The interactions between beta-blockers and anaesthetics. Experimental observations

Designer receptor manipulations reveal a role of the locus coeruleus noradrenergic system in isoflurane general anesthesia

Mechanisms driving emergence from general anesthesia are not well understood. The noradrenergic brain nucleus locus coeruleus (LC) modulates arousal and may have effects on general anesthetic state. Using virally delivered designer receptors to specifically control LC norepinephrine (NE) neurons, we investigated the causal relationship between LC-NE activity and general anesthetic state under isoflurane. Selective activation of LC-NE neurons produced cortical electroencephalography (EEG) activation under continuous deep isoflurane anesthesia. Specifically, LC-NE activation reduced burst suppression in EEG and drove a rightward shift in peak EEG frequency with reduced δ EEG power and increased θ EEG power, measures of cortical arousal. LC-NE activation also accelerated behavioral emergence from deep isoflurane anesthesia; this was prevented with β or α1 noradrenergic antagonists. Moreover, these adrenoreceptor antagonists alone were sufficient to markedly potentiate anesthetic duration when delivered centrally or peripherally. Induction of anesthesia also was retarded by LC-NE activation. Our results demonstrate that the LC-NE system strongly modulates the anesthetic state, and that changes in LC-NE neurotransmission alone can affect the emergence from isoflurane general anesthesia. Taken together, these findings extend our understanding of mechanisms underlying general anesthesia and cortical arousal, and have significant implications for optimizing the clinical safety and management of general anesthesia.

[Perioperative beta-blockers. Part one: fundamentals]

PURPOSE

To review the pharmacologic and pathophysiologic information necessary to prescribe beta-blockers (BB) in perioperative medicine.

DATA SOURCE

Manual retrieval and electronic research of the literature using MEDLINE (key-words: anesthesia and beta- blocker; surgery and beta-blocker).

DATA SYNTHESIS

Cardioselective BB inhibit preferentially beta-1 receptors, inducing a decrease in heart rate and cardiac inotropism leading to reduction of oxygen myocardial consumption. Non-cardioselective BB inhibit also beta-2 receptors, increasing bronchial and peripheral vascular resistances and uterine contractions. However, some BB are also vasodilators (carvedilol, celiprolol, labetalol). Contraindications to BB result logically from their pharmacological effects. Treatment with BB increases membrane beta-receptor density; this explains sympathetic overactivity observed during weaning of treatment. Since the discovery of propranolol in 1964, the use of BB has been controversial in anesthesia. Formerly, the adverse effects of partial sympatholysis during anesthesia and surgery were feared. However, since 1973, experimental and clinical data have suggested a protective hemodynamic effect.

CONCLUSION

Continued administration of BB up to the time of anesthesia has been encouraged except in patients with signs of intolerance such as hypotension or excessive bradycardia.

Interaction between inhalational anaesthetics and enoximone on isolated heart muscle

1. The present study describes the effects of halothane or isoflurane on enoximone activity in the isolated left atria of the rat. 2. Concentration-response curves were obtained for the positive inotropic effects of enoximone on electrically stimulated left atria. 3. Enoximone significantly (P < 0.01) increased the contractile force (56% maximum) with all the concentrations tested (10(-9) -10(-3) M). 4. When halothane (1.5% v/v) was present in the organ bath, the maximum effect obtained with enoximone (9%) was significantly lower than that obtained with enoximone alone. 5. Similar results were obtained with enoximone in the presence of halothane plus diltiazem. Isoflurane (1.5% v/v) did not significantly modify the maximum effect obtained with enoximone alone. 6. The administration of diltiazem antagonized the positive inotropic effects of enoximone in the presence of isoflurane or halothane. 7. These results shows that halothane, but not isoflurane, decreased the potency of enoximone on the isolated left atria and suggests that this effect may be mediated by the blocking of the influx of extracellular calcium through voltage-dependent calcium channels inhibited by diltiazem.