Cerebral state index during anaesthetic induction: a comparative study with propofol or nitrous oxide

BACKGROUND

Confidently predicting the depth of anaesthesia for the individual patient and independently of drug(s) type using EEG-based monitors has proven difficult. This open, randomized, explorative study of day surgical patients evaluates the ability of the Cerebral State Monitor (Danmeter AB, Odense, Denmark) of anaesthetic depth to identify loss of response (LOR) using either propofol or N(2)0 for induction.

METHODS

In this open, randomized study, day surgical patients (n=10 in each group) were studied using the Cerebral State Index Monitor. After baseline measurements, induction to LOR was achieved with either repeated 30-mg boluses of propofol every second minute or with N(2)0 (after premedication 5 min before with 30 mg propofol) increased every other minute in 15% increments (max. 75%). Sedation level was evaluated every other minute using the Observer's Assessment of Alertness/Sedation scale.

RESULTS

Baseline values were 91 (82-98) and 94 (82-100) for N(2)0 and propofol patients, respectively. During induction CSI decreased with increasing sedation in patients given propofol (P<0.001) but not in patients given nitrous oxide. Median value at LOR was 56 (40-76) and 95 (87-100) for the propofol and nitrous oxide group of patients, respectively.

CONCLUSION

The Cerebral State Index(trade mark) behaves as other depth of anaesthesia monitors with a progressive decrease during propofol induction but loss of consciousness with N(2)0 results in no change in CSI.

Effects of thoracic epidural analgesia on glucose homeostasis after cardiac surgery in patients with and without diabetes mellitus

BACKGROUND AND OBJECTIVE

Even moderate hyperglycaemia increases mortality/morbidity after coronary artery bypass grafting, stroke and myocardial infarction. The goal of this prospective study was to determine if using thoracic epidural analgesia from start of surgery until the end of the third postoperative day would blunt postoperative hyperglycaemia.

METHODS

Forty-four patients had diabetes mellitus, 60 did not; half of each group had an epidural with continuous local anaesthetics. All patients received continuous insulin infusions during the initial 24 h period beginning with surgery. Blood glucose was measured four times daily (fasting or 2-3 h post-prandial) until end of the third postoperative day.

RESULTS

For patients without diabetes, the epidural group had lower mean blood glucose and insulin requirements (P < 0.02) than controls during the initial 24 h period beginning with surgery. For patients with diabetes mellitus, thoracic epidural analgesia reduced mean blood glucose (P = 0.017) with unchanged insulin requirements. Epidural did not diminish the increase (vs. preoperative) in fasting blood glucose on the third postoperative day (32% vs. 22%, P < 0.001) for non-diabetics. Epidural analgesia was not able to attenuate hyperglycaemia during the first 3 postoperative days.

CONCLUSIONS

Epidural analgesia improved glucose homeostasis minimally during the initial 24 postoperative hours but did not attenuate hyperglycaemia during the subsequent 3 postoperative days.

Are even impaired fasting blood glucose levels preoperatively associated with increased mortality after CABG surgery?

AIMS

Impaired fasting glucose (IFG) below the diagnostic threshold for diabetes mellitus (DM) is associated with macrovascular pathology and increased mortality after percutaneous coronary interventions. The study goal was to determine whether pre-operative fasting blood glucose (fB-glu) is associated with an increased mortality after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

During 2001-03, 1895 patients underwent primary CABG [clinical DM (CDM) in 440/1895; complete data on fB-glu for n=1375/1455]. Using pre-operative fB-glu, non-diabetics were categorized as having normal fB-glu (<5.6 mmol/L), IFG (5.6< or =fB-glu<6.1 mmol/L), or suspected DM (SDM) (> or =6.1 mmol/L). fB-glu was normal in 59%. The relative risks of 30 day and 1 year mortality compared with patients with normal fB-glu was 1.7 [95% confidence interval (CI): 0.5-5.5] and 2.9 (CI: 0.8-11.2) with IFG, 2.8 (CI: 1.1-7.2) and 1.9 (CI: 0.5-6.3) with SDM vs. 1.8 (CI: 0.8-4.0) and 1.6 (CI: 0.6-4.3) if CDM, respectively. The receiver operator characteristic area for the continuous variable fB-glu and 1 year mortality was 0.65 (P=0.002).

CONCLUSION

The elevated risk of death after CABG surgery known previously to be associated with CDM seems also to be shared by a group of similar size that includes patients with IFG and undiagnosed DM.

Clinical comparison of three different anaesthetic depth monitors during cardiopulmonary bypass

The lack of a gold standard complicates the evaluation and comparison of anaesthetic depth monitors. This randomised study compares three different depth-of-anaesthesia monitors during cardiopulmonary bypass (CPB) at 34 degrees C with fentanyl/propofol anaesthesia adjusted clinically and blinded to the monitors. Coronary artery bypass grafting patients (n = 21) were randomly assigned to all three possible paired combinations of three monitors: Bispectral Index (Aspect Medical), AAI auditory evoked potential (Danmeter), Entropy (Datex-Ohmeda). Indices were manually recorded every 5 min during CPB. Agreement between paired indices was classified as good, non-, or disagreement. Anaesthesia was classed as adequate, inadequate, or excessive according to recommended index values. Of the 255 paired indices recorded, 62% showed good agreement, 33% showed non-agreement, and 5% showed disagreement. Using good agreement between two monitors as a gold standard, a quarter of the measurements indicate inappropriate anaesthetic depth monitoring during CPB with clinically titrated anaesthetic depth.

Entropy of EEG during anaesthetic induction: a comparative study with propofol or nitrous oxide as sole agent † †This article is accompanied by Editorial I

BACKGROUND

The search continues for an anaesthetic monitor that can define the level of anaesthesia in an individual patient irrespective of anaesthetic agent(s) used. Studies of available monitors based on bispectral analysis or evoked auditory potentials show the complexity of the problem. We assessed a new monitor, based on the entropy of the EEG, during induction of anaesthesia with either propofol or nitrous oxide.

METHODS

In an open, randomized study (two groups; n=10) of day surgical patients, we induced loss of response with incremental boluses of propofol. The other group was given propofol 30 mg and then increasing concentrations of nitrous oxide until loss of response. We measured entropy with the M-Entropy Module S/5 (Datex-Ohmeda) using forehead electrodes and recorded response entropy (RE; including frontal electromyogram) and state entropy (SE; only the cortical EEG). Values are median (range).

RESULTS

Baseline values were RE 98 (96-100), SE 89 (87-91) and RE 98 (96-99), SE 89 (87-91) for the propofol and nitrous oxide patients, respectively. During propofol induction, both entropy indices decreased with increasing sedation, with RE 40 (23-76) and SE 34 (17-70) at loss of response. Neither RE nor SE decreased during nitrous oxide inhalation, and at loss of response using nitrous oxide, RE and SE were unchanged at 98 (96-100) and 88 (85-91) respectively.

CONCLUSIONS

The entropy monitor of anaesthetic depth shows a successive decrease with propofol but loss of consciousness with nitrous oxide is not associated with change in entropy indices.

Entropy during propofol hypnosis, including an episode of wakefulness

Depth of anaesthesia has proved to be a complex process to quantify. Monitors based on bispectral analysis of the electroencephalogram and auditory evoked potential have been available, but only recently has a monitor based on entropy become available. This study determined state entropy and response entropy in nine healthy volunteers during propofol hypnosis with a brief intervening period of wakefulness. Both the calculated entropy indices decreased with increasing levels of sedation (r2 = 0.58 and 0.61, respectively) and they showed a high correlation with each other (r2 = 0.94). However, an overlap was observed in real time indices between different stages of the Observer's Assessment of Alertness/Sedation Scale. Only three of the nine volunteers had explicit memories from the episode of wakefulness. Electroencephalographic entropy monitors seem to have potential for staging clinical hypnotic effects.

The AAI index, the BIS index and end-tidal concentration during wash in and wash out of sevoflurane

The bispectral index (BIS), auditory evoked potential index (AAI) and the end-tidal sevoflurane concentration were studied during induction and emergence in 10 ASA I-II patients. Both during 'wash-in' and 'wash-out' of sevoflurane, the AAI and BIS indices show huge variability and an overlap of indices between awake and not responding to command. This was the most pronounced during induction and the range of values was larger for the AAI index as compared with the BIS index. Mean (range) BIS was 85 (73-98) and 48 (10-83) awake and unconscious, respectively, and mean AAI index was 71 (43-99) and 21 (4-85), respectively. This study demonstrates the difficulties of using processed EEG variables in real time in a clinical situation of non-steady state pharmacodynamics.

Docosahexaenoic, arachidonic, palmitic, and oleic acids are differentially esterified into phospholipids of frog retina

Docosahexaenoic acid (22:6n-3) is highly enriched in the retina. To determine if retinal cells take up and metabolize fatty acids in a specific manner, retinas from Rana pipiens were incubated for 3 h with an equimolar mixture of tritiated 22:6n-3, arachidonic acid (20:4n-6), palmitic acid, and oleic acid. The radiolabeling of retinal lipids was determined and compared to the endogenous fatty acid content of the lipids. The results showed that in most, but not all, cases, the relative labeling with the four precursor fatty acids was similar to their relative abundance in each glycerolipid. Thus, during retinal glycerolipid synthesis, either through de novo or acyl exchange reactions, fatty acids are incorporated in proportions reflecting their steady-state mass levels. Since other studies with labeled glycerol have shown greater differences between early labeling patterns and molecular species mass, the final incorporation we report may be due primarily to acyl exchange reactions.

Sevoflurane requirements during ambulatory surgery: a clinical study with and without AEP-index guidance

BACKGROUND

Several monitors have been developed to measure anesthetic depth. The auditory evoked response uses an auditory signal to actively test the level of brain activity. The aim of the present study was to determine whether sevoflurane titration with A-line auditory guidance from the evoked potential monitor would reduce gas consumption and improve recovery times.

METHODS

Patients (n=60, aged 18-65 years) undergoing elective knee arthroscopy were randomized to titrate the main anesthetic sevoflurane with O2:N2O (1:2), either clinically (30 patients) or in combination with a target auditory evoked potential index of 30+/-5 (30 patients) using the A-line monitor (version 1.4, Danmeter A/S; Odense, Denmark). Induction was supplemented with fentanyl, and randomized to 0.05, 0.10 and 0.15 mg immediately before propofol (10 in each group). Sevoflurane consumption and emergence times were the primary and secondary study end-points.

RESULTS

Guidance from the A-line monitor did not reduce the sevoflurane consumption time or the emergence, regardless of the fentanyl dose. However, it did reduce the time from the recovery room to discharge eligibility (P<0.05). Sevoflurane consumption decreased inversely with the fentanyl dose (P<0.01), with no impact on emergence times.

CONCLUSION

The auditory evoked potential index provided by the A-line monitor does not decrease sevoflurane consumption or emergence times for ambulatory knee arthroscopy.

Inhalation anaesthesia is cost-effective for ambulatory surgery: a clinical comparison with propofol during elective knee arthroscopy

BACKGROUND AND OBJECTIVE

Cost consciousness has become increasingly important in anaesthesia as elsewhere in healthcare. Cost-minimization with uncompromised patient safety and quality requires systematic comparisons of alternative techniques. Inhalation anaesthesia with desflurane or sevoflurane is compared in this study with propofol delivered by the target controlled infusion technique. Directly measured drug consumption and costs and emergence times are compared.

METHODS

Consumed anaesthetics were measured during elective arthroscopy of the knee, and costs were calculated for ASA I-II patients (n = 102) randomized to 3 groups: one group received anaesthesia using propofol administered by target controlled infusion, the others inhalation anaesthesia with either desflurane or sevoflurane in combination with nitrous oxide. A partial rebreathing system was used with a laryngeal mask airway. Vaporizers were weighed before and after each anaesthetic.

RESULTS

Anaesthetic duration, postoperative pain and emesis as well as discharge time did not differ between groups. Inhaled anaesthetic techniques with desflurane or sevoflurane were associated with 2-3 min shorter emergence times (P < 0.001) and approximately 45% lower cost for consumed anaesthetics as compared with a propofol technique based on target controlled infusion. The inclusion of waste costs improved the cost reduction to 55%.

CONCLUSIONS

For this patient group, use of inhalation anaesthesia reduced drug costs by half and shortened emergence times compared to target controlled infusion with propofol with equal perioperative patient conditions.

Interaction of the insulin receptor beta-subunit with phosphatidylinositol 3-kinase in bovine ROS

PURPOSE

To identify the tyrosine-phosphorylated protein(s) in bovine rod outer segments (ROS) that are associated with phosphatidylinositol 3-kinase (PI3K).

METHODS

Glutathione-S-transferase (GST) fusion proteins containing two SH2 domains of the p85 regulatory subunit of PI3K-GST-p85 (N-SH2), GST-p85 (C-SH2), and respective SH2 mutants (N-SH2, R358A, and C-SH2, R649A)-were prepared and used to pull down tyrosine-phosphorylated proteins in bovine ROS. Protein identity was established by Western blot analysis. PI3K activity was determined in the pull-down mixtures and in immunoprecipitates by incubation with phosphatidylinositol-4,5-bisphosphate (PI-4,5-P(2)) and [gamma(32)P]adenosine triphosphate (ATP).

RESULTS

The GST pull-down assays indicated the binding of a 97-kDa protein by GST-p85 (N-SH2) in tyrosine-phosphorylated (PY)-ROS that was not present in nonphosphorylated (N)-ROS. Binding was completely abolished when the Arg 358 in the N-SH2 domain was mutated to Ala. Increased binding of the p110alpha catalytic subunit to GST-p85 (N-SH2) fusion protein was also observed in the presence of the 97-kDa phosphorylated protein. Biochemical evidence indicated that the 97-kDa protein was the beta-subunit of the insulin receptor beta-subunit (IRbeta). Immunoprecipitates of PY-ROS and N-ROS with anti-PY antibodies, probed with anti-IRbeta, indicated the presence of IRbeta only in PY-ROS. Immunoprecipitates of PY-ROS and N-ROS with anti-IRbeta antibodies, probed with anti-p85 and anti-p110alpha antibodies, indicated increased amounts of both p85 and p110alpha in PY-ROS compared to N-ROS. Treatment of ROS with insulin, followed by immunoprecipitation with either anti-IRbeta or anti-PY, resulted in increased PI3K activity. Expression and phosphorylation of the cytoplasmic tail of retina insulin receptor showed direct involvement with the p85 subunit of PI3K in vitro.

CONCLUSIONS

Tyrosine phosphorylation of the beta-subunit of the insulin receptor is involved in the regulation of PI3K activity in ROS.

Protection of photoreceptor cells in adult rats from light-induced degeneration by adaptation to bright cyclic light

Light history has been shown to affect the susceptibility of the albino rat retina to the damaging effects of constant light exposure. Retinas of animals raised in relatively bright cyclic light are protected against light-induced degeneration compared with dim-reared animals. These effects were observed in animals raised from birth in bright cyclic light and are part of an adaptive response that protects photoreceptors from stress-induced degeneration. To determine if retinas of adult animals are capable of such adaptive changes or flexibility by switching between different light environments which do not pathologically damage photoreceptor cells, albino rats were maintained in less than 250 lux cyclic light for more than 3 weeks. At 12-13 weeks of age, they were placed into 800 lux cyclic light for 1 week, after which they were exposed to constant illumination of 1500-lux for 1, 3 or 7 days. Retinal function was evaluated by electroretinography and photoreceptor cell death was quantified by measuring outer nuclear layer thickness. After 1 week in bright cyclic light, the retinas were completely protected against 1 day constant light exposure that significantly damaged retinas of animals without 800 lux cyclic light adaptation. Significant protection was also observed in 3 day constant light exposed animals; limited protection occurred after 7 days exposure. These results indicate that the retinas of adult rats adapted to bright cyclic light within certain ranges that did not significantly damage photoreceptor cells are protected from constant light challenge. This phenomenon is a post-developmental response that demonstrates a remarkable plasticity of the retina. The mechanism(s) underlying the ability of this adaptation/flexibility in protecting photoreceptors could involve endogenous molecules that encompass many aspects of retinal cell and molecular biology and physiology. Identification of these molecules may provide insight into the development of therapeutic approaches to treat retinal degeneration.

A study of bispectral analysis and auditory evoked potential indices during propofol-induced hypnosis in volunteers: the effect of an episode of wakefulness on explicit and implicit memory

The bispectral index (BIS) and the auditory evoked potential (AEP) index as calculated by the new A-line monitor were measured during hypnosis with propofol, which included an episode of wakefulness. Both indices followed a similar pattern during sedation, with values decreasing with sedation and increasing when awake. Baseline AEP values varied between 60 and 98, and BIS values were between 96 and 98. The AEP-index value was at all times 10-20 points lower than the BIS-index. The transition to loss of response occurred at a mean AEP value of 46 and BIS value of 58. The transition to just responding following a period of unconsciousness occurred at a mean AEP value of 46 and BIS 65. Both monitoring techniques, however, displayed large interindividual variations making it impossible to discriminate in real time between subtle changes of clinical state. The new neurophysiological monitors A-line AEP and BIS are interesting tools for creating a better understanding of the anaesthetic effects of drugs; however, further refinements are required before their relative roles can be fully established in the clinical setting.

Impaired synthesis of DHA in patients with X-linked retinitis pigmentosa

Many patients with X-linked retinitis pigmentosa (XLRP) have lower than normal blood levels of the long-chain polyunsaturated omega3 fatty acid docosahexaenoic acid (DHA; 22:6omega3). This clinical trial was designed to test whether down-regulation of DHA biosynthesis might be responsible for these reduced DHA levels. DHA biosynthesis was assessed in five severely affected patients with XLRP and in five age-matched controls by quantifying conversion of [U-(13)C]alpha-linolenic acid (alpha-LNA) to [(13)C]DHA. Following oral administration of [U-(13)C]alpha-LNA, blood samples were collected at designated intervals for 21 days and isotopic enrichment of all omega3 fatty acids was determined by gas chromatography/mass spectroscopy. Activity of each metabolic step in the conversion of alpha-LNA to DHA was determined by comparison of the ratios of the integrated concentration of (13)C-product to (13)C-precursor in plasma total lipid fractions. The ratio of [(13)C]DHA to [(13)C]18:3omega3 (the entire pathway) and that of [(13)C]20:5omega3 to [(13)C]20:4omega3 (Delta(5)-desaturase) were significantly lower in patients versus controls (P = 0.03 and 0.05, respectively). The estimated biosynthetic rates of [(13)C]20:5omega3, [(13)C]22:5omega3, [(13)C]24:5omega3, [(13)C]24:6omega3, and [(13)C]22:6omega3 were significantly lower in XLRP patients (42%, 43%, 31%, 18%, and 32% of control values, respectively; P < 0.04), supporting down-regulation of Delta(5)-desaturase in XLRP. The disappearance of (13)C-labeled fatty acids from plasma was not greater in XLRP patients compared with controls, suggesting that XLRP was not associated with increased rates of fatty acid oxidation or other routes of catabolism.Thus, despite individual variation among both patients and controls, the data are consistent with a lower rate of Delta(5)-desaturation, suggesting that decreased biosynthesis of DHA may contribute to lower blood levels of DHA in patients with XLRP.

Being awake intermittently during propofol-induced hypnosis: a study of BIS, explicit and implicit memory

BACKGROUND

Being awake during anaesthesia is a serious complication. An anaesthetic depth monitor must discriminate in real time between wakefulness and unconsciousness. The present study created a period of wakefulness during propofol-induced hypnosis. Bispectral index (BIS), explicit and implicit memories of the awake period were investigated.

METHODS

Ten volunteers were studied. The calculated brain concentration of a target controlled infusion of propofol was increased until loss of response (LOR) to verbal command and then propofol was stopped. When fully awake, volunteers were presented with a picture, sound and smell. Propofol infusion was restarted until LOR and then ceased. BIS and the calculated brain concentration of propofol were recorded every minute. A structured interview was conducted for explicit memories after awakening and for explicit as well as implicit memories the day after.

RESULTS

Median BIS-index for the transition between awake and asleep and vice versa differed significantly. It was not possible, however, to establish any threshold value or zone for discriminating between wakefulness and LOR due to the large inter-individual variations in BIS-index. No volunteer could explicitly recall any of the stimuli presented during the period of wakefulness.

CONCLUSION

The BIS-index decreases with increasing sedation but because of the large individual variations, the real-time BIS-index for the individual subject cannot reliably discriminate wakefulness from unconsciousness during propofol infusion. Propofol causes such profound amnesia that lack of postoperative recall does not assure that episodes of awareness have not occurred during propofol-induced hypnosis.

Low docosahexaenoic acid levels in rod outer segment membranes of mice with rds/peripherin and P216L peripherin mutations

PURPOSE

Humans with retinitis pigmentosa and dogs with progressive rod-cone degeneration (prcd) have lower than normal blood levels of long-chain polyunsaturated fatty acids, including docosahexaenoic acid (DHA), the major fatty acid found in retinal rod outer segments (ROS). In addition, prcd-affected dogs have lower levels of DHA in their ROS than control animals. The present study was designed to determine whether mice that are heterozygous for the rds mutation and transgenic mice heterozygous for a specific rds/peripherin mutation (P216L) have lower DHA levels in their ROS and other tissues than do control mice.

METHODS

Wild-type (rds(+/+)) mice, mice with the rds(-/-) (null) and rds(+/-) mutations, and mice with the P216L rds/peripherin mutation on the rds(+/-) background were maintained in the vivarium under identical husbandry conditions, and tissues were removed from each group for analysis at approximately 2 months of age. Fatty acid compositions of total lipids from plasma, red blood cells, liver, and ROS were determined by gas-liquid chromatography. ROS purity from each group was determined by SDS-PAGE with silver staining. The morphologic status of retinas representing each genotype was analyzed by light and electron microscopy.

RESULTS

There was no difference between rds(+/-), P216L on rds(+/-), and rds(+/+) (control) animals in the fatty acid composition of plasma, expressed as relative mole percent or as nanomoles fatty acid per milliliter of plasma. Small but statistically significant differences were found in 18:0 and C-22 polyunsaturated fatty acids of red blood cells. In the liver, the control animals had higher levels of 20:4n-6. In contrast, the ROS of control animals had levels of DHA that were 1.4 times that of ROS from either rds(+/-) or P216L on rds(+/-) mice of the same age. The reduction in DHA was not accompanied by an increase in 22:5n-6, which always occurs in neural tissues of animals deprived of n-3 fatty acids. SDS-PAGE of the three ROS membrane preparations showed that they were of identical purity.

CONCLUSIONS

Mice heterozygous for the spontaneous rds/peripherin mutation or mice carrying the P216L mutation on this heterozygous background have a statistically significant reduction of DHA in their ROS membranes. The authors propose that reduction in DHA is an adaptive response to metabolic stress caused by the mutation.

High serum S100B levels for trauma patients without head injuries

OBJECTIVE

Studies of patients with head trauma have demonstrated a correlation between a serum marker of brain tissue damage, namely S100B, and neuroradiological findings. It was recently demonstrated that the increases in serum S100B levels after heart surgery have extracerebral origins, probably surgically traumatized fat, muscle, and bone marrow. The current study examined multitrauma patients without head trauma, to determine whether soft-tissue and bone damage might confound the interpretation of elevated serum S100B concentrations for patients after head trauma.

METHODS

A commercial assay was used to determine serum S100B concentrations for a normal population (n = 459) and multitrauma patients without head injury (n = 17). Concentrations of the two subtypes of S100B (S100A1B and S100BB) were determined using separate noncommercial assays.

RESULTS

The mean serum S100B concentration for a normal healthy population was 0.032 microg/L (median, 0.010 microg/L; standard deviation, 0.040 microg/L). The upper 97.5% and 95% reference limits were 0.13 and 0.10 microg/L, respectively. No major age or sex differences were observed. Among trauma patients, serum S100B levels were highest after bone fractures (range, 2-10 microg/L) and thoracic contusions without fractures (range, 0.5-4 microg/L). Burns (range, 0.8-5 microg/L) and minor bruises also produced increased S100B levels. S100A1B and S100BB were detected in all samples.

CONCLUSION

Trauma, even in the absence of head trauma, results in high serum concentrations of S100B. Interpretation of elevated S100B concentrations immediately after multitrauma may be difficult because of extracerebral contributions. S100B may have a negative predictive value to exclude brain tissue damage after trauma. Similarly, nonacute S100B measurements may be of greater prognostic value than acute measurements.