Modulating role of dopamine on anesthetic requirements

Minimum Alveolar Concentration-Awake of Sevoflurane is Decreased in Patients with Parkinson's Disease: An Up-and-Down Sequential Allocation Trial

Background

An increasing number of patients with Parkinson’s disease (PD) will have surgery under general anesthesia. A previous study demonstrated that propofol requirement for inducing unconsciousness in PD patients was lower than that in non-PD (NPD) patients. However, the requirement of inhaled anesthetics in PD patients has not been clarified. The aim of this study was to investigate the minimum alveolar concentration-awake (MAC_awake) of sevoflurane in patients with PD compared to NPD patients.

Patients and Methods

The current study is an up-and-down sequential allocation trial. The initial end-tidal concentration of sevoflurane (CETsevo) was estimated by the response of the previous patient to verbal command using the Dixon’s up-and-down method. The first patient in each group received CETsevo at 1%, and the step size between patients was 0.2%.

Results

Forty-one patients including 20 PD patients and 21 NPD patients were enrolled. Patients’ characteristics and arterial blood gas parameters (except blood sodium) were comparable between two groups. The MAC_awake of sevoflurane estimated by the Dixon’s up-and-down method in PD patients (0.47% ± 0.08% [Mean ± S.D.]) was significantly lower than that in NDP patients (0.64% ± 0.10%) (P=0.003). The estimated difference in means was 0.17% (95% CI, 0.10–0.24%). Probit analysis showed that the MAC_awake of sevoflurane in PD and NPD patients was 0.49% (95% CI, 0.42–0.57%) and 0.67% (95% CI, 0.59–0.76%), respectively. The relative median potency was 0.73 (95% CI, 0.38–0.94).

Conclusion

Patients with PD exhibit a significantly lower MAC_awake of sevoflurane compared with NPD patients. Clinicians should avoid an overdose of sevoflurane in patients with PD.

Trial Registration

Registered at ChiCTR1900026956.

From cells to sensations: A window to the physics of mind

Principles of methods for studying particles and fields that cannot be sensed by third-person observers by routine methods can be used to understand the physics of first-person properties of mind. Accordingly, whenever a system exhibits disparate features at multiple levels, unique combination of constraints offered by them direct us towards a solution that will be the first principle of that system. Using this method, it was possible to arrive at a third-person observable solution-point of brain-mind interface. Examination of this location identified a set of unique features that can allow an associatively learned (cue) stimulus to spark hallucinations that form units of first-person internal (inner) sensations reminiscent of stimuli from the associatively learned second item in timescales of milliseconds. It allows us to peep into a virtual space of mind where different modifications and integrations of units of internal sensations generate their different net conformations ranging from perception to an inner sense of hidden relationships that form a hypothesis. Since sparking of inner sensations of the late arriving (when far away) or non-arriving (when hidden) features of items started providing survival advantage, the focus of evolution might have been to optimize this property. Hence, the circuity that generates it can be considered as the primary circuitry of the system. The solution provides several testable predictions. By taking readers through the process of deriving the solution and by explaining how it interconnects disparate findings, it is hoped that the factors determining the physics of mind will become evident.

A pressure-reversible cellular mechanism of general anesthetics capable of altering a possible mechanism for consciousness

Different anesthetics are known to modulate different types of membrane-bound receptors. Their common mechanism of action is expected to alter the mechanism for consciousness. Consciousness is hypothesized as the integral of all the units of internal sensations induced by reactivation of inter-postsynaptic membrane functional LINKs during mechanisms that lead to oscillating potentials. The thermodynamics of the spontaneous lateral curvature of lipid membranes induced by lipophilic anesthetics can lead to the formation of non-specific inter-postsynaptic membrane functional LINKs by different mechanisms. These include direct membrane contact by excluding the inter-membrane hydrophilic region and readily reversible partial membrane hemifusion. The constant reorganization of the lipid membranes at the lateral edges of the postsynaptic terminals (dendritic spines) resulting from AMPA receptor-subunit vesicle exocytosis and endocytosis can favor the effect of anesthetic molecules on lipid membranes at this location. Induction of a large number of non-specific LINKs can alter the conformation of the integral of the units of internal sensations that maintain consciousness. Anesthetic requirement is reduced in the presence of dopamine that causes enlargement of dendritic spines. Externally applied pressure can transduce from the middle ear through the perilymph, cerebrospinal fluid, and the recently discovered glymphatic pathway to the extracellular matrix space, and finally to the paravenular space. The pressure gradient reduce solubility and displace anesthetic molecules from the membranes into the paravenular space, explaining the pressure reversal of anesthesia. Changes in membrane composition and the conversion of membrane hemifusion to fusion due to defects in the checkpoint mechanisms can lead to cytoplasmic content mixing between neurons and cause neurodegenerative changes. The common mechanism of anesthetics presented here can operate along with the known specific actions of different anesthetics.

Hypnotic hypersensitivity to volatile anesthetics and dexmedetomidine in dopamine β-hydroxylase knockout mice

BACKGROUND

Multiple lines of evidence suggest that the adrenergic system can modulate sensitivity to anesthetic-induced immobility and anesthetic-induced hypnosis as well. However, several considerations prevent the conclusion that the endogenous adrenergic ligands norepinephrine and epinephrine alter anesthetic sensitivity.

METHODS

Using dopamine β-hydroxylase knockout (Dbh) mice genetically engineered to lack the adrenergic ligands and their siblings with normal adrenergic levels, we test the contribution of the adrenergic ligands upon volatile anesthetic induction and emergence. Moreover, we investigate the effects of intravenous dexmedetomidine in adrenergic-deficient mice and their siblings using both righting reflex and processed electroencephalographic measures of anesthetic hypnosis.

RESULTS

We demonstrate that the loss of norepinephrine and epinephrine and not other neuromodulators co-packaged in adrenergic neurons is sufficient to cause hypersensitivity to induction of volatile anesthesia. However, the most profound effect of adrenergic deficiency is retarding emergence from anesthesia, which takes two to three times as long in Dbh mice for sevoflurane, isoflurane, and halothane. Having shown that Dbh mice are hypersensitive to volatile anesthetics, we further demonstrate that their hypnotic hypersensitivity persists at multiple doses of dexmedetomidine. Dbh mice exhibit up to 67% shorter latencies to loss of righting reflex and up to 545% longer durations of dexmedetomidine-induced general anesthesia. Central rescue of adrenergic signaling restores control-like dexmedetomidine sensitivity. A novel continuous electroencephalographic analysis illustrates that the longer duration of dexmedetomidine-induced hypnosis is not due to a motor confound, but occurs because of impaired anesthetic emergence.

CONCLUSIONS

Adrenergic signaling is essential for normal emergence from general anesthesia. Dexmedetomidine-induced general anesthesia does not depend on inhibition of adrenergic neurotransmission.

Sleep and Anesthesia Interactions: A Pharmacological Appraisal

Anesthetics have been used in clinical practice for over a hundred years, yet their mechanisms of action remain poorly understood. One tempting hypothesis to explain their hypnotic properties posits that anesthetics exert a component of their effects by "hijacking" the endogenous arousal circuitry of the brain. Modulation of activity within sleep- and wake-related neuroanatomic systems could thus explain some of the varied effects produced by anesthetics. There has been a recent explosion of research into the neuroanatomic substrates affected by various anesthetics. In this review, we will highlight the relevant sleep architecture and systems and focus on studies over the past few years that implicate these sleep-related structures as targets of anesthetics. These studies highlight a promising area of investigation regarding the mechanisms of action of anesthetics and provide an important model for future study.

Mechanisms of anesthetic actions and the brain

The neural mechanisms behind anesthetic-induced behavioral changes such as loss of consciousness, amnesia, and analgesia, are insufficiently understood, though general anesthesia has been of tremendous importance for the development of medicine. In this review, I summarize what is currently known about general anesthetic actions at different organizational levels and discuss current and future research, using systems neuroscience approaches such as functional neuroimaging and quantitative electrophysiology to understand anesthesia actions at the integrated brain level.

The effect of sevoflurane on the release of [3H]dopamine from rat brain cortical slices

Dopamine is a neurotransmitter that exerts major control on important brain functions and some lines of studies suggest that dopaminergic neurotransmission may be a potential target for volatile anesthetics. In the present study, rat brain cortical slices were labeled with [(3)H]dopamine to investigate the effects of sevoflurane on the release of this neurotransmitter. [(3)H]dopamine release was significantly increased in the presence of sevoflurane (0.46 mM) and this effect was independent of extracellular or intracellular calcium. In addition, [(3)H]dopamine release evoked by sevoflurane was not affected by TTX (blocker of voltage-dependent sodium channels) or reserpine (a blocker of the vesicular monoamine transporter). These data suggest that the dopamine release induced by sevoflurane is non-vesicular, independent of exocytosis and, would be mediated by the dopamine transporter (DAT). GBR12909 and nomifensine, inhibitors of DAT, decreased the release of [(3)H]dopamine evoked by sevoflurane. The same effect was also observed when the brain cortical slices were incubated at low temperature and low extracellular sodium. Ouabain, a Na(+)/K(+) ATPase pump inhibitor, which is known to induce dopamine release through reverse transport, decreased [(3)H]dopamine release induced by sevoflurane. In conclusion, the present study suggests that sevoflurane increases [(3)H]dopamine release in brain cortical slices that is mediated by DAT located at the plasma membrane.

Do dopamine receptors mediate part of MAC?

BACKGROUND

Depletion of central nervous system catecholamines, including dopamine, can decrease MAC (the minimum alveolar concentration of an inhaled anesthetic required to suppress movement in response to a noxious stimulus in 50% of test subjects); release of central nervous system catecholamines, including dopamine, can increase MAC; and increased free dopamine concentrations in the striatum can decrease MAC. Such findings suggest that dopamine receptors might mediate part of the capacity of inhaled anesthetics to provide immobility in the face of noxious stimulation.

METHODS

We measured the effect of blockade of D2 dopamine-mediated transmission with 0.3 mg/kg or 3.0 mg/kg droperidol on the MAC of cyclopropane, desflurane, halothane, isoflurane, or sevoflurane in rats, and the effect of 3.0 mg/kg droperidol on the dose or concentration of etomidate (an anesthetic known to act principally by enhancing the response of gamma-aminobutyric acid(A) receptors to gamma-aminobutyric acid) required to suppress movement in response to noxious stimulation.

RESULTS

Blockade of D2 dopamine-mediated transmission with droperidol does not decrease the MAC of cyclopropane, desflurane, halothane, isoflurane, or sevoflurane or its equivalent for etomidate in rats.

CONCLUSIONS

These data, plus data from studies by others about D1 dopamine receptors, indicate that dopamine receptors do not mediate the immobility produced by inhaled anesthetics.

Isoflurane induces dopamine transporter trafficking into the cell cytoplasm

Previous investigations have shown that the binding of a selective hydrophilic positron emission tomography radiotracer for the dopamine transporter (DAT) (2beta-carbomethoxy-3beta-(4-chlorophenyl)-8-(2-18F-fluoroethyl)nortropane) decreased in monkey striatum during deep isoflurane anesthesia. Immunohistochemistry experiments suggested but did not prove that isoflurane induced a decrease in cell surface DAT. The present investigation was undertaken to demonstrate quantitatively the isoflurane-induced internalization of DAT using a rapid and relatively uncomplicated biochemical technique in human embryonic kidney (HEK-293) cells stably expressing the human DAT (h-DAT) protein. Biotinylation followed by Western blot analysis was used to determine the extent of change in cell surface expression of the DAT under control conditions and in the presence of a clinically relevant concentration of isoflurane. Isoflurane treatment for 30 min resulted in a highly significant decrease in the amount of h-DAT on the cell surface (21 +/- 15% of control; P < 0.01) (mean +/- SD; n = 4). These data are consistent with the hypothesis that isoflurane results in internalization of DAT from the cell membrane and further validate our qualitative results reported previously. In addition, the current results confirm the hypothesis that biotinylation can be used to quantitate the extent of disappearance of DAT from the cell surface making dose-response studies and comparisons of DAT internalization with other general anesthetics practical.

Clonidine reduces dopamine and increases GABA in the nucleus accumbens: an in vivo microdialysis study

The effects of clonidine, an alpha2 adrenoceptor agonist, on extracellular concentrations of dopamine and gamma-aminobutyric acid (GABA) in the nucleus accumbens of rats were studied by using in vivo brain microdialysis. Clonidine (5 microg/kg i.v.) significantly decreased the brain microdialysate concentration of dopamine in the nucleus accumbens up to a maximum of 16% at its peak effect. This effect was inhibited by a dose of idazoxan (10 microg/kg i.v.), an alpha2-adrenoceptor antagonist. which itself did not affect the efflux of dopamine. A smaller dose of clonidine (1 microg/kg i.v.), which had no significant effect on dopamine efflux per se, decreased the dopamine efflux (21% reduction) when given together with an ineffective dose of midazolam (0.075 mg/kg i.v.), a benzodiazepine receptor agonist. The effect of clonidine (5 microg/kg i.v.) on mesolimbic dopamine efflux was abolished by bicuculline (1 mg/kg i.v.), a GABA(A) receptor antagonist, counteracted by beta-carboline-3-carboxylate ethyl ester (beta-CCE, 3 mg/kg i.p.), a benzodiazepine receptor inverse agonist, but not affected by flumazenil (6 microg/kg i.v.), a benzodiazepine receptor antagonist. Clonidine (5 microg/kg i.v.) increased the dialysate concentration of GABA in the nucleus accumbens up to a maximum of 250% at its peak effect, but not in the ventral tegmental area. It is hypothesized that GABA(A) binding sites in the nucleus accumbens form part of the sequence of events that is triggered by clonidine in an alpha2-adrenergic-specific manner and that ultimately results in a decreased release of dopamine in the nucleus accumbens.

Cellular localization of dopamine D2 receptor messenger RNA in the rat trigeminal ganglion

The actions of dopamine are mediated by specific, high-affinity, G protein-coupled receptors. Multiple subtypes of dopamine receptors have been characterized, including the D2 subtype (D2R). Cells within the dorsal root and petrosal ganglia of the rat express D2R messenger RNA (mRNA) consistent with D2R expression by primary sensory neurons. We hypothesized that neurons of the trigeminal ganglion express D2R mRNA. Total cellular RNA from rat trigeminal ganglia was analyzed on Northern blots under high stringency conditions. Hybridization of trigeminal ganglion RNA resulted in a signal which comigrated with striatal, pituitary, and hypothalamic D2R mRNA. To determine the distribution of D2R expressing cells in the trigeminal ganglion, cryostat sections were analyzed by in situ hybridization followed by emulsion autoradiography. We identified a population of clustered cells labeled with dense grain concentrations over their cytoplasms. These findings demonstrate the expression of D2 dopamine receptor mRNA in discrete subpopulations of neurons in the rat trigeminal ganglion. Our observations suggest that drugs active at dopamine receptors of the D2 subtype are potential modulators of sensory activity of neurons whose cell bodies reside in the trigeminal ganglion. D2 dopamine receptors may thus have a role in clinical pain syndromes involving the head and neck.

Metoclopramide and prochlorperazine do not decrease propofol hypnotic requirements

One hundred patients scheduled for minor surgery were given either saline, metoclopramide 0.1 mg.kg-1 or 0.2 mg.kg-1, or prochlorperazine 0.1 mg.kg-1 or 0.2 mg.kg-1 before induction of anaesthesia with a fixed rate infusion of propofol. Neither metoclopramide nor prochlorperazine reduced the induction dose of propofol. The possibility that these agents increased the induction dose could not be excluded.

Chronic administration of an alpha 2 adrenergic agonist desensitizes rats to the anesthetic effects of dexmedetomidine

alpha 2 adrenergic agonists are being administered perioperatively to facilitate the anesthetic management of the surgical patient. In some clinical settings, use of alpha 2 adrenergic agonists has been extended into the postoperative period to prolong the patients' sedative and stress-free state. We studied whether the administration of alpha 2 adrenergic agonists over an extended period of time would result in "desensitization" to the central actions of alpha 2 adrenergic agonists. Male Sprague-Dawley rats were administered dexmedetomidine, a highly selective alpha 2 adrenergic agonist, at rates varying between 1 and 10 micrograms.kg-1.h-1 via a chronically implanted SC osmotic pump. Spontaneous locomotor activity, tested in an open-field box, was significantly lower in both 3- and 10-micrograms.kg-1.h-1 treatment groups but returned to normal by the second or sixth day, respectively. The hypnotic response to dexmedetomidine IP was decreased in the 10-micrograms.kg-1.h-1 dose group from the second day, and by the fourth day in the 3-micrograms.kg-1.h-1 group. Recovery from the desensitized state was rapid and occurred on the third day after pump removal in the 3-micrograms.kg-1.h-1 group and by the fifth day after pump removal in the 10-micrograms.kg-1.h-1 dose group. By using a higher dose of dexmedetomidine IP (250 micrograms.kg in lieu of 100 micrograms/kg) at day 7 in "tolerant" rats, the hypnotic response could partially be "restored" towards normal. An attenuated hypnotic response could still be demonstrated even when dexmedetomidine was administered directly into the locus coeruleus (LC) in rats pretreated chronically with dexmedetomidine.(ABSTRACT TRUNCATED AT 250 WORDS)

Effets des anesthésiques intraveineux sur les neurones du système nerveux central : mécanismes d'action cellulaires et moléculaires

The mechanisms of action of intravenous anaesthetics are not yet completely elucidated. Until recently, most of the studies had focused on the interactions between anaesthetics and lipid bilayers. It has been proposed that loss of consciousness is produced by disorganization of the lipid phase of nerve membranes, which impairs the action potential propagation. However, new data obtained with sophisticated neuropharmacological tools such as the patch clamp technique have recently contributed to challenge this hypothesis. Indeed, several lines of evidence suggest that intravenous anaesthetics are thought to induce loss of consciousness by blocking the excitatory synaptic transmission. This can be achieved presynaptically, by inhibiting glutamate release from nerve endings via alterations in the gating properties of voltage-dependent calcium channels. Blockade of excitatory synaptic transmission can also occur at the postsynaptic level by antagonizing the glutamate receptors of the N-methyl D-aspartate subtype. Some anaesthetic agents including ketamine also block the nicotinic receptors, however the relevance of this finding with respect to clinical anaesthesia requires further investigation. Preliminary data also suggest that propofol and etomidate elicit uncoupling of gap junctions between astrocytes, which represent a major nonneuronal cell population in the central nervous system. This phenomenon might indirectly contribute to the hypnotic action of these compounds. Whether loss of consciousness involves preferential target structures within the brain remains to be delineated. A better understanding of the mechanisms of action of general anaesthetics might contribute to generate new agents with more pharmacological selectivity and less undesirable side-effects.