 Hz. Methods: The sensitivities of heterologously expressed rat TTX-r Nav1.8 is highly expressed in dorsal root ganglion neurons and is functionally linked to nociception. such as inhaled anesthetics. ANESTHESIOLOGY’s articles are made freely accessible to all readers. Nav1. Departments of Anesthesiology and Pharmacology. New York.org or on the masthead page at the beginning of this issue. Nav1.D. Maryland (to Dr.† Wei Ouyang. Weill Cornell Medical College.D.13 These findings support an important role for Nav1.9) ␣-subunit isoforms. Ph.edu.8 expressed in Xenopus oocytes has been reported to be insensitive to inhaled anesthetics.D. identified.8 in these neurons is an important component of this sensitization. Erlangen.4 This suggests that pharmacological differences in anesthetic sensitivity might also apply to other drugs.09 mM for TTX-s Nav.8.2 All Nav isoforms can be blocked by the puffer fish toxin tetrodotoxin.5.* Carla Nau.. Supported by grant DFG HE4554/5-1 from the German Research Foundation (Deutsche Forschungsgemeinschaft).78 ؎ 0. for personal use only.anesthesiology. Germany (to Dr. 0. 2009.56 ؎ 0.9 Nav1. 1. but the sensitivity of TTX-r isoforms to inhaled anesthetics is unclear. Peripheral sensory neurons express both tetrodotoxinsensitive (TTX-s) (Nav1. and Department of Anesthesiology and Intensive Care Medicine.22–25 In contrast to the TTX-s isoforms tested.D.. Charite ´-Universitaetsmedizin Berlin.20 or amphibian oocytes. Friedrich-Alexander-University Erlangen-Nuremberg. Isoflurane did not affect voltage-dependence of activation. LC-203. 2009.8 has been reported to be fourfold more sensitive to inhibition by lidocaine than the TTX-s channel Nav1.8 and by ؊7 mV for TTX-s Nav. Address correspondence to Dr. M.58 minimum alveolar concentration.67 ؎ 0.Anesthesiology 2009. Block of Nav1. Isoflurane Inhibits the Tetrodotoxin-resistant Voltage-gated Sodium Channel Nav1.D. Box 50. Sep 2009 .11 Activation of uninjured neurons appears critical to the hyperalgesia seen in neuropathic pain states..18 as well as various Nav ␣-subunit isoforms heterologously expressed in mammalian cell lines19. Hemmings). neurotransmitter release. Inc. and the slowly inactivating current to Nav1.8 and 0.. the American Society of Anesthesiologists.§ Background: Voltage-gated sodium channels (Nav) mediate neuronal action potentials.06.56 ؎ 0. VOLTAGE-GATED Naϩ channels (Nav) are critical to neuronal excitability.8-containing afferents transmit nociceptive signals to the spinal cord. Hemmings. Conclusion: Isoflurane inhibited the tetrodotoxin-resistant isoform Nav1.8 to 0. New York.and A␦-fibers.01 for control. Tetrodotoxin inhibits all Nav isoforms. Ph. New York.06 mM for Nav1. and Nav1.12 and upregulation of Nav1. Bonn.D. 111:591–9 Copyright © 2009. Nav1. hchemmi@med.1–Nav1.000-fold less sensitive) compared to other isoforms. Received from the Department of Anesthesiology.8 and Nav1.55 ؎ 0.8 with potency comparable to that for endogenous tetrodotoxin-sensitive Nav isoforms. isoflurane (0. such as persistent and slowly inactivating currents.64 ؎ 0.01 versus 0. IC50 values for inhibition of peak INa were 0.8 and endogenous tetrodotoxin-sensitive (TTX-s) Nav to the prototypic inhaled anesthetic isoflurane were tested in mammalian ND7/23 cells using patch-clamp electrophysiology.08 mM isoflurane reduced INa to 0. New York 10065.D. Weill Cornell Medical College. Berlin.8 in pain and identify it as an interesting target for the development of new analgesic drugs.9 are relatively tetrodotoxin-resistant (TTX-r) compared to other isoforms.06 mM. Jr. but three isoforms (Nav1. 6 months from the cover date of the issue.8 is exclusively expressed in small to medium-sized DRG neurons that give rise to C. Germany. M. functional expression of Nav1..9) are relatively resistant (200 to 10. and action potential initiation and propagation. indicating that sensitivity to inhaled anesthetics is conserved across diverse Nav family members. M.03 and of endogenous TTX-s Nav to 0. Campus Virchow-Klinikum and Campus Charite ´ Mitte. ‡ Research Associate. Nav1.‡ Hugh C. 1300 York Avenue. Isoflurane minimally inhibited INa from a holding potential of ؊140 mV. New York.66 ؎ 0. Herold) and by grant GM58055 from the National Institutes of Health Bethesda.6. Hemmings: Department of Anesthesiology. but the functional significance of the multiple isoforms is largely unclear.cornell.9.11 Antisense oligonucleotides against Nav1.53 ؎ 0. Indeed.3.8 Karl F. but Nav1.4. Information on purchasing reprints may be found at www. Ph. Lippincott Williams & Wilkins.8 in dorsal root ganglion neurons could contribute to the effects of inhaled anesthetics on peripheral nociceptive mechanisms.8.1 These channels consist of a highly processed 260-kDa ␣-subunit that contains the ion channel pore formed by four homologous domains associated with auxiliary ␤-subunits (␤1–␤4) of 33–36 kDa.10 These neurons play an important role in pain pathways as the majority of Nav1. V 111. Accepted for publication May 11. No 3.8 decreases in injured neurons but is upregulated in adjacent uninjured axons.15–17 including TTX-s Naϩ channels in DRGs. New York. Nav1.7) and TTX-resistant (TTX-r) (Nav1.7.1. Department of Anesthesiology.1 At least nine ␣-subunits (Nav1.2. Department of Anesthesiology. Inc.8.. but it significantly shifted voltage-dependence of steady-state inactivation by ؊6 mV for Nav1. New York. and Nav1. and § Professor and Vice Chair of Research.7 The persistent current has been attributed to Nav1.9) have been * Postdoctoral Associate.8.4 – 6 TTX-r Naϩ currents found in dorsal root ganglion (DRG) neurons show distinctive biophysical properties. Ph. Weill Cornell Medical College. Department of Anesthesiology.14 would have important implications for analgesic mechanisms and the structural basis of Naϩ channel anesthetic sensitivity and would be remarkable given the close sequence homologies between Naϩ channel iso591 Anesthesiology.21 Such reduced inhaled anesthetic sensitivity. New York. significant inhibition occurred at clinically relevant concentrations as low as 0.

Westbury.0 –2. In contrast to a previous report. and 100 ␮g/ml streptomycin (Invitrogen) at 37°C under 95% air/5% CO2. 2 CaCl2.8 to inhaled anesthetics under more physiologic conditions. Fire-polished patch pipettes were pulled from borosilicate glass capillaries (Warner Instruments) by using a Sutter P-97 puller (Sutter Instruments. from which a sample was taken for determination of aqueous isoflurane concentration by gas chromatography. Stimulation Protocols and Data Analysis The holding potential (Vh) used was either Ϫ70 mV or Ϫ140 mV. Louis. St. 10 NaCl. where INa is peak current. Solutions were perfused focally onto recorded cells via a 150-␮m diameter perfusion pipette by using polytetrafluoroethylene tubing to minimize isoflurane loss. Currents were low-pass filtered at 5 kHz and sampled at 20 kHz.16. and reflected approximately 10% loss that occurred from the syringe through the tubing to the pipette tip.0003 tetrodotoxin Anesthesiology. Carlsbad. CA). Japan) with external standard calibration as described.8/EGFP. CT) and continuously perfused with external solution containing (in mM): 129 NaCl.8. Mountain View.27.8-pCMV-Script (1–3 ␮g) and the pEGFP-N1 (Clontech. CA) reporter plasmid (0. like endogenous TTX-s Nav isoforms. 20 tetraethylammonium-Cl. adjusted to pH 7. HEROLD ET AL. Perfusate samples were also taken to determine isoflurane concentrations at the tip of the perfusion manifold. No 3. and facilitate comparisons to other studies of isoflurane on Naϩ currents. MO) and cultured in Dulbecco’s modified Eagle’s medium (Invitrogen.29 –31 which probably reflects a requirement for additional subunits and/or a neuronal background for functional expression. Tokyo.26. To analyze the voltage-dependence of activation. 2 MgCl2. and voltage errors were minimized by using 70 – 80% series resistance compensation. La Jolla.21 transfected TTX-r Nav1. CA) and the sequence of the entire Nav1. 0. Japan). 11 EGTA. At 48 h after transfection. 10 tetraethylammonium-Cl. To test the sensitivity of Nav1. Sep 2009 (Sankyo Kasei Co.8 and endogenously expressed TTX-s Nav in ND7/23 cells. Cells were grown on 12-mm glass coverslips in 35-mm polystyrene culture dishes and transiently transfected with rat Nav1. 3. Electrophysiological Technique and Recordings Coverslips containing ND7/23 cells were transferred into a small-volume open bath perfusion chamber (Warner Instruments. Previous attempts to express Nav1. NY). Capacitive transients were electronically cancelled. and recordings were discarded if the seal dropped below 1 G⍀. Average transfection efficiency was 60 –70% for Nav1. Linear leakage currents were digitally subtracted online by the P/4 protocol (except for inactivation and use-dependent experiments).0 M⍀ when filled with the following internal pipette solution (in mM): 120 CsF.8. 1 CaCl2. Vm is the test . Hamden. Experiments were performed at room temperature to minimize anesthetic losses. 5 D-glucose.8 in nonneuronal mammalian cell lines for electrophysiological analysis have been unsuccessful. and recordings were discarded if resistance exceeded 8 M⍀. was inhibited by clinical concentrations of isoflurane.. CA) and had a resistance of 1.27 However the hybrid ND7/23 cell line derived from rat DRG neurons and a mouse neuroblastoma cell line (N18TG2) exhibits sensory neuron-like properties28 and can express functional heterologously transfected Nav1. The conductance (GNa) was calculated by using the equation: GNa ϭ INa/ (Vm Ϫ Vrev).16 This stock solution was further diluted on the day of the experiment into gas-tight glass syringes. adjusted to pH 7. Isoflurane-saturated external solutions (containing 12– 12. The ND7/23 rat DRG/ mouse neuroblastoma fusion cell line was purchased from Sigma (Sigma-Aldrich. currents were evoked by 5-ms pulses ranging from Ϫ80 to ϩ70 mV in steps of 10 mV. the transfected cells were identified by expression of enhanced green fluorescent protein (EGFP) by using fluorescence microscopy. 10 HEPES. 1 MgCl2.4 (with NaOH) and 310 mOsm/kg H2O. V 111.05 ml/min was controlled by a pressurized perfusion system (ALA Scientific.5–1 ␮g) or reporter plasmid alone using Lipofectamine LTX (Invitrogen). CA) supplemented with 10% fetal bovine serum (Invitrogen).20 Isoflurane solution flow of 0. Sunnyvale.592 forms. 100 U/ml penicillin. Materials and Methods Transient Transfection and Cell Culture Rat Nav1. 10 HEPES. maximize recording stability.2 We have therefore reexamined this more closely by using a mammalian neuronal expression system. Voltage-clamp recordings were performed at room temperature (23– 24°C) in standard whole-cell configuration32 using an Axopatch 200B patch-clamp amplifier (Molecular Devices. Initial seal after establishing the whole-cell patch was 2– 4 G⍀. Novato. Tokyo.8 channel protein (NCBI nucleotide access number U53833) was verified by dideoxynucleotide sequencing.25 KCl. Untransfected ND7/23 cells were plated and seeded as described above and incubated for 48 h to study endogenous TTX-s Naϩ channels. 2 mM L-glutamine.8-cDNA was subcloned into the mammalian expression vector pCMV-Script (Stratagene.3 (with CsOH) and 315 mOsm/kg H2O. we investigated the effects of the halogenated ether isoflurane on heterologously expressed TTX-r Nav1. Liquid junction potential was not corrected. Series resistance was typically 1–5 M⍀. Isoflurane concentrations were determined by extraction into n-heptane (1:1 v/v) followed by analysis using a Shimadzu GC-8A gas chromatograph (Shimadzu.5 mM isoflurane) were prepared by shaking in gastight glass vials for 24 h as previously described.

plotted against the prepulse potential.06 for TTX-s Nav (n ϭ 6) (fig. From a more hyperpolarized holding potential of Ϫ140 mV.ISOFLURANE INHIBITS THE NAV1. indicating that ND7/23 cells do not express detectable endogenous TTX-r Naϩ channels (fig. 1.5. mean Ϯ SD) that rapidly activated and inactivated upon depolarization (fig. 2A). the interval from the beginning of Results Properties of Naϩ Currents in Wild-type and Nav1.33 We compared the effects of isoflurane on endogenously expressed TTX-s INa in untransfected ND7/23 cells and on TTX-r INa in ND7/23 cells transiently transfected with rat Nav1. 1A. Anesthesiology.8-transfected Cells ND7/23 cells express endogenous TTX-s Naϩ currents (INa) with properties similar to TTX-s currents in isolated DRG neurons.1. Redmond. The programs used for data acquisition and analysis were pClamp 10 (Axon/Molecular Devices).920 Ϯ 620 pA at Vh ϭ Ϫ140 mV. since Nav1. Excel (Microsoft Inc. n ϭ 6.8 and Ϫ10 mV for TTX-s Nav. Peak currents of the test pulse were measured. where V1/2 is the voltage that elicits half-maximal activation and k is the slope factor. Ϫ2. and fitted with a Boltzmann function.8 (n ϭ 8) and to 0. mean Ϯ SD) in the presence of 300 nM tetrodotoxin (fig. table 1). followed by a test pulse to ϩ10 mV (Nav1.7. and Vrev is the calculated reversal potential (ϩ65 mV).8 was studied at 1. Decay time constants of peak INa were obtained from a monoexponential fit to the decay phase of the macroscopic Naϩ current from 90% of peak current. n ϭ 8.03 for TTX-r Nav1.56 Ϯ 0. Peak INa was activated at a command potential of ϩ10 mV for TTX-r Nav1. voltage steps from ؊80 to ؉70 mV. V 111. P Ͻ 0.830 Ϯ 840 pA at Vh ϭ Ϫ70 mV. 3. 2). normalized (INa/INamax). and Prism 5 (GraphPad Software Inc. Statistical significance was assessed by analysis of variance with Newman-Keuls post hoc test. which blocks tetrodotoxin-sensitive Na؉ channels and results in pharmacological isolation of the tetrodotoxin-resistant Nav1.91 Ϯ 0. Vh ‫ ؍‬؊70 mV. Sep 2009 . pulse duration.3 (B) Recordings of an ND7/23 cell transfected with Nav1.2. isoflurane was much less effective and reduced normalized peak INa to 0. DRG neurons express a mixed population of Naϩ channels that includes Nav1.27 Though the specific Naϩ channel isoforms responsible for TTX-s currents in ND7/23 cells are unknown.8 (n ϭ 8) and 0. Inhibition was reversible upon washout of isoflurane (data not shown). Fig. n ϭ 6. Further analysis of time-to-peak values. IC50 values were determined by least squares fitting of data to the Hill equation: Y ϭ 1/(1 ϩ 10((logIC50 Ϫ X)h)). Normalized conductance (G/Gmax) plotted against command potential indicated no significant effects of isoflurane on voltage-dependence of activation for TTX-r Nav1. Representative voltage-clamp recordings of Na؉ currents. and 10 Hz with 60 10-ms test pulses up to a final potential of ϩ10 mV. at which most channels are in the closed resting state. 1A.01 for TTX-s Nav (n ϭ 6) (fig. which is sufficient to block all tetrodotoxin-sensitive Na؉ channels without affecting Nav1.55 Ϯ 0.3 ND7/23 cells expressed voltage-gated TTX-s INa (Ϫ1.8 ␣-subunit showed prominent voltage-gated TTX-r INa (Ϫ1. At a concentration of isoflurane (0. Peak currents were measured. or paired or unpaired Student t test. 3).8) or Ϫ10 mV (TTX-s Nav). Inset shows stimulation protocol. Normalized conductance (G/Gmax) was plotted against test potentials and fitted to the Boltzmann function: G/Gmax ϭ 1/[1 ϩ exp(V1/2 Ϫ V/k)].8 in the absence (left) or presence (right) of 300 nM tetrodotoxin. n ϭ 8. right).34. 5 ms. Usedependent block for Nav1.06 mM) equivalent to 1.05 was considered statistically significant. where Y is the current amplitude.6. and Nav1. Effect of Isoflurane on Peak Current and Activation Current-voltage relationships were determined for TTX-r Nav1. (A) Tetrodotoxin (TTX)-sensitive Na؉ currents endogenously expressed in an ND7/23 cell in the absence (left) or presence (right) of 300 nM tetrodotoxin.620 Ϯ 880 pA at Vh ϭ Ϫ70 mV. No 3. and h is Hill slope. WA). X is the isoflurane concentration. CA). normalized to the first pulse and plotted against pulse number.. Ϫ1. Steady-state and fast inactivation were measured by applying a double-pulse protocol that consisted of a 500 ms (hϱ) or 15 ms (fast inactivation) prepulse ranging from Ϫ120 to ϩ 20 mV in steps of 10 mV. 1B). San Diego.8 current.8 minimal alveolar concentration (MAC) in rat after temperature correction to 24°C. ND7/23 cells transfected with Nav1.8. These Naϩ currents were completely inhibited by 300 nM tetrodotoxin.8 is resistant to tetrodotoxin (IC50 Ͼ 100 ␮M).220 Ϯ 680 pA at Vh ϭ Ϫ140 mV.6. 2B. Values are reported as mean Ϯ SEM unless otherwise stated..53 Ϯ 0.8 in the presence of 300 nM tetrodotoxin to block endogenous TTX-s INa. There was no significant effect of isoflurane on the voltage-dependence of activation of TTX-r Nav1.8 or TTX-s Naϩ currents (fig.35 the normalized peak INa was 0.91 Ϯ 0. left).8 and TTX-s Nav at the physiologic holding potential of Ϫ70 mV (fig. Nav1. see table 1).03 for TTX-r Nav1. Nav1.30 Transfection of EGFP alone did not result in expression of TTX-r INa (data not shown).8 SODIUM CHANNEL 593 potential.8 or TTX-s Nav from either holding potential (for V1/2 and k values.

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Fig. 2. Current-voltage relationships and voltage-dependence of activation for tetrodotoxin-resistant (TTX-r) Nav1.8 (left) and tetrodotoxin-sensitive (TTX-s) Nav (right) currents performed in the absence or presence of isoflurane. Whole-cell currents were evoked from a holding potential of ؊70 mV using a series of depolarizing steps from ؊80 mV to ؉70 mV in 10-mV steps (inset). Data are shown as mean ؎ SEM (n ‫ ؍‬6 – 8) for control (open symbols) and isoflurane (0.53 ؎ 0.06 mM, equivalent to 1.8 minimum alveolar concentration [MAC] when corrected to 24°C, closed symbols). (A) Isoflurane reduced peak current amplitude but otherwise did not change the current-voltage relationship. (B) Activation curves (mean ؎ SEM, n ‫ ؍‬6 –10) for TTX-r Nav1.8 and TTX-s Nav conductance in the absence (open symbols) or presence (closed symbols) of isoflurane. The data show the normalized Boltzmann function for conductance (G/ Gmax) derived from the equation; G/Gmax ‫ ؍‬1/[1 ؉ exp(V1/2 ؊ V/k), where G is the measured conductance, Gmax is the maximal conductance, V1/2 is the membrane potential for half-maximal activation, and k is the slope.

Fig. 3. Current-voltage relationships and voltage-dependence of activation for tetrodotoxin-resistant (TTX-r) Nav1.8 (left) and tetrodotoxin-sensitive (TTX-s) Nav (right) currents performed in the absence or presence of isoflurane. Whole cell currents were evoked from a hyperpolarized holding potential of ؊140 mV at which most Na؉ channels are in the closed resting state using a series of depolarizing steps from ؊80 mV to ؉70 mV in 10-mV steps (inset). Data are shown as mean ؎ SEM (n ‫ ؍‬6 – 8) in the absence (open symbols) or presence of isoflurane (0.53 ؎ 0.06 mM, equivalent to 1.8 minimum alveolar concentration [MAC] when corrected to 24°C, closed symbols). (A) Isoflurane reduced peak current amplitude only minimally and did not change the shape of the current-voltage relationship. (B) Activation curves (mean ؎ SEM) for TTX-r Nav1.8 and TTX-s Nav conductance in the absence (open symbols) or presence (closed symbols) of 0.53 ؎ 0.06 mM isoflurane. See Fig. 2 legend for details of curve fitting.

the test pulse to peak INa amplitude, also showed no significant difference between control and isoflurane for TTX-r Nav1.8 and TTX-s Nav (data not shown). Effect of Isoflurane on Inactivation The voltage-dependence of Naϩ channel inactivation was studied by using a 2-pulse protocol that consisted of a series of command potentials from Ϫ120 mV to ϩ20 mV in 10-mV steps, followed by a test pulse to elicit peak INa (ϩ10 mV for TTX-r Nav1.8 and Ϫ10 mV for TTX-s
Table 1. Parameters for Na؉ Current Activation and Inactivation
Activation Vh-70 mV V1/2 k n V1/2 Activation Vh-140 mV k

Nav). This standard approach assesses the fraction of channels available for activation by the second pulse. As the membrane potential of the prepulse becomes more positive, more channels enter inactivated and nonconducting states such that fewer channels are available for activation by the second test pulse. Inactivation curves were determined by using two different prepulse durations; fast inactivation was measured by using a 15-ms prepulse27 and steady-state inactivation using a 500-ms prepulse (fig. 4). The INa of the second test pulse was normalized to peak INa (INa/INamax), plotted against prepulse potential, and fitted to a standard Boltzmann func-

Steady-state Inactivation (500 ms Prepulse) n V1/2 k n

Fast Inactivation (15 ms Prepulse) V1/2 k n

Nav1.8 Control Isoflurane TTX-s Control Isoflurane

Ϫ5.7 Ϯ 0.4 Ϫ5.7 Ϯ 0.7 Ϫ20.9 Ϯ 1.2 Ϫ21.6 Ϯ 0.9

5.1 Ϯ 0.2 5.6 Ϯ 0.1 5.3 Ϯ 0.3 5.8 Ϯ 0.3

8 8 6 6

Ϫ5.2 Ϯ 1.0 Ϫ6.6 Ϯ 1.3 Ϫ24.5 Ϯ 0.9 Ϫ25.9 Ϯ 1.3

5.2 Ϯ 0.2 5.4 Ϯ 0.3 5.5 Ϯ 0.2 5.7 Ϯ 0.4

8 8 6 6

Ϫ49.0 Ϯ 1.2 Ϫ54.6 Ϯ 1.3† Ϫ67.0 Ϯ 2.3 Ϫ74.1 Ϯ 2.1‡

9.6 Ϯ 0.3 10.8 Ϯ 0.4† 6.0 Ϯ 0.3 6.5 Ϯ 0.4

8 8 4 4

Ϫ29.5 Ϯ 1.8 Ϫ41.7 Ϯ 2.4† Ϫ55.7 Ϯ 0.6 Ϫ70.7 Ϯ 2.6†

10.9 Ϯ 0.8 13.1 Ϯ 1.0 13.6 Ϯ 0.4 16.6 Ϯ 2.0

8 8 4 4

Mean values were derived from Boltzmann equation fits of individual data sets as described in the Methods. Isoflurane was tested at 0.53 Ϯ 0.06 mM (equivalent to 1.8 minimum alveolar concentration [MAC] when corrected to 24oC). † P Ͻ 0.01; ‡ P Ͻ 0.001 vs. control, compared by paired two-tailed Student t-test. k ϭ slope; n ϭ number of experiments; TTX-s ϭ tetrodotoxin-sensitive; Vhϭ holding potential; V1/2 ϭ voltage at which half maximal activation or inactivation occurs.

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Fig. 5. Concentration-dependence for inhibition of tetrodotoxin-resistant (TTX-r) Nav1.8 (A) and tetrodotoxin-sensitive (TTX-s) Nav (B) by isoflurane. Left panels show representative traces of TTX-r Nav1.8 (A) or TTX-s Nav (B) Na؉ currents in the absence (control) or presence of two concentrations of isoflurane, and the subsequent washout of isoflurane (dotted line). The dashed line represents the baseline. Normalized peak INa values for TTX-r Nav1.8 (n ‫ ؍‬33) and for TTX-s Nav (n ‫ ؍‬13) were fitted to the Hill equation to yield IC50 values and Hill slopes (h). The IC50 values and Hill slopes were not significantly different by sum-of-squares F test. Holding potential, Vh ‫ ؍‬؊70 mV. Fig. 4. Inactivation of tetrodotoxin-resistant (TTX-r) Nav1.8 (A, B; n ‫ ؍‬8) and tetrodotoxin-sensitive (TTX-s) Nav (C, D; n ‫ ؍‬4) Na؉ currents. Peak Na؉ current (INa) was normalized to the maximal value (INamax) and plotted against the conditioning pulse potential. Data were fitted by a Boltzmann function according to the following equation: INa/INamax ‫ ؍‬1/[1 ؉ exp(V1/2 ؊ V/k), where V is the prepulse potential, V1/2 is the potential for half-maximal inactivation, and k is the slope. Data are shown for two prepulse durations of 500 ms (A, C) and 15 ms (B, D) (stimulation protocols shown in insets). Note the presence of a noninactivated fraction (10 –20%) with the shorter prepulse seen in TTX-r Nav1.8 (B). Isoflurane concentration used for the experiments was 0.53 ؎ 0.06 mM (equivalent to 1.8 minimum alveolar concentration when corrected to 24°C).

IC50 values for isoflurane inhibition of INa were obtained by eliciting peak INa from a holding potential of Ϫ70 mV. Normalized peak INa values were fitted to the Hill equation to yield IC50 and Hill slope values (fig. 5). The IC50 values of 0.67 Ϯ 0.06 mM for TTX-r Nav1.8 and 0.66 Ϯ 0.09 mM for TTX-s Nav, and Hill slopes of Ϫ1.12 Ϯ 0.16 for TTX-r Nav1.8 and Ϫ0.85 Ϯ 0.14 for TTX-s Nav were not significantly different. Significant inhibition occurred at isoflurane concentrations as low as 0.17 Ϯ 0.01 mM (equivalent to 0.58 MAC after temperature correction to 24°C) for both TTX-r Nav1.8 (P Ͻ 0.01; n ϭ 6) and TTX-s Nav (P Ͻ 0.001; n ϭ 8). Voltage-dependent Block of Nav1.8 At the physiologic holding potential of Ϫ70 mV, isoflurane (0.53 Ϯ 0.05 mM) significantly reduced the normalized peak INa to 0.55 Ϯ 0.03 for TTX-r Nav1.8 (P Ͻ 0.001, n ϭ 8) and to 0.56 Ϯ 0.06 for TTX-s Nav (P Ͻ 0.01, n ϭ 5) (fig. 6). Inhibition by isoflurane was significantly less from a holding potential of Ϫ140 mV, at which most channels are in the closed resting state (normalized peak INa was 0.91 Ϯ 0.03 (P Ͻ 0.05, n ϭ 8) for TTX-r Nav1.8 and 0.91 Ϯ 0.01 (P Ͻ 0.001, n ϭ 6) for TTX-s Nav). Use-dependent Block of Nav1.8 Preferential interaction of isoflurane with the inactivated state of Naϩ channels results in accumulation of drug-bound channels during high-frequency stimula-

tion from which the voltage of half-inactivation (V1/2) was determined (table 1). Isoflurane (0.53 Ϯ 0.06 mM) produced a negative shift in the voltage-dependence of steady-state inactivation (500 ms prepulse) of Ϫ5.6 Ϯ 0.8 mV for TTX-r Nav1.8 and Ϫ7.1 Ϯ 0.3 mV for TTX-s Nav (P Ͻ 0.001), and a negative shift in the voltagedependence of fast inactivation (15-ms prepulse) of Ϫ9.2 Ϯ 2.1 mV for TTX-r Nav1.8 and Ϫ15 Ϯ 2.3 mV for TTX-s Nav (P Ͻ 0.01). There were no significant effects on slope values. The time constant of Naϩ current decay at peak INa (␶) was significantly increased by isoflurane for both TTX-r Nav1.8 and TTX-s Nav. The ␶ values for Nav1.8 were 2.5 Ϯ 0.1 ms in control and 3.0 Ϯ 0.2 ms with isoflurane (P Ͻ 0.05, n ϭ 8), and for TTX-s Nav were 0.54 Ϯ 0.04 ms in control and 0.58 Ϯ 0.04 ms with isoflurane (P Ͻ 0.05, n ϭ 6).
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Fig. 6. Voltage-dependent effects of isoflurane on inhibition of peak INa. Tetrodotoxin-resistant Nav1.8 (closed bars) and tetrodotoxin-sensitive (TTX-s) Nav (open bars) Na؉ currents were inhibited strongly by isoflurane (0.53 ؎ 0.06 mM, equivalent to 1.8 minimum alveolar concentration [MAC] when corrected to 24°C) at the physiologic holding potential of ؊70 mV, but minimally when held at ؊140 mV. *** P < 0.0001, paired two-tailed Student t test, n ‫ ؍‬5–10).

tion.36 Native TTX-r Naϩ channels found in DRG neurons recover quickly from inactivation after membrane repolarization,37 and similar behavior has been reported for Nav1.8 in ND7/23 cells.30 We used 60 pulses to ϩ10 mV to determine the decay in peak amplitude of Nav1.8 at various frequencies (1, 3, and 10 Hz). In control experiments, use-dependent block was more pronounced at higher stimulation frequencies (fig. 7). In the presence of isoflurane (0.56 Ϯ 0.08 mM), Nav1.8 currents showed a greater use-dependent decrement compared to control at all three stimulation frequencies tested. At a stimulation frequency of 1 Hz, the plateau of normalized peak INa, which was determined by fitting the data to a single exponential function, was 0.94 Ϯ 0.01 in control and 0.85 Ϯ 0.02 in the presence of isoflurane (P Ͻ 0.001, n ϭ 5). At a stimulation frequency of 3 Hz, the plateau of normalized peak INa was 0.88 Ϯ 0.01 in control and 0.81 Ϯ 0.01 in the presence of isoflurane (P Ͻ 0.001, n ϭ 5). At the highest frequency of 10 Hz, the plateau of normalized peak INa was 0.78 Ϯ 0.01 in control and 0.64 Ϯ 0.01 in the presence of isoflurane (P Ͻ 0.001, n ϭ 5). Control data for use-dependent reductions in Nav1.8 current are comparable to those published previously for this channel.27,30

Fig. 7. Use-dependent block of tetrodotoxin-resistant Nav1.8 currents in the absence (control, open symbols) or presence (closed symbols) of isoflurane (0.56 ؎ 0.08 mM; 1.6 minimum alveolar concentration [MAC]). Whole-cell currents were evoked by 60-step depolarization commands (holding potential ؊70 mV; test potential ؉10 mV; pulse duration 10 ms) delivered at 1 Hz (A), 3 Hz (B) or 10 Hz (C). Peak-current amplitude values (mean ؎ SEM, n ‫ ؍‬5) were normalized to that of the first response at each frequency and plotted against pulse number. The normalized first pulse amplitude was reduced to 0.54 ؎ 0.03 of control by isoflurane. (D) Representative recordings at 10 Hz in the absence (left) or presence (right) of isoflurane. Arrows mark traces for pulse 1 and pulse 60 (dashed line represents baseline). Data were fitted by a mono-exponential equation, and values for fractional block of the plateau of normalized INa are shown in E. *** P < 0.001, paired two-tailed Student t test, n ‫ ؍‬5.

Discussion
Voltage-gated Naϩ channel isoforms are pharmacologically distinguishable, and are in fact classified, by their differential sensitivities to the specific inhibitor tetrodotoxin. Considerable evidence indicates that TTX-s isoforms are reversibly inhibited by clinical concentrations of volatile anesthetics, but anesthetic effects on the TTX-r isoforms are poorly characterized. A previously published study suggested that Nav1.8 was unique among Nav isoforms tested in its resistance to inhibition by isoflurane when tested using heterologous expression in amphibian oocytes,21 but this has not been confirmed in neuronal cells. We investigated the effects of the commonly used inhaled anesthetic isofluAnesthesiology, V 111, No 3, Sep 2009

rane on endogenously expressed TTX-s and heterologously expressed TTX-r Nav1.8 currents in a neuronal cell line. Isoflurane inhibited both TTX-r Nav1.8 and endogenous TTX-s Nav with similar potencies (IC50 ϭ 0.67 mM or 0.66 mM, respectively). These concentrations correspond to 2.3 MAC in rat after temperature correction to 24°C, and they are similar to those reported previously for inhibition of Nav1.2, Nav1.4, and Nav1.5 heterologously expressed in Chinese hamster ovary cells by isoflurane (IC50 ϭ 0.70, 0.61, and 0.45 mM, respectively).20 Although the IC50 values are somewhat higher than clinically relevant concentrations, significant inhibition occurs in the more clinically relevant concentration range of more than 0.5 times MAC.20,24,38 Moreover, small reductions in INa can have large physiologic effects due to nonlinear coupling.24 The finding that isoflurane inhibits Nav1.8 expressed in a mammalian neuronal cell line but not when expressed in Xenopus oocytes21 demonstrates the importance of an appropriate expression system for pharmacological studies of these channels.

ISOFLURANE INHIBITS THE NAV1.8 SODIUM CHANNEL

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It is now clear that both TTX-r and TTX-s Nav isoforms are inhibited by inhaled anesthetics and do not exhibit major differences in anesthetic sensitivity.20 Sensitivity to inhaled anesthetics is even present in the homologous prokaryotic Naϩ channel NaChBac, indicating that anesthetic sensitivity is related to a fundamental evolutionarily conserved Naϩ channel property.39 In addition to their differential sensitivities to tetrodotoxin, Nav isoforms have been reported to have different sensitivities to local anesthetics. In rat DRG neurons and with oocyte expression, TTX-r currents (primarily Nav1.8) are more sensitive to inhibition by lidocaine than TTX-s channels, despite their highly conserved amino acid sequences.7,14 Sensitivity of Nav isoforms to local anesthetics is determined primarily by conserved residues in the DIV-S6 segment,40 whereras the greater sensitivity of Nav1.7 and Nav1.8 to lidocaine has been proposed to result from minor sequence differences in the DI and DII S6 segments,14 although this could be affected by differences in voltage dependence of inactivation. The comparable sensitivities of various Nav isoforms to isoflurane suggest a conserved drug-binding domain, perhaps in DIV-S6. Analysis of Nav1.8 pharmacology has been hampered by difficulties in expressing functional channels. Initial expression in Xenopus oocytes showed relatively small currents,4 and attempts by other groups to express Nav1.8 in mammalian cell lines, including COS-7,41 CHO,42 and HEK-293 cells,27 resulted in very low levels of functional expression. However ND7/23 cells, derived from rat DRG and mouse neuroblastoma (N18TG2) cells, are suitable for transient and stable expression of recombinant Nav1.8 in a mammalian neuronal environment.28 These cells endogenously express Nav ␤1- and ␤3-subunits,27 which are sufficient for the functional expression and stability of Nav1.8 ␣-subunits. Cotransfection of Nav1.8 with the ␤1-subunit29 or ␤3-subunit27 does not alter current kinetics, activation, or inactivation characteristics of TTX-r currents in ND7/23 cells. Isoflurane had negligible effects on the voltage dependence of Nav1.8 activation, but it produced a hyperpolarizing shift in the voltage-dependence of fast and steady-state inactivation. This behavior is consistent with selective interaction of isoflurane with channels in the inactivated state as described previously for other Naϩ channel isoforms including Nav1.2 and Nav1.4.19 –21 The molecular basis of this block has yet to be determined for volatile anesthetics. Our results suggest that the shift in voltage-dependence of inactivation might result from slowing of inactivation evidenced by the increased time constants of current decay. The functional consequence is a reduction in the range of membrane potentials over which Nav1.8 can operate, as confirmed by the voltagedependence of isoflurane inhibition. Other Naϩ channel blockers such as local anesthetics (e.g., lidocaine) and certain anticonvulsants and antiarrhythmics also exhibit state-dependent drug interactions
Anesthesiology, V 111, No 3, Sep 2009

with Nav as described by the modulated receptor hypothesis.43 Voltage-dependent block by local anesthetics results in a hyperpolarizing shift in steady-state inactivation, thus enhancing channel block at normal as opposed to hyperpolarized potentials. Isoflurane apparently inhibits Naϩ channels by a similar mechanism involving enhanced inactivation. Selective interaction with inactivated states is consistent with the use-dependent block by isoflurane, which increases the fraction of channels in the inactivated state. Naϩ channels undergo both fast and slow inactivation, and slow inactivation contributes to the use-dependent effects of some drugs.44 The contribution of slow inactivation to the effects general anesthetics on Nav block is an interesting question for future investigation. The rate at which Naϩ channels recover from inactivation (repriming) determines how well channels respond to high firing rates. Isoform-specific differences in repriming rates have been reported.45 Interestingly, repriming rates of TTX-r Naϩ currents, which are “slow” in terms of time to peak current and time constant of current decay, are about 10-fold faster than those of TTX-s Naϩ currents in rat DRG neurons. Use-dependent block of Nav1.8 by isoflurane could be due to its slow dissociation from blocked channels during repolarization, effectively slowing the repriming rate, but this is unlikely given the low affinity interaction. Lidocaine does not interfere with movement of the cytoplasmic inactivation loop, which is the underlying mechanism for fast inactivation, such that lidocaine-induced slowing of Naϩ channel repriming does not result from slow recovery of the fast-inactivation gate.46 This suggests that use-dependent block does not involve accumulation of fast-inactivated channels, but it could involve effects on slow inactivation mechanisms. By analogy with local anesthetics, stabilization of inactivated channel states and/or open channel block by isoflurane is currently a more plausible explanation.38 The Naϩ current underlying the depolarization phase of the action potential in nociceptive DRG neurons is carried primarily by Nav1.8, which is expressed exclusively in this cell type.4,10 Slowly inactivating TTX-r Naϩ currents are eliminated in DRG neurons of Nav1.8 knockout mice, which confirms the role of Nav1.8 in conducting these currents.8 Both antisense and knock-out studies support a role for Nav1.8 activation in inflammatory pain.8 Previous studies using antisense nucleotides suggested a role for Nav1.8 in neuropathic pain,13 but a recent study shows that Nav1.8 is necessary for mechanical, cold, and inflammatory pain, but not for neuropathic and heat pain.47 Visceral pain, a major consideration in the perioperative setting, has been attributed to Nav1.8 since knockout mice show decreased visceral pain and referred hyperalgesia.48 Subanesthetic concentrations of isoflurane, which would probably have relatively small effects on Nav1.8, depress the nociceptive

Lawson SN: The TTX-resistant sodium channel Nav1. Exp Neurol 2007. J Pharmacol Exp Ther 1975. 204:288–98 13. Franks NP. Dib-Hajj SD: Functional role of the Cterminus of voltage-gated sodium channel Na(v)1.8. Halsey MJ. Ure J.and voltage-dependence of isoflurane block. Hemmings HC Jr: Selective depression by general anesthetics of glutamate versus GABA release from isolated cortical nerve terminals. Jang JH. Kobayashi J. Wood JN. 67:1591–9 26. Park KA. 28:365–8 3.8 and TTX-s Nav were inhibited by isoflurane at concentrations that occur during clinical anesthesia. (Rapid Communication) J Neurosci 1999. based on the frequency. Fitzgerald M. Hofmann F. Neuron 2000. Hemmings HC Jr: Isoflurane and propofol inhibit voltage-gated sodium channels in isolated rat neurohypophysial nerve terminals. Black JA: Sodium channels. 88:1043–54 17. Chevrier P.8 in uninjured axons enables neuropathic pain. Theveniau M. Porreca F. 100: 663–70 25. Wegert S. 142:576–84 15.8 tetrodotoxin-resistant sodium channels. Carr RW. Trezise DJ: Heterologous expression and functional analysis of rat Nav1.8 is essential for pain at low temperatures. HEROLD ET AL. Wu XS. Souslova V. Black JA. Liu J. Priestley T: Vinpocetine is a potent blocker of rat NaV1. Dib-Hajj SD. J Neurosci 1992. Duch DS. ANESTHESIOLOGY 1998. Sangameswaran L. Novel cell lines display properties of nociceptive sensory neurons. Reiprich A. Nau C. Netter YB. Vysotskaya TN. Lai J. Muscle Nerve 1999. Scholz A. Hunter JC: A comparison of the potential role of the tetrodotoxin-insensitive sodium channels. Barchi RL. Schlame M. Babes A. Sep 2009 . Ouyang W. Bevan SJ. Caldwell JH. Dickenson AH. Nau C: Use-dependent block by lidocaine but not amitriptyline is more pronounced in tetrodotoxin (TTX)Resistant Nav1.8 peripheral nerve sodium channels by the local anesthetic lidocaine. Maguire M. Meisler MH. Hill R.55 Anesthetic modulation of peripheral Naϩ channels such as Nav1. Stanfa LC. Mohapatra DP. 320:354–64 30. Tyrrell L. Koblin DD. and the molecular basis of pain. 12:2104–11 8. Kallen RG. Woolf CJ: Developmental expression of the TTX-resistant voltage-gated sodium channels Nav1. 64:373–81 16. This inhibition would be enhanced at high firing frequencies and depolarized membrane potentials. Sidhu HS. Kim CS. which has implications for the development of postoperative pain. Tate S. Nature 1996. has the potential to modulate these poorly characterized pronociceptive mechanisms.49. including isoflurane. Mol Pharmacol 2003. The critical role of Nav1. Nat Neurosci 1999. Wood JN: The tetrodotoxin-resistant sodium channel SNS has a specialized function in pain pathways. Noda M. 550:739–52 11. Crona J. Rabert DK. Annu Rev Physiol 2001.9 (SNS2) in primary sensory neurons.598 reflex to single electrical stimuli in humans. Hemmings HC Jr: Inhibition by volatile anesthetics of endogenous glutamate release from synaptosomes by a presynaptic mechanism. Bian D. 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Curr Opin Neurobiol 2003. Catterall WA: Nomenclature of voltage-gated sodium channels. Harmar A. Westphalen RI. 241:187–94 29. Ogata N. Hemmings HC Jr: Differential effects of anesthetic and nonanesthetic cyclobutanes on neuronal voltage-gated sodium channels. Eglen RM.52–54 The anesthetic concentrations required for these effects on pain processing are consistent with the sensitivity of Nav1. Ryan TA: The general anesthetic isoflurane depresses synaptic vesicle exocytosis. This is consistent with a conserved drug-binding site among various Nav isoforms.82:1406–16 23. 23:158–66 12. Eur J Neurosci 1998. Porreca F. Lai J: Redistribution of Na(V)1. Kim DW. Pflugers Arch 1981. discussion 27A 20. 447:855–8 32. V 111. England S. J Pharmacol Exp Ther 2004. Hemmings HC Jr: Isoform-selective effects of isoflurane on voltage-gated Naϩ channels. Kim KH. 92:529–41 18. Treanor J. Leem JW: The role of uninjured C-afferents and injured afferents in the generation of mechanical hypersensitivity after partial peripheral nerve injury in the rat.50 In addition. Djouhri L. Akopian AN. Dong XW. PN3/SNS and NaN/SNS2. Kassotakis L. Westphalen RI. Wang R. Costigan M. Wood JN: A tetrodotoxin-resistant voltage-gated sodium channel expressed by sensory neurons. Morrison C. Proc Biol Sci 1990. Zhou X. Leffler A. Hick C. Vogel W: Two types of TTX-resistant and one TTXsensitive Naϩ channel in rat dorsal root ganglion neurons and their blockade by halothane. Wood JN. Wang G. Neuropharmacology 2004. Goldin AL: Resurgence of sodium channel research. J Pharmacol Exp Ther 2007. therefore. Wu LG: Isoflurane inhibits transmitter release and the presynaptic action potential. No 3. Boyce S.8 to inhibition by isoflurane and a possible role in nociceptive processing by DRG neurons. J Physiol 2003. 22:1177–87 7. isoflurane has peripheral antinociceptive effects in a number of animal models in which supraspinal modulatory and/or pronociceptive effects were surgically or pharmacologically eliminated. 379:257–62 5. Crowder M. Narahashi T: Differential properties of tetrodotoxin-sensitive and tetrodotoxin-resistant sodium channels in rat dorsal root ganglion neurons. Shiraishi M. Waxman SG: A novel persistent tetrodotoxin-resistant sodium current in SNS-null and wild-type small primary sensory neurons. Kerr BJ.8 (SNS) and Nav1. 63:871–94 4. Ossipov MH. Chahine M: Differential modulation of Nav1. Rougon G. Cendan CM. 195:225–36 Anesthesiology. Ouyang W. The role of isoflurane inhibition of Nav1. Goldin AL. Zimmermann K. Xiao YH.51 Moreover. significantly suppress development of spinal sensitization in the rat paw formalin test. J Neurosci 2001. Sakmann B. Sun JY. Eger EI 2nd. Coote PR. Hamill OP. Ratnakumari L.8 than in TTX-sensitive Naϩ channels.304:1188–96 24. In conclusion. 13:291–7 34. Sigworth FJ: Improved patchclamp techniques for high-resolution current recording from cells and cell-free membrane patches. References 1. Recent studies also implicate volatile anesthetic activation and sensitization of TRPV1 ion channels in lowering the threshold for heat activation. Waxman SG. 21:6077–85 6. conditions that occur with tissue injury and inflammation. J Neurosci 2003. Hunter JC. rats.84:1223–33. Dib-Hajj S. Wood JN. Wood JN. McMahon SB. Hemmings HC Jr. 10:2547–56 19. Reeh PW: Sensory neuron sodium channel Nav1. Gold MS. Okuse K. Akopian AN. Leffler A.8 (SNS/PN3): Expression and correlation with membrane properties in rat nociceptive primary afferent neurons. Lee WT. Courtney KR: Mechanism of frequency-dependent inhibition of sodium currents in frog myelinated nerve by the lidocaine derivative GEA. Roy ML. volatile anesthetics. Cummins TR. 2:541–8 9. Howe JR. Tate S. Lai J. 572:256–60 27. Hunter JC.8. 309:987–94 22.49.50 whereas anesthetic concentrations of 1 MAC are required to depress the response to repetitive stimuli critical to central hyperexcitability in humans. John VH. Nam TS. Clare JJ. ANESTHESIOLOGY 1996. both TTX-r Nav1. Catterall WA: From ionic currents to molecular mechanisms: The structure and function of voltage-gated sodium channels. Waxman SG.107:91–8 21. ANESTHESIOLOGY 2000. Novakovic S. Evers AS.8 in acute perioperative pain and the development of hyperexcitability is an interesting topic for further investigation. Neuron 2000. Ratnakumari L. Taheri S. Benn SC. Gladwell ZM. in rat models of chronic pain. 46:425–38 28. 96:7640–4 14. Tamkun MM. Wood JN. 26:13–25 2. Rehberg B.8 in peripheral pain mechanisms suggests that its inhibition could contribute to the antinociceptive and possibly antiinflammatory effects of isoflurane and other inhaled anesthetics capable of blocking these channels. Akopian AN. 72:627–34 35. Laster MJ: What solvent best represents the site of action of inhaled anesthetics in humans. J Pharmacol Exp Ther 2003. Duch DS: Central nervous system sodium channels are significantly suppressed at clinical concentrations of volatile anesthetics.

Guo TZ. Science 2008. 321:702–5 48. Arendt-Nielsen L. Antognini JF. 265:1724–8 41. Brau ME. cold. 113:7–16 47. 96:367–74 54. 82:259–66 52. 550:921–6 49. Cendan CM. Br J Anaesth 1999. Antognini JF. Sep 2009 . ANESTHESIOLOGY 1995. Br J Anaesth 1995. 2001. Hille B: Classical Mechanisms of Block. Fitzgerald EM. Mashimo T. Nassar MA. Wood JN: Annexin II light chain regulates sensory neuron-specific sodium channel expression. J Pharmacol Exp Ther 2007. 3rd Edition. Matta JA. J Gen Physiol 1999. Tashiro C. Sunderland. and inflammatory pain. McPhee JC. Bjerring P. Cervero F: The tetrodotoxinresistant Naϩ channel Nav1. Waxman SG: Downregulation of tetrodotoxin-resistant sodium currents and upregulation of a rapidly repriming tetrodotoxin-sensitive sodium current in small spinal sensory neurons after nerve injury. Kingery WS. Mol Pharmacol 2008. Abrahamsen B. Clark JD. Wang GK: Interactions of local anesthetics with voltage-gated Naϩ channels. Scheuer T. Hemmings HC Jr: Comparative effects of halogenated inhaled anesthetics on voltage-gated Naϩ channel function. Fischer M. Malik-Hall M. J Neurosci 1997. Carstens E. J Physiol 1998. Yoshiya I: Alterations in pain threshold and psychomotor response associated with subanaesthetic concentrations of inhalation anaesthetics in humans. Anesth Analg 2006. Br J Anaesth 1993. Cannon SC: The position of the fast-inactivation gate during lidocaine block of voltage-gated Naϩ channels. 82:244–9 53. ANESTHESIOLOGY 2002. Moss SJ: cAMP-dependent phosphorylation of the tetrodotoxin-resistant voltage-dependent sodium channel SNS. Kong H.ISOFLURANE INHIBITS THE NAV1. Elliott AA. Sawamura S. Nau C. Sinauer Associates. Catterall WA: Molecular determinants of state-dependent block of Naϩ channels by local anesthetics. Cornett PM. Vedantham V. Souslova V. MA. 103:753–60 55. O’Connor TC. Roth D. ANESTHESIOLOGY 2009. Agashe GS. Baker MD. Martinez-Barbera JP. Okuse K. Rush AM. Dutton RC. 75:55–60 51. Correa AM. Wood JN. Ahern GP: General anesthetics sensitize the capsaicin receptor transient receptor potential V1. No 3. Zhao J. 417:653–6 43. Carstens E: The differential effects of halothane and isoflurane on windup of dorsal horn neurons selected in unanesthetized decerebrated rats. 17:3503–14 46. Ion Channels of Excitable Membranes. 201:1–8 45. Jinks S. pp 504 –38 44. Ouyang W. Inc. Nishimura M. Jih TY. Science 1994. Marsh S. Nishimura S. 511:771–89 38. Herold KF. Zhang TT.. 74:1261–8 Anesthesiology. Roza C. J Physiol 2003. Chao MV. Dolphin AC.8 SODIUM CHANNEL 599 37. Kobilka BK. Davies MF. Ouyang W. V 111. Wood JN. Asante CO. Hemmings HC Jr: Isoflurane inhibits NaChBac. 110:582–90 39. Mitsuyo T. 70:684–6 50. Simons C: Isoflurane can indirectly depress lumbar dorsal horn activity in the goat via action within the brain. Yagi M. Petersen-Felix S. Pak M. a prokaryotic voltage-gated sodium channel. Cummins TR. Tomi K. Buzin V. 516:433–46 42. Zbinden AM: Analgesic effect in humans of subanaesthetic isoflurane concentrations evaluated by experimentally induced pain. Bak P. Maze M: Isoflurane and nociception: Spinal ␣2A adrenoceptors mediate antinociception while supraspinal ␣1 adrenoceptors mediate pronociception. Nature 2002. Ragsdale DS. Laird JM. Poon WY. Dickenson AH. 322:1076–83 40.8 is essential for the expression of spontaneous activity in damaged sensory axons of mice. Elliott JR: Electrophysiological properties of sodium current subtypes in small cells from adult rat dorsal root ganglia. Abram SE: Inhibition of nociception-induced spinal sensitization by anesthetic agents. Wood JN: The cell and molecular basis of mechanical. J Membr Biol 2004. Okuse K. J Physiol 1999.

1 Several mechanisms have been proposed to cause postshock vascular hyporeactivity.9 Nitrous oxide. Department of Anesthesiology. Postbus 196.D. Henning. M. California.. as arterial hypotension and vascular leakage have been recognized as hallmarks of the postshock state. the contractile response to phenylephrine was increased in the Shock as compared with the Sham and Resuscitated groups (Emax ‫ ؍‬3. i. multiple organ dysfunction syndrome. This implies that vascular reactive properties during anesthesia in hemorrhagic shock conditions may be influenced by the choice of anesthetics.4. and Resuscitated groups. hypotension has been associated with altered vascular reactivity to different modulators of vascular tone. Shock. 600 Anesthesiology. Adjunct nitrous oxide to sevoflurane (at 1. 27. ** Professor of Pharmacology. 2009..5 ؎ 0.5 mN.. Epema.6. including systemic and local release of nitric oxide.‡ Martin C.7 Moreover. Groningen. Shock induced a down-regulation of cyclooxygenases-1.V. subsequently leading to a decrease in blood pressure. Ph. University Medical Center Groningen..5 minimum alveolar concentration [MAC]) or isoflurane (at 1. The contractile response was abrogated in the isoflurane-anesthetized groups that underwent shock.8. University of Groningen. Inc. the American Society of Anesthesiologists. In the Sham isoflurane group. † Staff. University of Groningen. Adjunct nitrous oxide increased phenylephrine contraction to a similar level in all three groups. Accepted for publication April 30. Both groups were divided into Sham. Department of Pathology and Medical Biology.13 although venoconstrictor effects of nitrous oxide and sympathetic stimulation have been proposed as a possible explanation. Vascular reactivity to phenylephrine and acetylcholine and expression of cyclooxygenases were studied in the aorta.2–5 Patients with hemorrhagic shock frequently receive anesthesia to facilitate diagnostic and therapeutic procedures.§ Francis M. Sep 2009 .4.4%) or with isoflurane (1. University Medical Center Groningen. which may contribute to organ hypoperfusion.samarska@med. the authors examined the influence of adjunct nitrous oxide on the vascular responsiveness after short-term hemorrhagic shock under isoflurane anesthesia..31 g) were anesthetized with isoflurane (1. The Netherlands. Information on purchasing reprints may be found at www.nl. acetylcholine caused a biphasic response: An initial relaxation followed by a contractile response sensitive to cyclooxygenases inhibition by indomethacine. Conclusion: Adjunct nitrous oxide attenuates shock-induced changes in vascular reactivity and cyclooxygenases expression of mice under isoflurane anesthesia.* Matijs van Meurs.2 ؎ 0. ࿣ Resident. early changes in vascular responsiveness may be of significance. Inc. and to investigate the effects of adjunct nitrous oxide administration on the observed changes.. In all groups. ‡ Assistant Professor of Pharmacology. ANESTHESIOLOGY’s articles are made freely accessible to all readers.10 –12 The mechanisms through which nitrous oxide offsets the hemodynamic effects of volatile anesthetics are still not fully understood.. Many of the agents employed interfere with vasoresponsiveness and/or influence the therapeutic effectiveness of vasoactive drugs and the development and outcome of hemorrhagic shock. these agents may influence systemic secretion of vasoconstrictors such as vasopressin. Submitted for publication October 10. and 2.. Methods: Spontaneously breathing mice (n ‫ ؍‬31. In this study. myocardial depression. M.. Received from the Department of Clinical Pharmacology. Please see: Sanders RD. Samarska.† Robert H. The Netherlands.org or on the masthead page at the beginning of this issue. still widely used as an adjunct in various anesthetic techniques. The Netherlands. Volatile anesthetics interfere with vasoresponsiveness. which was normalized by adjunct nitrous oxide. decreased plasma levels of vasopressin. Ph. has also been implied to influence hemodynamics. Maze M: Does correcting the numbers improve long-term outcome? ANESTHESIOLOGY 2009. V 111.4%) and adjunct nitrous oxide (66%). San Francisco. Ph. 111:600 – 8 Copyright © 2009. adjunct nitrous oxide preserved the contractile phase. further contributing to a reduction in blood pressure and deterioration of organ microcirculation. # Professor of Life Sciences. Lippincott Williams & Wilkins. M.v. However. 1. The Netherlands.1–3 Indeed.D. Houwertjes. for personal use only. 2008. Results: In the isoflurane-anesthetized groups.Ⅵ CRITICAL CARE MEDICINE Anesthesiology 2009.࿣ Grietje Molema.† Hendrik Buikema. Wulfert. ultimately. October 13–17. 111:475–7. * Research Fellow.D. and endothelin. University of Groningen.2 ؎ 0. § Technician.anesthesiology. respectively).D. Department of Clinical Pharmacology.D.S.** Background: Hemorrhagic shock is associated with changes in vascular responsiveness that may lead to organ dysfunction and. The mechanisms underlying this syndrome are not fully understood. 6 months from the cover date of the issue. Ph.6 ؎ 0. Department of Clinical Pharmacology. ᭜ This article is accompanied by an Editorial View. and changes in properties of vascular smooth muscle cells.D.D. Adjunct Nitrous Oxide Normalizes Vascular Reactivity Changes after Hemorrhagic Shock in Mice under Isoflurane Anesthesia Iryna V. angiotensin.45 MAC) stabilizes several hemodynamic parameters of regional and systemic flow.D. Supported by an Ubbo Emmius Scholarship (I. 9700AD Groningen. M. Volatile anesthetics may evoke peripheral vasodilatation.) from the Groningen Institute for Drug Exploration.Sc. Samarska: University Medical Center Groningen. CHANGED vascular reactivity in hemorrhagic shock may represent an important factor in the development of a multiple organ dysfunction syndrome. M. No 3. 2007. Address correspondence to Dr. M. Presented in part at the Annual Meeting of the American Society of Anesthesiologists.12 The purpose of this study was to determine the change in vascular responsiveness obtained from mice after short-term hemorrhagic shock under isoflurane anesthesia.# Anne H.umcg. and lower sympathetic nervous system activity.D.

61 mm). Louis. The length of the aortic strips was assessed by microscopy. Bad Homburg. After a second centrifugation (13. the descending thoracic aorta was immediately placed into cold physiologic saline. St. blood gas analysis was performed just after femoral cannulation (t ϭ 0 min) and immediately before killing (t ϭ 24 h). Denmark).14 Briefly. with a continuous monitoring of MAP. after induction of anesthesia the left femoral artery was cannulated with polyethylene tubing (internal diameter 0. Shock animals underwent anesthesia and hemorrhage and were sacrificed after 90 min of hemorrhagic shock. Contraction was measured by obtaining concentration-response curves to phenylephrine (10 nM–100 ␮M). Littau. MO) were used as a primary antibodies. In the Sham groups. and a group of mice that were anesthetized with isoflurane (1. Resuscitated mice were sacrificed 24 h after induction of shock. and kept under anesthesia for 90 min before being killed. containing 6 ml of Krebs solution. A fixed– blood pressure model of hemorrhagic shock was used as described previously. the freshly isolated thoracic aorta was collected for in Anesthesiology. Then the rings were subjected twice to stimulation with potassium chloride (60 mM) to obtain reproducible contractile responses. 3 min). warmed to 37°C and bubbled continuously with 95% O2/5% CO2 to maintain pH at 7. The resuscitation volume was twice the estimated volume of the blood withdrawn to induce hemorrhagic shock.6 Ϯ 0. after grinding.000 revolutions per minute. Vasomotor Responses After removal. blood gas analysis was measured twice: Just after femoral cannulation (t ϭ 0 min) and after the shock period immediately before killing (t ϭ 90 min). An initial 0. Harlan. Zeist. The total amount of blood withdrawn was estimated from the number of portions taken from the animal. This study was performed in 31 adult mice (27. Small increments of blood were infused or withdrawn during the shock period to maintain MAP at 30 mmHg. Rockford. followed by additional portions of about 0. Western Blotting The methods used were described previously. this blood pressure reduction was reached in approximately 11 min. the frozen aortas were placed in 300 ␮l of boiling 2% sodium dodecyl sulfate (SDS) followed by pounding by a polytron (Kinematica AG. Hercules. Hypotension at 30 mmHg was maintained during 90 min. After killing.4 (Voluven. Sham animals were anesthetized and cannulated but not hemorrhaged. Cyclooxygen- . Each group was divided into three experimental subgroups (n ϭ 5– 6 per group). Lausen. San Diego. ␤-actin served as a housekeeping protein. Switzerland).000 revolutions per minute. CA) and anti-␤actin (Sigma. MacrophageϩIFNg/LPS (BD Bioscience Pharmingen) was used as a positive control for cyclooxygenase-2. Horseradish peroxidase-linked rabbit antimouse antibody was applied as a secondary antibody.4. anticyclooxygenase-2 antibody (BD Bioscience Pharmingen. Switzerland). endothelium-independent relaxation was measured by applying the nitric oxide donor sodium nitroprusside (0. At the end of each experimental protocol. All animals were breathing spontaneously throughout the protocol. Protein concentration was determined by Bio-Rad Protein Assay (Bio-Rad.4%) and adjunct nitrous oxide (66%) in oxygen (33%). No 3.15. The blood was collected in a heparinized 1-ml syringe to prevent clotting. 1 min) and boiled (95°C) for 5 min. Then the samples were centrifuged (4. IL) and transferred to nitrocellulose membranes.NITROUS OXIDE MAINTAINS VESSEL FUNCTION AFTER SHOCK 601 Materials and Methods The experimental protocol was approved by the Institutional Animal Care and Use Committee of the University of Groningen (Groningen. Resuscitated animals underwent anesthesia with hemorrhagic shock for 90 min. Germany). Endothelium-dependent relaxation was measured by obtaining concentrationresponse curves to acetylcholine (10 nM–300 ␮M) in rings precontracted with phenylephrine. Hemorrhagic shock was induced by blood withdrawal until mean arterial pressure (MAP) reached 30 mmHg. The blots were analyzed using Super Signal assay (Pierce). In both Resuscitated groups. The abdominal aorta was removed and snap-frozen in liquid nitrogen without pretreatment with any drug.28 mm and external diameter 0. Sep 2009 vitro vasomotor studies.16 Briefly. and stored at Ϫ80°C until analysis. supernatant was collected and used for measurements. blood gas analysis was performed only immediately before killing (90 min) to avoid potential activation of endothelium and modification of vascular reactivity by withdrawal of blood at t ϭ 0. CA). Fresenius-Kabi.31 g. Anticyclooxygenase 1 antibody (ALEXIS Biochemicals. Aortic rings were equilibrated for 40 min until they were at a steady baseline.4%) in an oxygen/air mixture (33%).1 ml until MAP reached 30 mmHg. Aarhus.5–2 mm in length) were mounted on two 200-␮m stainless wires in the individual myograph baths wire myograph (Danish Myo Technology A/S.5 ml of blood was withdrawn. Freshly isolated thoracic aortic rings (1. The Netherlands) housed under standard conditions with free access to food (standard rat chow) and drinking water throughout the study. followed by resuscitation with 6% hydroxyethyl starch 130/0. The Netherlands). The influence of vasoactive prostanoids on the response to acetylcholine was examined by incubating the rings with the nonspecific cyclooxygenase inhibitor indomethacine (10 ␮M) administered 20 min before application of phenylephrine. V 111. In both Shock groups. Experimental animals were assigned to two groups: A group of mice that were anesthetized with isoflurane (1. Forty ␮g of total protein from each sample was separated on 4 –20% Precise Protein Gels (Pierce.1 mM).

5 glucose. sodium nitroprusside. After instrumentation at the start of the experimental protocol. base excess. ase-1 and cyclooxygenase-2 levels are expressed as ratios to ␤-actin protein levels.5 CaCl2. SaO2. Adjunct nitrous oxide resulted in a similar pH in the Sham isoflurane/nitrous oxide and Shock isoflurane/ nitrous oxide groups (table 1).2 for Windows (SPSS Inc. Sep 2009 was done by one-way ANOVA followed by a Bonferroni test. HCO3Ϫ. Mean arterial pressure (MAP. All other drugs were dissolved in deionized water. hemoglobin. Stock solution (10 mM) for indomethacine was prepared in 96% ethanol. * Significantly different curves between Sham ISO and Sham ISO؉N2O (P < 0. Other blood gas parameters were similar in both Shock groups. Shock.response curves to phenylephrine and acetylcholine were characterized by area under the curve. followed by a near normalization to baseline values in resuscitated animals (fig. and the negative logarithm of the molar concentration that caused halfmaximal response (EC50).2 MgSO4. Concentration-response curves of individual rings were plotted with SigmaPlot version 10. hemodynamic parameters were comparable between the three experimental subgroups for a given type of anesthesia. Statistical analysis was done with SPSS 16.05). or anesthesia with isoflurane and adjunct nitrous oxide (ISO ؉ N2O. as compared with the Sham isoflurane group.9 KCl. phenylephrine. shock was confirmed by a significant drop in blood pressure.602 SAMARSKA ET AL. All other compounds were purchased from Sigma. San Jose. Concentration.2 NaH2PO4. and hematocrit did not significantly differ between both Sham groups at all time points measured (table 1). 1. 5.. No 3. .0 (Systat Software Inc. Drugs Krebs solution was prepared freshly and of the following composition (mM): 120. The concentrations presented in the concentration-curve responses are expressed as a final molar concentration in the organ baths. the maximal response (Emax). Statistical Analysis Data are presented as mean Ϯ SD and n refers to the number of animals in the corresponding group. All tests were two-tailed. A). 2. indomethacine. and NG-Monomethyl-L-arginine acetate salt. CA).4 NaCl. Differences between concentration-response curves were evaluated by two-way repeated measures ANOVA followed by a Bonferroni test.0 NaHCO3.05 Sham versus corresponding Shock and Resuscitated groups. During shock. Blood gases..0. France). IL). MAP varied between 26 –36 mmHg during the 90-min shock period. these chemicals were obtained from Merck (Darmstadt. femoral artery) of the Sham. 1. pO2. 25. as compared with the group with adjunct nitrous oxide (table 1). pO2 was slightly increased in animals anesthetized with isoflurane only. The pH was increased in the Shock isoflurane group. In mice undergoing blood withdrawal. 11. ** P < 0. EC50 was calculated by Four Parameter Logistic Curve (SigmaPlot) for each ring. The independent sample t test was used to compare the means of two groups where applicable. Fig. and differences were considered significant at P Ͻ 0. Germany).05. The following drugs were used: Acetylcholine chloride. hemodynamic measurements and blood gas analyses were performed. 1).05). B). Comparison of single parameters among multiple groups Anesthesiology. The main difference between both types of anesthesia was that in Sham isoflurane animals MAP was slightly lower ( 10 mmHg throughout the protocol) as compared with Sham isoflurane/nitrous oxide animals receiving adjunct nitrous oxide (P Ͻ 0. V 111. Chicago. and relaxant responses to acetylcholine and sodium nitroprusside are expressed as a percentage of the preconstriction obtained with phenylephrine (0.1 mM). The contractile response to phenylephrine was expressed in mN. Results Hemodynamic Changes and Routine Lab Parameters To monitor the animals during the procedure. Levene’s test was used to confirm the homogeneity of variance. NG-Monomethyl-L-arginine acetate salt was purchased from MP Biomedicals (Illkirch. and Resuscitated groups during the experimental procedure in animals anesthetized with isoflurane (ISO. 1.

35 Ϯ 0.2 1. ‡ P Ͻ 0.05) and an unchanged EC50 (P ϭ 0.7 13.6 Ϯ 1.5 Ϯ 4. BE ϭ base excess.6 Ϯ 2. These findings suggest that both shock and nitrous oxide increase contractility in a nonadditive manner. Resuscitated isoflurane ϩ nitrous oxide.9 Ϯ 0. Relaxation Responses to Acetylcholine Administration of acetylcholine to aortic rings from mice subjected to sham conditions caused a biphasic Sham Shock Resuscitated 1.8 Ϯ 1.7 Ϯ 0. Contractile responses of isolated aortic rings were obtained by constructing concentration-response curves to phenylephrine.4 — — 13.6 — 5 26.0 Ϯ 1.3 39.6 — — 35.3 1.5 Ϯ 1.6 — Ϫ11.8 Ϯ 2.2 Ϫ9.5 — 14.4 Ϯ 0.6 — 100.7 7. 2).2 Ϯ 13.0 Ϯ 2.7 Ϯ 0.9 Ϯ 1.7 — –8.05 — 7.9 Ϯ 0.1 100.3 Ϯ 1..2 Ϯ 1.37 Ϯ 0.5 Ϯ 2.0 18.5 Ϯ 0. Width of Aorta Rings in All Groups Groups Isoflurane Isoflurane/Nitrous Oxide contractile response to phenylephrine in the Shock isoflurane and Resuscitated isoflurane groups was also enhanced as compared with the Sham isoflurane group (P Ͻ 0.34 Ϯ 0.7 Ϯ 9.1 Values are mean Ϯ SD in millimeters.2 — — Ϫ10.8 — 15.6 — — Ϫ10.6 Ϯ 0.1 1.6 Ϯ 2. Hb.9 Ϯ 0.3 Ϯ 1.4 Ϯ 0.3 Ϯ 5.0 Ϯ 0 — 8.9 — — 34.5 — — 7.6 — 39.e.3 — –7. Anesthesiology.05 Sham isoflurane vs. 2). SaO2.7 Ϯ 3.9 — 99. and Hct in groups of mice anesthetized with isoflurane sole and isoflurane with adjunct nitrous oxide. Hb ϭ hemoglobin.4 Ϯ 1.1 — — 22. Shock isoflurane ϩ nitrous oxide. The contractile response to phenylephrine in the Sham isoflurane/nitrous oxide group was enhanced (P Ͻ 0.7 100.0 Ϯ 0 — 99.32 Ϯ 0.7 –6.05 — — 3.7 — — 100.2 7.4 17.4 31.5 Ϯ 0.8 Ϫ11. and between the Resuscitated isoflurane and Resuscitated isoflurane/nitrous oxide groups (fig.6 Ϯ 0. Hct ϭ hematocrit.4 3.5 28.4 Ϯ 2.8 Ϯ 0.1 Ϯ 0.1 23.1 Ϯ 1.3 Ϯ 0.2 — 16.4 42.9 Ϯ 2. pO2 ϭ partial arterial pressure of oxygen.2 — Ϫ9.9 — 39.2 — 3.9 Ϯ 0. This enhancement was characterized by an increased Emax (P Ͻ 0.7 Ϯ 4.4† 27.08 7.4 — 3.0 Ϯ 3. no significant differences were observed in the Emax and EC50 values between the corresponding two groups (table 3).7 Ϯ 0.3 5.0 Ϯ 0 — 7. HCOϪ3.4 — 2.4 Ϯ 2.03† — 4.7 Ϯ 0.05. * P Ͻ 0.1 Ϯ 0.3 Ϯ 2.5 — — 13.3 Ϯ 3. BE.1 25.9 — 25.7 — 30.8 Ϯ 0.8 Ϯ 0.8 — — 33.07 4.9 Ϯ 0.9 Ϯ 0.4 Ϯ 2. 2A).9 Ϯ 0.6 Ϯ 0.6 Ϯ 0.9 Ϯ 0.3 5 26.0 Ϯ 0 100.3 Ϯ 3.3 7.0 Ϯ 0 — — 6.5 — 5 28.3 Ϯ 1.3 — 41.33 Ϯ 0.42 Ϯ 0.4 — 5 29.01* — — 3.37 Ϯ 0.0 Ϯ 3.1 — 12.9 Ϯ 2.7 30.9 Ϯ 2.6 Ϯ 2.05 Shock isoflurane vs.4 Ϯ 0.NITROUS OXIDE MAINTAINS VESSEL FUNCTION AFTER SHOCK 603 Table 1. pO2. pCO2 ϭ partial arterial pressure of carbon dioxide.5 Ϯ 0.6 — — 99.6 Ϯ 3.2 Ϯ 1.1 Ϯ 6. V 111.0 –8.9 Ϯ 0.34 Ϯ 0.9‡ — 27.5 Ϯ 3.0 Ϯ 0 8.2 — 16. i.2 1. Contractile Reactivity Experiments in vitro were performed on freshly isolated aorta rings of similar length (P ϭ 0.1) in all groups (table 2).05) and an unchanged EC50 (P ϭ 0. table 3).7. HCOϪ3 ϭ bicarbonate.0 Ϯ 0 — 100.7 Ϯ 0.01 — 3.9 Ϯ 0.4 4. This enhancement was also characterized by an increased Emax (P Ͻ 0. Arterial Blood Gas Data at the Different Time Points of the Experimental Protocol Isoflurane Parameters Sham Group Shock Group Resuscitated Group Sham Group Isoflurane ϩ Nitrous Oxide Shock Group Resuscitated Group No.05) as compared with the Sham isoflurane group (fig.6 Ϯ 1.9 7. Shock isoflurane.0 — 7.2 100.06 4. fig.6 2.05 Resuscitated isoflurane vs.03 7.5 — 7.3 Ϯ 1.1 1. the contractile response to phenylephrine was identical between the Shock isoflurane and Shock isoflurane/nitrous oxide groups.3 Ϯ 0.6 Ϯ 1.3 Ϯ 1. table 3).4 Ϯ 2. † P Ͻ 0.1 Data on the values of pH.40 Ϯ 0.2. However.5 — 3. No 3. SaO2 ϭ oxygen saturation. Sep 2009 .1 7. The Table 2.4 13.04 — 7. pCO2.1 — 18.29 Ϯ 0. of Animals Weight (g) pH 0 min 90 min 24 h pCO2 (kPa) 0 min 90 min 24 h pO2 (kPa) 0 min 90 min 24 h BE (mM/l) 0 min 90 min 24 h HCOϪ3 (mM/l) 0 min 90 min 24 h SaO2(%) 0 min 90 min 24 h Hb (mM/l) 0 min 90 min 24 h Hct 0 min 90 min 24 h 5 26.5 — 6 27.

0* 6. In contrast.2 Ϯ 1.9 Ϯ 0. 3B). which was maximal at 0. Inserts show the responsiveness to phenylephrine presented as maximal response (Emax) in mN. * P < 0. N2O ϭ nitrous oxide.1 Ϯ 1. No 3. but changes did not reach statistical significance (fig.8 Ϯ 1. 3. The biphasic pattern in the acetylcholine concentration-response curve was also abolished in the presence of indomethacine. Bonferroni test.28 Ϯ 0. Emax ϭ maximal contractile response. the relaxant response to sodium nitroprusside was similar in all groups (table 4). Vascular Cyclooxygenase-1 and Cyclooxygenase-2 Expression Since short-term hemorrhagic shock differentially affected relaxation responses to acetylcholine with both modes of anesthesia. adjunct nitrous oxide also preserved the biphasic pattern after conditions of shock and resuscitation (fig. Sep 2009 . B. Contractile reactivity of aortic rings to phenylephrine of mice anesthetized with isoflurane (A) and isoflurane with adjunct nitrous oxide (B) in the Sham.8 Ϯ 0.24 Ϯ 0. followed by a recovery during resuscitation (fig.9 Ϯ 1. A and B).05 Sham versus Shock isoflurane. and C). A similar pattern was observed for vascular cyclooxygenase-2 expression.048. N2O ‫ ؍‬nitrous oxide. * P ϭ 0.2 Ϫ6. 4. Parameters of Phenylephrine-mediated Contraction during Different Phases of Experimental Shock after Anesthesia with either Isoflurane or Isoflurane with Adjunct Nitrous Oxide ISO Groups ϪlogEC50 AUC Emax (mN) ϪlogEC50 ISO/N2O AUC Emax (mN) Sham Shock Resuscitated Ϫ6. as compared with groups with adjunct nitrous oxide (at 1 ␮M). C and D). AUC ϭ area under the curve. Consequently. cyclooxygenase-1 expression was preserved in groups receiving adjunct nitrous oxide. Table 3.54 Ϫ7.17 Ϯ 0. an inhibitor of cyclooxygenase (fig. two-tailed t test.6 7.1 Ϯ 0.604 SAMARSKA ET AL.41 Values are mean Ϯ SD. A. the contractile phase and hence the biphasic pattern in the concentration-response curve was fully suppressed (fig. Shock. 2. V 111. followed by a contractile response at concentrations Ն 0. and Resuscitated groups. † P Ͻ 0.4 2.3 ␮M.19 Ϯ 0. Collectively.44 2. ISO ϭ isoflurane.5 Ϯ 0.8† 4.3 Ϫ7. Sham isoflurane vs. The latter is also reflected by the profound increase in acetylcholine concentration at which maximal relaxation was seen in Shock and Resuscitation groups that received anesthesia with isoflurane only (at 10 ␮M).8 1. 3A).3 ␮M (Sham groups in fig. we subsequently investigated vascular protein expression of cyclooxygenase-1 and cyclooxygenase-2 in segments collected from the unstimulated abdominal aorta. one-way ANOVA followed by Anesthesiology. In Shock isoflurane and Resuscitated isoflurane mice.43† 2. ISO ‫ ؍‬isoflurane.0 Ϯ 0.05.41 3. vascular cyclooxygenase-1 expression decreased significantly after shock. under these conditions concentration-response curves for acetylcholine did not differ between groups. suggesting that acetylcholine responses represent changes in endothelial cell function rather than altered vascular smooth muscle response to nitric oxide. Sham-ISO vs.8 3.2 Ϫ7. Shock isoflurane.31 3.8 Ϯ 2. These findings imply the involvement of contractile prostaglandins in the upward stroke at higher concentrations of acetylcholine. Fig.0 Ϯ 0.1 Ϫ6. While groups differed in anesthetic regimes and the levels of phenylephrine precontraction. In contrast.2 Ϯ 1. 3. In mice anesthetized with isoflurane only.05 Sham versus Shock isoflurane.3 4.9 Ϯ 0.0 Ϯ 0. response characterized by a relaxation. Sham isoflurane/nitrous oxide.2 2. these findings indicate that the biphasic pattern of the response to acetylcholine after conditions of shock and resuscitation was maintained by adjunct nitrous oxide. # P < 0.

These functional changes were accompanied by a decrease in the vascular expression of cyclooxygenase-1. 3. Discussion We investigated the effects of nitrous oxide adjunct to anesthesia with isoflurane on vascular reactivity in an experimental model of shock in mice.7 99. Anesthesiology. No differences were found between groups (one-way ANOVA).2 Ϯ 1. Importantly.1 mM) and are presented as mean ؎ SD.8 101.1 101. Collectively.NITROUS OXIDE MAINTAINS VESSEL FUNCTION AFTER SHOCK 605 Fig. adjunct nitrous oxide aug- mented phenylephrine-induced contractility of Sham mice. Sep 2009 . these findings suggest that vascular reactivity during different phases of shock may be preserved when adjunct nitrous oxide is employed. adjunct nitrous oxide protected from the loss of contractile response to acetylcholine during shock and preserved the vascular expression of cyclooxygenase-1.1 98.0 Ϯ 11. Shock groups (open circles) and Resuscitated groups (triangular up) are expressed as percentage of preconstriction value to phenylephrine (0. SNP ϭ sodium nitroprusside. ISO ‫ ؍‬isoflurane. Shock. Our data show that hemorrhagic shock in animals that received isoflurane during the procedure induced profound changes in the subsequent vascular reactivity of isolated thoracic rings.5 Ϯ 1. In addition.4 Ϯ 7. particularly cyclooxygenase-1. the changes observed in vascular reactivity in the shock group under Table 4. No 3. 4. V 111. Acetylcholine-induced relaxation of aortic rings from Sham. the influence of anesthetics on vascular reactivity has not been explored in this way before. which may involve (among others) a preservation of vascular cyclooxygenase expression. INDO ‫ ؍‬indomethacine. A and B). To our knowledge. and Resuscitated groups anesthetized with isoflurane (A and C) or isoflurane with adjunct nitrous oxide (B and D). we investigated the effect of different anesthetic techniques applied during hemorrhagic shock in vivo on the vascular properties of aortic tissue that was harvested subsequently and examined in the absence of anesthetics. In this study. consisting of an increased contraction to phenylephrine and a loss of cyclooxygenase-mediated contraction to acetylcholine. Collectively. and in the absence of indomethacine (A and B) or presence of indomethacine (C and D). Concentration-response curves of Sham groups (closed circle).2 Ϯ 21.3 Data are expressed as a percentage of phenylephrine-mediated precontraction and were calculated from concentration response curves at 0. N2O ‫ ؍‬nitrous oxide.3 103. these findings suggest that adjunct nitrous oxide mitigates the shock-induced decrease in the expression of cyclooxygenases.4 Ϯ 8. Second. Maximal Relaxant Response to Sodium Nitroprusside in All Groups Maximal Relaxation to SNP (%) Isoflurane Sham Shock Resuscitated Sham Isoflurane ϩ Nitrous Oxide Shock Resuscitated 101. but no further increase was observed when these animals underwent shock.1 mM of sodium nitroprusside.

that shock increased constriction to phenylephrine. In turn. a study in patients under sevoflurane anesthesia suggests that adjunct nitrous oxide normalizes hemodynamic parameters of regional and systemic flow. It thus appears that contractile mechanisms become mobilized to maintain perfusion pressure during shock and overrule the effect of anesthesia.4. Vascular responsiveness was also investigated by studying endothelial-mediated responses.606 SAMARSKA ET AL. isoflurane anesthesia imply that this procedure induces protracted changes in the vascular bed. such view is in keeping with the observed down-regulation of cyclooxygenase-1 in this group.17 and its general depressant effects on hemodynamics are quite notorious indeed. showed that addition of 70% nitrous oxide to isoflurane anesthesia results in improved arterial and central venous pressures. contractility to phenylephrine was not further increased after shock with adjunct nitrous oxide. Expression of COX-1 (A) and COX-2 (B) was assessed in Sham (n ‫ ؍‬5). Pypendop et al. or anesthesia with isoflurane and adjunct nitrous oxide (ISO ؉ N2O). indicating that the effect of nitrous oxide was not additive. but not in those receiving adjunct nitrous oxide. decreased arterial pressure was observed together with decreased constriction to phenylephrine in isolated aortic ring preparation obtained from Sham mice anesthetized with isoflurane. thus generating a biphasic concentration-response curve. thus indicating the involvement of contractile prostaglandins derived from cyclooxygenase herein. V 111. Interestingly. as compared with monoanesthesia with isoflurane.25 administration of acetylcholine caused relaxation at low concentrations and contraction at higher concentrations.18–24 all of which might have contributed to decreased contractility after anesthesia. Investigation of the underlying mechanisms was not within the scope of this study. Shock. Fig. Data are normalized to the expression level of ␤-actin and presented in arbitrary units. but previous studies reported the involvement of decrements in processes such as myofilament calcium sensitivity. Such findings suggest that shock may alter the production of contractile prostaglandins. The difference between groups was borderline significant with one-way ANOVA (P ‫ ؍‬0. particularly during conditions of shock in which tissue perfusion is already at threat. In mouse aorta. Sep 2009 also be noted. an independent t test showed a significant reduction of COX-1 expression in Shock ISO versus Sham ISO (* P < 0. Preincubation with indomethacine fully abolished the normal upward stroke in the concentration-response curve. Shock (n ‫ ؍‬5). Systemic hypotension after isoflurane anesthesia has been reported previously. No 3. Resuscitated (n ‫ ؍‬5) groups anesthetized with sole isoflurane with isoflurane and adjunct nitrous oxide (C). In keeping with that. intracellular calcium concentration. Representative expressions pattern in Sham (n ‫ ؍‬5).25 implicating that contractile cyclooxygenases metabolites are derived from endothelial cells. or voltage-gated calcium influx. endothelial denudation abolishes the acetylcholine-mediated contractile responses.05).12. As reported previously. Recently. However. this would implicate that the decreased cyclooxygenase-1 expression as observed after shock is caused by down-regulation of the enzyme in . In this study. as compared to those receiving adjunct nitrous oxide.11 These findings suggest that hemodynamics may be better preserved during adjunct anesthesia with nitrous oxide. which may be preserved during anesthesia with adjunct nitrous oxide. the upward stroke in the concentration-response curve was also lost in aorta preparations of shock-mice anesthetized with isoflurane. Indeed. Shock (n ‫ ؍‬5) and Resuscitated (n ‫ ؍‬5) groups. It should Anesthesiology. Expression level of cyclooxygenase (COX) enzymes in aortic tissue from Sham.12 In addition. 4. however.10 It may represent an important unwanted side effect of anesthesia. and Resuscitated groups in groups anesthetized with isoflurane (ISO).06).

Ahn DS. which induces systemic and local vasoconstriction. these results likely reflect vascular changes present in the immediate postshock period. it is unknown how these results obtained in isolated arteries correspond to vasoreactivity in in vivo conditions.33 However. Research Fellow. The authors thank Bernadet D. making the involvement of hyperhomocysteinemia unlikely. Sharma P. Sep 2009 However. 345:588–95 3. an endogenous inhibitor of nitric oxide synthase. Trentz O: Pathophysiology of polytrauma. ANESTHESIOLOGY 2007. 94:727–32 5. 101:399–408 4. or of cyclooxygenase expression may have been unnoticed. Nowadays. Oliver JA: The pathogenesis of vasodilatory shock. The present study shows positive effects of adjunct nitrous oxide on vasoresponsiveness after short-term hemorrhagic shock in mice. upon blockade of prostaglandin synthesis. we cannot comment on possible intraoperative differences in circulating volume. Alternatively. University of Groningen. Lynch C: Myocardial depressant effects of desflurane: Mechanical and electrophysiologic actions in vitro. Injury 2005. Landry DW. Our data suggest that the choice of the anesthetic regimen during emergency surgery for hemorrhagic shock may influence postsurgery vascular reactivity. most likely because of a preservation of normal endothelial function. Takahashi S: Mechanisms of direct inhibitory action of isoflurane on vascular smooth muscle of mesenteric resistance arteries. However. despite intensive scientific discussion on the influence of adjunct nitrous oxide to volatile anesthesia. as the study aimed to evaluate the effect of adjunct nitrous oxide. i. V 111. Department of Clinical Pharmacology.27 and that both cyclooxygenase-1 and cyclooxygenase-2 may be involved in production of contractile prostaglandins.g. ANESTHESIOLOGY 2001. we chose to use the same isoflurane concentration in all experimental groups. Consequently. but it did not affect cyclooxygenase-1 and cyclooxygenase-2 protein expression. 99:666–77 9. Karaian JE. Baumert JH. which were prevented by the use of nitrous oxide during the shock period. 106:956–66 7. 23:576–81 6. small differences in calculated parameters of acetylcholine and phenylephrine-mediated responsiveness. Moreover.30 Asymmetric dimethylarginine has been reported to increase arteriolar basal tone31 and participate in the maintenance of vasospasm. the findings of this study show that vascular reactivity after hemorrhagic shock is affected by the choice of general anesthesia. Keel M. Akata T: General anesthetics and vascular smooth muscle: Direct actions of general anesthetics on cellular mechanisms regulating vascular tone. Chung N. The Netherlands.e. Xu J.32 Previously. Groningen. University Medical Center Groningen. The results of this study also indicate that cyclooxygenase proteins participate in shock-dependent changes of vasoresponsiveness to acetylcholine.M. Musser JB. Liu L: The role of calcium desensitization in vascular hyporeactivity and its regulation after hemorrhagic shock in the rat. Takahashi S: Role of endothelium in the action of isoflurane on vascular smooth muscle of isolated mesenteric resistance arteries. Also. 106:365–91 8.. adjunct nitrous oxide counteracts these changes. Akata T. Previous studies suggest both isoforms of cyclooxygenase to be expressed in aorta endothelial and/or vascular smooth muscle cells. Aortic rings were studied in the absence of anesthetics in the organ bath. e. Kanna T. Izumi K. References 1. Furthermore.29 Taken together. there are few data on the influence of isoflurane on cyclooxygenase-protein expression. Br J Anaesth 2005. Akata T.Sc. Finally. ANESTHESIOLOGY 2007. Yoshino J. Reyle-Hahn SM. nitrous oxide-evoked hyperhomocysteinemia may offer an explanation for enhanced vascular reactivity to phenylephrine in Sham animals.26. isoflurane and isoflurane/ nitrous oxide groups differed in depth of anesthesia.34 Whether this phenomenon also explains the normalization of phenylephrine-mediated contraction in resuscitated animals from the nitrous oxide group remains to be established. Anesthesiology. Hecker KE. Mongan PD: Hemorrhagic shock in swine: Nitric oxide and potassium sensitive adenosine triphosphate channel activation. because the blood volume withdrawn for the induction of hemorrhagic shock was not assessed. Rossaint R: Haemodynamic effects of haemorrhage during xenon anaesthesia in pigs. Meijering. Short-term hemorrhagic shock under isoflurane anesthesia increased phenylephrine-mediated contractile response and suppressed the acetylcholine-evoked contractile effect in thoracic mouse aorta. ANESTHESIOLOGY 2004.NITROUS OXIDE MAINTAINS VESSEL FUNCTION AFTER SHOCK 607 endothelial cells. In view of the absence of volatile anesthetics and nitrous oxide in the organ baths. since this anesthetic agent normalized vascular reactivity after as observed under isoflurane anesthesia. 36:691–709 2. Shock 2005. Further. our results indicate that the loss of acetylcholine-induced contractile function in Shock mice anesthetized solely with isoflurane is because of decreased endothelial production of contractile prostaglandins caused by down-regulation of endothelial cyclooxygenase-1. acetylcholine-evoked relaxation of groups with and without nitrous oxide was similar in the presence of indomethacine. No 3. N Engl J Med 2001. while adjunct nitrous oxide may attenuate changes in vascular reactivity caused by hemorrhagic shock and/or subsequent resuscitation. This effect possibly explains the increased MAP during anesthesia with nitrous oxide. In summary. Kim MH. Chae JE. M. nitric oxide–mediated relaxation does not differ between both groups. It has been reported that isoflurane produces cyclooxygenase-2 mediated anesthetic preconditioning. Our study clearly demonstrates vasomotor changes and decreased expression of cyclooxygenase-1 in the postshock period. Park WK..33–38 only few experimental data regarding this question are available. because of an increase in asymmetric dimethylarginine. nitrous oxide anesthesia has been shown to enhance homocysteine concentration and impairment of endothelial function. nitrous oxide was reported to stimulate the sympathetic nervous system. for the expert technical consultation. Griffith S. as the number of experiments was about six.28. 95:990–8 . Jee YS. ANESTHESIOLOGY 2003. since equivalent concentrations of isoflurane were used. At present. Bentley TB. Hein M. at the postanesthesia care unit or intensive care unit.. Horn NA.

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Part 2: Regulatory mechanisms modulating Ca2ϩ mobilization and/or myofilament Ca2ϩ sensitivity in vascular smooth muscle cells. 29:65–70 24. De Salvia MA. Yamazaki M. Burger H. ANESTHESIOLOGY 2003. Varadharaj S. Li T. Darblade B. but not beta-. van Meurs M. Bosnjak ZJ. Kokita N. Lentz SR: ADMA and hyperhomocysteinemia. 109:707–22 14. thromboxane synthase and COX isoforms in normal aortic endothelium. Koller A: Asymmetrical Dimethylarginine inhibits shear stress-induced nitric oxide release and dilation and elicits superoxide-mediated increase in arteriolar tone. Stekiel WJ: Mechanisms of isoflurane-mediated hyperpolarization of vascular smooth muscle in chronically hypertensive and normotensive conditions. 294:H2444–55 27. Hu ¨ pfl M. Krust A. Nacci C. Hypertension 2007. 91:207–14 21. Metsa ¨honkala L. Parinandi N. Molema G: Early organ-specific endothelial activation during hemorrhagic shock and resuscitation. Liu L. Paech MJ. Best Pract Res Clin Anaesthesiol 2005. 100:547–54 29. Best Pract Res Clin Anaesthesiol 2005. ANESTHESIOLOGY 2001. Shock 2008. Stekiel WJ: Potassium channel-mediated hyperpolarization of mesenteric vascular smooth muscle by isoflurane. J Anesth 2007. 74:79–88 18. Hinkka S. 109:36–43 36. De Haes A. Pendaries C. Stekiel TA. Dubick MA: Hemorrhage-induced vascular hyporeactivity to norepinephrine in select vasculatures of rats and the roles of nitric oxide and endothelin. 19:208–14 25. Wiener C. Forman SA. Liu LM. Oikonen V. Zweier JL: Acetylcholine causes endothelium-dependent contraction of mouse arteries. Am J Physiol Heart Circ Physiol 2008. 94:496–506 20. Bosnjak ZJ. La ˚ngsjo ¨ JW. Tera ¨s M. Lau CW. Knol AJ. ANESTHESIOLOGY 2008.608 SAMARSKA ET AL. Fouque MJ. Liu J. Myles PS. Vasc Med 2005. Berendes E: Nitrous oxide–an outdated anaesthetic. Circ Res 2002. Scheinin H: Effects of sevoflurane.

05). mask. Department of Anesthesiology. The Cleveland Clinic. Conventional sidestream capnometers.6 Because various factors are associated with postoperative respiratory depression. Tokyo Women’s Medical University. The authors evaluated the accuracy of a mainstream capnometer with an oral guide nasal cannula and a sidestream capnometer with a nasal cannula that did or did not incorporate an oral guide in spontaneously breathing non-obese patients and obese patients with and without OSA during recovery from general anesthesia. 111:609 –15 Copyright © 2009. it was 3. University of Louisville. Japan. Obese and obstructive sleep apnea (OSA) patients at risk for respiratory complications may benefit from Etco2 monitoring. ‡ Professor and Chair.4 ؎ 3.13 Furthermore in our experience. 6.0 ؎ 3. which presumably increases the likelihood of respiratory depression.9 ؎ 2. Tokyo.‡ Makoto Ozaki. and Clinical Instructor. M. Department of Anesthesiology and Perioperative Medicine. 6 months from the cover date of the issue. Received from the Department of Anesthesiology and Perioperative Medicine. Neuroscience ICU. The Cleveland Clinic. for personal use only. End-tidal carbon dioxide pressure was measured by using three capnometer/cannula combinations (oxygen at 4 l/min): (1) a mainstream capnometer with oral guide nasal cannula.. and 20 obese patients with OSA.7 more than 40% of patients whose pain is controlled with patient-controlled analgesia systems experience a bradypnea episode. Department of OUTCOMES RESEARCH. Cleveland. the sample line can become occluded with water and secretions.9 –11 However.6 mmHg.1 mmHg. In obese non-OSA patients. Some investigators report that Etco2 can be accurately measured via a nasal cannula during spontaneous ventilation in both adult and pediatric patients.8 Although measuring Etco2 in intubated patients is technically easy. The sponsor had no input into the study design. Accepted for publication May 15. it is difficult to predict which patient will experience respiratory complications and when. M. Ohio 44195.. sampling Etco2 through a nasal cannula is potentially problematic when expired gas mixes with ambient air.4 is considered a standard of care and is believed to reduce ventilation-related complications.5 Postoperative respiratory monitoring is important because respiratory failure is the second most common postoperative morbidity after ischemic heart events.0 ؎ 2. Kentucky. Arterial carbon dioxide partial pressure was determined simultaneously. and use of opioids. In obese OSA patients. 2008. M.05).D. Tokyo Women’s Medical University.* Ozan Akc ¸ a. None of the authors has a personal financial interest in this research. as might be used in the PACU. END-TIDAL carbon dioxide partial pressure (Etco2) is a breath-to-breath and noninvasive estimate of arterial carbon dioxide tension.. Information on purchasing reprints may be found at www. can compromise the accuracy of Etco2 values in two ways. was similar.§ Ryu Komatsu. Furthermore. Sep 2009 . Address correspondence to Dr. a mouth piece.2 Monitoring Etco2 during general anesthesia3. Department of OUTCOMES RESEARCH. unintubated patients. * Research Fellow. the American Society of Anesthesiologists.5 mmHg with the sidestream capnometer and a standard cannula (P < 0.anesthesiology. Results: In non-obese patients. Inc. with and without OSA. M. Sessler.3 ؎ 3. § Professor and Chair. No 3. Methods: The study enrolled 20 non-obese patients (body mass index less than 30 kg/m2) without OSA. The resulting inaccurate measurements produce artificially low values compared to a closed system with minimal dead space (e. type of surgery. Neuroscience ICU. 2009. and (3) a sidestream capnometer with a standard nasal cannula. Funded by Nihon Kohden. M. in spontaneously breathing. Accuracy in non-obese and obese patients. 6. and the Department of Anesthesiology.1 mmHg.D. Louisville. and 7. Conclusions: Mainstream capnometry performed best. especially in the early postoperative period. V 111. Second. or endotracheal tube).9 ؎ 2. The Cleveland Clinic. The major outcome was the arterial-to-end-tidal partial pressure difference with each combination. Department of Anesthesiology and Perioperative Medicine. Cleveland. Opioid-induced respiratory depression is especially hard to predict. 100 –150 ml/min) dilutes the expired gas sample with entrained ambient air. and 8. Currently.6 mmHg. Japan. Tokyo Women’s Medical University. it was 4. and 8. a high aspiration flow rate (i. University of Louisville. Department of OUTCOMES RESEARCH. Sessler: Professor and Chair.1 ؎ 3. respectively (P < 0. 20 obese patients (body mass index greater than 35 kg/m2) without OSA. (2) a sidestream capnometer with a nasal cannula that included an oral guide. data collection or analysis.† Daniel I. DS@OR. Tokyo. or manuscript preparation. Accuracy of Postoperative End-tidal PCO2 Measurements with Mainstream and Sidestream Capnography in Nonobese Patients and in Obese Patients with and without Obstructive Sleep Apnea Yusuke Kasuya. Department of Anesthesiology.D. including those who are obese and those with obstructive sleep apnea (OSA)..e.D. ANESTHESIOLOGY’s articles are made freely accessible to all readers. Inc.org or on the masthead page at the beginning of this issue. Tokyo Women’s Medical University. According to Overdyk et al.. and Attending physician. 9500 Euclid Ave—P77. such as age. First..1.6 (mean ؎ SD) mmHg with the mainstream capnometer.12. University of Louisville. Lippincott Williams & Wilkins. Ohio. † Associate Professor.Anesthesiology 2009. Etco2 measurements collected through the nasal cannula are usually inaccurate when patients breathe through their mouths. Department of Anesthesiology.3 mmHg with the sidestream capnometer and oral guide cannula.0 mmHg. it can be difficult to obtain accurate values in the postanesthetic care unit (PACU) when patients are no longer intubated. OUTCOMES RESEARCH Institute. a nasal cannula with an oral guide may improve measurement accuracy in these patients.3 ؎ 4.14 Two new capnometers designed for measurement of Etco2 in unintubated patients have recently become available com609 Anesthesiology. ͉͉ Research Fellow.org.͉͉ Background: Obtaining accurate end-tidal carbon dioxide pressure measurements via nasal cannula poses difficulties in postanesthesia patients who are mouth breathers.1 ؎ 5. arterial-to-end-tidal pressure difference was 3. postoperative opioid administration is common. respectively (P < 0.g.05).2 mmHg.. University of Louisville. delaying Etco2 readings. Etco2 monitoring is not a standard procedure during postoperative recovery. Submitted for publication November 17. and an oral guide improved the performance of sidestream capnometry.D. 4.

610 KASUYA ET AL. MA). Needham. It is also unknown whether adding an oral guide to nasal cannulae improves Etco2 measurements in the PACU. Japan). Microstream (Microcap. and greater still in obese patients with obstructive sleep apnea. . Nihon Kohden. patients were randomly assigned to three different capnometer systems (device/cannula combination) (fig. 20 were non-obese (defined by a body mass index less than 30 kg/m2) without a diagnosis of OSA (Non-obese non-OSA). (A) Cap-ONE (Nihon Kohden. 20 were obese (body mass index greater than 35 kg/m2) without a diagnosis of OSA (Obese non-OSA). Errors caused by ambient air mixing with the sample gas are thus less likely than with other systems. Anesthesiology. With the mainstream device. (B) Microcap sidestream capnometer with a Smart CapnoLine Plus nasal cannula (Oridion Capnography Inc.15 The other new capnometer is a mainstream system designed for use in unintubated patients (cap-ONE. (2) ⌬co2 is greater in obese versus non-obese patients. Intermittent mouth breathing might also contribute to underestimated Etco2 values. so it is small enough to be incorporated into a nasal cannula.17 Nasal obstruction is associated with apneic episodes during sleep. Kentucky) approved the protocol. Obstructions in the pathway caused by moisture and humidity are reduced because of the low flow rate.18.. MA). MA). (3) a nasal cannula with an oral guide outperforms a similar cannula without an oral guide. however. Oridion Capnography Inc. No 3. Mouth breathing is common in obese patients. (C) CapnoLine H cannula (Oridion Capnography Inc.19 To reduce the effect of oral breathing on the capnogram. V 111.) that incorporates an oral guide along with Fig. the gas flow rate can be reduced to 50 ml/min while maintaining adequate accuracy and response time.16. General anesthesia was administered by using tracheal intubation or a laryngeal mask airway. mainstream capnometer system that includes an oral guided nasal cannula. It remains unknown whether mainstream capnography systems perform better than conventional sidestream systems in PACU patients. Needham. cardiac disease (New York Heart Association classification grade 3 or above). We thus tested the following hypotheses: (1) the arterialto-end-tidal partial pressure difference (⌬co2) is less with mainstream than sidestream devices. Tokyo. patients were asked to complete the Epworth Sleepiness Scale. To avoid assigning undiagnosed OSA patients in either of the non-OSA groups. and nasal airway resistance tends to be high in OSA patients. especially those with a history of OSA. It weighs only 10 g. and each patient gave written informed consent. and 20 were obese with OSA diagnosed by polysomnography (Obese OSA). preventing distortion of the capnogram. Microstream technology is based on molecular correlation spectroscopy (MCS) that generates an infrared emission.. with no other restrictions on anesthetic management. with or without obstructive sleep apnea. The first new capnometer is a sidestream model. Tokyo. Measurements Patients were extubated in the operation room and just after patients admitted to PACU. or who would be indicated for a facemask for postoperative oxygen delivery rather than nasal cannula were also excluded. Needham. it does not require a sampling tube. water and secretion obstructions are less likely to interfere with measurements. especially in patients who are obese. The high emission efficiency and carbon dioxide specificity allows for a short light path and allows the use of a small 15-␮l sample cell.. We recruited 60 patients who were scheduled for general anesthesia with continuous arterial pressure monitoring via an arterial catheter. Sep 2009 Materials and Methods The University of Louisville Human Studies Committee (Louisville. nasal cannula are now available that include an oral guide designed to trap exhaled gas via mouth and to improve the accuracy of Etco2 measurements in patients who breathe through their mouths. 1): (A) Cap-ONE mainstream capnometer system (Nihon Kohden) that includes an oral guided nasal cannula (Mainstream oral guide).20 a simple questionnaire to determine daytime sleepiness. a nasal cannula for sidestream Microcap capnometer with oral guide. Most capnometer technology has been based on nondispersive black body infrared radiation techniques. Because the sample cell is so small. Exhaled flow distribution between the mouth and nose highly affects the accuracy of capnometry. Patients with known severe pulmonary disease (Hugh-Jones classification grade 3 or above). Nasal cannulas with an oral guide designed to capture expiratory flow from the mouth are available for both systems and may increase the accuracy of Etco2 measurements during oral breathing. matching the absorption spectrum of the carbon dioxide molecule. a conventional nasal cannula (with no oral guide) for sidestream Microcap capnometer. Patients having an Epworth Sleepiness Scale of 10 or more were excluded from the non-OSA groups. 1. (B) Smart CapnoLine Plus cannula (Oridion Capnography Inc. As the mainstream carbon dioxide sensor is located on the site that covers both oral and nasal exhaled gas passways. mercially. Japan).

an arterial blood sample was taken for blood gas analysis. height. Sep 2009 Data Analysis Our major outcome was the accuracy of Etco2 measurements with each capnometer system in the three patient groups.3 Ϯ 3.05) from both the Non-obese non-OSA and Obese non-OSA patients.8 3 1 3 2 4 3 4 0 49. The mean Etco2 value for each device/ cannula combination measurements was subtracted from the arterial partial pressure of carbon dioxide (PaCO2) measurement that was measured simultaneously.. we examined Pearson’s . which defined accuracy.3 Ϯ 14.005 0. The average Etco2 during the final 60 s of 5-min measurement period was recorded by a computerized system. repeated-measures ANOVA. * Statistically significantly different (P Ͻ 0.7 Ϯ 11. male/female Race Caucasian African American Asian Latino BMI. the application order of the two capnometers and two sidestream cannulas was randomized on the basis of computer-generated assignments that were kept in sequentially numbered opaque envelopes that were opened in the PACU. body mass index. Because the respiratory state was not always stable during the measurements and might be influenced by opioids given for pain control. The factors were (1) the three device/ cannula combinations (Mainstream oral guide. length of philtrum.e. Non-obese non-OSA ϭ normal weight patients (defined as a BMI Ͻ 30 kg/m2) without a diagnosis of OSA. kg Philtrum. Obese nonOSA.7 168 Ϯ 8 69 Ϯ 10 17 Ϯ 2 2. Nihon Kohden). Patient Characteristics Non-obese Non-OSA (n ϭ 20) Obese Non-OSA (n ϭ 20) Obese OSA (n ϭ 20) P Value Age. ⌬CO2. From a preliminary study of the mainstream device (cap-ONE.001 Data reported as means Ϯ SDs or number of patients. Anesthesiology. significantly different (P Ͻ 0. Etco2 was determined breath-by-breath by each capnograph.1 Ϯ 1.05) from Non-obese non-OSA patients. No 3. † Statistically BMI ϭ body mass index.0 13/7 14 5 1 0 24. yrs Gender. Exhaled carbon dioxide was recorded (capnogram) for 5 min by using each capnometer system. This provided the difference between the Etco2 and the PaCO2 (⌬CO2). Morphometric and demographic characteristics of the participating patients were recorded.58 Ͻ 0. All patients had their Etco2 measured by using each system and a constant oxygen flow rate of 4 l/min through the nasal cannula. mm Epworth Sleepiness Scale Type of surgery Gynecological Orthopedic Spine Major vascular Thoracotomy Neurosurgical or neurointerventional Other major abdominal Mastectomy 55.001 0. a carbon dioxide sampling port (Sidestream oral guide). age.1 Ϯ 6. Assuming values within patients to be correlated at least at r ϭ 0.20 Ͻ 0. kg/m2 Height.8* 166 Ϯ 8 111 Ϯ 24* 18 Ϯ 4 10. Significant differences between groups were analyzed using Tukey post hoc testing. MA).4* 164 Ϯ 6 108 Ϯ 20* 18 Ϯ 3 2.05. Obese OSA). gender. (GEM Premier 3000. Instrumentation Laboratory.001 0.1 5/15 17 2 0 1 40. ␣ ϭ 0.) with a CapnoLine H nasal cannula (standard nasal cannula with no oral guide) (Sidestream standard).3 Ϯ 2.6 Ϯ 10.ACCURACY OF MAINSTREAM CAPNOGRAPHY 611 Table 1. we expected the SD of the ⌬CO2 to be 4. Obese non-OSA ϭ obese patients (body mass index Ͼ 35 kg/m2) without a diagnosis of OSA. mixed model. An average ⌬CO2 difference of 3 mmHg between any two combinations of capnometers and nasal cannulas in obese versus non-obese or OSA versus non-OSA was determined a priori as technically important bias. To further analyze the effectiveness of each combination of capnometer and nasal cannula. i.5 mmHg. Etco2. race.2 Ϯ 7. body weight.23 0.50 Ͻ 0. At the end of each 5-min interval. and PaO2 were compared in a two-factor (both having three levels). Obese OSA ϭ obese patients (body mass index Ͼ 35 kg/m2) with polysomnographydiagnosed OSA. Lexington.3*† 8 3 1 4 2 0 1 1 0.4 Ϯ 2.5. and type of surgery. or (C) Microcap sidestream capnometer (Oridion Capnography Inc. During measurements. and Sidestream standard) and (2) the three patient groups (Non-obese non-OSA. Our secondary outcome was oxygenation efficacy. V 111. Sidestream oral guide. cm Weight. if needed hydromorphone or morphine was given for analgesia according to physician’s order who was independent of this study. we needed 17 patients in each patient group to have 90% power to detect a difference of 3 mmHg with a repeatedmeasures ANOVA.8 4/16 16 3 1 0 40.1 13 1 0 3 1 0 2 0 50.

Sep 2009 . and greater still for the sidestream capnometer with the standard nasal cannula (fig. slightly greater with the sidestream capnometer with an oral guide. The arterial-to-end-tidal partial pressure difference (⌬CO2) for each device/cannula and patient group.01. Patients in the Obese OSA group reported a significantly greater Epworth Sleepiness Scale score (10 Ϯ 3) than the Non-obese non-OSA group (2 Ϯ 2) and the Obese non-OSA group (2 Ϯ 2. and PaCO2. Fig. V 111. Chicago. Correlation coefficients were highest with the Mainstream oral guide device and lowest with the Sidestream standard device. 20 obese patients (body mass index > 35 kg/m2) without a diagnosis of obstructive sleep apnea (Obese non-OSA). No patients in the Non-obese non-OSA or Obese non-OSA groups reported a score greater than 10. and 20 obese patients with polysomnography-diagnosed obstructive sleep apnea (Obese OSA). Discussion This study shows that Etco2 measured with a mainstream capnometer produces better correlation between Fig. * P < 0. All statistical analyses were done by SPSS for Windows version 16. 2). Bias was also greater with the standard nasal cannula than with the cannula that included an oral guide. 20 obese patients (body mass index > 35 kg/m2) without a diagnosis of obstructive sleep apnea (Obese non-OSA). * P < 0. including pH. Patient characteristics for the three groups are shown in table 1.05 was considered statistically significant. bicarbonate. All other blood gas measurements. 2. P Ͻ 0. 3). PaO2 was similar in all groups during all device/cannula combinations. Although gender was not uniformly distributed among the groups. and 20 obese patients with polysomnography-diagnosed obstructive sleep apnea (Obese OSA). bias was more widely distributed in Obese patients with and without OSA. Individual data points are plotted along with means and SDs for 20 normal weight patients (defined as a body mass index < 30 kg/m2) without a diagnosis of obstructive sleep apnea (Non-obese non-OSA).0 (SPSS Inc. correlation coefficient and used a Bland-Altman analysis to check for bias and effect modification with the capnometer and nasal cannula combinations across the full range of measured values. the length of the philtrum was similar in all groups. P Ͻ 0.21 Data are presented as means Ϯ SDs for continuous variables and percentages for categorical variables. The correlations between Etco2 and PaCO2 are shown in figure 4. Individual data points are plotted along with mean and 95% confidential interval for 20 normal weight patients (defined as a body mass index < 30 kg/m2) without a diagnosis of obstructive sleep apnea (Non-obese non-OSA). Of these. ** P < 0.05. Results A total of 180 Etco2–PaCO2 measurement pairs were analyzed from 60 patients.05. No 3. ⌬CO2 was smallest when measured with the mainstream capnometer. IL). 20 patients were nonobese without OSA (Non-obese non-OSA).21 On Bland-Altman plots. The bias in the relationship between Etco2 and PaCO2 is illustrated in figure 5 where the difference is plotted against the average of the values. 3. were similar among device/ cannula combinations in all patient groups. Carbon dioxide data and correlations were the most accurate when using the mainstream device. except for the obese non-OSA patients who had a higher PaO2 during the period when they were measured by sidestream standard device (fig. Anesthesiology. There were significant differences in ⌬CO2 among the three device/cannula combinations in all three patient groups.001). and 20 were obese with OSA (Obese OSA).612 KASUYA ET AL. but they tended to be highest in Non-obese non-OSA group and lowest in Obese OSA group. 20 were obese without OSA (Obese non-OSA). Arterial oxygen partial pressure (PaO2) with each device/cannula and patient group. base excess.

ACCURACY OF MAINSTREAM CAPNOGRAPHY 613 Fig. Etco2 and PaCO2 than other systems. especially in patients with obesity and OSA. No 3. Patient groups are normal weight patients (defined as a body mass index < 30 kg/m2) without a diagnosis of obstructive sleep apnea (Non-obese non-OSA). In healthy young adults. ** P < 0. obstructive lung disease. Sep 2009 . and obese patients (body mass index > 35 kg/m2) with obstructive sleep apnea (Obese OSA). V 111. Solid broken lines represent mean of the bias and thin broken lines represent 95% CI for 20 normal weight patients (defined as body mass index < 30 kg/m2) without a diagnosis of obstructive sleep apnea (Nonobese non-OSA). Bland-Altman plots show that the mainstream capnogram was more accurate in predicting PaCO2 than the sidestream system. 5. Anesthesiology.23 ⌬CO2 tends to increase with age. in situations where alveolar dead Fig. and 20 obese patients with polysomnography-diagnosed obstructive sleep apnea (Obese OSA).22. ⌬CO2 is normally between 2 and 5 mmHg. 20 obese patients (body mass index > 35 kg/m2) without a diagnosis of obstructive sleep apnea (Obese non-OSA). obese patients (body mass index > 35 kg/m2) without a diagnosis of obstructive sleep apnea (Obese non-OSA). 4. Pearson correlation coefficients between end-tidal carbon dioxide pressure (Etco2) and arterial carbon dioxide pressure (PaCO2) with each device/cannula and patient group.01. Bland-Altman plot. Our results also indicate that both obesity and OSA reduce the correlation between Etco2 and PaCO2 and accordingly increase ⌬CO2 unpredictably.

that even in obese OSA patients—the most vulnerable patient population29—the difference of mean ⌬CO2 between mainstream device and sidestream with conventional cannula was only 4. Moseley H. and high fresh oxygen supply. Hillman DR. J Appl Physiol 1991. V 111. 35:354–9 5. ANESTHESIOLOGY 1988. Herrin AE. Garrett JS. ⌬CO2 is expected to be high when the tidal volume is near dead space volume or when the respiratory rate gets too high to give an end-expiratory plateau. 91:31–9 19. Dunphy JA: Accuracy of expired carbon dioxide partial pressure sampled from a nasal cannula. Veriter C: Pattern of simulated snoring is different through mouth and nose. Callura J. Stanescu D. Russell GB.3 mmHg. Krauss B: Microstream capnograpy technology: A new approach to an old problem. though. But an important factor is that the correlation between Etco2 and PaCO2 was low without an oral guide in obese OSA patients (r ϭ 0.8 mmHg by using a sidestream nasal cannula capnometer in preanesthetic patients getting 3 l/min oxygen. Bateman PE: Occupational exposure to anesthetics in 20 hospitals. Considering that OSA patients are at the high risk for adverse respiratory events and that intense respiratory monitoring is recommended. low expiratory flow.27 The determined ⌬CO2 values in this study were greater than those previously reported. Maddox RR. 1:307–10 . Colclasure B: Clinical experience with patient-controlled analgesia using continuous respiratory monitoring and a smart infusion system. Anesth Analg 2007. was similar. 105:1081–6 6.39) and was markedly Anesthesiology. ANESTHESIOLOGY 1988. Oglesby H. Bhende MS: NPB-75: A portable quantitative microstream capnometer.26 showed that ⌬CO2 is highly dependent on tidal volume. Hauptman SA. The most likely reason for the differences between the reported values is the dissimilarity of the circumstances under which the data were collected. J Clin Monit Comput 1999. Silvestri JM. Bhavani-Shankar K. Etco2 is defined as partial pressure of carbon dioxide at the end of the expiratory phase of the respiratory cycle. McDuffee A. readings from mainstream capnometers were both accurate and statistically significantly better than alternative approaches. We note. Sleep 1992. ANESTHESIOLOGY 2006.28 Consequently. However. 39:617–32 4. Kenny AS. Chest 1992. Venkataraman ST. In summary. Anesthesia 1980. Henriquez C: Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Liu SY. Butler B. Obesity is also considered to be a risk factor for postoperative atelectasis.6 Ϯ 3. 6:217–25 2. The cost of these systems is difficult to estimate because there are differences from country-to-country. Graybeal JM: The arterial to end-tidal carbon dioxide difference in neurosurgical patients during craniotomy. Urmey WF: Accuracy of expired carbon dioxide partial pressure sampled from a nasal cannula. our results support using a cannula that includes an oral guide for OSA patients. Wardley-Smith B. obtained their data before induction of anesthesia.S. Can J Anaesth 1992. Crit Care Med 1995. 68:960–1 14. low peak flow rates. M. Kentucky. This is an important distinction because hypoventilation or mouth breathing diminishes nasal expiratory flow rate. 102:1512–5 11. Takano et al. it appears that the nondisposable and disposable components for each tested system cost similar amounts. Ventilation and perfusion mismatch is commonly increased immediately after endotracheal tube extubation because of transient atelectasis. The authors thank Gilbert Haugh. 20:513–37 7.72). To the extent that this proves to be the case in any particular hospital. Wittels EH. Kumar AY. Carter R. Biostatistician. dilution and a physiologic obstructed pattern often results in inconsistency of the expiratory plateau and slope of Phase 3 of the Etco2 waveform. Accuracy in non-obese and obese patients. Office of Clinical Research Services and Support. References 1. Klein EF Jr: Accurate determination of end-tidal carbon dioxide during administration of oxygen by nasal cannulae. Tobias JD: Noninvasive monitoring of end-tidal carbon dioxide tension via nasal cannulas in spontaneously breathing children with profound hypocarbia. Colman Y. thereby increasing ⌬CO2. Flanagan JF.. Watson CB: Respiratory complications associated with anesthesia. Bongard F: Accuracy of capnography in nonintubated surgical patients. and with hemodynamic instability as well. Weingarten M: Respiratory monitoring of carbon dioxide and oxygen: A ten-year perspective. Halsey MJ. Lee TS. Platt PR. Given that the oxygen supply rate of 4 l/min was constant for all patients. 105:412–8 8. Cheney FW. Lancet 1986. Bowe et al. In non-obese and obese patients without OSA. Bowe EA. Overdyk FJ. 70:2736–41 20. Saville A. 23:1140–2 12. and cost depends on use levels and negotiating power of specific hospitals. mainstream capnometry performed best. However. clinicians will presumably prefer the most accurate system. with and without OSA. Liistro G. University of Louisville. J Clin Monit 1990.614 space increases24 and results in a ventilation-perfusion mismatch. 63:157–64 9. Altman DG: Statistical methods for assessing agreement between two methods of clinical measurement. Our results demonstrate that the arterial-to-endtidal PCO2 gradient in spontaneously breathing postoperative patients depends on the patient population and type of capnometer. whereas our results were obtained during recovery. Singh S. and an oral guide improved the performance of sidestream capnometry.25 Obese patients are therefore prime candidates for having a large ⌬CO2 in during recovery. Eastwood PR: The upper airway during anaesthesia. 15:376–81 21. Otolaryngol Clin North Am 1990. Am J Health Syst Pharm 2006. 16:124–9 18. Broome JA.2 mmHg and a PaCO2 of 38. Maddox RR. Bass MT. Oral guide devices proved to be more accurate measure of Etco2 as compared to a standard sidestream measurement.9 reported a ⌬CO2 of 2. Anesth Analg 1995.1 Ϯ 2. Johns MW: Reliability and factor analysis of the Epworth Sleepiness Scale. Caplan RA. Lee LA. 81:806–10 3. Thompson S: Obstructive sleep apnea and obesity. Br J Anaesth 2003. This difference is relatively small because many clinicians already assume that Etco2 underestimates arterial partial pressures by 2–5 mmHg. Louisville. Davenport HT. 68:959–60 13. Bland JM. No 3. Sep 2009 KASUYA ET AL. Anesthesiol Clin North America 2002. Domino KB: Trends in anesthesia-related death and brain damage: A closed claims analysis. Bowe et al. 5:105–10 10. Weese-Mayer DE. or patient’s airway is partially obstructed due to bronchospasm. Boysen PG. Delph Y: Capnometry and anaesthesia. Etco2 values are especially misleading under the combination of severe obstructive pattern. Williams CK. Am J Emerg Med 2001. for help with statistical analysis. improved by addition of an oral guide (r ϭ 0. the inconsistencies of ⌬CO2 between patient groups likely resulted from differences in dead space and respiratory pattern for each patient group. Pediatr Pulmonol 1993. 23:751–60 17. 19:208–10 15. Pearsall SM: Polysomnography in obese children with a history of sleep-associated breathing disorders. J Clin Monit 1989. 15:403–9 16. Posner KL.

Br J Anaesth 1984. Morioka N. Anesth Analg 2002. ANESTHESIOLOGY 2002. Moseley HS. Frascarolo P. Iscoe S. Proietti S. 56:109–19 25. Kiyofuji C. Fisher J. Kumar AY. Spahn DR. 97:801–6 24. Ryoo JJ. Whalen FX Jr. Bhavani-Shankar K. Morgenthaler TI: Management plan to reduce risks in perioperative care of patients with presumed obstructive sleep apnea syndrome. 11:175–82 23. Takano Y. 95:1788–92 26. Sakamoto O. Sessler DI: Hypercapnia improves tissue oxygenation. V 111. Schroeder DR. Respir Med 2003. J Clin Monit 1995. No 3. 72:521–8 28. Ito K: A comparison of the end-tidal CO2 measured by portable capnometer and the arterial PCO2 in spontaneously breathing patients. Hedenstierna G. Fletcher R. 100:884–8 29. Wicky S. Sep 2009 . A meaningful variable? Minerva Anestesiol 2006. 3:582–8 Anesthesiology. Falk JL: Capnogram shape in obstructive lung disease. Krauss B. J Clin Sleep Med 2007. Magnusson L: Morbid obesity and postoperative pulmonary atelectasis: An underestimated problem. Olson EJ. Ahyee-Hallsworth R: Terminology and the current limitations of time capnography: A brief review. Gali B. Deykin A. Sandhagen B: Assessing dead space.ACCURACY OF MAINSTREAM CAPNOGRAPHY 615 22. 97:476–81 27. Hampton DR. Schmitt PW. Suter M. Akca O. Eichenberger A. Doufas AG. Effects of tidal volume and frequency of respiration. Lam A. Anesth Analg 2005. Gay PC. Plevak DJ. Jonson B: Deadspace and the single breath test for carbon dioxide during anaesthesia and artificial ventilation.

substantially excluded by the blood-brain barrier. Conclusion: CR665 had a selective effect on visceral pain.001) and cuff pressure pain tolerance threshold (P < 0. California. and (4) pain rating thresholds to distension and thermal stimulation of the esophagus. V 111. Adverse effects like euphoria. Arendt-Nielsen: Center for Sensory-Motor Interaction (SMI). and duration). and (3) placebo administered intravenously and orally. Mountain View. (3) cuff pressure pain tolerance threshold. Methods: The study was designed as a single-center. Department of Health Science and Technology.D. No 3. Compared to placebo. Hayward. Aalborg University.5 Peripheral ␬-opioid receptors in the gut have been suggested as an important feature of the visceral pain system6 and a possible target for attenuating peripheral nociception. Results: Compared to placebo. Inc.6 The analgesic effects of novel compounds can be difficult to evaluate in patients due to a number of well-known and frequently encountered illness-related or iatrogenic confounding factors.P.2.36 mg/kg) administered intravenously over 1 h. sedation. Ph. elevating thresholds for cutaneous. by Det Obelske Familie Fond. Measurements were performed before dosing and at 30. Received from Center for Sensory-Motor Interaction. intensity. cross-modality effect on visceral pain. The use of multi-modal. M. Sep 2009 . 6 months from the cover date of the issue.7 In addition. Oxycodone exhibited a generalized effect. Cara Therapeutics Inc. ͉͉ Impax Pharmaceuticals. (2) oxycodone (15 mg) administered orally.. and the pain provocation can be standardized (including the modality. three-way. or both often limit the usage of opioids. Olesen..anesthesiology.12.D. In particular. and ALZA Corporation. D3. Supported with an unrestricted grant by Johnson and Johnson. CR665.3. Lippincott Williams & Wilkins. California. Information on purchasing reprints may be found at www. Denmark.9 We recently.8. M. we used this approach to compare the efficacy profiles of oxycodone and morphine. is a tetrapeptide agonist at the ␬-opioid receptor. Aalborg.. Ph. (2) pressure pain detection and tolerance thresholds. California. peripherally selective ␬-opioid agonists should be safer and better tolerated than classic ␮-opioid agonists.D. 111:616 –24 Copyright © 2009.aau.Ⅵ PAIN MEDICINE Anesthesiology 2009. DEEP pain from muscle or viscera occurs frequently and causes major challenges in pain management. Denmark. Multi-tissue Experimental Human Pain Model Selective Effect on Visceral Pain Lars Arendt-Nielsen. Aalborg University. constipation.13 CR665 has been shown to relieve pain in a 616 Anesthesiology. Aalborg Hospital. Ph.3 For example. placebo and active-controlled. Denmark.† Camilla Staahl. double-blind. muscle.D. and 90 min after dosing.Sc. and by the Spar Nord Foundation. as well as pain rating thresholds (visual analogue scale ‫ ؍‬7) to esophageal distension (P < 0.* Anne E. and this knowledge has stimulated new approaches to improve opioid analgesia.. dose-dependent attenuation of visceral nociception.007). CR665. The experimental compound under evaluation in the present study. Denmark. and nausea are mainly mediated by ␮-receptors in the central nervous system. Denmark. Accepted for publication March 17.. Aalborg.10 consistent with the view that oxycodone may act through an additional population of opioid receptors (e. because of the absence of respiratory depression. with essentially no activity at other opioid receptor subtypes. in addition to ␮-opioid receptors11). 2009. Department of Health Science and Technology...# Background: Peripherally selective opioids may be beneficial in visceral pain management due to absence of centrally mediated side effects.͉͉ Gilbert Y.002). Department of Health Science and Technology. Denmark.org or on the masthead page at the beginning of this issue. Center for Sensory-Motor Interaction.1 Morphine and other centrally acting ␮-receptor opioid agonists are * Professor. frequency. Shelton. § Vice President of Research Development..§ Sherron Kell. ANESTHESIOLOGY’s articles are made freely accessible to all readers.D. CR665 significantly increased the pain rating threshold to esophageal distension (P < 0. oxycodone elevated cutaneous pinch pain tolerance (P < 0. M. whereas ␮.Pharm.‡ Fre ´ de ´ rique Menzaghi.001) and thermal stimulation (P < 0. there has been a focus on opioids with selective peripheral actions. and viscera.g. as well as activity at receptor subtypes other than the classic ␮-opioid receptor. double-dummy. and (2) contrast these effects with those of oxycodone (centrally acting opioid). and Department of Gastroenterology.3. crossover study in healthy males. However. Aalborg University.. and visceral pain stimulation. multi-tissue human pain testing may act as a proxy for some of the mechanisms involved in clinical pain conditions. inadequate analgesia. Wong.D. Inc. randomized. Center for Sensory-Motor Interaction. The following pain tests were used: (1) cutaneous pinch pain tolerance threshold.and ␦-opioid agonists were found to produce only modest analgesia to colorectal distension. often used in the treatment of deep pain. 2009. ‡ Assistant Professor. for personal use only. Address correspondence to Dr. LAN@hst. Connecticut. on experimental pain from multi-modal stimulation of skin.001). Submitted for publication January 14.dk. † Research Assistant.005) but reduced the pain tolerance threshold to skin pinching (P ‫ ؍‬0. the American Society of Anesthesiologists. and abuse liability. Mountain View.4. Human experimental pain models can therefore be advantageous in evaluation of analgesic actions in proof-of-concept studies in healthy volunteers. Denmark.͉͉ Asbjørn M. respiratory depression. and we found that oxycodone exhibited a superior.8 Most external factors can be controlled. Analgesic Efficacy of Peripheral ␬-Opioid Receptor Agonist CR665 Compared to Oxycodone in a Multi-modal. 60. excessive adverse effects. ␬-opioid. DK-9220 Aalborg E. Subjects received the following treatments in randomized order: (1) CR665 (0. localization. Department of Health Science and Technology. singledose. deep somatic. Aalborg University. Fredrik Bajers Vej 7. peripherally restricted ␬-agonists produced a substantial. M. Ph.H. The objectives of this study were: (1) to assess the effects of a peripherally selective tetrapeptide ␬-opioid receptor agonist. # Professor. Drewes.

(2) partners must consent to use a medically acceptable method of contraception throughout the entire study period. the subject received a concealed randomization assignment. and were paid for participating. gave their written informed consent before participating. physical examination including vital signs (orthostatic blood pressure and heart rate measurements taken after the subject had been semirecumbent for 5 min and then after the subject had been standing for 3 min. renal. according to the pain modality.1-ml vial.5 g/dl (7. six had CR665. (3) no known allergies to any of the compounds used in the study. Materials and Methods Subjects and Study Design Eighteen healthy.5 kg. placebo-controlled pain study were: (1) to investigate. Aalborg. (3) any abnormality on the screening electrocardiogram. hematologic. singledose. and six had placebo in each of the three study periods.6 kg/m2) were recruited to participate in this single-center.4 –94. placebo. Sep 2009 the first dose of study medication. median age 25 yr.␬ AGONIST AND EXPERIMENTAL VISCERAL PAIN 617 variety of rodent models. Preadmission medical and concomitant medication history.3.13 On the basis of this pharmacological profile. double-dummy. Subjects underwent a urine drug screen and a test for alcohol at check-in before each treatment period. V 111. Subjects remained in a semirecumbent position for the first 12 h after the beginning of dosing. Copenhagen. Subjects were admitted to the unit on the morning of dosing. or acute infection.g. double-blind. Treatment A: CR665 intravenous solution. nonsmoking. clinical laboratory tests (hematology. and urinalysis) and urine drug screening tests were performed. weight 62. respiratory. gastrointestinal.4 kg/m2. BCA. Volunteers entering the study were in good health and had no residual pain complaints from any previous illness.6 it is believed that CR665 could inhibit visceral pain in humans. The randomization ensured that six subjects had oxycodone. The study protocol was approved by the Regional Committee on Biomedical Research Ethics. whether CR665 had differential analgesic effects in tissues associated with somatic or visceral pain.and active-controlled. The study was conducted in accordance with the Declaration of Helsinki on biomedical research involving human subjects. Inclusion. multi-tissue.. After . flavored beverage used for the oral placebo solution in Treatment A and a 1-h intravenous infusion of vehicle placebo solution. and none of the persons involved in performing the study was involved in the randomization. Exclusion. (8) use or planned use of medication during participation in the study. (6) greater than 20-mmHg systolic or greater than 10-mmHg diastolic drop in blood pressure or greater than 30-beats per minute increase in heart rate within 3 min of standing or symptoms of lightheadedness or dizziness or fainting upon standing. endocrine. chemistry. This dose is selected on the basis of a safety phase I trial. Denmark (reference number 2612-3145). Treatment C: 1-h intravenous infusion of vehicle placebo solution and oral placebo solution as used in Treatments A and B. (2) to determine whether the actions of the drugs could be differentiated within tissues. and Exclusion. Medication Equal numbers of subjects were randomly assigned to one of three treatment sequences (ABC. pulmonary. and all subjects received the following three treatments. or cardiovascular system abnormalities. (5) resting heart rate at screening of less than 45 or greater than 85 beats per minute. crossover study. (7) hemoglobin less than 12. white male volunteers (age 19 – 43 yr. weight and body mass index. median body mass index 23.12. 12-lead electrocardiogram. median weight 80. Treatment B: Oxycodone. 10 mg/ml. as well as other preclinical studies. total dose of 0.VN20060021) and by the Danish Medicine Agency. psychiatric disorders. Inclusion. reproductive.8 mmol/l) or donated blood or plasma or blood loss of more than 400 ml within 4 weeks before dosing. family history of long QT syndrome) or the use of concomitant medications that prolong the QT/QTc interval (Q and T peaks of the electrocardiogram/heart rate-corrected QT interval). This ensured a balanced design. All subjects were informed about the risks of the study. The following inclusion criteria were applied: (1) semirecumbent blood pressure (after resting for 5 min) between the ranges of 90 –139 mmHg systolic (inclusive) and 50 – 89 mmHg diastolic (inclusive). height. respiratory rate. Screening. neurologic. Denmark (registration no. No 3. The aims of this proof-of-concept human experimental multi-modal. or CAB). for the first time in man. and the multi-modal esophageal tube was placed before dosing. body mass index 20. hypokalemia. opioid-naı ¨ve.36 mg/kg administered as an intravenous infusion over 1 h at a rate of 25 ml/h. The following exclusion criteria were applied: (1) any evidence of clinically significant hepatic. heart failure. and body temperature). 1. and (3) to compare these effects to oxycodone. Immediately before administration of Anesthesiology. Subjects meeting the preadmission criteria were then scheduled for a visit during which the different pain tests were administered to ensure that each subject could tolerate the tests. including jejunal distension-induced visceral pain. randomized.0 kg. (2) any esophageal disease or disorders.5–27. and an oral placebo solution consisting of a colored. flavored beverage. 15 mg oral liquid solution mixed with the colored. three-way. (4) confirmed screening of QTc (heart rate-corrected QT interval [Q and T peaks of the electrocardiogram]) greater than 450 ms or a history of additional risk factors for torsades de pointes (e.

60. Ho ¨ rby. The probe was gradually retracted to identify the location of the lower esophageal sphincter as a zone of high resting pressure that decreases with swallowing. National Instruments. The cuff was automatically inflated (compression rate 0. (2) Blood and urine laboratory evaluations. a known pharmacological effect of peripherally selective as well as centrally acting ␬-opioid agonists. TX). Each treatment was followed by a 1.500 ml of water from Ϫ24 to Ϫ3 h. subjects were required to consume at least 250 ml of water at 1. and visceral stimulation were measured before treatment and at 30. The electronic cuff algometer (Aalborg University. Subjects remained in a semirecumbent position with the head tilted back 30 degrees. clinical laboratory tests (hematology. 1.5 h. Austin. The pressure was increased at a rate of 30 kPa/s until the pain detection or the pain tolerance thresholds were reached. The pressure was continuously increased at a rate of 30 kPa/s until the threshold was reached. 2. Denmark) was connected to an electric-pneumatic converter (ITV2030.5. urine analysis). Sweden). subjects were required to consume at least 1. A probe with a surface area of 0. and 90 min after drug administration. 8. and subjects received intravenous fluids (saline) for 1. Japan) and controlled by a computer through a data acquisition card (PCI 6024E. Hvidovre. as follows: predose. V 111. muscle. respectively. weight and body mass index (screening only). The bag was 40 mm in length and could be inflated with fluid and then maintained at a constant volume through a pair of infusion channels. stand. a single 10-point electronic VAS was used to assess nonpainful (VAS Ͻ 5) as well as painful sensations (VAS Ն 5) in response to the experi- the 12-h period. SMC Corp.5 to 4 h as needed to fully replace urine loss. The computer continuously controlled the compression rate to ensure a linear increase in pressure. fluid balance monitoring. The 0 and 10 cm extremes on the VAS were defined. Aalborg. The bag completely enclosed a side hole. Skin The cutaneous pinching pain tolerance threshold was determined by pinching a skin fold on the volar forearm at 20 cm distal from the elbow with an electronic pressure algometer (Somedic AB. body temperature). Denmark14. No 3.50 kPa/s). Viscera (Esophagus) The multi-modal esophageal probe16 was inserted through the mouth and passed into the stomach. 24 h after dosing initiation. subjects were allowed to sit up. The bag was placed 7 cm proximal to the sphincter. Denmark) that was used to fill the bag at a volume rate of 10 ml/min. The next morning. The infusion channels were connected to a precision infusion-withdrawal pump (type 111.28 cm2 was pressed onto the supinator muscle on the left forearm at 10 cm distal to the elbow. heart rate. the following assessments were performed: physical exam. respiratory rate. 30 min. The compressor (Condor MDR2. and 1. For all visceral stimuli. and 24 h (termination) after dose initiation. A temperature probe (PR Electronics. the following safety measurements were obtained: (1) Vital signs (semirecumbent and standing blood pressure and heart rate. respiratory rate. urine drug screen and alcohol test. a computer-controlled air compressor. 12-lead electrocardiogram.15) consisted of a pneumatic tourniquet cuff. Rønde. After dose initiation. Pain Assessment The different pain assessment parameters from skin. and the probe was taped to the subject’s cheek. Muscle The pressure pain detection and tolerance thresholds were determined by an electronic pressure algometer Anesthesiology. Sep 2009 . or walk with assistance only if their sustained standing heart rate was less than 100 beats per minute. The subjects could immediately terminate compression by means of a hand-held pressure release button connected to the data acquisition card. 12. and the pressure continued to increase until the subject pressed the pressure release button again when the maximum pain tolerance threshold was reached. and body temperature) were obtained at the screening visit and then during the treatment period. The subject was instructed to rate the pain intensity continuously on the VAS from the first sensation of pain. including vital signs (semirecumbent and standing blood pressure. (4) Before treatments and at the end of the study.. (Somedic). Tokyo. The probe was 0. JUN-AIR International A/S. The two probes each had a surface area of 0. (3) Adverse events were recorded throughout the study. chemistry. and cardiac evaluation were obtained before and throughout the treatment period. as no pain and as the worst pain imaginable. Nørresundby. 16. The pain intensity was recorded continuously on the VAS and sampled at 100-ms intervals.618 ARENDT-NIELSEN ET AL. and an electronic 10-cm visual analogue scale (VAS).28 cm2. and at least 500 ml from Ϫ3 to Ϫ2 h before dosing.to 3-week washout period. 3. height (screening only). 4. Monitoring During each treatment period. To preclude possible physiologic effects from aquaretic activity. Ole Dich Instrument Makers. which was used for measurement of pressure within the bag.5 cm in diameter with a polyurethane bag attached to the distal end for mechanical and thermal stimuli. Denmark) was used to continuously monitor the fluid temperature in the bag. the subject was released from the clinic if no symptoms were observed. The pneumatic tourniquet cuff was wrapped tightly around the gastrocnemius muscle.

intermittent. P Ͻ 0.3°C/s. 3. Further post hoc analysis showed that oxycodone was better than placebo (P Ͻ 0. Further post hoc analysis showed that oxycodone increased pinching pain tolerance threshold in comparison with placebo and CR665 (P Ͻ 0.7 Ϯ 8. 4). and 4 of 18 for placebo. the esophageal balloon was filled with 37°C water at a constant infusion rate of 10 ml/min until the subjects reached the pain threshold (VAS ϭ 5) and moderate visceral pain intensity (VAS ϭ 7) ratings.16 and the volume of fluid in the bag was held constant. The average baseline thermal energy (temperature °C ϫ time [s]) was 205. Denmark) (for allergy in the placebo period) during the study. the subjects rated the painful visceral sensations from 5–10.007) and oxycodone (P Ͻ 0. The software package Sigma Stat 3.␬ AGONIST AND EXPERIMENTAL VISCERAL PAIN mental visceral stimuli. 3).187 ml for CR655. respectively. For overall statistical assessment of baseline-corrected stimulus intensities associated with the sensation and pain thresholds under investigation. The results are expressed as mean Ϯ SD unless otherwise indicated. Before recirculation. P ϭ 0. 1). The heat pain stimulus was generated by recirculating temperature-controlled water (55°C) in the esophageal probe.001).2 ml. the change in stimulus intensity relative to baseline was calculated for each measure for each subject. Thus.002 and P Ͻ 0. CR665 was not different from placebo (fig.18. No 3. There was a significant difference in the effect of drugs (F ϭ 26. CR665 decreased pinching pain tolerance threshold compared to placebo (P ϭ 0. No differences were found among groups (P Ͻ 0. Muscle Stimulation The average baseline pressure pain detection and pressure pain tolerance thresholds were 475 Ϯ 182 kPa and 716 Ϯ 330 kPa.1 ml and 24. respectively.546 ml for placebo.0 (Systat Software. which were all mild in severity with the exception of one episode of moderate increased heart rate in the CR655 treatment period. Further post hoc analysis showed that oxycodone significantly increased the threshold compared to placebo and CR665 (P ϭ 0. Results All included 18 volunteers completed the study. For mechanical stimulation. There was a significant difference in the effect of drugs (F ϭ 7.003).001) and that CR665 was better than placebo (P ϭ 0. A rating of 5 was defined as the pain threshold. V 111. Point Richmond.0 Ϯ 11. One subject used a concomitant medication (Zyrtec® [cetirizine hydrochloride].001).15.154. 619 CR655. For the VAS ϭ 7 threshold. 2).001) (fig..05 kPa. where 7 was rated as moderate pain. The total volumes (ml) required to reach these ratings were recorded.17 The subjects rated the intensities of the nonpainful visceral sensations from 1– 4. and 3. There was a significant difference in the effect of drugs (F ϭ 12.05 was considered significant. Skin Stimulation The average baseline pinching pain tolerance threshold was 900 Ϯ 319 kPa. 3 of 18 for oxycodone. Table 1 summarizes all adverse events. UCB Nordic.001) (fig.3. The averaged baseline pain detection threshold (VAS ϭ 5) and a moderate pain threshold (VAS ϭ 7) to distension were 17. No serious adverse events were reported.001.858) and neither oxycodone nor CR665 was different from placebo.463 ml for oxycodone. two-way analysis of variance was used with the factors of drug and time. and only possibly related to the study medication. The difference in urine level was analyzed by one-way analysis of variance with drug as a factor. P ϭ 0. the stimulus intensity was calculated as the area under the curve (temperature [°C] ϫ time [s]) from start to end of the stimulation. Further post hoc analysis showed that oxycodone was better than placebo (P Ͻ 0. The perfusate temperature was increased gradually until a constant temperature of 55°C was obtained.001). Visceral Stimulation Repeated visceral stimuli are known also from previous studies10 to cause a reduction in threshold over time.001).001). No significant difference in the effect of drug was found (F ϭ 0. CA) was used. with increasing stimulus intensity.68 Ϯ 13.3. P Ͻ 0. Further post hoc analysis showed that compared to placebo and CR665. P Ͻ 0.16 Statistical Analysis To correct for individual differences in baseline pain recordings. there was a significant difference in the effect of drugs (F ϭ 9. P Ͻ 0.005) (fig.001). the bag was filled with a volume of water corresponding to a mechanical VAS ϭ 3 rating (prepain) to ensure reliable mucosal contact. respectively). oxycodone significantly increased the cuff pressure-pain tolerance thresholds (P Ͻ 0. The number of volunteers who urinated during the first 2 h after drug administration was 13 of 18 for Anesthesiology. Inc. P Ͻ 0. The dysphoria was characterized as mild. The average cuff pressure-pain tolerance thresholds were 48.148).8 Ϯ 141. For the VAS ϭ 5 threshold there was a significant difference in the effect of drugs (F ϭ 6. The mean volume of urine collected during the entire session was 4. Tukey test was used for post hoc analysis. As a measure of the total thermal energy delivered to the tissue.96. This temperature was maintained for 90 s or until the pain detection threshold (VAS ϭ 5) was reached. Sep 2009 Discussion The present human proof-of-concept experimental pain study showed significant analgesic effects of the .

and dizziness).6%) 1 (5. visceral pain is often difficult to alleviate with morphine and other ␮-agonists.6%) 0 6 (33.6%) 0 15 (83. which was moderate. but it is not known whether the drug can cause .6%) 2 (11.6%) 8 (44.6%) 1 (5. No 3.7%) 0 0 0 0 0 0 0 0 1 (5.24 ␬-Opioid agonists like fedotozine25 and asimadoline have been tested for analgesic activity against pain from colonic distension in patients with irritable bowel syndrome and functional dyspepsia21.6%) 0 1 (5. All Reported Adverse Events for Each Treatment Group CR665 (n ϭ 18).27 The side effects of CR665 were mainly limited to mild pruritus at the site of administration and to mild facial tingling (paraesthesia).6%) 0 1 (5. and it has been shown that ␬-opioid agonists can be effective.g. with the exception of one episode of increased heart rate in the CR665 treatment period.20 Peripherally Acting ␬-Opioid Agonists In the clinic. other central nervous system side effects were reported (paraesthesia. asimadoline caused slight hyperalgesia in nonvisceral postoperative pain. Sep 2009 In the current study. in general.1%) 1 (5. However.4%) 1 (5.26 Anesthesiology. Oxycodone showed pronounced effects on pain from somatic as well as visceral structures supporting previous studies. n (%) Oxycodone (n ϭ 18). V 111.6%) 0 0 1 (5. CR665 showed less centrally related effects as observed with centrally acting ␬-opioid agonists (e.19. Facial paraesthesia could be associated with ␬-receptor activation.1%) 1 (5.6%) 0 1 (5. All adverse events were mild in severity.18 The side effects after oxycodone were typical of ␮-opioid agonists. Pande et al. the dysphoria was characterized as mild.7%) 15 (83.21.3%) 1 (5.6%) 0 0 0 0 1 (5.6%) 1 (5. n (%) Placebo (n ϭ 18).6%) 0 0 11 (61. The hyperalgesic effect of ␬-agonists on cutaneous pain has not been reported previously in any preclinical or clinical studies on ␬-opioid agonist.3%) 1 (5.620 ARENDT-NIELSEN ET AL. QT ϭ Q and T peaks of the electrocardiogram.6%) 1 (5.6%) Summary of all reported adverse events presented.22.23. Table 1.6%) 1 (5. somnolence. CR665 caused hyperalgesia to skin pinching.6%) 0 0 10 (55.23 with reported clinical effectiveness. All but one adverse event (hypersensitivity during placebo dosing) was considered related to study medication.6%) 1 (5. peripherally acting ␬-opioid agonist CR665 on visceral pain and a paradoxical hyperalgesic action on skin pinching pain.10.22. but it is known that central effects of dynorphin A (endogenous ␬-opioid agonist) possess pronociceptive properties. and only possibly related to the study medication. The most frequently reported adverse events associated with the use of CR665 were infusion site pruritus and paraesthesia..6%) 0 1 (5. No serious adverse events were reported during the study. which could be associated as a central effect. However.28 One example of dysphoria was observed after CR665.6%) 0 0 0 1 (5.29).6%) 1 (5. However. intermittent.3%) 3 (16. n (%) Subjects with no adverse events Subjects with at least one adverse event Cardiac disorders Bradycardia Atrioventricular block first degree Sinus bradycardia Tachycardia Ear and labyrinth disorders Ear discomfort Gastrointestinal disorders Vomiting General disorders and administration site conditions Infusion site pruritus Infusion site erythema Pyrexia Immune system disorders Hypersensitivity Investigations Heart rate increased Body temperature increased Electrocardiogram QT prolonged White blood cell count increased Nervous system disorders Paraesthesia Dizziness Somnolence Psychiatric disorders Dysphoria Skin and subcutaneous tissue disorders Cold sweat Erythema Hypoaesthesia facial Pruritus Vascular disorders Orthostatic hypotension 3 (16.6%) 0 1 (5.6%) 0 0 1 (5.6%) 0 0 0 0 0 0 0 0 1 (5.6%) 0 1 (5.6%) 0 0 1 (5.

60. black bar ‫ ؍‬oxycodone.3. hatched bar ‫ ؍‬CR665. White bar ‫ ؍‬placebo. Studies in humans with enadoline (CI977). black bar ‫ ؍‬oxycodone. No 3. The mean ؎ SEM changes from baseline (30. Anesthesiology. particularly for visceral pain. and 90 min after drug administration) in the skin pinching pain tolerance threshold (kPa). hatched bar ‫ ؍‬CR665. # Significant difference from placebo and CR665. 60. # Significant difference from placebo and CR665. 2. Negative values show sensitization compared with baseline. and 90 min after drug administration) in the cuff pressure pain tolerance threshold (kPa). 1. centrally ac- Fig.␬ AGONIST AND EXPERIMENTAL VISCERAL PAIN 621 Fig. to some degree. central actions.29 It is evident that peripherally located ␬-receptors are of importance. White bar ‫ ؍‬placebo.31 Clinical studies have been performed with a number of peripherally acting (and usually also. The mean ؎ SEM changes from baseline (30.30 a highly selective and potent ␬-opioid agonist. Sep 2009 . although associated with neuropsychiatric side effects. V 111. * significant difference from placebo and oxycodone. have shown analgesic effects.

g. Sep 2009 . Anesthesiology. Machelska et al. the heat energy to elicit visual analogue scale (VAS) ‫ ؍‬5 was calculated as the area under the curve (AUC) (temperature [°C] ؋ time [s]) from start to end of the stimulation..599). 3. 4. Fig.37 enadoline (CI-977).23 These clinically tested ␬-opioids have all produced unacceptable central side effects (e. White bar ‫ ؍‬placebo.32 including asimadoline (EMD61753). hatched bar ‫ ؍‬CR665..38 fedotozine. Bars indicate mean ؎ SEM changes from baseline (30.g. 60. black bar ‫ ؍‬oxycodone.40 and ADL-10-0101.36 ICI 204448.622 ARENDT-NIELSEN ET AL. ting) experimental ␬-opioids. hatched bar ‫ ؍‬CR665. White bar ‫ ؍‬placebo.35 GR 94839. The mean ؎ SEM changes from baseline (30.34 niravoline (RU 51.41) at analgesic doses or unreliable efficacy that may be related to off-target activity (e. and 90 min after drug administration) in the volume (ml) to esophageal distension to elicit visual analogue scale ‫ ؍‬7. and 90 min after drug administration) in AUC.33 RP 60180.26 and Coruzzi et Fig. # Significant difference from placebo and CR665. No 3.066E). Pfeiffer et al. There were no difference in drug effect of oxycodone and CR665. V 111. As a measure of the total thermal energy delivered to the tissue. * Significant difference from placebo. black bar ‫ ؍‬oxycodone.39 spiradoline (U62. 60.

of these two metabolites. Pain 1999. This battery has recently been used to explore the differential analgesic effects of 15 mg of oxycodone and 30 mg of morphine10. Gastroenterology 1996. designated JNJ-3848850212. the rational next step in the development of CR665 is to apply it to patients with inflammatory visceral pain. 67:173–82 2.5 h). and at the same time causes constipation. noroxymorphone reaches the higher maximum plasma concentration (7. preclinical studies indicate that the antinociceptive effects of oxycodone are mediated by a combination of ␮-opioid and ␬-opioid receptors.57 Future Perspectives and Conclusion In patients with severe pain originating from the gastrointestinal tract. Gebhart GF: Effects of kappa-opioid receptor agonists on . 141:1331–4 4. which is still about five-fold lower than the concentration of oxycodone itself. but these compounds are still 15-fold more potent at ␮-opioid receptors. nonopioid analgesics are often insufficient to relieve pain to an acceptable level. these opioids were found to be equipotent in somatic pain (skin and muscle). Allescher et al.49 However. Angermeyer MC: Health status of the german population: Results of a representative survey using the EuroQol questionnaire. Br J Pharmacol 2004.46 E-2078. To address these problems. Snider A. Sengupta JN. FE200665 (CR665). preclinical studies with FE200041.43).44.8.51.52 Consistent with this view. 111:968–80 5. Anesthesiology. Experimental Pain Models The need to improve the characterization of new compounds for the treatment of pain has led to development of a comprehensive battery of multi-modal..1– 8 was found to readily cross the blood-brain barrier and produce apparently nonopioid analgesia in monkeys in doses overlapping with the sedative dose range.12. Gebhart GF: Kappa. a synthetic.10 This study was then repeated in patients with chronic pancreatitis. CR665 and oxycodone differ from traditional ␮-opioid agonists50 and have shown significant effects on visceral pain and may hence provide new opportunities in the management of clinical visceral pain. Su X. No 3.. References 1. whereas oxycodone-tolerant rats fail to display analgesia with morphine. and the efficacy of oxycodone on the various experimental pain parameters was found to be significantly enhanced18 possibly due to the inflammatory components of the pancreatitis. the ␮-opioid activity of oxycodone and its metabolites is collectively much greater than ␬-opioid activity. Su X. These clinical reports. multi-tissue experimental pain models. together with physiologic evidence for a role of ␬-opioid receptors in modulating visceral pain. Gebhart GF: Effects of kappa opioids in the inflamed rat colon.13) have been developed with the idea that a peptide should be less likely than a nonpeptidic small molecule to cross the blood-brain barrier and cause centrally mediated side effects. demonstrated antinociception that was confirmed.g.56 In addition.000 nM. Cremonini F. all-L-amino acid analog of dynorphin A. the only two metabolites with significant ␬-opioid receptor binding activity are oxymorphone (receptor affinity 148 nM) and noroxymorphone (receptor affinity 87 nM). and the development of new types of opioids that interact with different opioid receptors. Gesundheitswesen 2005. which is very potent at the ␮-opioid receptor (receptor affinity 16 nM).9 Collectively. which itself can be painful. Burton MB. peripherally selective ␬-opioids. this experimental concept has provided a valuable tool for differentiating visceral pain from other forms of pain and enables the profiling of new compounds such as CR665. as well as substantial preclinical evidence that peripheral opioid analgesia is enhanced in the presence of inflammation.␬ AGONIST AND EXPERIMENTAL VISCERAL PAIN al. an all-D-amino acid tetrapeptide ␬-opioid agonist. this imbalance may not completely preclude some contribution of ␬-opioid activity because interactions between ␮-opioid and ␬-opioid receptors appear to play a significant role in how nociception is mediated.53 Recently. Konig HH.45 have lead to an intensified search for high-affinity. but not mu or delta.11. Park MI. with suitable antagonists to be peripherally mediated and selective via ␬-opioid receptors.56 Clearly.8 ng/ml at about 1.55). Is Oxycodone Acting via The ␬-Opioid Receptor? Although oxycodone has been generally considered to act as a typical ␮-opioid agonist in humans. Sengupta JN. 16:383–94 7. In human subjects. However. 79:175–85 6.47 FE200041 (an earlier analog of CR66548). V 111.g. SK-9709. De Schepper HU. Schafer M. but without activity at the ␬-opioid receptor at 1. This strategy is not invariably effective: E-2078. Bernert S. 9:1003–8 3. and FE200665 (CR665. it is difficult to attribute these findings to ␬-opioid receptor binding activity of oxycodone (receptor affinity greater than 1000 nM) or its metabolites (Staahl et al. Nat Med 2003. new therapeutic approaches have emerged. confirmed this profile of peripheral ␬-opioid selectivity and demonstrated peripheral antinociceptive activity in a wide range of preclinical visceral pain models. Machelska H: Attacking pain at its source: new perspectives on opioids. On the basis of these observations. Riviere PJ: Peripheral kappa-opioid agonists for visceral pain. Sep 2009 623 morphine-tolerant rats continue to exhibit analgesia with oxycodone.42) and/or low affinity for the ␬-opioid receptor (e.48 Subsequent evaluation of an improved analog. Peptidic ␬-opioids.13 The current experimental pain study with CR665 substantiates these animal data in man. opioids attenuate responses to distention of afferent fibers innervating the rat colon. it has also been shown that oxycodone and morphine have distinctly different pharmacological profiles in rat models of neuropathic pain. Camilleri M: Opioids and the gut: Pharmacology and current clinical experience. e.58 Treatment with traditional ␮-opioid agonists also often fails to relieve the pain sufficiently.50. then. whereas oxycodone was clearly more effective than morphine in visceral pain.54 Nevertheless. Stein C. Neurogastroenterol Motil 2004.

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Wadenberg ML: A review of the properties of spiradoline: A potent and selective kappa-opioid receptor agonist. Oomura Y. Larsson H: Involvement of kappaopioid receptors in visceral nociception in mice. Upton R. Kendall S. J Clin Pharmacol 1994. 20:1157–64 46. Whorwell PJ. Schteingart CD. Curatolo M.and delta-opioid receptor functions after repeated stimulation of kappa-opioid receptors. Gastroenterology 1999. Hayes AG: GR 94839. Classen M. Suzuki M. Stalewski J. Andersen SD. August 17-22: Progress in Pain Research and Management. 5:267–77 15. Woods JH: Systemic effects of E-2078. Vivian JA. Rajagopalan R: Diuretic effects. 73:151–7 12. Menzaghi F. Sasaki Y: Synthesis and opioid activities of [D-Leu8] dynorphin (1-8) fragments containing a reduced peptide bond. Arakawa Y. Edited by Jensen TS. 43:1547–50 47. Pain 1997. Rogers H. Arendt-Nielsen L: Induction and assessment of experimental pain from human skin. Drewes AM: A comparative study of oxycodone and morphine in a multi-modal. 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Leung.D. Accordingly. Address correspondence to Dr. Despite more opioid use. A portion of this work was presented at the 2005 Annual Meeting of the American Society of Anesthesiologists in Las Vegas.ucsf. adjusting for known covariates for delirium. Postoperative delirium did not limit the use of PCA. M. M.0051. Indiana. Department of Statistics.. Materials and Methods Patient Recruitment The study was approved by the University of California.10 In addition. and from the Department of Statistics. San Francisco. San Francisco Medical Center.19... # Staff Research Associate. Received from the Department of Anesthesia & Perioperative Care. and informed consent was obtained preoperatively from each study patient. POD 2: 3. University of California. M.D. San Francisco. 2005. there was an ordered association between levels of pain and the development of postoperative delirium. 3. resulting in more reportable pain? If the answer is yes.3 ؎ 0.D. Indiana (to Dr. Supported in part by Grant #1K24 AG00948-05 from the National Institute of Aging. The study inclusion criteria included English-speaking patients 65 yr of age and older undergoing noncardiac surgery requiring anesthesia and who were anticipated to stay in the hospital for longer than 48 h. National Institutes of Health. www.A.5 In the perioperative period.67 mg. B. Purdue University. Department of Anesthesia and Perioperative Care.§ Sakura Kinjo.H. Delirium was measured by using the Confusion Assessment Method. ᭛ This article is featured in “This Month in Anesthesiology.edu. 10% to 60% of patients have delirium. Conclusions: Postoperative delirium did not limit PCA use. then an alternative to PCA is indicated to provide postoperative analgesia to patients with postoperative delirium. DELIRIUM is an acute confusional state with alterations in attention and consciousness. Path coefficients from structural equation model revealed that pain and opioid use affect delirium status. California 94143-0648. Inc. Submitted for publication September 12.23 vs.. Future studies on delirium should consider the role of pain and pain management as potential etiologic factors. ‡ Graduate Student. the current study aimed to determine whether patients with and without delirium differed in the amount of postoperative opioid used. page 9A. the precipitating risk factors for the development of postoperative delirium in older patients include an unfamiliar environment. We hypothesized that postoperative delirium did not limit the patient’s use of on-demand PCA.25 ؎ 0.2.6 –9 We recently demonstrated that the methods of pain relief and the severity of postoperative pain both independently increase the occurrence of postoperative delirium after controlling for factors such as age and educational level in a cohort study of patients 65 yr of age or older undergoing elective noncardiac surgery. Accepted for publication April 27. and its associated mortality rate is 10% to 65%.† Sudeshna Paul. Purdue University. Previously published studies have analyzed how patient-related factors and surgical factors contribute to postoperative delirium. This article may be accessed for personal use at no charge through the Journal Web site. but the exact etiology is frequently not identifiable. A subset of 215 patients in this study was 625 * Professor of Anesthesia and Perioperative Care. Methods: The authors conducted a nested cohort study in older patients undergoing noncardiac surgery and used PCA for postoperative analgesia. the American Society of Anesthesiologists. 521 Parnassus.” Please see this issue of ANESTHESIOLOGY. 111:625–31 Copyright © 2009.anesthesiology.* Laura P. M. San Francisco Committee on Human Research. and 120 (35.4 Delirium is a serious problem for hospitalized geriatric patients.‡ Tim Joseph. Patients were selected from an ongoing larger study investigating the pathophysiology of postoperative delirium in older surgical patients. 2009. P ‫ ؍‬0. from 2001–2006. M. Inc. Leung). Only patients who received PCA by using intravenous opioid analgesics in the postoperative period were included in this study. Lippincott Williams & Wilkins. Leung) and by the Anesthesia Healthcare Partners Research Award from the Anesthesia Patient Safety Foundation. V 111. 1. § Medical Student. Does postoperative delirium limit the patient’s use of ondemand patient-controlled analgesia (PCA).# Background: Postoperative pain Is an independent predictor of postoperative delirium. visual analog scale scores were higher in patients with delirium. leungj@anesthesia. Whether postoperative delirium limits patient-controlled analgesia (PCA) use has not been determined. † Professor. Indianapolis. Results: Of 335 patients.004). P ‫ ؍‬0.S. Sep 2009 .org.02). San Francisco. 2008. California. Department of Anesthesia & Perioperative Care.24 ؎ 0. Room C-450. Nevada. Patients with postoperative delirium used more PCA in a 24-h period (POD 2) compared to those without delirium (mean dose of hydromorphone ؎ SE adjusted for covariates was 2.3 After major noncardiac surgery. University of California.1 Delirium occurs in 14% to 50% of hospitalized medical patients. The study took place at the University of California. This result raises an important question.P. Maryland (to Dr.. It may be caused by an underlying medical illness. Anesthesiology.3 ؎ 0.Anesthesiology 2009. ͉͉ Assistant Clinical Professor of Anesthesia and Perioperative Care. the stress of surgery. Ph. Despite more opioid use..͉͉ Tiffany Tsai. Indiana. Does Postoperative Delirium Limit the Use of Patient-controlled Analgesia in Older Surgical Patients? Jacqueline M. and exposure to medications that have the potential for profound effects on the central nervous system (CNS).23 vs. but delirium does not affect subsequent opioid dose. Excluded were those who could not provide informed consent. San Francisco. October 26.5 ؎ 0. School of Nursing. Bethesda. Leung: University of California. West Lafayette. 2.D. Sands.2%) developed delirium on postoperative day (POD) 1. patients with delirium reported higher Visual Analogue Scale scores than those without delirium (POD 1: mean visual analog scale ؎ SE at rest 4. 108 (32.2 ؎ 0. San Francisco. The authors computed a structural equation model to determine the effects of pain and opioid consumption on delirium status and the effect of delirium on opioid use. No 3.22.71 mg vs. West Lafayette. P ‫ ؍‬0.8%) on POD 2.

Anesthesiology.626 LEUNG ET AL. To ensure consistency in the evaluation. By using this method. We computed two intraclass correlations: one for subjects who were delirious and one for subjects who were not delirious on day one to assess consistency in their reports of pain at rest on postoperative day one and day two.10 The covariates included current pain at rest. surgical risk. patients were stratified by the presence or absence of delirium on postoperative days one or two. defined by Confusion Assessment Method (CAM). for administration of the CAM. The Telephone Interview for Cognitive Status. a detailed examination was conducted to evaluate the cognitive status. after adjusting for covariates that have potential effects on postoperative delirium by using analysis of covariance. and other covariates. disorganized thinking. The daily doses of the PCA opioid analgesic administered postoperatively (hydromorphone) were recorded for the first three postoperative days. the patients were evaluated for depressive symptoms. the CAM algorithm consists of four clinical criteria: acute onset and fluctuating course. Additional analyses were performed to determine whether delirium was associated with the dose of PCA delivered opioids in the next 24 h for those with and without delirium after adjustment for covariates. preoperative narcotic use. Trained research assistants measured patient pain levels during structured interviews by using a verbal version of the visual analog scale (VAS). respectively. chi-square tests for categorical variables. in which a rating of zero corresponds to no pain and a rating of ten corresponds to maximum pain. During this preoperative interview. which was determined by the attending physicians. Structural equation modeling was performed to model how pain and initial postoperative opioid use affect delirium status and how delirium status affects subsequent opioid use. The measurements of pain status were performed at the same time that patients were evaluated for delirium. The preoperative interview occurred less than 48 h before surgery in the preoperative clinic. and Fisher exact test when variable categories included fewer than five patients. All patients in this report used PCA as the method of postoperative pain relief. Structural equation modeling is an extension of the general linear model (that includes regression). included in a previous manuscript evaluating the predictors of postoperative delirium that included the measurements of pain. plus either criterion three or four. pain. Statistical Methods Patients with delirium on either day one or day two after surgery were compared with patients who did not experience delirium on either day after surgery by using t tests for continuous valued variables. V 111. To assess this.11 modified from the Mini Mental Status Examination. we computed several analyses of covariance to assess whether the mean doses of hydromorphone used on each of the postoperative days differed between patients with and without delirium. and it has a high interobserver reliability12 and convergent agreement with four other mental status tests. On the basis of a structured interview. delirium status is considered a latent variable that can be . We sought to determine whether subjects with delirium were less consistent in their reports of pain compared to subjects without delirium. and hydromorphone was typically the opioid used.13 and use of other medications with CNS effects. which could be administered in person or over the phone. CAM has a sensitivity of 94 –100% and a specificity of 90 –95%. Latent variables are unobserved traits that can be measured with observed variables. and functional status. Patients were asked to rate their pain at rest preoperatively and on postoperative days 1 and 2. In addition. each patient was evaluated by the same research assistant for all three interviews. postoperative medications. To investigate the temporal relationship between drug dosages given in the postoperative period and the occurrence of postoperative delirium. which allows estimation of latent variables and modeling associations between observed and latent variables.12 The occurrence of delirium was defined as the patient meeting CAM criteria for delirium on any of the postoperative day assessments. Sep 2009 Postoperative delirium assessments were validated by a second investigator with advanced training in psychology (Dr. both the first and second criteria have to be present. For this study. and altered level of consciousness.10 Patient Assessment The same trained research assistant conducted preoperative and postoperative patient interviews in person.12 This method was developed as a screening instrument based on operationalization of the Diagnostic and Statistical Manual of Mental Disorders-III-R criteria for use by nonpsychiatric clinicians in high-risk settings. The research assistant was trained in the use of the CAM based on a detailed manual developed by Inouye et al. No 3. For delirium to be defined. we computed intraclass correlation coefficients based on a two-way random effects analysis of variance model. Sands). Postoperative Pain Measurement and Management The study design did not control the postoperative pain management strategy. inattention. Delirium Assessment A trained research assistant conducted structured interviews preoperatively and on the first two postoperative days between the hours of 9:00 AM to 12:00 PM to determine the presence of delirium. was used to measure baseline cognitive status.

surgical risk resting pain. A value of zero for a coefficient would indicate no association. Arrows that extend from each of these observed variables to delirium status show the direction of the hypothesized association.05 (two-tailed) was considered statistically significant. Inc.POSTOPERATIVE DELIRIUM AND OPIOIDS USE 627 Fig. The significance of path coefficients is tested by using t tests that assess whether the coefficient is significantly different than zero. We report the standardized regression weights (path coefficients) next to each arrow. a chi-square test. use of CNS medications. All data were presented as mean Ϯ SEM unless stated otherwise. IL). and loadings above 0.90. Preoperatively. One patient had missing data for delirium on postoperative day one due to mechanical ventilation and 13 patients had missing data for delirium on postoperative day two. All structural equation modeling computations Anesthesiology. No 3.5 Ϯ 6.2 yr (range. The reasons for missing data for postoperative day two .8%) developed delirium on postoperative day two. and 120 (35. we computed unadjusted and adjusted goodness-of-fit index. NC).0 (Chicago.10 for a good-fitting model. Figure 1 shows that these four variables are used to measure delirium status as illustrated by the four arrows that extend from delirium status to each of these four observed variables. inattention. figure 1 also shows the hypothesized associations between the current opioid use and delirium status on subsequent opioid use. which should be close to zero and is typically near 0. represented by four indicators that are used in combination to diagnose delirium (acute onset and fluctuating course.2%) developed delirium on postoperative day one. (2) opioid dose on day one affected delirium status on day one. V 111. and altered level of consciousness). we describe that delirium status was represented by the four criteria used to measure the presence of delirium. In all tests. Finally. The majority of patients underwent orthopaedic surgery. Results Three hundred and thirty five patients were included in the study. which should be above 0. surgical risk. pain. 65–96 yr). which were computed by using SPSS version 16. and the root mean square residual. except for the intraclass correlation coefficients. 36% of patients received an opioid analgesic for pain. P Ͻ 0. 185 patients (55%) developed delirium on either day one or day two after surgery. and CNS drug use affect opioid use. All statistical analysis was performed with SAS. This figure depicts our heuristic model for the association between postoperative delirium and opioid use. and (3) delirium status on day one did not affect opioid dose on day two. The mean age (ϮSD) of patients was 73. Patients who developed postoperative delirium on either of the postoperative days tended to be older. and opioid use affect delirium status.70 are considered to be strong indicators of the latent trait. Our hypotheses were (1) rest pain on postoperative day one affected delirium status on day one. which should not be significant because it would suggest the data do not fit the model. Shown also in figure 1 is our second hypothesis that preoperative narcotic. To evaluate whether the hypothesized model shown in figure 1 was a good fit. We report pattern coefficients (factor loadings). version 9.1. In this model. 108 patients (32. Of the 335 patients studied. Shown in the same figure is our hypothesis that preoperative narcotic use. 1. The majority of patients were intermediate surgical risk candidates with two or more medical comorbidities. Sep 2009 were performed by using Proc CALIS in SAS (SAS Institute. disorganized thinking.. and had more self-reported symptoms of depression as indicated on the geriatric depression score (table 1). Cary. Preoperative patient characteristics and surgical and medical data are shown in table 1. were more likely to be female.

63 Ϯ 3.0051.36 115 70 158 27 56 121 72. the amount of missing data for VAS in our study was low (Ͻ 3% overall for both postoperative days).38 133 17 0.and postoperative periods.05. mean postoperative VAS at rest 4.62 Ϯ 2.44 81 69 0. for postoperative day two. In contrast. and the differences in missing data between those with and without delirium were not significantly different for the different postoperative days. which takes into consideration the type and duration of surgery.5 Ϯ 0. V 111.71–0. and too sleepy to respond (n ϭ 4). Age (mean Ϯ SD) Gender Female Male Race White Nonwhite Education High school graduate or incomplete Incomplete college or above History of central nervous system disorders None Yes Daily alcohol intake None Yes Independent in performing 5 ADLs No Yes Independent in performing 7 IADLs No Yes Geriatric depression score (mean Ϯ SD) TICS scores (mean Ϯ SD) Types of surgery Spine/knee/hip Abdominal/thoracic Peripheral/others Surgical risk Low Intermediate High Number of coexistent medical conditions 0 1 Ն2 ASA classification 1&2 Ն3 Preoperative opioids No Yes Anesthesia type General Regional 74.87) Ͻ 0. * P < 0.3 Ϯ 0. the characteristics (demographic and surgical data) of patients with missing data on delirium were not different from those with delirium data.15 32 63 90 92 93 114 71 165 20 33 37 80 0. Sep 2009 .. Surgical risk was estimated using the guidelines from the American College of Cardiology and American Heart Association update for the perioperative cardiovascular evaluation for noncardiac surgery. mean postoperative VAS at rest 3. More importantly.47 Ϯ 4. The preoperative VAS scores were not significantly different between patients who subsequently developed postoperative delirium versus those without delirium (fig.004).0001 The intraclass correlations between postoperative day one and day two resting pain scores were significantly different than zero in patients with and without postoperative delirium.016 0.24 37 107 0.12 45 140 26 124 0. Anesthesiology.53 32. The 95% confidence intervals Table 2.63) 0. Similarly.37–0.77 94 90 89 93 78 70 0.3 Ϯ 0.80 (0.52 (0.22. P ϭ 0. TICS ϭ telephone interview of cognitive status. P ϭ 0.2 Ϯ 0.628 Table 1.023 0.82 Ϯ 5. patients who were delirious postoperatively experienced significantly higher VAS scores than nondelirious patients (for postoperative day one.053 0.0046 0. Consistency in Reporting Pain Between Postoperative Day One and Day Two Not Delirious on Day 1 (n ϭ 217) Delirious on Day 1 (n ϭ 102) Delirious refers to patients with delirium on either postoperative day 1 or 2.15 91 94 3. a cognitive assessment tool modified from the Mini Mental Status Examination.33 Ϯ 2. which can be used in person or over the telephone.23 vs.12 104 45 130 19 0.23 vs.13 Ϯ 6. refusal to answer questions (n ϭ 3). Shown are the visual analog scale (VAS) pain scores plotted as mean ؎ SEM for patients with and without postoperative delirium in the pre.58 included early discharge or unavailable during interviews (n ϭ 6).19. Intraclass correlation between day one and day two resting pain scores (95% confidence interval) P value 0.77 Fig. The 95% confidence intervals suggest that subjects with delirium were no less consistent than subjects without delirium in reporting pain. 0. 3. and intraoperative blood loss (see text for citation).87 70 80 0. IADL ϭ independent activities of daily living.97 31. 2. 2).0001 Ͻ 0. ADL ϭ activities of daily living.33 62 88 2.29 62 82 0. 2. No 3. ASA ϭ American Society of Anesthesiologists.030 3 129 18 0.90 128 34 23 3 139 43 107 25 18 0. Demographics and Clinical Characteristics (n ‫ ؍‬335) Demographic and Clinical Data Delirious (n ϭ 185) Nondelirious (n ϭ 150) P Value LEUNG ET AL. The intraclass correlations for postoperative resting pain scores on day one and day two were significantly different than zero in patients with and without postoperative delirium (table 2).

For patients with delirium on postoperative day two. patients with and without delirium on postoperative day one used similar amount of hydromorphone on postoperative day one and the subsequent day (table 3).0001)). the quantitative validity of the VAS in delirious patients is uncertain and needs further investigation. The strengths of the relationship between the covariates and the dependent variable (hydromorphone doses) are shown in figure 1. we showed that postoperative delirium did not limit patient’s use of on-demand PCA. An important question is whether patients with delirium can actually communicate their pain experience. Although an association is shown between opioids and delirium in these two groups of patients.72 Ϯ 0. delirium status. Table 4.71 vs.75 Ϯ 0.24 mg Ϯ 0. was reasonable.28 Ϯ 0. all of which indicated an adequate fit to the proposed model. there is no other existing standard to determine that the VAS is actually valid in patients with delirium. mg Hydromorphone dose on POD 2.001) and delirium status (P Յ 0. The standardized path coefficients are displayed above their respective arrows in figure 1. Surgery Risk. Hydromorphone Dose by Delirium on Postoperative Day (POD) 2 Adjusted for Current Pain at Rest. 26. The variances in resting pain scores on day one and day two for patients who were and were not delirious on day one also did not differ significantly (P ϭ 0. whether the P Value Hydromorphone dose on POD 2. resting pain on day 1 for hydromorphone dose on day 1. 18. delirium status on day one does not affect opioid use on day two. Discussion We evaluated the association between delirium. e. Although our test-retest reliability assessment suggested that patients with delirium were consistent in reporting their pain experience. After adjusting for the VAS scores.62 Ϯ 0. V 111. patients with postoperative delirium still experienced higher VAS scores than those who were not delirious.74 0.98 1.67 0. The presence of postoperative delirium did not limit the use of PCA opioids as shown in tables 3 and 4. Second.05) and subsequent opioid use on day two (P Յ 0.001).67.24 Ϯ 0.82 and 0. Current pain refers to resting pain measured on the same day of the opioid dose. However.92 1. and Use of Other Medications with Central Nervous System Effects Adjusted Means No Delirium on POD 2 (n ϭ 202) Delirium on POD 2 (n ϭ 120) Figure 1 shows that our choice of indicator variables for measuring the latent variable.99. Comparison with Previous Studies In healthy volunteers without preexisting cognitive impairment.38 Ϯ 0.71 1.g. Three indicator variables (acute onset. P ϭ 0. despite the use of PCA opioids. and use of medications with CNS effects on the day of the opioid dose measurement. No 3.25 mg Ϯ 0. On postoperative day one. Sep 2009 . dF ϭ 25. we cannot determine whether their self reported higher pain state actually reflects a ceiling effect of the PCA not completely mitigating their acute postoperative pain. and if so.70 2. The difference in the magnitude of intraclass correlations could not be explained by differences in the ranges and variances of scores. Hydromorphone Dose by Delirium Status on Postoperative Day (POD) 1 Adjusted for Current Pain at Rest. Surgical Risk.93 0.6% of patients with delirium and 15. we do not have an independent method to verify the validity of VAS scores.14 –17 The association between delirium and opioid use has also been studied in patients with cancer and adults with acute pain. for the intraclass correlation coefficients suggest that patients who were delirious were equally consistent in their reports of resting pain evaluation as those who were not delirious. There are several novel findings from the current study.1% of patients without delirium reported resting VAS pain scores of zero (P ϭ 0.POSTOPERATIVE DELIRIUM AND OPIOIDS USE 629 Table 3. mg Hydromorphone dose on POD 3.51). mg 1. As a result.14). Rest pain on postoperative day one significantly affects both postoperative opioid use (P Յ 0. Specifically. preoperative narcotic use.06 Anesthesiology.68 0. P ϭ 0. First. Preoperative Narcotic Use.41. inattention. 1. respectively). root mean square residual (0.34 Ϯ 0. surgical risk. substantial cognitive impairment was associated with parenterally administered opioids.02 0. they used substantially more PCA hydromorphone than those who were nondelirious on day two (adjusted mean dose 2. Postoperative opioid use on day one significantly affects delirium on day one (P Յ 0.5% of patients with delirium and 23. and pain management to provide insight into whether treatment for postoperative pain should include the patient’s delirium status. pain.02) (table 4). The overall model fit was assessed by using statistics such as the adjusted goodness-of-fit index (0.. whether the VAS scores in these patients are reproducible. chi-square (␹2 ϭ 23.7% of patients without delirium reported resting VAS pain scores of zero (P ϭ 0.25 Ϯ 0.55).98).68 4. and the impairment was dose-related.01) on day one. and Use of Other Medications with CNS Effects Adjusted Means No Delirium on POD 1 (n ϭ 226) Delirium on POD 1 (n ϭ 108) P Value Hydromorphone dose on POD 1.52) and on postoperative day two. and altered level of conscious) loaded highly on the latent variable that we called delirium status. root mean square error of approximation (P Ͻ 0. mg 4.42 The results are shown in dose of hydromorphone (mg) Ϯ SEM. Preoperative Narcotic Use.

relationship is causal cannot be demonstrated because these patients typically have other comorbid conditions such as organ failure. VAS scores and postoperative delirium. Our results suggest that there is room for improvement of pain management in older patients who are at risk of developing postoperative delirium. In addition. Future investigations are needed to determine the precise relationship. the occurrence of postoperative delirium is likely a multifactorial phenomenon. Previously published studies suggest that pain relief may be associated with an improvement in cognitive performance. rather. etc. given the higher reported VAS scores in delirious patients despite similar or even higher amount of opioids used in the postoperative period. we cannot determine the mechanism of how these factors interact to precipitate postoperative delirium. dementia. Although the current study did Anesthesiology. and delirium. Sep 2009 not specifically address the other factors previously shown to be associated with postoperative delirium. Which condition precipitates delirium? Is it undertreated pain or opioids? Several studies in both medical and surgical patients have investigated the importance of pain management on delirium. No 3. .23 higher pain scores at rest were associated with an increased risk of delirium over the first three postoperative days in patients undergoing noncardiac surgery. as subjects in this investigation were included in a larger studying examining perioperative management and delirium.630 LEUNG ET AL. We used pain measurement at the same time of delirium assessment to represent the pain status for each specific postoperative day. our methodology of adjusting opioid usage by VAS scores may be an oversimplification of this complex relationship between opioid usage. Although we have described an association between postoperative opioids use. As a result. Prevention and treatment of geriatric syndromes such as postoperative delirium should focus on intervening on common sets of high-impact risk factors. however.10. delirium. the current findings show that pain is associated with postoperative delirium not because of patients’ inability to use the on-demand PCA device. despite the important side effects known to occur with opioids such as respiratory depression. pain.. even after adjusting for VAS scores and other covariates associated with postoperative delirium. The measurement of pain at one point in time may not accurately represent the dynamic nature of pain over a 24-h period. Clinical Implications In current clinical practice. or hypoxia. In a study of patients who suffered hip fracture. are unable to determine the “chicken or the egg” causality dilemma with respect to the relationship between pain and postoperative delirium. In a prospective observational study by Lynch et al. incidents of lateronset delirium may have been missed. opioids are considered the standard of treatment for acute postoperative pain. and it is not clear whether the effects of various precipitating factors are additive or multiplicative. The illustrative model depicted in figure 1 shows the hypothesized association between postoperative opioid use. Complete avoidance of opioids in the postoperative period is generally not feasible because nonopioid analgesics are typically not potent enough to alleviate acute surgical pain. therefore.19 –22 our study was the first to use consecutive daily assessments of resting pain. mental status changes including delirium.18 In contrast to the several prospective studies of hospitalized patients that showed that opioid use was associated with delirium. constipation. Therefore. Future studies investigating the role of these opioid-sparing techniques to decrease postoperative delirium are indicated. Future investigations to evaluate the validity of VAS in patients with postoperative delirium are clearly indicated. delirium. V 111. the use of a subjective instrument in measuring pain such as the VAS may pose substantial limitations in subjects with perceptual disturbance such as postoperative delirium because the validity of the assessment is uncertain. a proactive evidence-based comprehensive geriatric assessment program recognizes that postoperative pain control is an important area to target for intervention for outcomes improvement. In fact.26 Whether this result can be extended to older patients with acute postoperative pain needs to be determined by future studies because the pathophysiology of chronic pain is different from acute pain. one possible clinical implication is that adjuvant techniques that are opioid-sparing may be good candidates to be used in patients at risk of postoperative delirium.25 which showed that both pain and opioids are contributing factors to the occurrence of postoperative delirium. showed that avoiding opioids or using very low doses of opioids increased the risk of in-hospital delirium24 In addition to our previous work. and pain. these patients were using the device just as frequently as their nondelirious counterparts as reflected by the amount of hydromorphone used.28 Potential Limitations We focused on measuring delirium in the early postoperative period. Morrison et al. we need to be mindful that in addition to pain and opioids. such as the management of pain. as shown in patients with neuropathic pain. Our present results. and opioid dose to show that patients who were delirious used either the same amount or more opioids. These techniques may include adjuvant nonopioid analgesics27 or regional techniques such as peripheral nerve blocks or epidural analgesia. One way to determine if pain and/or opioids are causative factors for postoperative delirium is through an interventional trial to reduce acute postoperative pain by either nonnarcotic adjuvant or by regional analgesia.

executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Com- mittee to update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). 348:1223–32 27. Age Ageing 2007. McLaughlin MA. Noveck H. Neuropsychiatry Neuropsychol Behav Neurol 1988. Magaziner J. No 3. Mullen E. 275:852–7 7. J Pharmacol Exp Ther 1999. Strauss E. Zacny JP: Comparing the subjective. These results suggest that additional studies are needed to determine the optimal way to measure and manage pain in patients with postoperative delirium. 94:1052–64 14. Anesth Analg 1995. 152:31–9 15. Poses R. Hill JL. Reisner L. Orosz G. Roy MA. 5:157–66 16. Lind L. 58:76–81 25. Strom B. Vaurio L. 267:827–31 22. Charpentier P: Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. Peterson M.POSTOPERATIVE DELIRIUM AND OPIOIDS USE 631 Summary Postoperative delirium did not appear to limit the patient’s use of on-demand PCA. Brauer C. evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Schor JD. Siu AL: Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Leung J: The role of pain and medications on postoperative delirium. Leung J. Siegal A. Ann Intern Med 1990. Babic-Illman G. Anesth Analg 2002. Inouye S. Mattis S. Sands L. Taylor K. Silberzweig SB. JAMA 1990. Lazor M. Francis J. N Engl J Med 1989. 86:781–5 24. Irving GA: The cognitive effects of opioids. JAMA 1994. Chou D. Tremblay A: Opioid medications and longitudinal risk of delirium in hospitalized cancer patients. Koval KJ. Thompson WK: Comparing the subjective. 320:578–82 3. Berlin J. 102:267–73 11. Williams-Russo P. 80:1223–32 5. Coda B. Anesth Analg 2006. 272:1518–22 21. Orav J. Marcantonio E: The impact of postoperative pain on the development of postoperative delirium. Despite the use of more intravenous opioids. Martin D. Alessi C. JAMA 1995. Ames C. Mullen EA. 67:1–3 28. Inouye S: The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Siu AL: The cause of delirium in patients with hip fracture. 97:278–88 4. Katz N. Szatrowski T. Gaudreau JD. JAMA 1987. Evans DA: Risk factors for delirium in hospitalized elderly. psychomotor and physiological effects of intravenous butorphanol and morphine in healthy volunteers. Salvati E. ANESTHESIOLOGY 2000. Cancer 2007. Walker DJ. Juarez G. Chung C: Postoperative delirium in the elderly. 160:1856–60 6. Psychopharmacology (Berl) 2000. 263:1097–101 20. Liguori G. Hill H. and physiological effects of cumulative doses of opioid mu agonists in healthy volunteers. Sep 2009 . Wang Y. Harari D. N Engl J Med 2003. Balkin S. Morrison RS. Williams-Russo P. Am J Geriatr Psychiatry 2007. J Pharmacol Exp Ther 1994. Arch Intern Med 2000. Mackie A: Concentration-related effects of morphine on cognition and motor control in human subjects. Mattis S. Horwitz R: Clarifying confusion: The confusion assessment method. Rowe JW. Anesth Analg 1998. ACC/AHA guideline update for the perioperative cardiovascular evaluation for noncardiac surgery . ANESTHESIOLOGY 1999. Leung JM: The effects of postoperative pain and its management on postoperative cognitive dysfunction. Lipowski Z: Delirium in the elderly patient. Lichtor JL. J Gerontol A Biol Sci Med Sci 2003. Goldman L. Rowbotham MC. Cleary PD. Wang Y. 274:44–50 10. 36:190–6 Anesthesiology. Mancuso C. Vaurio L. 5:75–93 19. Lee TH: The relationship of postoperative delirium with psychoactive medications. Gilbert M. Sands LP. postoperative VAS scores were significantly higher in patients with postoperative delirium compared to those who were nondelirious. van Dyke C. 91:926–35 9. Parikh S. Chapman CR. Orav EJ. Flemming D. O’Hara D. Zacny JP. Lipowski Z: Delirium (acute confusional states). Levkoff SE. Gellis J. Coalson DW. Twilling L. psychomotor. 258:1789–92 2. Dahl J. Lawrence V. 15:50–9 26. Hollenberg J. and physiological effects of intravenous hydromorphone and morphine in healthy volunteers. Am J Med 1994. 270:579–88 18. Sands L. Mangione CM. References 1. psychomotor. Ersek M. Rico M. Lockwood L. Overman SS. Cook EF. Rowbotham M. Marcantonio ER. 92:947–57 8. Sculco T: Randomized trial of hypotensive epidural anesthesia in older adults. Hunt E. Ludwig LE. Hopper A. Buffington V. Carson J: The effect of anesthetic technique on postoperative outcomes in hip fracture repair. JAMA 1996. Charlson M: Cognitive effects after epidural versus general anesthesia in older adults. Martin F: Proactive care of older people undergoing surgery (’POPS’): Designing. 289:1454–64 17. JAMA 1992. Petersen K. Brandt J. Spencer M. Huber E. Davies PS. 109:2365–73 23. Lynch E. Harel F. Lipsitz LA. Gagnon P. Calogero M. Mohr D: Oral opioid therapy for chronic peripheral and central neuropathic pain. Neurology 2006. Kerr B. Neuropsychopharmacology 1991. Sharrock N. Kapoor WN: A prospective study of delirium in hospitalized elderly. Thapar P. Cherrier MM. Zacny JP: Subjective. Dhesi J. Morrison RS. 113:941–8 13. Reilly CH. Goldman L. Weinstein P: Pilot clinical trial of gabapentin to decrease postoperative delirium in older surgical patients. Duff A. 1:111–7 12. Ranawat C. Inouye S. Sharrock N. Folstein M: The telephone interview for cognitive status. embedding. Pain Manag Nurs 2004. V 111.

Center for Palliative Care and Pain Management. 2008.† Helge Beck. and functional magnetic resonance imaging is necessary to evaluate the exact physiologic basis. Methods: Thermographic imaging was performed in 50 healthy volunteers randomly assigned to four groups: Acupuncture of Hegu (LI 4). needling of a cutaneous and a muscular point where no acupuncture point has been described yet. Fifty healthy volunteers aged 31. Inc. Bad Iburg. P < 0. Support was provided solely from institutional and/or departmental sources. ‡ Professor. In sham acupuncture. ANESTHESIOLOGY’s articles are made freely accessible to all readers.g. as well as psychological effects of the patienttherapist-interaction cannot be ruled out. thus physicians merely depend on patients’ statements. kagarwal@doerenberg-klinik. No 3. to distinguish skin response during true acupuncture from sham acupuncture by contact-free thermographic imaging. such as transcutaneous electrical nervous stimulation or laser treatment. Agarwal-Kozlowski: Center for Palliative Care and Pain Management. Infrared thermograms were gathered at defined points in each group. With the aid of thermometry infrared electromagnetic waves of 0. Submitted for publication December 19. When transferred into Western medicine.de. endogenous opioid release. Contact-free Infrared Thermography for Assessing Effects during Acupuncture: A Randomized. Division of Pain Management. to find an objective method to judge the effect of inserting acupuncture needles in true and sham acupuncture It could be shown that dermal reaction to true needling was different as opposed to sham acupuncture or no manipulation. it has not been possible to discriminate the effects of the venue from specific results of needling itself.0°C and to 31.D. M.anesthesiology.1 ؎ 2. and without manipulation. for personal use only. If its flow is obstructed. Division of Pain Management. Still.Anesthesiology 2009. as well as without manipulation. because of lack of control groups and/or low number of probands. Although the effects of acupuncture have not scientifically been proven yet. Single-blinded. † Resident. University Medical Center Hamburg-Eppendorf. Another possibility is the use of obviously different remedies in control groups.. as minimal acupuncture may not be a physiologically static placebo. Address correspondence to Dr. So far. Information on purchasing reprints may be found at www. M.001). The objective of this investigation was as follows: 1. each proband completed all four arms of the protocol in a random order. usually some form of sham acupuncture or no treatment * Head of the Department. ACUPUNCTURE has been applied at least for the past 2. 632 Anesthesiology. Unfortunately. hormone release. as well as without any manipulation resulted in a decrease of temperature in the monitored area. Still. Stagnation and/or lack of qi may lead to maladies. Department of Anesthesiology. In a crossover protocol. and relieving effects of sham acupuncture are discussed. it may cause swelling and lack of energy in the distal part of the meridian. microneurography). and many questions on efficacy and mode of action of this ancient method are still unanswered yet. acupuncture has long been used in the treatment of multiple maladies. needles are placed just under the skin and/or at locations where no acupuncture point has been described.7°C [SD] to 31. Germany. further investigation such as measurement of sympathetic activity (e. Lippincott Williams & Wilkins. Materials and Methods Probands The study protocol was approved by the ethics review board (Hamburg. M. doubts on effect and mechanism arise as evidence-based medicine is becoming inevitable..org or on the masthead page at the beginning of this issue. V 111. at all serves as a control.000 yr originating in China being a part of traditional Chinese medicine.D.1°C can be pursued and may help track response to acupuncture as opposed to needling of nonacupoints to objectively estimate effects of needling. Hamburg. Placebo-controlled Crossover Clinical Trial Kamayni Agarwal-Kozlowski. record number 2974). Results: A significant increase in surface temperature occurred within 2 min after needling the acupuncture point Hegu (from 30. This procedure was pursued by a few research groups in the past. Germany. In randomized trials on the efficacy of acupuncture. for example. 49186 Bad Iburg. with qi being vital energy that flows along meridians. healthy human bodies emit waves with a length of 3–10 ␮M. Doerenberg Medical Center. Conclusion: Contact-free infrared thermographic imaging is a reliable and easy-to-handle tool to distinguish between needling at Hegu and needling of a nonacupoint (“sham” acupuncture). resulting in pain. The authors investigated the efficacy of infrared thermography in distinguishing response to true acupuncture as compared to nonacupoint cutaneous and muscular needling (sham or minimal acupuncture). Doerenberg Medical Center.5°C after 10 min. its use is widespread.5 Ϯ 10. Findings of clinical investigations are controversial. University Medical Center Hamburg-Eppendorf. Germany. Sep 2009 . Germany.. validity of these investigations may be low when trying to distinguish sham from true acupuncture.9 yr (range.2 ؎ 3. 6 months from the cover date of the issue. the American Society of Anesthesiologists. 2009. Accepted for publication May 5.D. Am Kurgarten 7. Inc.7–1000 ␮M (which the human eye is unable to identify) can be visualized.* Ann-Christin Lange. which is important in studies on acupuncture where sham acupuncture often serves as a control 2. Received from the Department of Anesthesiology. as double-blinding.‡ Background: Although evidence of its effects is tentative. Temperature differences as low as 0. the impact of psychological effects remains unclear. whereas needling of the cutaneous and muscular point. choice of acupuncture and sham points. 21– 66 yr.9 ؎ 2. 111:632–9 Copyright © 2009. It is assumed that needling initiates and eases the flow of qi.

subcutaneous puncture was performed at the metocarpophalangeal joint of the index finger (articulationes metacarpophalangeales II) distant from Hegu. Next. During thermographic imaging without needling. The median of these 20 values was taken and compared intraand interindividually. No 3. one point was chosen at the middle of the nail bed of each finger and another point at the middle of each metacarpal bone. proband information. No adverse events occurred (collapse. To exclude a musculovasal reaction. thermographic imaging without needling. Sep 2009 with true acupuncture at Hegu. Each healthy subject underwent each set of the investigation in a random order. separately for each proband. Changes in skin color as well as occurrence of pain were monitored. Declaration of Helsinki. 3B Scientific. they had never received acupuncture before participating in this study. and touching/manipulation at the area to be monitored was kept to a minimum. and 30 min after needling. Here. No further manipulation was carried out. Assessment of Temperature Specific points on the hands in the thermographic images were analyzed before. and to adhere to the recommendations of the American Academy of Thermology. Germany). i. 1 Cun equals the width of the thumb at the interphalangeal joint) in all three arms with insertion of a needle. Set III. subjects acclimatized for 30 min in a standardized room with laminar air flow at 23..e. excessive pain. On arrival. 10. the second sham point was chosen in the abductor pollicis brevis muscle. hemorrhage. Test persons were excluded if they were on any medication or alterations in any body system were disclosed. International Conference on Harmonization—Good Clinical Practice after the study protocol. 21/29) were included after written informed consent was obtained. or sweating). Sterile single-use disposable needles were used. To rule out cutanovasal reactions to needle insertion. Needles were inserted perpendicular to the skin in true and muscular needling. Set II. They were asked to refrain from eating. Participants were recruited with written announcements on the medical campus.5-0. with a size of 0. the exact course of that day’s treatment was explained again to the volunteer by the thermographist. infection. and thermographic imaging was repeated immediately upon as well as at 1.DISTINGUISHING TRUE FROM SHAM ACUPUNCTURE 633 median 29 yr. 20. Initial thermograms were taken before needling to compare skin temperature before manipulation..1 As volunteers had no experience with or knowledge about acupuncture.5°C and a humidity of 45–50%.e. a needle was inserted according to the protocol that had been put up for each proband. and Set IV. and informed consent approval by the ethics review boards. they were oblivious about the treatment performed. To identify subjects with undiagnosed or subclinical Raynaud’s syndrome where cutaneous perfusion might be impaired.20 ϫ 15 mm (Seirin B-type needle No. during. The therapist was not allowed to converse with the proband. who was unaware of the needling point before the intervention. as superficial manipulation at acupoints may facilitate reactions as in true acupuncture (acupressure). 4. Hamburg. thermographic imaging Anesthesiology. They were insured according to German medical law for testing of innovative procedures (proband cover). and at an angle of approximately 5–10 degrees in subcutaneous needling. Needling Points With Hegu (LI 4) being an essential acupoint in the treatment of various disorders often initiating the “de-qi” phenomenon (emanating sensation of warmth/cold and/or well-being supposed to denote successful needling distinct from the sensation during perforation of the skin with a needle). 3. probands had to be classified as Category I according to the Catalogue of the American Society of Anesthesiologists (no preexisting comorbidities). Meanwhile. Procedure The investigation was realized respecting common guidelines for clinical trials. and smoking 4 h before arriving for the investigation. 5. . probands were told that needling could not be performed since baseline measurements revealed inconstant temperature. both hands were placed in ice water for 3 min. V 111. The needle was removed 10 min after insertion. but did not occur in any proband. 3. men/women. as vasospasms will be induced in patients with primary Raynaud’s syndrome with this procedure.8 Cun (Chinese measure. i. Probands were randomly assigned to the order of the four arms of this investigation: Set I. This was performed in both hands. To ensure blinding. and after needling. cold provocation testing was carried out in each case. this easily accessible site was chosen. The sham acupuncture locations were accordingly selected on the hand where no acupoint has been described in traditional Chinese medicine to compare cutaneous response monitored thermographically. proband cover. A curtain was put up between the face of the volunteer and the therapist to shade the proband from the acupuncture site and to reduce the chance of nonverbal communication. drinking. This depth is recommended for true needling at Hegu in textbooks on acupuncture. thermographic imaging with cutaneous sham acupuncture. since hormonal changes may alter cutaneous response and acupuncture at Hegu may provoke uterine contractions. thermographic imaging with muscular sham acupuncture. As temperature changes are most likely to be observed in the tips of the fingers. The needle was advanced about 0. 2. Preinclusion testing included history taking (interviews and questionnaires) and physical examination including pregnancy testing in fertile women.

9°C could be detected.0 –1.01. and persisted for the remaining duration of the observation (fig. whereas no needling or sham acupuncture produced a steady state or decrease (fig. Opposed to that. As can be seen from the figure. in addition. no significant difference could be detected (P ϭ 0. the expected probability of a change in temperature during true acupuncture. sham acupuncture. again persisting for the rest of the observation. in 12% temperature increased Յ 0.0 –1. Figure 3 depicts the differences in temperature at inserting the needle 2. Surface temperature after needling Hegu increased significantly at every point (P Ͻ 0. the number of probands (n) was calculated with the chisquare test to obtain statistically significant results with a power of 90% and a level of significance of 0.4°C. increase ranging from1. no statistically significant difference could be detected when comparing the different arms of the study (P ϭ 0. increase ranging from 0.001).001). Looking at the group without manipulation. As temperature differences were most prominent at 10 min. Temperature stabilized. a significant difference could be perceived. as two different tests were conducted. Exact temperatures for all sets at all points are given in table 1. the initial condition was comparable in all four arms. but after removing the needle. an insignificant change of temperature was identified after 2 min into the examination (P ϭ 0. 2). whereas no one had an increase of Ն 1. Nevertheless. a significant decline of temperature could already be observed at inserting the needle (P Ͻ 0. this point was chosen to quantify differences between and within the groups.5°C.4°C. Grouping probands without manipulation according to the abovementioned differences.021).4°C could be observed.5°C. a one-time significant difference between temperatures after cutaneous and muscular needling could be identified that persisted at 4 min into the examination. another 20% presented an increase of 1. whereas 46% of the test persons had an increase of Ն 1. Results Differences between median temperatures for different points of assessment between the arms were analyzed with the aid of the Kruskal-Wallis test. and no acupuncture was estimated: The odds of a temperature increase of Ն 0. Quantification of Temperature Differences Temperature differences were observed at all points during the examination. Statistical Analysis Number of Probands. significant differences within the groups were calculated. Depending on the type of needling (true/sham/no acupuncture). In the initial thermogram (after 30 min of acclimatization). This value was chosen to address a potential Type-I error. decrease in temperature could be observed as compared with the preinterventional temperature. It persisted at 3 and 4 min and again insignificantly rose at 5 min. After 3 min. They were divided into five subgroups: Temperature loss or increase Ͻ 0°C. whereas the likelihood of an increase to this extend in the sham acupuncture group as well as no needling was approximated to be Յ 20% of the cases. Germany). Then a slight decrease could be detected for the remaining 20 min.518). in 10% an increase of 1.4°C. hence. Cutaneous needling did not alter mean temperature.5°C. During cutaneous needling. However. To detect differences within each arm of the study. Significance testing was two-tailed: Increase as well as decrease of surface temperature was analyzed. It is eminent that needling of Hegu resulted in an increase of surface temperature. insertion of the needle at Hegu produced a temperature increase. the temperature increase after needling Hegu remained significantly higher at all points. as these were the points when major differences could be detected. temperature never reached as low values as initially measured. in 8% it rose 0. in 8% temperature increased Յ 0. Statistical analysis was performed with the aid of Sigma Stat 3. When inserting the needle. whereas no manipulation and cutaneous as well as muscular needling resulted in a decrease. As results were analyzed after muscular needling. 1). the Friedman test was applied for median temperatures.5– 0. No 3. an increase could be observed when needling Hegu. a slight Anesthesiology. Nevertheless. Intending to reveal. muscular needling resulted in a temperature decrease. Initial temperature rose after inserting the needle and peaked at 10 min as the needle was removed. increase ranging from 0 – 0. even though temperature kept decreasing towards the end of the observation. and 30 min into the examination.4°C.9°C.0 –1.5– 0. A P value of 0. Findings at 1 and 2 min into the examination were similar. and increase Ͼ 1. Erkrath.4°C. After 20 min into the examination a decrease occurred. these differences varied.9°C. As compared with this. Sep 2009 . V 111. Before the investigation. Median scores were analyzed with the Kruskal-Wallis one-way ANOVA by ranks to assess differences on the median in each group at each point. in 70% a decrease in surface temperature was detected.5°C when needling Hegu were reckoned to be 75% of the cases. in 20% a rise of 0. To assess n. an additional decrease was identified for the remaining time of the observation. With the Friedman repeated measures ANOVA by ranks. intraindividual as well as interindividual differences.634 AGARWAL-KOZLOWSKI ET AL. in the acupuncture group only 6% of the probands showed a decrease of surface temperature.1 (Systat Software.864).5– 0.01 was defined to be statistically significant. a total of 50 persons were examined in a crossover design. 10. The null hypothesis was defined as no difference between the groups.

0–34.6 Ϯ 3.a. No proband in the cutaneous needling group and 6% in the muscular needling group presented an increase of 1.4 Ϯ 3.4°C 18.5°C.3 Ϯ 3.0–34.1 Ϯ 2.5 Ϯ 3.5–33. No 3.9°C 29.8 Ϯ 2.7°C 32.4 Ϯ 3.7–34.7°C 30.3°C 20.2°C 19.5 Ϯ 2.6–34.4°C.0°C 30. double-blind placebo-controlled clinical trials have been accepted.3°C 29.8–34.6°C 30.8°C 20.6°C 29.5–34. Twenty eight percent of the probands in the group with cutaneous needling and 6% with muscular needling showed an increase in temperature of 0. When needling the cutaneous point as well as the muscular point.a.a.9–34.4°C 32.6°C 21.7–34.6°C 20.5°C 18.7–34.3–33.5°C 22.7–34. A physiologic and neurobiological basis has been demonstrated in previous investigations that will be discussed in the following.1 Ϯ 2.2°C 21.7 Ϯ 2.6°C 32.4°C 29.2°C 29.5–34.2–35.5°C 29.6°C 22.5 Ϯ 3.3 If needles are used.6–34.4.7–34. some reasonable doubts remain.6°C 18.7°C 31.5– 0.8°C 29. Double-blind designs have not been possible: The acupuncturist has to be aware of the method applied.0 –1.9–34.0°C 32.9°C 30.2°C 30.2 Ϯ 2.0°C 30. Sep 2009 Discussion Evidence of acupuncture effects is indeterminate.4°C 21.3 Ϯ 3.9°C 31. results resembled those observed in the group without any needling: Decrease of surface temperature was observed in 60% of the probands with cutaneous needling and in 84% of the probands receiving sham acupuncture into the muscle.2°C 31.8°C 22. median as well as range).5°C 30. n.9°C 22.0°C 30.8–34.2 The major problem research and evidence based medicine in acupuncture have to face is the concept of blinding and the control group.6–34.4°C Temperature is in degrees Celsius at all points of investigation of all four arms.9 Ϯ 2.3–34.3°C 20.5°C 19.6–34.8°C 30.0–33.9°C 29.0 Ϯ 3.4°C 30.0°C 31.3°C 30.5 Ϯ 3.5°C 18.5 Ϯ 3. 30.0°C 30.5°C 30.9°C 31.1°C 20.0°C 29.7°C 22.7–33.2°C 30.5°C 30.1 Ϯ 2.9°C 31. and no one in the muscular needling group showed an increase of Ն 1.6–34.2 Ϯ 2.9°C 31.4°C or less.6°C 31.0°C 22.8°C 30.7°C 18. only 4% of the test persons in the cutaneous needling group.1 Ϯ 3.6°C 19.8 Ϯ 2.0°C 18.5°C 30.8°C 30.5°C 29.5°C 30.5–34.9 Ϯ 3.0°C 22.6–34.9 Ϯ 2.5–35.3°C 30.5°C 32. patients expect the sensation of a skin prick.5–33.1 Ϯ 3.5°C 18.9 Ϯ 2.4–34.9°C 30.3–34.0 Ϯ 2.6–33.2 Ϯ 2.8 Ϯ 2.5°C 22. Anesthesiology. V 111.8°C 31.1 Ϯ 2. Note that temperature increase in true needling can be depicted on insertion of the needle (Hegu) and remains significantly elevated throughout the investigation.2°C n.5°C 21.5°C 21.2 Ϯ 2.1°C 29.6–34.7°C 29.9°C 22.9°C 29. which is difficult to simulate.3°C 20.1°C 30.5°C 30.6–35.DISTINGUISHING TRUE FROM SHAM ACUPUNCTURE 635 Table 1.6°C 22.6.9°C 20.2–34.0 Ϯ 2.7°C 31.0 Ϯ 2.a.9°C 30. In columns 3–6 the corresponding temperatures of the four arms of the investigation are given (mean Ϯ SD.3–33.7 In study .8 Ϯ 3.5 hence.0°C 31.1°C 19. Temperatures for Each Arm of the Investigation at Each Set Point Time No Manipulation Hegu True Needling Cutaneous Needling Muscular Needling Before Mean Ϯ SD Median Range Needling Mean Ϯ SD Median Range 1 min Mean Ϯ SD Median Range 2 min Mean Ϯ SD Median Range 3 min Mean Ϯ SD Median Range 4 min Mean Ϯ SD Median Range 5 min Mean Ϯ SD Median Range 10 min Mean Ϯ SD Median Range 20 min Mean Ϯ SD Median Range 30 min Mean Ϯ SD Median Range 30. a special needle was introduced for placebo needling.5 Ϯ 3.0°C 30. time at each point is given.2°C 31.0–35.5–34.9°C 22.3°C 31.0°C 31.8°C 30.1°C 29.8°C 29. In the first column.9°C 31.0°C 30.0°C 30. whereas a rise of 0.2 Ϯ 3.9°C 22.4°C 30.7°C 30.6–34.5°C 20.7–34.7°C 20.9°C 30.9°C 32. ϭ not applicable.7 Ϯ 2.4°C 30. As the gold standard for demonstrating a specific effect over placebo.5°C 30.1 Ϯ 2. n.2°C 30.5–34.1°C 22.0°C 30.9°C could be found in 8% of the probands receiving cutaneous stimulation as opposed to 6% in the group with muscular needling.4°C 30.7°C 29. Still.0°C 30.3 Ϯ 3.8°C 22.9°C 30. n.1°C 21.

thermograms on needling Hegu. thermograms at 30 min into investigation. heat. whereas a decrease in temperature can be found in columns 1. thermograms at inserting the needle (1 min into investigation).e. column 4. a reference bar for color-coding of different temperatures is given.8 Randomized trials in acupuncture involve sham acupuncture as a control that engages needles placed subcutaneously remote from acupoints. thermograms at 5 min into investigation. vibration) as diffuse as noxious inhibitory controls15 and the release Anesthesiology. . No 3.22 This is of major importance. and superior sensitivity. realtime visualization.10 As neither acupuncture nor sham acupuncture can easily be explained biologically.19. Row a. it is inevitable to implement an instrument to objectively determine results.20 they are efficient in adapting the temperature of the whole organism by varying emission of heat. thermograms without manipulation. because in previous acupuncture trials the success of the sham acupuncture over notreatment controls caused uneasiness about blinding and general credibility.g. designs involving laser treatment.13 The impact of psychological factors cannot be ruled out completely. Thermograms of one proband throughout the investigation on 4 different days after acclimatization for 30 min: Column 1. Sep 2009 of endogenous opioids. surface temperature is least stable at the tips of the fingers. At the very right. Physical functioning may measure some difference.. the effects are difficult to discuss. thermograms after cutaneous needling. thermograms after muscular needling. row e.11–13 Because of the lack of a satisfactory placebo treatment to acupuncture.6 Looking at these obstacles and therapists depending on patients’ statements. Note that after needling Hegu (column 2) an increase in temperature can be detected (acra light up in red). thermograms before intervention. as minor manipulation (e. row f. easy to handle. the patient may be blinded by switching the laser off. row c.636 AGARWAL-KOZLOWSKI ET AL. Patients’ symptoms can be relieved by a pain-suppressing system in the spinal cord activated by stimuli (ice massage. with minor or no disparity bilaterally reproducible in measurements over years.18 comprising many advantages (i. 1. it is inevitable to state the difference objectively. Usually temperature is stable for each region of the body. thermograms at 20 min into investigation.14 it has not been possible to differentiate effects of the therapeutic setting from specific effects. and resolution). V 111. 3 and 4 (acra turn from a reddish color to green/blue).16.. column 3. row b.9 presupposing that needling is the characteristic treatment element but physiologic effects could still be involved. thermograms at 10 min into investigation (just before removing the needle). 21 Thermography has been applied in negotiation acupuncture effects: No specific effects of needling could be evaluated in a study without a control group.19 Under physiologic conditions. column 2. Fig.8.17 Changes in surface temperature can be detected with infrared thermography. row d. Thermoregulation is sustained sympathetically. contrast. Therefore.

tumor. 2.DISTINGUISHING TRUE FROM SHAM ACUPUNCTURE 637 Fig. This decreases the validity of the acquired data. an increase in surface temperature is expected. Mean temperature differences of all four groups before. 3. A cutanovasal or musculovasal reaction could be ruled out. as dots above and below the boxes illustrate highest and lowest temperature observed. penetrating the skin at Hegu clearly led to an increase of surface temperature. functio laesa). Here. cutaneous. The bar in the middle depicts median temperature. The second major problem in the abovementioned study22 was that less than 10 probands were examined. calor. Sep 2009 . V 111. The line with square dots depicts the temperature on needling Hegu. The lines attached to the boxes represent the 90% interval. The drop of temperature at the end of the investigation after 30 min is insignificant. With calor (warming). Graphic portrayal of temperature over time. as can be seen from the negotiation of statistical Fig. a significant increase in surface temperature can be depicted. and 30 min after insertion of the acupuncture needle at different locations. 2 min after insertion. scratches. at insertion. cutaneous (triangles. The upper end of the box is the value of the higher quartile (75%). dolor. or no needling from insertion of the needle. Note that mean temperature is significantly elevated when needling Hegu as compared to no. 10 min after insertion. In the present study. cuts) cause typical cardinal symptoms of infection (rubor. whereas no (diamonds with interrupted line). respectively. Anesthesiology. line with dots and strokes) as well as muscular (crucifix with strokes) needling results in significantly lower surface temperature. No 3. the lower end shows the lower quartile (25%) of temperatures measured.

Streitberger K. 106:401–9 8. Lewith G: Placebo controls for acupuncture studies. In the present investigation. Regulation of peripheral blood flow and vessel diameter is mediated sympathetically.25. Lewith G.24 As probes had to be inserted into the muscle for evaluating modified blood flow. it is unclear if increased flow may be attributed to the insertion of the acupuncture needle only.g. Lancet 1998. especially in studies with placebo needling as a control. since two points close to the median nerve were chosen. 70:767–74 3. Germany) for his valuable aid on setting up pictures as well as digital art work.28 If increase of surface temperature after needling is mediated by the sympathetic nervous system. Baltimore. still. [In German] Schweiz Med Wochenschr 1981. it could be expected that this would be a good choice in sympathetically mediated pain. 352:364–5 7. No 3. a change in surface temperature as a result of manipulation of the muscle that might induce an increase of blood flow or metabolic changes) on needling Hegu can be excluded. J R Soc Med 1995. microneurography). Melsen B. References 1. resulting in a contraction of smooth muscles in the vessel wall. Reflec- . an insignificant decrease was detected. A decrease in sympathetic activity produces relaxation of the wall with swelling of the vessel caused by hydrostatic pressure. Still. herbal medicine. a statistically significant decrease in surface temperature was detected in cutaneous stimulation. After cutaneous penetration. Leroy PL. which is eminent in patients with cognitive deficits.23 In the present study. Training of young acupuncturists can be improved. Further investigation is crucial to correlate surface temperature and muscular blood flow. Jensen LB.. a significant decrease in surface temperature after muscular needling was observed that might be explained by activation of the sympathetic nervous system with consecutive vasoconstriction caused by local pain. Increased skin temperature after sham acupuncture and after needling Neiguan (PE 6) has been described. bilateral increase in temperature may rather be initiated by a central spinal or supraspinal sympathetic rather than a local effect. Objectively measuring the effects eases the interpretation of acquired results. pp 202–12 2.638 AGARWAL-KOZLOWSKI ET AL. 1992.. smooth muscles are innervated by postganglionic neurons. acupuncture is combined with tuina.27 Thus. Vincent C. Evaluation and treatment of chronic pain. a specific response could be observed in this investigation. this needs to be verified for other acupoints. As Hegu is a major acupoint manipulated in virtually every treatment. The authors would like to thank the reviewers for their expert guidance and Frank Kozlowski (digital artist and freelancer. presented findings may facilitate further research and efficacy of complementary treatments can be reconsidered. 87:373–80 5. It is crucial to test other acupoints. sham and true acupuncture may be discriminated more easily by a nonnoxious pain– free method. which may be attributed to the fact that sites for the insertion of needles was chosen far from major nerves supplying the hand. Circulation 1984. Edited by Aronoff GM. For needling Hegu. A significant increase in surface temperature occurred as soon as the needle was inserted at the acupuncture point and persisted for 30 min. A nervocutaneous reaction may be expected here. 88:199–202 4.29 claimed that vasodilatation is initiated by increase of Anesthesiology. Pain 2003. investigations on the measurement of sympathetic activity (e. analysis on the number of probands mentioned in the Methods section. On the other hand.26 If stimulated. Williams and Wilkins. closely looking at other anatomical structures that might mediate the effect described above and to correlate findings with hormone and/or endorphin levels and functional magnetic resonance imaging. Gallacchi G: Acupuncture and laser treatment for cervical and lumbar syndrome. Jensen SB: Effect of acupuncture on headache measured by reduction in number of attacks and use of drugs. Here. Sep 2009 nitrous oxide. The major problem of relying solely on patients’ statements can be eliminated. infrared thermography is a valuable tool to distinguish the effects. Feinstein AR: Current problems and future challenges in randomized trials. hormone release. therapists are often unsure whether the desired effect does not emerge because of incorrect needling or if the patient is not able to sense and respond adequately..e. a musculocutaneous reaction (i. cross-over pilot trial. in future research on acupuncture. V 111. Kubiena G: Considerations of the placebo problem in acupuncture. White P. An intensified blood flow in the tibialis anterior muscle after penetration with a needle was detected that might not necessarily result in an augmented cutaneous blood flow. resulted in a decrease. Norderstedt. although the enzyme nitric oxide– synthetase is modulated by the sympathetic nervous system as well. The fact that both hands reacted the same way is captivating and might hint towards more centrally controlled processes such as sympathetic response. Nevertheless. treatment in Chinese medicine focuses on syndromes rather than symptoms and is multimodal (i. thus further investigation on this subject is inevitable. Prescott P: The placebo needle. 111:1360–6 6. Loaiza et al. Kleinhenz J: Introducing a placebo needle into acupuncture research. Hopwood V. single-blind. as well as no manipulation. dietetics. Scand J Dent Res 1979. 2nd edition. and qi gong).22 This finding correlates with patients’ statements of a feeling of warmth and relaxation during acupuncture. norepinephrine is released and ␣1 receptors are activated. probably resulting from a minor sympathetic response as a result of a less painful stimulus. According to the findings in the present study. endogenous opioid release and functional magnetic resonance imaging are necessary to evaluate the exact physiologic basis. whereas needling of the cutaneous and muscular point. Filasky R: Thermography as a diagnostic aid in the management of chronic pain: An update. is it a valid and convincing placebo for use in acupuncture trials? A randomised.e. Even if it is not yet apparent precisely what the pathophysiological basis is. since they would be able to trace and visualize acupuncture effects in real time.

Lindberg LG. Long D. Wakayama I: Changes in skin blood flow and skin sympathetic nerve activity in response to manual acupuncture stimulation in humans. Van Someren EJ. J R Soc Med 1995. Electromyogr Clin Neurophysiol 1981. Habighorst LV. Auton Neurosci 2002. Edited by Stux G. V 111. 21:25–33 23. Masuda K. Wallin BG.DISTINGUISHING TRUE FROM SHAM ACUPUNCTURE 639 tions on usefulness. Walther HU. Pain 1999. 13:329–34 21. Brinkhaus B. J Neurosurg 1988. 88:199–202 15. pp 192– 6 28. Willich SN: Acupuncture in patients with osteoarthritis of the knee: A randomised trial. Jena S. Hungerford D. 34:189–96 27. Chaput de Saintonge DM. Ernst M. Kozikowski J. Long DM: Quantification of thermal asymmetry. Seller H: Neurovegetative Regulation. 101:362–7 9. Scherder EJ. Sandberg M. 1:721–78 19. Exp Neurol 1986. 69:556–61 18. ethical justification. Gaw AC. BMJ 2005. Part 2: Application in low-back pain and sciatica. Nilsson G: Changed skin blood perfusion in the fingertip following acupuncture needle introduction as evaluated by laser Doppler perfusion imaging. 20:291–4 22. [In German] Radiologe 1973. 97: 103–9 Anesthesiology. 1989. Uematsu S. 366:136–43 12. Hummelsberger J. Wang L. De Broucker T. Shaw L–C: Efficacy of acupuncture on osteoarthritic pain: A controlled. 330:1202–5 11. N Engl J Med 1975. Eur J Appl Physiol 2003. Am J Chin Med 2006. Wallin BG: Sympathetic nerve activity after acupuncture in humans. Hendler N. Le Bars D. Lundeberg T. Dieppe P: Characteristic and incidental (placebo) effects in complex interventions such as acupuncture. Streng A. Kirsch I. Nicholls SS: An analysis of factors that contribute to the magnitude of placebo analgesia in an experimental paradigm. Swaab DF: Circadian and age-related modulation of thermoreception and temperature regulation: Mechanisms and functional implications. Edited by Silbernagel R. Lancet 2005. Kim W. Elam M. Ernst M. Berlin: Springer Verlag. Pain 1998. Price DD. Heidelberg. standardization and differentiated use of placebos in acupuncture. 94:1–10 29. Vincent C. Lewith G: Placebo controls for acupuncture studies. Herxheimer A: Harnessing placebo effects in health care. Witt C. Knardahl S. 21:165–82 17. Lasers Med Sci 2002. Yamaguchi S. Montgomery GH. Pommeranz B. 293:375–8 10. Ohshima N: Electro-acupuncture stimulation to muscle afferents in anesthetized rats modulates the blood flow to the knee joint through autonomic reflexes and nitric oxide. Gerdle B: Effects of acupuncture on skin and muscle blood flow in healthy subjects. Linde K. Lee MH: Sympathetic effects of manual and electrical acupuncture of the Tsusanli knee point: Comparison with the Hoku hand point sympathetic effects. pp 79–112 16. Kimura K. double-blind study. Lehrbuch der Physiologie. Ito M. Paterson C. Edwin DH. Jankel WR. Willer JC. Wien Klin Wochenschr 1989. Klinke S. Duff A. 90:114–9 25. Muscle Nerve 2007. 75:19–25 26. Georg Thieme Verlag 1996. Uematsu S. Clement DL: Sympathetic nervous control of muscle and skin circulation. Pain 1985. Melchart D. Wagenpfeil S. Milling LS. Huber E. Scientific bases of acupuncture. Sep 2009 . 36:595–614 20. Lee MH: Sympathetic vasomotor changes induced by manual and electrical acupuncture of the Hoku point visualized by thermography. 43:147–56 14. No 3. Charkoudian N: Sympathetic neural control of integrated cardiovascular function: Insights from measurement of human sympathetic nerve activity. Chang LW. Stuttgart. J Cardiovasc Surg 1979. Ageing Res Rev 2002. 344:995–8 13. 17:19–25 24. Rosenbaum A. Ono N: Thermography and electromyography in the differential diagnosis of chronic pain syndromes and reflex sympathetic dystrophy. Lancet 1994. Loaiza LA. Raymann RJ. Olausson B. Litscher G. Buchwald W. Villanueva L: Neurophysiological mechanisms involved in the pain-relieving effects of conter-irritation and related techniques including acupuncture. Daanen HA. Hu ¨ lse R: Thermography in blood circulation disorders of the extremities.

Science.5 spinal nerve transection. Methods: Male Sprague-Dawley rats underwent either unilateral plantar hind paw incision (postoperative pain model) or L5 spinal nerve transection (neuropathic pain model). Japan.ac.gunma-u. ANESTHESIOLOGY’s articles are made freely accessible to all readers.. including sciatic inflammatory neuropathy. Maebashi. Ph.org or on the masthead page at the beginning of this issue. however.11–14 Although markers for both microglia and astrocytes are upregulated in the spinal cord in a rat model of postoperative pain. hobata@showa. were used in the study. MICROGLIA are immune cells in the central nervous system.3 partial sciatic nerve ligation. Spinal microglial activation was evaluated by OX42 immunohistochemistry. In contrast. Pain hypersensitivity after nerve injury and paw incision depends on activation of the p38 MAPK signaling pathway in the dorsal horn of the spinal cord.6 We hypothesized that microglial p38 MAPK activation is equally important for postoperative mechanical hypersensitivity. Submitted for publication October 24.10 a 1-cm–long incision was made in the left hind paw. The behavioral characteristics of a postoperative pain model in rats produced by hind paw incision resemble postoperative hypersensitivity in humans.. and if so.20 and p38 MAPK is exclusively activated in microglia. Activation of spinal cord microglia after peripheral nerve injury contributes to mechanical hypersensitivity. the American Society of Anesthesiologists.D. minocycline did not suppress mechanical hypersensitivity. Information on purchasing reprints may be found at www. Address correspondence to Dr. Supported by Grantsin-Aid for Scientific Research from the Ministry of Education. of evidence suggest that the nature of hypersensitivity in this pain model is different from that of other sustained pain models. M.17 spinal cord contusion injury.16 the role of spinal cord microglia in postoperative hypersensitivity is not well understood.D. They are active and versatile cells. Conclusions: The results of the present study suggest that spinal OX42 expression has a more important role in the development of neuropathic pain than in postoperative pain.Anesthesiology 2009. and not in the neurons or astrocytes in the dorsal horn after nerve injury. Sports.† Shigeru Saito. Lippincott Williams & Wilkins.6. Thus. in the present study. housed under a 12-h light-dark cycle with free access to food and water. Number 12671451. Here. The study protocols and procedures were approved by the Animal Care and Experimentation Committee (Gunma University Graduate School of Medicine. is not well understood. Inc. for personal use only.anesthesiology.jp. Spinal Microglial Expression and Mechanical Hypersensitivity in a Postoperative Pain Model: Comparison with a Neuropathic Pain Model Naomi Ito. and Technology of Japan (Tokyo. following the protocol outlined by Brennan et al.9 Postoperative pain represents an unmet medical need.* Hideaki Obata. Japan). Sep 2009 . the purpose of the present study was to determine whether microglia are important for the development and maintenance of postoperative hypersensitivity. Gunma 371-8511. as compared with neuropathic pain models. Surgical Preparations For hind paw incision (postoperative pain model). the role of microglia and p38 MAPK in the spinal dorsal horn in hypersensitivity after paw incision was compared with that after peripheral nerve injury. The contribution of spinal cord microglia to hypersensitivity after surgery.‡ Background: Postoperative pain control contributes to quality of life. M. but did inhibit an increase in spinal OX42 expression. Culture. Showa. Japan). in the neuropathic pain model.7 and peripheral inflammation. 3-39-22.. but not in the postoperative pain model. Results: In the postoperative pain model. Gunma.. 6 months from the cover date of the issue.2 chronic constriction nerve injury.18 and spinal nerve ligation.5. No 3. start640 Anesthesiology.D. Gunma University Graduate School of Medicine. Japan. Minocycline inhibits microglial activation and also reduces nociception.1 Spinal microglia contribute to the development and maintenance of mechanical hypersensitivity after a variety of peripheral nerve injuries. similar to neuropathic hypersensitivity. including that resulting from tissue injury and inflammation-evoked pain.D.5. Inc. Maebashi. Maebashi. Ph. Department of Anesthesiology. Accepted for publication May 26. minocycline reduced mechanical hypersensitivity in a dose-related manner and inhibited spinal OX42 expression. SB203580.8. We also tested the effect of intrathecal administration of a p38 mitogen-activated protein kinase inhibitor.D. and that an increase in spinal OX42 expression does not contribute to postoperative mechanical hypersensitivity.4 spinal nerve ligation. whether the effect differed from that in a rat neuropathic pain model. Showa. ‡ Professor and Chair.10 Several lines * Graduate Student. The role of p38 mitogen-activated protein kinase (p38 MAPK) was also evaluated in the postoperative pain model. such as the neuropathic pain model. 2008. Materials and Methods Animals Male Sprague-Dawley rats (200 –270 g). Gunma University Graduate School of Medicine. and adapt to different stimuli through a sequence of reactive profiles. V 111. Obata: Department of Anesthesiology. the authors evaluated whether inhibition of spinal microglia reduced postoperative mechanical hypersensitivity. Therefore. Gunma University Graduate School of Medicine. and the development of mechanical hypersensitivity was assessed using von Frey filaments. Our findings suggest that spinal microglia have only a minor role in the postoperative pain model. 2009. 111:640 – 8 Copyright © 2009.19 In the present study. † Associate Professor.. the role of spinal microglia in the rat model of postoperative pain induced by paw incision was evaluated using minocycline. The microglial inhibitor minocycline was intraperitoneally administered daily for either 3 or 7 days.6. M. SB203580 attenuated hypersensitivity in the neuropathic pain model. Received from the Department of Anesthesiology.15.

The animals were housed individually after surgery and allowed to recover for 4 to 5 days before being used in the experiments. rats (200 –220 g) were randomly assigned to receive either intraperitoneal injections of minocycline or water for 3 days. 5. In the SNT model. intrathecally 24 h and 72 h after surgery. the L5 spinal nerve of rats was tightly ligated with 6-0 silk sutures distal to the dorsal root ganglion. complement receptor type 3/CD11b (mouse monoclonal. Sep 2009 . Withdrawal thresholds were determined before paw incision. and on Days 1. 3. and after completion of testing. For peripheral nerve injury (neuropathic pain model).5 cm from the heel under isoflurane anesthesia (2–3% in 100% oxygen).01 mm inner diameter.23 Changes in general behavior.1 M phosphate-buffered saline (pH 7.5% normal goat serum (Vector Laboratories. minocycline was injected twice a day (at 9:00 and 17:00) for either 2 or 6 days (50 mg · kgϪ1 · dayϪ1 or 100 mg · kgϪ1 · dayϪ1). First. Sections were incubated with an antibody for a microglial marker. Spinal cord sections (L4-L5) of 40 ␮m thickness were cut using a cryostat. Paris. Briefly. Experimental Procedures Minocycline was used to examine the role of microglial activation after paw incision and SNT. In the postoperative pain model. SaintGobain Performance Plastics. To evaluate the role of p38 MAPK in the postoperative pain and neuropathic pain models. On the left side. and again 7 h after surgery. From Day 1. Withdrawal thresholds were determined before (preoperation) and 24 or 72 h after incision (0 min). blinded manner. The filaments were applied vertically to an area adjacent to the wound for 5 to 6 s with gentle bending of the filament. and any animals exhibiting such deficits were immediately killed. rats (260 –270 g) were randomly assigned to receive intraperitoneal injections of either minocycline or water. The plantaris muscles were lifted and incised longitudinally. Endogenous peroxidase activity was quenched with 15-min incubation in 0. minocycline. a single intraperitoneal administration of minocycline was performed 1 or 3 days after paw incision to determine the appropriate dose of Anesthesiology. and then every 60 min up to 240 min after drug administration. After being deeply anesthetized with sodium pentobarbital (100 mg/kg). IL). PA) was inserted through a puncture hole in the atlanto-occipital membrane and advanced caudally 7.02 mm inner diameter). as previously described. Burlingame. MO). and allowed to acclimate to the environment for 30 min.01 M phosphate buffered saline ϩ 0. followed by 4% paraformaldehyde in 0. were noted throughout the testing period. Rats that underwent p38 MAPK studies were implanted with an intrathecal catheter as described previously. mounted on glass slides. The wound was closed with two 5. The animals were examined for neurologic deficits after surgery. Upon completion of testing. the rats were perfused for immunohistochemical analysis. The mechanical withdrawal threshold was determined using calibrated von Frey filaments (Stoelting. Behavioral Testing The rats were placed in individual plastic chambers with a plastic mesh floor. the 32-G polyurethane catheter containing a guide wire (ReCath Co. then again 30.4). Withdrawal thresholds were determined before surgery (preoperation) and before drug administration (0 min). and cut just distal to the ligature under isoflurane anesthesia (2% in 100% oxygen). Nonspecific binding was blocked with 1. OX42. repetitive movements.21 with some modifications. we injected a selective p38 MAPK inhibitor.5% normal goat serum. No 3. 60. We also examined the effect of daily intraperitoneal injections of minocycline for 3 or 7 days in other groups of rats.3% hydrogen peroxide followed by 4 washes with PBST. including vocalization.22 with slight modifications. France) via a Tygon tubing cuff (0. LLC. Indwelling catheters were constructed with 32-G polyurethane tubing connected to Tygon tubing (0.5 cm so that the tip of the catheter was at the level of the lumbar enlargement. and 3 or Days 1. the rats were perfused for immunohistochemical analysis as described below. Sections of the lower lumbar spinal cord were removed and postfixed in 4% paraformaldehyde for 2 to 3 h. and 90 min after the administration of minocycline (25 mg/kg or 50 mg/kg) or water. 1:200 in 1. Tissue Preparation Spinal cord tissue was obtained from rats at the indicated times after surgery. St. every 30 min between 30 and 120 min. Allison Park. and activity level. The sections were washed 4 times in 0. Louis. as described below.3% Triton-ϫ100 (PBST). CA) for 1 h at room temperature. under isoflurane anesthesia. and 7 before the first minocycline injection. the animals were perfused transcardially with 0. Immunohistochemistry Immunohistochemistry was performed on free-floating spinal cord sections.SPINAL MICROGLIAL ACTIVATION AND POSTOPERATIVE PAIN 641 ing 0. Wood Dale. we used the L5 spinal nerve transection (SNT) model under isoflurane anesthesia as previously described. Minocycline (25 mg/kg or 50 mg/kg) was injected 1 h before paw incision.0 silk mattress sutures. V 111. Tissue was then cryoprotected for 72 h at 4°C in 30% sucrose.. All studies were performed in a randomized. The tactile stimulus producing a 50% likelihood of withdrawal threshold was determined using the up-down method. SB203580 (10 ␮g).01 M phosphate-buffered saline containing 1% sodium nitrite. All catheter joints were fused using cyclohexanone (Sigma Chemical Co. 2. and stored at Ϫ80°C.

Dimethyl sulfoxide (2%) diluted in distilled water was used as the vehicle. The person performing the data quantification was blinded to drug and dose. NY). Vector Laboratories) for 1 h at room temperature. The spinal cord sections were visualized using confocal laser scanning microscopy (LSM 510 META. microglia assessed by OX42 immunostaining were more hypertrophic on the side of the paw incision than on the contralateral side. 1A). Sections were washed in PBST. Sep 2009 Results Effect of Minocycline on Mechanical Hypersensitivity after Paw Incision and SNT Animals demonstrated robust mechanical hypersensitivity at 24 h after paw incision. a microglial surface antigen antibody. fig.001 by two-way ANOVA. P Ͻ 0.05 was considered statistically significant. For OX42 immunostaining. Drugs and Administration Minocycline and SB203580 were purchased from Sigma Chemical Co.0 (Jandel Scientific. intraperitoneal injection of minocycline twice daily for 3 days reduced mechanical hypersensitivity in rats with SNT in a doserelated manner (n ϭ 8. overnight at 4°C.0 ml) and injected intraperitoneally (25 mg/kg or 50 mg/kg). Time courses of the effects of minocycline and SB203580 were analyzed using two-way ANOVA.01 M PBST and placed in biotinylated secondary antibodies (goat antimouse. CA). fig. the number of p-p38 MAPK immunopositive cells in the whole dorsal horn of L4-L5 spinal cord slices was counted using SigmaScan Pro 5. antiphospho-p38 MAPK (1:200.. 1:200. In contrast. New York. All drug injections were randomized.. Vector Laboratories) for 1 h. A P value of less than 0. the results are presented as the mean Ϯ SEM of the withdrawal thresholds. V 111.0. with four slices quantified per animal. Carl Zeiss. Japan) using a QIMAGING MicroPublisher camera and QCapture software (VayTek. Quantification of OX42 immunostaining was performed by calculating the percentages of immunostaining ([number of pixels of positively labeled objects within the fixed area]/[number of pixels within the same fixed area] ϫ 100). Statistical Analysis We chose a sample size of at least 4 for behavioral studies and immunostaining based on a previous study. Molecular Probes. Immunohistochemical data are presented as the mean percentages of the areas of immunostaining Ϯ SEM and were analyzed using one-way ANOVA with Student-Newman-Keuls post hoc test. Japan) software. and washed twice in PBST.15 This treatment. Sections were mounted on glass slides. and coverslipped. OR). After incubation. Antibodies were visualized using the enhanced glucosenickel-diaminobenzidine method. Vectastain ABC-Elite kit.14 Statistical analysis was conducted using Sigmastat (Version 3. Immunofluorescence Sections were washed in PBST and incubated in 1. coverslipped with ProlongGold. Intraperitoneal injection of minocycline twice daily for either 3 or 7 days also did not affect the withdrawal thresholds (n ϭ 8. CA) or StatView (Version 5. tissue sections were washed in PBST and incubated for 2 h at room temperature in the secondary antibody solution (antirabbit immunoglobulin G-conjugated Alexa Fluor 488 or antimouse immunoglobulin G-conjugated Alexa Fluor546. For quantification of phosphorylated (p-p38) MAPK immunostaining. Minocycline was dissolved in sterilized distilled water (2. Eugene. then incubated overnight at 4°C in the primary antibody. IA). Novato. Effect of Minocycline on OX42 Immunoreactivity after Paw Incision To examine whether microglia were activated in the dorsal horn of the spinal cord in rats that underwent paw incision. Systat software Inc. Labeling was quantified in the whole dorsal horn of L4-L5 spinal cord slices stained with diaminobenzidine. because a pilot study demonstrated that OX42 immunoreactivity increased 3 days after paw incision.1. 3). cleared with xylene. fig. Temecula. and sealed with fingernail polish. dehydrated through an ascending series of alcohols.001 by two-way ANOVA. In the vehicle-treated group. For the behavioral studies. We also injected minocycline (50 mg/kg) 72 h after paw incision. fig. Hulinks Co. Beverly. MA) and OX42 (1:200). Sections were washed twice in 0. positively labeled areas in the whole dorsal horn of the spinal cord were identified for automated counting using SigmaScan Pro 5. Cell Signaling. 2%). Anesthesiology. Images were captured on an Olympus BX41 microscope (Olympus Co. Sections were washed twice in PBST. 1B). Tokyo. mounted on slides. Withdrawal thresholds increased after intraperitoneal administration of minocycline when injected 24 h after paw incision (n ϭ 8. did not increase withdrawal thresholds (n ϭ 6. especially in the medial parts of the dorsal . placed in ABC complex (1:100. we performed immunohistochemical analysis with an antibody targeting OX42. 2). One-way ANOVA with Student-Newman-Keuls post hoc test was used for comparisons at each time point when significant differences were detected by two-way ANOVA. Fairfield. however. Chemicon International. 1:200. CA) at a preset intensity threshold. P ϭ 0.642 ITO ET AL. SB203580 was dissolved in 100% dimethyl sulfoxide and diluted with sterile distilled water (final concentration of dimethyl sulfoxide. San Jose. Tokyo. Inc.0. and injected intrathecally in a volume of 5 ␮l. No 3.5% normal goat serum for 1 h at room temperature.

05 as compared with vehicle-treated group by one-way ANOVA. No 3. Minocycline administration reduced the upregulation of OX42 immunoreactivity after paw incision.001 by one-way ANOVA. H. 4). 2. V 111. and C). B. The highest dose of minocycline. (A).05 as compared with vehicle-treated group by one-way ANOVA. Effect of a single intraperitoneal injection of vehicle. Effect of Minocycline on OX42 Immunoreactivity after SNT In the vehicle-treated group. . Effect of twice-daily intraperitoneal injection of vehicle. The administration of minocycline twice daily for 3 days reduced OX42 immunostaining in a dose-related manner (n ϭ 4. did not increase the withdrawal threshold when injected 72 h after paw incision (B). Fig. on postoperative mechanical hypersensitivity. and I) minocycline for 3 days. fig. Representative images of microglia in the ipsilateral (ipsi) and contralateral (contra) spinal cord after paw incision. 25 mg/kg or 50 mg/kg minocycline. Anesthesiology. and F) and 100 mg · kg؊1 · day؊1 (G.SPINAL MICROGLIAL ACTIVATION AND POSTOPERATIVE PAIN 643 Fig. 1. 4. Sep 2009 Fig. Minocycline reduced mechanical hypersensitivity after twice-daily intraperitoneal injection of vehicle.001 by two-way ANOVA). respectively. Withdrawal thresholds were not altered after treatment. P Ͻ 0. respectively. Increased OX42 expression was observed in the medial parts of the ipsilateral dorsal horn of the spinal cord after injection of vehicle. * P < 0.001 by one-way ANOVA.001 by two-way ANOVA). OX42 immunoreactive cells in the whole dorsal horn of the spinal cord is shown in figure 6. 3. Similarly. * P < 0. (C). E. fig. 50 mg · kg؊1 · day؊1 (D. (E) and (H). Figure 5 shows representative images of OX42 immunoreactivity in the ipsilateral spinal dorsal horn after paw incision and L5 spinal nerve transection. however. 50 mg · kg؊1 · day؊1 or 100 mg · kg؊1 · day؊1 minocycline for 3 days in a dose-related manner (P < 0. (D) and (G) are high-magnification images of the squares in the ipsilateral spinal cord shown in (B). OX42 immunoreactivity increased in the whole dorsal horn of the spinal cord on the side of SNT. 50 mg · kg؊1 · day؊1 or 100 mg · kg؊1 · day؊1 minocycline for 3 days (A) and 7 days (B) in the postoperative pain model. whereas this increase was suppressed by horn. (F). P Ͻ 0. (E) and (H). The hind paw withdrawal thresholds (g) are shown as mean ؎ SEM (n ‫؍‬ 8 for each group). The percentage of Fig. Withdrawal threshold increased after the administration of minocycline when injected 24 h after paw incision (A) (P ‫ ؍‬0. Scale bar ‫ ؍‬400 ␮m. Microglia are represented by OX42 immunoreactivity after twice-daily intraperitoneal injection of vehicle (A. The hind paw withdrawal thresholds (g) are shown as mean ؎ SEM (n ‫ ؍‬8 for each group). 6C). Minocycline inhibited this increase in OX42 (fig. and (I) are high-magnification images of the squares in the contralateral spinal cord shown in (B). The maximum dose of minocycline for 7 days also inhibited OX42 upregulation (n ϭ 4. 6A). The hind paw withdrawal thresholds (g) are shown as mean ؎ SEM (n ‫ ؍‬6 – 8 for each group). Effect of minocycline on L5 spinal nerve transection model.

925.05 as compared with the normal group by one-way ANOVA. paw incision. 7B). 8B) and SNT (fig. p-p38 MAPK expression (green) was increased in the ipsilateral dorsal horn of the spinal cord 3 days after paw incision (fig. or 100 mg · kg؊1 · day؊1 (C) minocycline for 3 days. In rats with SNT.001 by one-way ANOVA. Representative images of microglia in the ipsilateral spinal dorsal horn after paw incision and L5 spinal nerve transection. microglia are represented by OX42 immunoreactivity after twice-daily intraperitoneal injection of vehicle (G).05 as compared with the vehicle-treated group by one-way ANOVA. In contrast. the stained structures therefore likely represent the nuclei and cytosol/cell surface. 8C). respectively. microglia are represented by OX42 immunoreactivity after twice-daily intraperitoneal injection of vehicle (A). (I) Images of microglia in the spinal dorsal horn of a normal rat. Effect of p38 MAPK Inhibition in the Postoperative Pain and Neuropathic Pain Models Figure 7 shows the effect of p38 MAPK inhibition on hypersensitivity in the spinal cord. a single injection of minocycline 1 day after paw incision suppressed postoperative hypersensitivity. Anesthesiology. Percentages of immunostaining are expressed as mean ؎ SEM (n ‫ ؍‬4 for each group). and the effect continued for 2 to 3 h after injection when SB203580 was administered 24 h and 72 h after SNT (n ϭ 4. SB203580 did not alter hypersensitivity after paw incision (n ϭ 5. OX42 upregulation was decreased. respectively (n ϭ 4). Fig. The mean number of p-p38 MAPK immunopositive cells in SNT. 5. * P < 0. 6. intrathecal administration of SB203580 (10 ␮g) inhibited mechanical hypersensitivity. V 111. fig. 8A). of microglia. fig. 7 days (C) and the L5 spinal nerve transection (SNT) model for 3 days (B). Sep 2009 . # P < 0. Twice-daily minocycline injection.644 ITO ET AL. microglia are represented by OX42 immunoreactivity after twicedaily intraperitoneal injection of vehicle (D). and normal rats in the ipsilateral whole dorsal horn of the spinal cord was 1. Discussion In the present study. or 100 mg · kg؊1 · day؊1 minocycline (H) for 7 days. 50 mg · kg؊1 · day؊1. D–F). however. P Ͻ 0. Phosphorylated-p38 MAPK expression was higher after SNT than after paw incision. Comparison of Phosphorylated p38 MAPK Expression between the Postoperative Pain and Neuropathic Pain Models As compared with normal rats (fig. No 3. fig. OX42 immunoreactivity in the whole dorsal horn was increased on the ipsilateral side of the spinal cord after paw incision and L5 spinal nerve transection. or 100 mg · kg؊1 · day؊1 (F) minocycline for 3 days. 5. In contrast. Minocycline inhibited the area of OX42 immunostaining (microglia) after twice-daily injections in a dose-related manner. 8. 6B). Scale bar ‫ ؍‬200 ␮m. 50 mg · kg؊1 · day؊1 (B). Quantification of microglial expression in the whole dorsal horn of the spinal cord after twice-daily injection of vehicle. Most p-p38 MAPK staining occurred in the centers of the OX42-positive structures. Minocycline reduced the area of immunostaining in a dose-related manner after twice-daily administration for 3 days (n ϭ 4. After L5 spinal nerve transection. After paw incision. After twice-daily administration of minocycline. 7A). D and E) of OX42 (red) and p-p38 MAPK (green) staining. did minocycline administration (fig. Fig. 50 mg · kg؊1 · day؊1 (E). P Ͻ 0. and 409. twice-daily minocycline injection after paw incision did not attenuate hypersensitivity. After paw incision.841.001 as compared with the vehicle-treated group by two-way ANOVA. or 100 mg · kg؊1 · day؊1 minocycline in the postoperative pain model for 3 days (A). The increase in p-p38 MAPK in microglia was inferred based on the merged images (fig.

reduce the expression of OX42.36 Huntington’s disease. although p-p38 MAPK expression in the dorsal horn of the spinal cord increased after paw incision. Further. 8. In the L5 spinal nerve transection model. and 50 ␮m for (D).19 and attenuates the development of pain hypersensitivity in spinal immune activation by sciatic inflammatory neuropathy and intrathecal human immunodeficiency vi- Fig. however. Until recently. however.27 Parkinson’s disease.35.18 prevents the development of nociceptive behaviors induced by L5/6 spinal-nerve ligation. Merged double-labeled immunofluorescence images demonstrate colocalization (arrows) of OX 42 (red) and p-p38 MAPK (green) in the postoperative pain model (D) and the L5 spinal nerve transection model (E). Minocycline is a second-generation tetracycline derivative that exerts antiinflammatory effects independent of its antimicrobial activity. withdrawal thresholds were increased by intrathecal administration of SB203580 (10 ␮g) when injected at 24 h and 72 h after the nerve transection. Microglia have a significant role in exaggerated pain states with inflammatory and neuropathic etiologies. Representative images of phosphorylated p38 (p-p38) mitogen-activated protein kinase (MAPK) expression in the spinal dorsal horn in a normal rat (A). proliferation. p-p38 MAPK immunoreactivity was higher than that in normal rat and the postoperative pain model. intrathecal administration of the p38 MAPK inhibitor SB203580 did not attenuate hypersensitivity. V 111.34 glutamate-induced neurotoxicity. Effect of a p38 MAPK inhibitor (SB203580) after paw incision (A) and L5 spinal nerve transection model (B).8 prevents carrageenan-induced thermal hyperalgesia. and function. including cerebral ischemia.32 intracerebral hemorrhage. and 3 days after L5 spinal nerve transection (SNT. Sep 2009 .33 traumatic brain injury. Intrathecal minocycline reduces formalin-evoked second-phase flinching behavior. both minocycline and SB203580 effectively decreased hypersensitivity. indicate that neuroimmune alterations may also contribute to pain hypersensitivity. chronic pain has been considered to be a result of sensitization and reorganization of the central nervous system.37 and amyotrophic lateral sclerosis. * P < 0.SPINAL MICROGLIAL ACTIVATION AND POSTOPERATIVE PAIN 645 Fig. C) in the ipsilateral (ipsi) spinal dorsal horn. In the neuropathic pain model. 15 suggested that upregulation of microglia and astrocytes in the spinal cord contributes to mechanical hypersensitivity after paw incision. Recent reports.39 Minocycline also inhibits exaggerated pain induced by inflammation or nerve injury. Highly magnified images of the ipsilateral spinal dorsal horn are shown in the square in the upper panels. Microglial activation results in upregulated receptor function and further changes in microglial morphology. and minocycline attenuated OX42 expression in the spinal dorsal horn. 3 days after paw incision (B). 7.17 reverses spinal-cord injury-induced nociceptive behaviors. Obata et al. Anesthesiology.24 Although the role of microglia in postoperative pain has not been clarified. There were no changes in the withdrawal thresholds in the postoperative pain model after the administration of SB203580. Scale bar ‫ ؍‬200 ␮m for (A).25 Minocycline prevents microglial activation and thus has neuroprotective effects in various models of neurologic disease. No 3.31. The mean hind paw withdrawal thresholds (g) are shown as mean ؎ SEM (n ‫ ؍‬4 or 5). These findings suggest that the role of spinal microglia in postoperative pain differs from that in neuropathic pain.05 as compared with the vehicle-treated group by one-way ANOVA.28 –30 multiple sclerosis. After SNT. a microglial marker.38.26.

In the present study. and intrathecal administration of p38 inhibitors reduces neuropathic pain behavior. it is exclusively expressed in microglia at 1 day after paw incision. and consequently inhibits its enzymatic activity without affecting the phosphorylation of p38 MAPK. p38 MAPK is specifically activated in microglia in the spinal cord. we determined the dose of minocycline for twice-daily administration.40 reported that the expression of ionized calcium-binding adapter molecule 1. inhibited by minocycline.and 12-g von Frey filaments. but this treatment also did not suppress mechanical hypersensitivity after paw incision. Based on this outcome. Based on their findings that minocycline attenuated the development of hypersensitivity. minocycline attenuated the mechanical hypersensitivity of neuropathic pain. In contrast. These results suggest that microglia in the spinal cord have only a minor role in the postoperative pain model. To evaluate whether p38 inhibition has a role in existing hypersensitivity after paw incision and SNT.45 These findings strongly suggest that p38 phosphorylation is a key intracellular signal in microglial activation. we determined the withdrawal threshold using the up-down method. was closely correlated with mechanical hypersensitivity in a postoperative pain model. The surface marker complement receptor type 3/CD11 recognized by OX42 might reflect a morphologic change rather than a functional alteration of microglia.15 Therefore.5. the withdrawal threshold increased after a single intraperitoneal administration of minocycline (25 or 50 mg/kg) 1 day after paw incision in the postoperative pain model. Assessment using multiple markers may help to determine if there is a causative link between microglial activation and behavioral change. On the other hand.41– 43 In neuropathic pain models. we administered a single intrathecal injection of SB203580 on Days 1 and 3 after surgery.5.46 We determined the . the effect of minocycline on mechanical hypersensitivity in the SNT model was less than in a previous study by Raghavendra et al.7 evaluated hypersensitivity by determining the number of paw withdrawals with 30 stimulations of the plantar surface of the hind paw using 2. V 111. In the neuropathic pain model.20 We also demonstrated with double immunofluorescence studies that p-p38MAPK expression is increased in microglia 3 days after paw incision. in the spinal cord is associated with mechanical hypersensitivity after paw incision. This speculation is supported by the findings of a previous study. similar to previous findings. Specific microglial markers may have different roles in different types of pain. Another possible explanation for the inconsistency between the behavioral findings and OX42 expression is that this marker is not associated with microglial function.6. Sep 2009 ITO ET AL. We expected that this treatment would suppress mechanical hypersensitivity after paw incision. however.15 which showed that the increased immunoreactivity of glial fibrillary acidic protein immunoreactivity.7 Twice-daily intraperitoneal injections of minocycline for 3 days produced a dose-related reduction in mechanical hypersensitivity after SNT in the present study. we tested the effect of twicedaily intraperitoneal injections of minocycline for 7 days. Previous studies indicate that p-p38 MAPK staining is not colocalized with that of either NeuN (neuronal marker) or glial fibrillary acidic protein. did not parallel mechanical hypersensitivity. This finding suggests that minocycline has only a short-term effect in the postoperative pain model. but is completely colocalized with OX42 in the spinal cord after nerve injury. Furthermore. therefore it is possible that spinal microglia strongly contribute to neuropathic pain. Alternatively. spinal microglial expression was Anesthesiology. but. the expression of p-p38 MAPK increased in the ipsilateral dorsal horn of the spinal cord after paw incision and SNT. after SNT. whereas in their study.and inflammation-induced spinal pain processing. and that this effect is not cumulative. but not existing hypersensitivity. No 3. an astrocyte marker. This drug binds to the adenosine triphosphate pocket in p38 MAPK. surprisingly. microglia may have an active role only at specific time points.44. another microglia marker. there was no effect after twice-daily intraperitoneal minocycline injections for 3 days.7 In the present study.6. These results suggest that the effect of noxious stimulation to increase OX42 expression in neuropathic pain is more robust. we speculate that this dissociation between the two studies is a result of the differences in the experimental methodology. 40 mg · kgϪ1 · dayϪ1 minocycline produced a 50% reduction of hypersensitivity. minocycline (100 mg · kgϪ1 · dayϪ1 either for 3 or 7 days) inhibited the expression of OX42 after paw incision. although p-p38 MAPK might be initially present in another cell type. Therefore. A pilot study demonstrated that OX42 immunoreactivity begins to increase 3 days after paw incision and continues for up to 5 days. In the present study. Activation of p38 MAPK in spinal cord microglia plays a critical role in nerve-injury. In contrast. as compared with normal rats. Romero-Sandoval et al. such as behavioral testing with von Frey filaments.5.6 In the postoperative pain model. OX42 immunoreactivity.646 rus-1 gp120 administration. microglial immunoreactivity on the ipsilateral side was more extensive than that in the postoperative pain model.2 Intraperitoneal injection of minocycline prevents the development of L5 SNT-induced mechanical hypersensitivity. we injected minocycline beginning 1 h before nerve transection. and that the spontaneous resolution of postoperative pain parallels the spontaneous reduction in spinal calcium-binding adapter molecule 1 expression. and microglia may have a more important role in the development of neuropathic pain than in postoperative pain.7 We used a minocycline dose of 100 mg · kgϪ1 · dayϪ1 for 3 days and observed a 20% change. Raghavendra et al.

Urban MO. Peeling J: Intracerebral hemorrhage induces macrophage activation and matrix metalloproteinases. Pogrel JW. Patel PD. 93:14014–9 26. Jung SJ. Shigemoto-Mogami Y. reduces inflammation and protects against focal cerebral ischemia with a wide therapeutic window. Ona VO. Wang CC: Activation of p38 mitogen-activated protein kinase in spinal microglia contributes to incision-induced mechanical allodynia. J Immunol 2001. Eur J Neurosci 2004. Coyle DE: Partial peripheral nerve injury leads to activation of astroglia and microglia which parallels the development of allodynic behavior. Woolf CJ. McBurney DL. Brain 2002. Pain 2005.SPINAL MICROGLIAL ACTIVATION AND POSTOPERATIVE PAIN dose of SB203580 (10 ␮g) based on a previous study5 in which this dose effectively attenuated hypersensitivity after nerve injury. Hussain H. 166:7527–33 Anesthesiology. Koistinaho JE: Minocycline provides neuroprotection against N-methyl-D-aspartate neurotoxicity by inhibiting microglia. Raghavendra V. 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Chung YM. 98:14669–74 29. ANESTHESIOLOGY 2007. Ann Neurol 2002. Eisenach JC: Spinal cannabinoid receptor type 2 activation reduces hypersensitivity and spinal cord glial activation after paw incision. Cho IH. Romero-Sandoval A. because intrathecal administration of SB203580 reduced existing hypersensitivity in the neuropathic pain model. 64:493–501 11. Inoue K: Activation of p38 mitogen-activated protein kinase in spinal hyperactive microglia contributes to pain hypersensitivity following peripheral nerve injury. Tsaur ML. Attur MG. Glia 1998. p-p38 MAPK expression was greater after SNT than after paw incision. Jackson-Lewis V. Proc Natl Acad Sci U S A 1996. Ma Z. Eisenach JC. Yeh GC. Brennan TJ: Lack of effect of intrathecally administered N-methyl-D-aspartate receptor antagonists in a rat model for postoperative pain. Ischiropoulos H. Triarhou LC. Lin S. Vadseth C. Sep 2009 . In the present study. Parker R. Yaksh TL: Quantitative assessment of tactile allodynia in the rat paw. Vyas PR. Bynum T. Luecke S. Suter MR. Yong VW: Targeting leukocyte MMPs and transmigration: Minocycline as a potential therapy for multiple sclerosis. Pan YY. 110: 155–65 21. Ledeboer A. Duncan ID: Inhibition of autoimmune encephalomyelitis by a tetracycline. Lee SJ. 10:1387–94 2. Eur J Neurosci 2005. J Neurosci 2002. Hua XY. 909:187–93 30. Chernet E. Chaplan SR. Raghavendra V. 7:816–22 16. 106:787–94 17. Obata H. Pain 2003. Goldsteins G. Glia 2004. Physiol Behav 1976. Tsuda M. Watkins LR: Minocycline attenuates mechanical allodynia and proinflammatory cytokine expression in rat models of pain facilitation. Crisp T: Microglial proliferation in the spinal cord of aged rats with a sciatic nerve injury. 96:1153–60 13. 125:1297–308 33. Eisenach JC: Cyclooxygenase-1 in the spinal cord plays an important role in postoperative pain. Lovell JA. Neurosurgery 2001. Hutchinson MR. Conklin D. Tieu K. Linington C. Yaksh TL. Brennan TJ. Phebus LA. He Y. 88:143–56 14. Przedborski S: Blockade of microglial activation is neuroprotective in the 1-methyl-4-phenyl-1. daily intraperitoneal administration of minocycline did not attenuate mechanical hypersensitivity after paw incision. Our data were consistent with the findings of this previous study. Pogatzki EM. Goetz BD. 21:131–46 25. 95:15769–74 27. Li M. Oh SB: Systemic administration of minocycline inhibits formalin-induced inflammatory pain in rat. Zahn PK. Choi DK. In summary. Imai Y. Nelson DL. DeLeo JA: Complete Freunds adjuvant-induced peripheral inflammation evokes glial activation and proinflammatory cytokine expression in the CNS. Lin CS. Patel IR. Park SH. Sanchez Mejia RO. Tanga F. Park K. Teismann P. Brain Behav Immun 2007. Stuesse SL. was not effective in the postoperative pain model. J Pharmacol Exp Ther 2003. despite the decline in OX42 expression in the spinal cord. tissue damage. but does not drive microglial prostaglandin production or mechanical hypersensitivity after incisional surgery in rats. Yaksh TL. Wu YS. Sun WZ. Matsui T. Proc Natl Acad Sci U S A 1998. minocycline and SB203580 were efficacious in attenuating nerve injury–induced hypersensitivity. Pain 1992. J Neurosci Methods 1994. Keina ¨nen R. J Neurosci 2003. Vincler MA. Brain Res 2001. Ji RR: p38 mitogen-activated protein kinase is activated after a spinal nerve ligation in spinal cord microglia and dorsal root ganglion neurons and contributes to the generation of neuropathic pain. 26:4308–17 19. Hanisch UK. Cheng JK: Chronic intrathecal infusion of minocycline prevents the development of spinal-nerve ligation-induced pain in rats. Zhang SC. 115:71–83 3. Metz LM. Kim JS. Nat Neurosci 2007. Ji RR. Wang TY. 53:55–63 24. Keina ¨nen R. Piao ZG. Fitzsimmons B. Proc Natl Acad Sci U S A 2001. Pellikka M. Bernard CC. Brain Res 2006. however. In contrast. Patel RN. V 111. 125:43–52 12. Glia as the “bad guys”: Implications for improving clinical pain control and the clinical utility of opioids. ANESTHESIOLOGY 2002. Tanga FY. Koizumi S. The same drug treatment. Bach FW. Bymaster FP. Kettenmann H: Microglia: Active sensor and versatile effector cells in the normal and pathologic brain.

Friedlander RM: Minocycline inhibits cytochrome c release and delays progression of amyotrophic lateral sclerosis in mice. Rogers S. Westerlund A. Przedborski S. Sommer C. Chai N. 92:1508–20 44. Sep 2009 . Ona VO. Cha JH. No 3. Svensson CI. Feng Y. 14:1153–7 42. Nat Struct Biol 1997. 1219:116–26 41. 417:74–8 40. 4:311–6 Anesthesiology. Brown ML. Sorkin LS: Tumor necrosis factoralpha induces mechanical allodynia after spinal nerve ligation by activation of p38 MAPK in primary sensory neurons. Protter AA. 36. Hua XY. Nat Med 2000. Yaksh TL: Activation of p38 mitogen-activated protein kinase in spinal microglia is a critical link in inflammation-induced spinal pain processing. Sarang S. Nutile-McMenemy N. Scha ¨fers M. Cho HJ: Activation of p38 MAP kinase in the rat dorsal root ganglia and spinal cord following peripheral inflammation and nerve injury. Powell HC. J Neurochem 2003. Tikka T.648 ITO ET AL. 21:2580–8 37. Drozda M. Tong L. Neuroreport 2002. J Neurochem 2005. Freshwater JD. Yaksh TL: Spinal p38beta isoform mediates tissue injury-induced hyperalgesia and spinal sensitization. Liu AS. Cywin CL. Keinanen R. Ona V. Ferrante RJ. Svensson CI. Vonsattel JP. Fiebich BL. Calcutt NA. J Neurosci 2001. 86:1534–44 43. Deleo JA: A comparison of spinal Iba1 and GFAP expression in rodent models of acute and chronic pain. Kim JY. V 111. Kristal BS. Hobbs W. Kim BY. Goldsteins G. 6:797–801 38. 10:268–78 39. Pargellis CA: A highly specific inhibitor of human p38 MAP kinase binds in the ATP pocket. Protter AA. Nguyen MD. Bian J. Guo L. 23:2517–21 46. Neuroreport 2003. Hersch SM. Li M. Scott B. Romero-Sandoval A. Fitzsimmons B. Nature 2002. Wu DC. Svensson CI. Yaksh TL: Spinal p38 MAP kinase is necessary for NMDA-induced spinal PGE(2) release and thermal hyperalgesia. Neurobiol Dis 2002. Hua XY. Gullans S. Koistinaho J: Minocycline. Campana WM. Hartley DM. Powell HC. J Neurosci 2003. Azizi S. Brain Res 2008. Crane KM. White DM. Julien JP: Minocycline slows disease progression in a mouse model of amyotrophic lateral sclerosis. Zhu S. Lee KM. a tetracycline derivative. Li M. Zhu S. Lee HL. Farrell LA. 13:2483–6 45. Fink KB. is neuroprotective against excitotoxicity by inhibiting activation and proliferation of microglia. Kim SY. Pav S. Kim DS. Kriz J. Chen M. Ferrante RJ. Bae JC. Svensson CI. Stavrovskaya IG. Marsala M. Friedlander RM: Minocycline inhibits caspase-1 and caspase-3 expression and delays mortality in a transgenic mouse model of Huntington disease. Catalano R.

along with a recent study in patients with severe sepsis. 2009. Inc. † Senior Lecturer. There is increasing interest in the use of central and mixed venous oxygen saturation to guide therapeutic interventions during the perioperative period. Pearse. The resulting abstracts were screened to identify relevant investigations in adult patients undergoing major surgery. the more conveniently measured variable of hemoglobin saturation is preferred.S.B. Submitted for publication February 14. London E1 1BB. London. and Mark A. M. M. Mark A.4 – 6 Even for those patients who survive to leave hospital. Germany. therefore. Pearse has received honoraria for speaking from Pulsion Medical Systems. Address correspondence to Dr. Inc. and Edwards Lifesciences.B. Barts & The London School of Medicine and Dentistry. Lippincott Williams & Wilkins.D.11–14 * Specialist Trainee. Whitechapel. SvO2. respectively. served as Handling Editor for this article.C. oxygen consumption and cardiac output. which. Materials and Methods Searches of the MEDLINE and Cochrane CENTRAL databases from January 1968 to December 2008 were performed by both authors using the following search terms: (venous saturation OR venous oximetry OR SvO2 OR ScvO2) AND (surgery OR surgical OR ‫* گ‬operative OR operation). Bibliographies of relevant articles were also screened. Venous oxygen saturation reflects the balance between global oxygen delivery and oxygen consumption.C.. Munich. Physiology of Venous Oxygen Saturation The terms central (ScvO2) and mixed venous oxygen saturation (SvO2) refer to the hemoglobin saturation of blood in the superior vena cava and proximal pulmonary artery. ScvO2. However. surgery. California. M. The etiology of postoperative complications is complex.. Dr. 111:649 –56 Copyright © 2009.6 It is therefore essential that we seek to improve outcomes for patients undergoing major surgery. The etiology of postoperative complications is complex.P. United Kingdom.7–10 The use of fluid and inotropic therapy to enhance tissue oxygen delivery may reduce the incidence of postoperative complications. V 111. This article may be accessed for personal use at no charge through the Journal Web site. but no restrictions were placed on source.. Queen Mary’s University of London. There is an increasing body of literature describing changes in central (ScvO2) and mixed venous oxygen saturation (SvO2) during the perioperative period.. A further online search was then carried out using the Google Scholar search engine by using the following key words: venous saturation. but poor cardiorespiratory reserve appears a key factor. Sep 2009 . Warner.anesthesiology. Accepted for publication April 17. The Royal London Hospital. United Kingdom.Ⅵ REVIEW ARTICLES David S.uk. United Kingdom. Irvine.. Warner. No 3. Only articles published in English were included. rupert.D.16 Rearrangement of the Fick equation illustrates that venous oxygen content is determined by arterial oxygen content. IT is estimated that 234 million major surgical procedures are performed worldwide each year.3 Data from across the developed world confirms that poor outcomes after high-risk surgery are a global problem. A detailed understanding of these principles is essential for the safe and effective application in clinical practice.R.D.1Complications after major surgery are a leading cause of morbidity and mortality.D.† Complications after major surgery are a leading cause of morbidity and mortality.pearse@ bartsandthelondon. Pearse is a Clinician Scientist with the National Institute of Health Research.. M.S. M. Manuscripts were screened initially by title and then by abstract before obtaining the full text of relevant articles. but poor cardiorespiratory reserve appears to be a key factor. M. Editors Anesthesiology 2009.2.org. F. High-risk surgical patients account for more than 80% of deaths but less than 15% of in-patient procedures. Warner. A number of reports indicate that poor outcomes after major surgery are strongly associated with derangements in tissue oxygen delivery that may in turn relate to impaired microvascular flow. Role of Central and Mixed Venous Oxygen Saturation Measurement in Perioperative Care Stephen J. London. United Kingdom.B.nhs. Studies were excluded if they had not been published in a peer-reviewed journal.15 has led to interest in the use of venous saturation as a therapeutic goal for surgical patients.B.* Rupert M.17 The quantity of dissolved oxygen is small under standard conditions. United Kingdom. The aim of this article is to describe the physiology and measurement of SvO2 and ScvO2 and to describe the findings of the clinical investigations of the use of these variables in perioperative care. Shepherd. Barts & The London NHS Trust. Pearse: Intensive Care Unit. www. which may be affected by a wide range of factors during the perioperative period. The purpose of this article is to describe the physiology and measurement of mixed and central venous oxygen saturation and to explore the findings of clinical investigations of their use in perioperative care. a detailed understanding of the physiologic principles of venous oximetry is essential for safe and effective use in clinical practice. Dr. venous oximetry.A. the complexities of the physiology of venous oxygen saturation are poorly recognized. Received from the Barts & The London School of Medicine and Dentistry. M. This is summarized in the equation 649 Anesthesiology. 2009. Queen Mary’s University of London..R. However. postoperative complications remain an important determinant of long-term survival. the American Society of Anesthesiologists.

CaO2 refers to arterial oxygen content. ScvO2 decreased from 75% at baseline to 60%. below. hemoglobin concentration. at higher partial pressures of oxygen.24. If oxygen consumption.19 –22 In common with other global physiologic variables. where CO refers to cardiac output.26 where DO2 refers to oxygen delivery and CO to cardiac output where the Bunsen solubility coefficient for O2 at 37°C is 0. and it is of particular importance to recognize that changes in venous saturation may reflect a variety of physiologic and pathologic changes (fig. 2).29 –34 Changes in ScvO2 and SvO2 in these circumstances reflect both the severity of hemodynamic disturbances and response to treatment. such as those typical of venous blood. pathologic. Common physiologic.24 Values of SvO2 and ScvO2 may often be as low as 65% in hospital in-patients before elective surgery. the change in venous saturation in re- Where oxygen supply is insufficient to meet metabolic requirements.18 VO2 and DO2 both fluctuate significantly during the perioperative period. 1). The safe use of venous saturation as a therapeutic goal depends on the prompt recognition of the cause of any derangement. It may be anticipated from the oxyhemoglobin dissociation curve that. At lower partial pressures. Sep 2009 .24 Over the same time period.25 Oxygen Delivery as a Determinant of Venous Oxygen Saturation Global oxygen delivery is determined by cardiac output and the oxygen content of arterial blood as shown in Anesthesiology. No 3.35 Consequently. There is little published data describing the normal value of venous saturation in health.29 –32 The affinity of hemoglobin for oxygen is affected by the partial pressure of oxygen (fig.650 SHEPHERD AND PEARSE Fig. 1. as a consequence.34͒ ϩ ͑0. the same incremental rise in PO2 will result in a greater increase of hemoglobin saturation due to the greater oxygen affinity of deoxyhemoglobin.28 In a study of healthy volunteers. increased tissue oxygen extraction results in a decrease in the oxygen content of effluent venous blood.7 l minϪ1 at the onset of presyncopal symptoms. Although commonly quoted as 70%. the available data suggest this may vary from 70% to 80% in healthy individuals.02. increases in PO2 will result in only small increases in hemoglobin saturation. the apparent simplicity of a single variable is often associated with a lack of sensitivity to detect regional abnormalities in an apparently stable patient. SvO2 remained unchanged.23. and VO2 refers to oxygen consumption.02 ϫ PaO2͔͒ Adequate tissue oxygen delivery therefore depends on the adequacy of both respiratory and cardiovascular function. Venous oxygen saturation therefore reflects the balance between global oxygen delivery (DO2) and global oxygen consumption (VO2).24 A clinical series of patients undergoing one-lung ventilation demonstrated that cardiac output increased in response to sudden decreases in arterial saturation. this relationship has been demonstrated in several studies in man. changes in SvO2 are therefore directly proportional to those in cardiac output. Safe use of venous saturation as a therapeutic goal requires prompt recognition of all causes of any derangement. orthostatic hypotension resulted in a decrease in cardiac output from 4. and therapeutic factors that influence venous oxygen saturation (ScvO2 and SvO2) during the perioperative period.27 DO2 ϭ CO ϫ ͓͑SaO2 ϫ Hb ϫ 1. and arterial saturation remain constant. CvO2 refers to venous oxygen content. CO ϭ CaO2 Ϫ CvO2 VO2 І CvO2 ϭ CaO2 Ϫ VO2 CO the equation below.3 to 2. Regional variations in DO2 and VO2 are also commonplace and clinically relevant differences in the oxygen content of venous blood are to be expected in different parts of the circulation. V 111.28 Several reports describe reduced venous saturation in patients with a reduced cardiac output due to myocardial infarction and/or heart failure.

52 and intravenous anesthetic agents such as propofol similarly reduce metabolic demand.31. benzodiazepines.73 This lack of numerical equivalence has been demonstrated in various groups of critically ill patients.72.56 Reductions in neuronal oxygen consumption occur with the administration of volatile anesthetic agents.50 Intravenous hypnotics such as benzodiazepines appear to exert similar effects on metabolic demand by blunting the sympathetic neurohumoral response. septic and hemorrhagic shock.16 largely because of the high oxygen content of effluent venous blood from the kidneys.66.67 but we are unaware of reports specifically describing effects on VO2. This may reflect poor recognition of the importance of VO2 as a determinant of venous saturation. Clinical and laboratory investigations have shown that an increase in fractional inspired oxygen concentration results in a greater increase in oxygen saturation of venous than arterial blood.74 In healthy individuals.76 –78 This has also been demonstrated in patients undergoing general anesthesia for cardiac71. Considerable changes in oxygen consumption may occur during the perioperative period.45– 49 Volatile anesthetic agents decrease the basal metabolic Anesthesiology. Sep 2009 . which usually increases myocardial inotropy by increasing general sympathetic activity. No 3.75 In shock states. and body temperature.68 –72 This observation is sometimes cited in support of continued use of the pulmonary artery catheter.38 – 42 whereas the corresponding treatments may rectify such derangements. As the use of the pulmonary artery catheter declines.55. anxiety. or shivering may all result in a decrease in venous saturation.VENOUS OXYGEN SATURATION IN PERIOPERATIVE CARE 651 Fig.44 General anesthesia results in a decrease in VO2 through reductions in general motor activity.80 Although trends in ScvO2 may closely reflect those of SvO2. the relationship between the two variables is complex and they cannot be used interchangeably. and the absolute value of ScvO2 may exceed that of SvO2 by up to 20%. including those with cardiogenic. work of breathing. ScvO2 is usually 2–5% less than SvO2.22 This relationship changes during periods of hemodynamic instability because blood is redistributed to the upper body at the expense of the splanchnic and renal circulations. In situations where ScvO2 or SvO2 values are being used as hemodynamic endpoints for the administration of intravenous fluid or inotropic therapies. These changes are the result of anesthesia itself as well as neuromuscular blockade and invasive ventilation. The drainage of myocardial venous blood directly into the right atrium via the coronary sinus and cardiac chambers via the Thebesian veins results in further discrepancies. with reductions in sympathetic tone and cardiac output being more pronounced at higher doses.36. The potential for such simple interventions to mask the effects of shock emphasizes the importance of a detailed understanding of venous oximetry. the observed relationship between ScvO2 and SvO2 may reverse.54 Sympatheticolytic agents such as clonidine reduce perioperative VO2. However. measurement of ScvO2 is usually sponse to a step change in fractional inspired oxygen concentration may differ considerably from simultaneous changes in arterial hemoglobin saturation. neuronal activity. Oxygen Consumption as a Determinant of Venous Oxygen Saturation Few studies have explored the relationship between VO2 and venous saturation during the perioperative period. an increase in venous saturation resulting from an increase in fractional inspired oxygen concentration may be misinterpreted as an indication of adequate hemodynamic resuscitation. therefore.51.68 –73 Regional variations in the balance between DO2 and VO2 result in differences in the hemoglobin saturation of blood in the superior and inferior vena cavae.43 Experimental data suggests that the extent of such derangements may correlate with the magnitude of oxidative stress. 2. there is no evidence to suggest one variable is of greater clinical value than the other. The greater affinity of deoxy-hemoglobin results in a greater step change in sulfur dioxide (SO2) in venous blood than in arterial blood after an increase in fractional inspired oxygen concentration. SvO2 reflects the balance between oxygen supply and demand averaged across the entire body but ScvO2 is affected disproportionately by changes in the upper body.74 Streaming of caval blood continues within the right atrium and ventricle and complete mixing only occurs during ventricular contraction. with the probable exception of ketamine.69.68 –70.53. barbiturates. This phenomenon has the potential to cause confusion in cases where venous saturation is employed as an endpoint for hemodynamic therapy. and propofol.62– 65 Neuraxial blockade has both sympatheticolytic and analgesic effects. rate. absolute values differ and the variables cannot be used interchangeably. V 111. Increases in VO2 resulting from pain.57– 61 Opiates may similarly reduce perioperative VO2.37 The administration of supplemental oxygen may therefore be sufficient to rectify significant abnormalities in venous saturation even though these abnormalities may not specifically result from alveolar hypoxia. Relationship between SvO2 And ScvO2 While the determinants of ScvO2 and SvO2 are very similar.16 Consequently. Oxy-hemoglobin dissociation curve illustrating the difference in gradient at PO2 levels typical for arterial and venous blood.79 and noncardiac surgery.

.84 When taking blood samples. although ScvO2 measurements cannot be cannot be used to calculate VO2 or shunt fraction. 3. and catheter misplacement. However.84 As with any form of venous oximetry.83. Observational Studies of Perioperative Changes in ScvO2 and SvO2 Abnormalities of venous saturation are common during and after major surgery and are associated with an increased incidence of postoperative complications. Anesthesiology. Changes in central venous oxygen saturation (ScvO2) after major noncardiac surgery.0001).82 However. and sampling from the incorrect site. in clinical practice it may be inconvenient to make frequent measurements by using this approach. a considerable decrease in ScvO2 was observed within the first hour after surgery.92–95 These observations are no surprise. V 111. syringe aspiration should be gentle enough to avoid high negative pressure that may increase the aspiration of pulmonary capillary blood and hence produce falsely high readings for oxygen saturation.87– 89 Noncardiac Surgery Two studies have been performed in noncardiac surgical patients with complementary findings. which are common during the perioperative period. The differences in light absorption spectra between oxygenated and deoxygenated hemoglobin allow calculation of the hemoglobin saturation of blood. not all of which are pathologic in nature. Specific errors result from sample contamination. DO2. a major advance that allowed the measurement of SvO2 and hence application of Fick’s principle to measure cardiac output. interpretation errors may arise due to intracardiac shunts. although the latter can be addressed by recalibration.72 Measurement of Venous Oxygen Saturation Cardiac catheterization was first performed in 1929 by Werner Forssmann. The most appropriate therapy to achieve a venous saturation endpoint may vary.29. Advances in the technology have addressed the problem of interference from other optically active compounds such carboxyhemoglobin and bilirubin. possibly as a consequence of increased VO2 after the cessation of general anesthesia (fig. The major benefit of this approach is the provision of continuous data allowing the detection of sudden fluctuations in venous saturation. the optimal cut-off for the lowest ScvO2 value being 64. Changes in central venous saturation after major surgery and association with outcome. Reductions in ScvO2 below 65% were associated with an increased incidence of postoperative complications. given the wide range of pathologic abnormalities that affect venous saturation in the perioperative period. In a further multicenter observational study of 60 patients. the mean value of ScvO2 was found to be reduced at various time points throughout the perioperative period in patients who developed complications. No 3. which may reflect increases in oxygen consumption after cessation of general anesthesia (*P < 0. In the first observational study of 117 patients.86 The principle disadvantages of this technology are the additional cost and signal drift.81. 9:R694 –9. Intermittent Blood Sampling and Cooximetry Cooximetry involves the measurement of hemoglobin saturation by spectrophotometry by using widely available blood gas analysis technology. the lowest recorded value of ScvO2 in the early postoperative period was independently associated with subsequent complications.87–91 Reductions in ScvO2 and SvO2 also have prognostic significance in heart failure. Note the significant decrease in ScvO2 in the first hour after surgery. Critical Care 2005.4%. This also allows the identification of other forms of hemoglobin such as methemoglobin and carboxyhemoglobin. tricuspid regurgitation. These investigations not only provide strong evidence to support the role of ScvO2 as a therapeutic target. Cooximetry is a reliable and well-established technique. A range of factors influence VO2. but they are also highly consistent in suggesting the most appropriate target value to be an ScvO2 value of approximately 75%. trauma. and therefore venous saturation during the perioperative period.87 Interestingly. Adapted from Pearse R. and sepsis. Continuous Measurement Using an Indwelling Fiberoptic Catheter The introduction of optical fiber technology has allowed the continuous measurement of venous saturation by spectrophotometry using indwelling pulmonary artery or central venous catheters. et al. However. these findings do not indicate how venous saturation should be used as a therapeutic goal. Sep 2009 Fig.652 SHEPHERD AND PEARSE more convenient than SvO2.33 Measurement of venous saturation may be performed either intermittently by blood sampling and cooximetry or continuously through the use of a spectrophotometric catheter.88 The optimal cutoff value in this study for the mean ScvO2 value was 73%.85. it was not until 1970 that the introduction of the balloontipped pulmonary artery catheter facilitated the routine clinical measurement of SvO2. delayed measurement. 3).81 Reports of the clinical utility of ScvO2 predate those of SvO2 by several years.

changes in SvO2 reflected adverse clinical events. 70.89 –91 Derangements in SvO2 occur before any changes in mean arterial pressure or heart rate are observed. SvO2 may prove a more specific indicator of global oxygen delivery. but there were greater improvements in SvO2 in the SvO2 group (control group 69 Ϯ 5% vs. The report provides little information regarding the standardization of interventions that are frequent confounders in trials of this size.VENOUS OXYGEN SATURATION IN PERIOPERATIVE CARE 653 Cardiothoracic Surgery Alterations in SvO2 have been described in patients undergoing cardio-thoracic surgery. In particular.05).1%) perhaps explaining the similar outcomes. derived through measurement of SvO2.91. final SvO2 values were similar in the two groups (70.05).4 Ϯ 2.73.86 Early work in patients undergoing both cardiac and pulmonary surgery demonstrated that sustained reductions in SvO2 below 65% were associated with a higher incidence of complications.8%).1% to 68. the use of SvO2 as a therapeutic endpoint for inotropic therapy was not associated with any change in outcome. urine output. P Ͻ 0. Dobutamine was administered more frequently and in greater Anesthesiology. the small sample size limits the generalizability of the findings. In an earlier study of patients undergoing peripheral vascular surgery.108 Dobutamine was administered in doses of up to 15 ␮g · kgϪ1 · minϪ1 where the target SvO2 was not achieved with intravenous fluid alone. 13. although this series is too small to support any more detailed conclusions. dobutamine up to 15 ␮g · kgϪ1 · minϪ1 and blood transfusions to achieve predefined goals for arterial pressure. although fluid challenges were commenced earlier stage in the ScvO2 group.97 Increases in oxygen extraction ratio. V 111. postoperative sedation. However. Cardiothoracic Surgery Polonen et al. and central venous pressure.90.100.8%] vs. absolute values not reported).80. SvO2 group 67 Ϯ 6%).68. SvO2 was similar in the two groups at baseline (control group 67 Ϯ 6% vs.6 Ϯ 4. and other aspects of postoperative critical care. randomized 196 patients undergoing elective cardiac surgery to a protocol involving the administration of intravenous fluid and inotropic therapy to attain a target SvO2 of at least 70% in the first 8 h after surgery. whereas mortality was low in both groups (2. the study has a number of limitations. although no reports of changes in ScvO2 were identified. These include anesthesia.76. ventilation.2 ␮g · kgϪ1 · minϪ1.8%]. This was an important investigation with encouraging findings. Control group patients were administered intravenous fluid and dobutamine to meet goals for pulmonary artery occlusion pressure. particularly arrhythmias.103 Fluctuations in SvO2 and ScvO2 closely mirror periods of hemorrhage and subsequent resuscitation in anesthetized dogs. Sep 2009 doses to the ScvO2 group (2. Interventional Trials Utilizing ScvO2 and SvO2 as Therapeutic Targets in the Perioperative Period Noncardiac Surgery Our literature search identified only one interventional trial using ScvO2 as a therapeutic goal in perioperative care.9% vs.73. temperature maintenance. All patients received fluid challenges. Trial interventions were continued until an unspecified time on the first postoperative day. much larger trials are clearly needed to resolve the question of effectiveness in routine clinical practice.96 and they appear to correlate well with changes in cardiac index. 20 of 67 patients [29. there is little or no description of those interventions likely to limit excessive VO2. the use of ScvO2 to calculate oxygen extraction ratio is considered unreliable. . P ϭ 0.99 During cardiopulmonary bypass. and hematocrit.98 During lung transplantation.73. Initial values of SvO2 were surprisingly low but responded significantly in the intervention group (59. Fewer patients in the ScvO2 group developed organ failure (8 of 68 patients [11.107 Patients undergoing aortic reconstruction or limb salvage procedures were admitted to intensive care 12 hours preoperatively for pulmonary artery catheter placement. Although this may reduce the effects of alveolar hypoxemia as a confounder.102 A case series of ten victims of mainly penetrating trauma described similar changes in SvO2. Volumes of intravenous fluid and transfused blood were similar in the two groups. However.0%. 3. arterial pressure. P Ͻ 0.102. and the data do not appear to support such conclusions. The duration of hospital stay was also reduced in the ScvO2 group (11. No 3.102.104 However.1 days.106 In common with a number of similar trials.3 Ϯ 3. It is unclear why the investigators chose to use estimated oxygen extraction ratio as a hemodynamic goal rather than absolute values of ScvO2.0 ␮g · kgϪ1 · minϪ1 vs. there are some limitations that prevent full interpretation of the results. 0. cardiac index. pump flow (or cardiac output) and metabolic rate are generally constant in these circumstances.103 Venous saturation may provide a useful indication of the severity of blood loss that is more reliable than conventional cardiovascular variables such as heart rate and arterial and central venous pressure.105 These same therapies were administered in the intervention group to achieve the additional goal of an estimated oxygen extraction ratio of less than 27%.0% vs. have also been associated with postoperative organ failure and prolonged intensive care stay.4 Ϯ 6.001).103 A single small case series describes the use of normal levels of SvO2 as therapeutic target in trauma patients in which the authors suggest a survival benefit.8 days vs. analgesia.11–13 Although the multicenter design offsets this somewhat. the value of which was calculated using intermittent measurements of ScvO2.101 Trauma The effects of hypovolemia on venous saturation have been described in both animals and humans.105 This was a multicenter trial of 135 patients undergoing major abdominal (including aortic) surgery.

Aiko T: Oxygen delivery as a factor in the development of fatal postoperative complications after oesophagectomy. Miran A. Cole J. Weiss C. Jorgensen J. and response to treatment. 2:315–25 19. Jhanji S. JAMA 1993. Vertrees R. the intervention protocol principally targeted SvO2 by increasing DO2. Jacobs L: Central mixed and splanchnic venous oxygen saturation monitoring. Nielsen L. Vuvinic M. Kramer G: Mixed venous oxygen saturation during cardiopulmonary bypass poorly predicts regional venous saturation. Morris C. Lapital M. Pott F.6%] vs. 69:1005–9 29. Breizat A. 106:630–6 10. Appl Cardiopulm Pathophysiol 1989. and rewarming are all commonly used perioperative interventions that affect venous oxygen saturation. V 111. The Lancet 2008. Crit Care 2006. pp 517– 87 27. Dellinger E. Moss A: Central venous oxygen saturations: The value of serial determinations in patients with acute myocardial infarction. Haynes AB. 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