Pretreatment with Dexmedetomidine

Clinical Use of a Multivariate Electroencephalogram (Narcotrend) for Assessment of Anesthetic Depth in Horses during Isoflurane-Xylazine Anesthesia

Objective

To investigate the use of the Narcotrend electroencephalogram (EEG) monitor for the assessment of anesthetic depth in horses undergoing xylazine balanced isoflurane anesthesia.

Study design

Blinded experimental study.

Animals

Seven healthy warm-blooded horses, aged 10.6 ± 5.9 years, weighing 535 ± 55 kg.

Methods

Horses were anesthetized for a terminal surgical trial with xylazine, thiopentone, and guaiphenesin for induction and isoflurane and xylazine continuous rate infusion for maintenance. After surgery, an EEG was recorded and processed by the Narcotrend monitor. It displays an index [Narcotrend index (NI)] between 0 and 100, which is supposed to indicate anesthetic depth. This index was recorded and correlated with eight different end tidal (ET) isoflurane concentrations between 0.8 and 2.2 vol%. In addition, anesthetic depth was numerically scored based on common clinical signs with a score of 1 (plane “too deep”) to 4 (plane “too light”). After testing for normal distribution, both clinical scores and NI were correlated with different ET isoflurane concentrations using Spearman rank correlation.

Results

Correlation of NI with ET isoflurane concentrations was poor (r_s = 0.24). The NI ranged between maximal 48 and minimal 13 in the horses. The clinical scores decreased with increasing ET isoflurane concentrations (r_s = 0.80). They ranged from 1 to 4 in different horses at the concentrations investigated.

Conclusion

In this study, the NI did not seem to be useful for assessment of anesthetic depth in horses receiving isoflurane anesthesia balanced with a xylazine constant rate infusion.

Pharmacokinetics of dexmedetomidine administered intravenously in isoflurane-anesthetized cats

OBJECTIVE

To determine the pharmacokinetics of dexmedetomidine administered as a short-duration IV infusion in isoflurane-anesthetized cats.

ANIMALS

6 healthy adult domestic female cats.

PROCEDURES

Dexmedetomidine hydrochloride was injected IV (10 μg/kg over 5 minutes [rate, 2 μg/kg/min]) in isoflurane-anesthetized cats. Blood samples were obtained immediately prior to and at 1, 2, 5, 6, 7, 10, 15, 30, 60, 90, 120, 240, and 480 minutes following the start of the IV infusion. Collected blood samples were transferred to tubes containing EDTA, immediately placed on ice, and then centrifuged at 3,901 × g for 10 minutes at 4°C. The plasma was harvested and stored at -20°C until analyzed. Plasma dexmedetomidine concentrations were determined by means of liquid chromatography-mass spectrometry. Dexmedetomidine plasma concentration-time data were fitted to compartmental models.

RESULTS

A 2-compartment model with input in and elimination from the central compartment best described the disposition of dexmedetomidine administered via short-duration IV infusion in isoflurane-anesthetized cats. Weighted mean ± SEM apparent volume of distribution of the central compartment and apparent volume of distribution at steady-state were 402 ± 47 mL/kg and 1,701 ± 200 mL/kg, respectively; clearance and terminal half-life (harmonic mean ± jackknife pseudo-SD) were 6.3 ± 2.8 mL/min/kg and 198 ± 75 minutes, respectively. The area under the plasma concentration curve and maximal plasma concentration were 1,061 ± 292 min•ng/mL and 17.6 ± 1.8 ng/mL, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

Disposition of dexmedetomidine administered via short-duration IV infusion in isoflurane-anesthetized cats was characterized by a moderate clearance and a long terminal half-life.

Effect of dexmedetomidine on the minimum alveolar concentration of isoflurane in cats

This study reports the effects of dexmedetomidine on the minimum alveolar concentration of isoflurane (MAC(iso) ) in cats. Six healthy adult female cats were used. MAC(iso) and dexmedetomidine pharmacokinetics had previously been determined in each individual. Cats were anesthetized with isoflurane in oxygen. Dexmedetomidine was administered intravenously using target-controlled infusions to maintain plasma concentrations of 0.16, 0.31, 0.63, 1.25, 2.5, 5, 10, and 20 ng/mL. MAC(iso) was determined in triplicate at each target plasma dexmedetomidine concentration. Blood samples were collected and analyzed for dexmedetomidine concentration. The following model was fitted to the concentration-effect data: [Formula in text] where MAC(iso.c) is MAC(iso) at plasma dexmedetomidine concentration C, MAC(iso.0) is MAC(iso) in the absence of dexmedetomidine, I(max) is the maximum possible reduction in MAC(iso), and IC(50) is the plasma dexmedetomidine concentration producing 50% of I(max). Mean ± SE MAC(iso.0), determined in a previous study conducted under conditions identical to those in this study, was 2.07 ± 0.04. Weighted mean ± SE I(max), and IC(50) estimated by the model were 1.76 ± 0.07%, and 1.05 ± 0.08 ng/mL, respectively. Dexmedetomidine decreased MAC(iso) in a concentration-dependent manner. The lowest MAC(iso) predicted by the model was 0.38 ± 0.08%, illustrating that dexmedetomidine alone is not expected to result in immobility in response to noxious stimulation in cats at any plasma concentration.

Bispectral analysis of the electroencephalogram: a review of its development and use in anesthesia

OBJECTIVE

To evaluate the different methodologies used to monitor anesthetic depth and to review the principles and potential applications of bispectral index (BIS) monitoring in veterinary anesthesia.

DATABASES USED

Medline (1966 to present); Pubmed (mid-1960s to present); personal files.

CONCLUSIONS

Current anesthetic monitoring techniques rely on indirect measures of corticocerebral arousal after a noxious stimulus. Some anesthetics and pre-anesthetics suppress responses that are used to gauge adequate hypnosis and analgesia. The BIS is a direct measure of corticocerebral activation and is inversely related to the degree of hypnosis. Dynamic changes in the BIS after a noxious stimulus may signify early nociceptive activation of the cerebral cortex and may be a useful marker of inadequate analgesia. However, application of this technique during the use of various drug combinations (i.e. clinical anesthesia) will require further research and understanding.

Preservation of the cortical somatosensory-evoked potential during dexmedetomidine infusion in rats

Successful somatosensory-evoked potential (SEP) monitoring has been performed during the administration of dexmedetomidine to patients, but a systematic investigation of the dose response of the SEP to dexmedetomidine has not been reported. In this study, we evaluated the effect of a range of dexmedetomidine doses on the cortical SEP in rats. Twelve rats were initially anesthetized with ketamine and the lungs were mechanically ventilated. Femoral arterial and venous catheters were placed. Anesthesia was maintained with constant infusions of remifentanil (5-15 microg. kg(-1). min(-1)) and vecuronium (56 microg. kg(-1). min(-1)). Dexmedetomidine was infused at 0.1, 0.25, 0.5, 1.0, and 2.0 microg. kg(-1). min(-1) in a stepwise manner with 10-min infusion periods at each step. In eight rats, an additional large-dose infusion of dexmedetomidine at 10 microg. kg(-1). min(-1) was administered for 30 min. The cortical SEPs were recorded after stimulation of the tibial nerve. At all infusion rates, there was a statistically insignificant increase in the SEP amplitude. Dexmedetomidine consistently increased the SEP latency, but these increases were not statistically significant. These data demonstrate that dexmedetomidine maintains technically adequate conditions for SEP monitoring in rats and provides support for future studies of the effect of dexmedetomidine on SEP monitoring in humans.

IMPLICATIONS

In rats, the administration of a wide range of infusion rates of dexmedetomidine did not significantly affect the somatosensory-evoked potential. These results suggest that dexmedetomidine might be a useful adjunctive drug in patients undergoing intraoperative somatosensory-evoked potential monitoring.

Dexmedetomidine modulates cardiovascular responses to stimulation of central nervous system pressor sites

Halothane attenuates the alterations in arterial pressure (BP) and heart rate (HR) produced by central nervous svstem (CNS) stimulation. We examined the effects of the alpha2-adrenergic agonist dexmedetomidine, with and without halothane, on cardiovascular regulation during CNS pressor site stimulation in chronically instrumented cats. Stimuli trains via bipolar stimulating electrodes in the hypothalamus and reticular formation elicited pressor responses. Dexmedetomidine-induced (15 microg/kg PO) bradycardia was greater in the presence of halothane. CNS stimulation increased BP and HR, which were dose-dependently attenuated by halothane (hypothalamic stimulation 71 +/- 9 mm Hg at control, 25 +/- 5 and 15 +/- 3 mm Hg at 1.0% and 1.5% halothane, respectively). Although dexmedetomidine alone did not alter pressor responses, halothane plus dexmedetomidine attenuated pressor responses in a potentially synergistic fashion (hypothalamic stimulation 67 +/- 8 mm Hg at control, 2 +/- 1 and 1 +/- 0.4 mm Hg at 1.0% and 1.5% halothane, respectively). These results suggest differences in the disruptive effects of CNS-mediated cardiovascular responses by halothane and dexmedetomidine, and that dexmedetomidine has an anesthetic-sparing effect on these CNS-mediated cardiovascular control mechanisms, potentiating the depressant effect of halothane.

IMPLICATIONS

A new potential anesthetic adjunct, dexmedetomidine, does not attenuate brain-mediated increases in blood pressure, but the combination of dexmedetomidine and the anesthetic halothane acts to modulate central cardiovascular responses.