Assessment of the relationship of bispectral index values, hemodynamic changes, and recovery times associated with sevoflurane or propofol anesthesia in pigs

How is depth of anaesthesia assessed in experimental pigs? A scoping review

BACKGROUND

Despite the large number of pigs involved in translational studies, no gold standard depth of anaesthesia indicators are available. We undertook a scoping review to investigate and summarize the evidence that sustains or contradicts the use of depth of anaesthesia indicators in this species.

METHODS

Medline, Embase and CAB abstract were searched up to September 22nd 2022. No limits were set for time, language and study type. Only original articles of in vivo studies using pigs or minipigs undergoing general anaesthesia were included. The depth of anaesthesia indicators reported in the selected papers were divided in two categories: A, indicators purposely investigated as method to assess depth of anaesthesia; B, indicators reported but not investigated as method to assess depth of anaesthesia.

RESULTS

Out of 13792 papers found, 105 were included after the screening process. Category A: 17 depth of anaesthesia indicators were found in 19 papers. Studies were conducted using inhalant anaesthetics as the main anaesthetic agent in the majority of the cases (13/19 = 68.4%), while 3/19 (15.8%) used propofol. The most investigated depth of anaesthesia indicators were bispectral index (8/19 = 42.1%) and spectral edge frequency 95% (5/19 = 26.3%). Contrasting results about the specific usefulness of each depth of anaesthesia indicators were reported. Category B: 23 depth of anaesthesia indicators were found in 92 papers. The most reported depth of anaesthesia indicators were: motor response following a stimulus (37/92 = 40.2%), depth of anaesthesia scores (21/92 = 23.3%), bispectral index (16/92 = 17.8%) and spectral edge frequency 95% (9/92 = 9.8%).

CONCLUSION

Results highlight the lack of scientifically valid and reliable indicators to ensure adequate depth of anaesthesia in pigs.

Usability of the SedLine® electroencephalographic monitor of depth of anaesthesia in pigs: a pilot study

To investigate the usability of the SedLine® monitor in anaesthetized pigs. Five juvenile healthy pigs underwent balanced isoflurane-based general anaesthesia for surgical placement of a subcutaneous jugular venous port. The SedLine® was applied to continuously monitor electroencephalographic (EEG) activity and its modulation during anaesthesia. Computer tomography and magnetic resonance were performed to investigate the relationship between electrodes' positioning and anatomical structures. The pediatric SedLine® EEG-sensor could be easily applied and SedLine®-generated variables collected. An EEG Density Spectral Array (DS) was displayed over the whole procedure. During surgery, the EEG signal was dominated by elevated power in the delta range (0.5-4 Hz), with an underlying broadband signal (where power decreased with increasing frequency). The emergence period was marked by a decrease in delta power, and a more evenly distributed power over the 4-40 Hz frequency range. From incision to end of surgery, mean SedLine®-generated values (± standard deviation) were overall stable [23.0 (± 2.8) Patient State Index (PSI), 1.0% (± 3.8%) Suppression Ratio (SR), 8.8 Hz (± 2.5 Hz) Spectral Edge Frequency 95% (SEF) left, 7.7 Hz (± 2.4 Hz) SEF right], quickly changing during emergence [75.3 (± 11.1) PSI, 0.0 (± 0.0) SR, 12.5 (± 6.6) SEF left 10.4 (± 6.6) SEF right]. Based on the imaging performed, the sensor does not record EEG signals from the same brain areas as in humans. SedLine®-DSA and -generated variables seemed to reflect variations in depth of anaesthesia in pigs. Further studies are needed to investigate this correlation, as well as to define the species-specific brain structures monitored by the EEG-sensor.

Correlation of Sedline-generated variables and clinical signs with anaesthetic depth in experimental pigs receiving propofol

Most of currently available electroencephalographic (EEG)-based tools to assess depth of anaesthesia have not been studied or have been judged unreliable in pigs. Our primary aim was to investigate the dose-effect relationship between increasing propofol dose and variables generated by the EEG-based depth of anaesthesia monitor Sedline in pigs. A secondary aim was to compare the anaesthetic doses with clinical outcomes commonly used to assess depth of anaesthesia in this species. Sixteen juvenile pigs were included. Propofol infusion was administered at 10 mg kg-1 h-1, increased by 10 mg kg-1 h-1 every 15 minutes, and stopped when an EEG Suppression ratio >80% was reached. Patient state index, suppression ratio, left and right spectral edge frequency 95%, and outcomes from commonly used clinical methods to assess depth of anaesthesia in pigs were recorded. The best pharmacodynamic model was assessed for Patient state index, suppression ratio, left and right spectral edge frequency 95% in response to propofol administration. The decrease of Patient state index best fitted to an inhibitory double-sigmoid model (including a plateau phase). The increase of suppression ratio fitted a typical sigmoid Emax model. No relevant relationship could be identified between spectral edge frequency 95% values and propofol administration. A large variability in clinical outcomes was observed among pigs, such that they did not provide a reliable evaluation of propofol dose. The relationship between propofol dose and Patient state index/suppression ratio described in the present study can be used for prediction in future investigations. The evaluation of depth of anaesthesia based on common clinical outcomes was not reliable.

Heart Transplantation With Donation After Circulatory Death

Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.

Differential effects of sevoflurane and propofol on swine cardiac conduction system

OBJECTIVE

To compare the effects of sevoflurane and propofol on the porcine cardiac conduction system.

STUDY DESIGN

A prospective, comparative study of electrophysiological properties of anaesthetics agents in an experimental porcine model.

ANIMALS

A total of 36 hybrid Landrace-Large White pigs.

METHODS

After premedication with 20 mg kg^-1 of intramuscular ketamine, anaesthesia was induced with 4.5 mg kg^-1propofol intravenously. In 18 consecutive animals, anaesthesia was maintained with propofol (13 mg kg^-1 hour^-1) and in the remaining 18 animals with 2.66% sevoflurane. The femoral artery and vein were canalized for invasive monitoring, analytical blood gas sampling and intracardiac catheter insertion. Following instrumentation and after a period of stabilization, a customary electrophysiological evaluation was performed. We compared the electrophysiology of the sinus and atrioventricular node (AV) node under sevoflurane or propofol anaesthesia, and the effects of both anaesthetics on atrial and ventricular refractoriness.

RESULTS

There was a significant difference in sinus node recovery time between sevoflurane and propofol (907 ± 231 versus 753 ± 146 ms, p = 0.02). Sevoflurane in comparison with propofol significantly prolonged specialized AV conduction times, represented by an increased Wenckebach cycle length (272 ± 54 versus 235 ± 40 ms, p = 0.03) and AV nodal refractoriness (327 ± 34 versus 287 ± 30 ms, p = 0.002). In addition, sevoflurane prolonged ventricular refractoriness (298 ± 27 versus 255 ± 38 ms, p = 0.007) and the QT corrected interval (0.50 ± 0.05 versus 0.46 ± 0.09 ms, p = 0.005).

CONCLUSIONS AND CLINICAL RELEVANCE

Sevoflurane in comparison with propofol, depresses several parameters of sinus and AV nodal function and prolongs the ventricular refractoriness of the porcine cardiac conduction system. These findings should be taken into consideration for the choice of anaesthetic agents in clinical and experimental settings.

Are neuromuscular blocking agents being misused in laboratory pigs?

The literature (2012-4) describing experimental pig surgery was reviewed to estimate the extent to which neuromuscular block (NMB) is used, to examine methods for ensuring unconsciousness, and to identify the rationale for use of NMB and establish the anaesthetist's training. In the first stage of a two-stage review, NMB use was estimated using Web of Knowledge to identify articles describing NMB during pig surgeries. In the second stage, PubMed and Google Scholar were used to increase the number of articles for determining measures taken to prevent accidental awareness during general anaesthesia (AAGA). The corresponding authors of screened articles were emailed four times to establish the reason for using NMB and the anaesthetists' backgrounds (medical, veterinary, or technical). The first search revealed NMB use in 80 of 411 (20%) studies. Of the 153 articles analysed in the second stage, two described strategies to reduce AAGA. Some (6%) papers did not provide information on anaesthetic doses; citations supporting anaesthetic efficacy were found in only 13. Five of 69 papers using inhalation agents measured end-tidal anaesthetic concentrations based on human, not porcine, minimal alveolar concentrations. The methods in 13% of articles reporting anaesthetic depth assessment were incomplete or questionable, or both; four described using somatic motor reflexes. Corresponding authors of 121 articles reported that the principal reason for NMB was improved 'surgical visualization' (26%). Medical or veterinary anaesthetists supervised anaesthesia in 70% of studies; non-anaesthetists provided NMB, unsupervised, in 23. Nine respondents prioritized experimental expediency over pig welfare. In laboratory pig studies, AAGA may be prevalent; reported details of its attempted prevention are woefully inadequate.

The influence of acute pulmonary hypertension on cardiac output measurements: calibrated pulse contour analysis, transpulmonary and pulmonary artery thermodilution against a modified Fick method in an animal model

BACKGROUND

In critically ill patients with significant pulmonary hypertension (PH), close perioperative cardiovascular monitoring is mandatory, considering the increased morbidity and mortality in this patient group. Although the pulmonary artery catheter is still the standard for the diagnosis of PH, its use to monitor cardiac output (CO) in patients with PH is decreasing as a result of increased morbidity and possible influence of tricuspid regurgitation on the measurements. However, continuous CO measurement methods have never been evaluated under PH regarding their agreement and trending ability. In this study, we evaluated the influence of acute PH and different CO states on transpulmonary thermodilution (TPTD) and calibrated pulse contour analysis (PiCCO; both assessed with PiCCO plus™), intermittent pulmonary artery thermodilution (PATD), and continuous thermodilution (CCO) compared with a modified Fick method (FICK) in an animal model.

METHODS

Nine healthy pigs were studied under anesthesia. PH of 25 and 40 mm Hg (by administration of the thromboxane analog U46619), CO decreases, and CO increases were induced to test the different CO measurement techniques over a broad range of hemodynamic situations. Before each step, a new baseline data set was collected. CO values were compared using Bland-Altman analysis; trending abilities were assessed via concordance and polar plot analysis. The influence of pulmonary pressure on CO measurements was analyzed using linear mixed models.

RESULTS

A mean bias of -0.26 L/min with prediction intervals of -0.88 to 1.4 L/min was measured between TPTD and FICK. Their concordance rate was 100% (94%-100% confidence interval), and the mean polar angle -3° with radial limits of agreement of ±28° indicated good trending abilities. PATD compared with FICK also showed good trending ability. Comparisons of PiCCO and CCO versus FICK revealed low agreement and poor trending results with concordance rates of 84% (71%-93%) and 88% (74%-95%), mean polar angles from -17° and -19°, and radial limits of agreement of ±45° and 40°. Pulmonary pressures influenced only the difference between FICK and PiCCO, as assessed by linear mixed models.

CONCLUSIONS

TPTD compared with FICK was able to track all changes induced during the study period, including those by PH. It yielded better agreement than PATD both compared with FICK. PiCCO and CCO were not mapping all changes correctly, and when used clinically in unstable patients, regular controls with intermittent techniques are required. Acute pharmacologically induced PH did influence the difference between FICK and PiCCO.

Electroencephalogram-based anaesthetic depth monitoring in laboratory animals

Objective measurements of physiological parameters controlled by the autonomic nervous system such as blood pressure, heart rate and respiration are easily obtained nowadays during anaesthesia by the use of monitors: oscillometers, pulseoximeters, electrocardiograms and capnographs are available for laboratory animals. However, the effect-site of hypnotic drugs that cause general anaesthesia is the central nervous system (the brain). In the present, the adjustment of hypnotic drugs in veterinary anaesthesia is performed according to subjective evaluation of clinical signs which are not direct reflexes of anaesthetic effects on the brain, making depth of anaesthesia (DoA) assessment a complicated task. The difficulties in assessing the real anaesthetic state of a laboratory animal may not only result in welfare-threatening situations, such as awareness and pain sensation during surgery, but also in a lack of standardization of experimental conditions, as it is not easy to keep all animals from an experiment in the same DoA without a measure of anaesthetic effect. A direct measure of this dose-effect relationship, although highly necessary, is still missing in the veterinary market. Meanwhile, research has been intense in this subject and methods based on the brain electrical activity (electroencephalogram) have been explored in laboratory animal species. The objective of this review is to explain the achievements made in this topic and clarify how far we are from an objective measure of DoA for animals.

A 10min "no-touch" time - is it enough in DCD? A DCD animal study

Donation after cardiac death (DCD) is under investigation because of the lack of human donor organs. Required times of cardiac arrest vary between 75s and 27min until the declaration of the patients' death worldwide. The aim of this study was to investigate brain death in pigs after different times of cardiac arrest with subsequent cardiopulmonary resuscitation (CPR) as a DCD paradigm. DCD was simulated in 20 pigs after direct electrical induction of ventricular fibrillation. The "no-touch" time varied from 2min up to 10min; then 30min of CPR were performed. Brain death was determined by established clinical and electrophysiological criteria. In all animals with cardiac arrest of at least 6min, a persistent loss of brainstem reflexes and no reappearance of bioelectric brain activity occurred. Reappearance of EEG activity was found until 4.5min of cardiac arrest and subsequent CPR. Brainstem reflexes were detectable until 5min of cardiac arrest and subsequent CPR. According to our experiments, the suggestion of 10min of cardiac arrest being equivalent to brain death exceeds the minimum time after which clinical and electrophysiological criteria of brain death are fulfilled. Therefore shorter "no-touch" times might be ethically acceptable to reduce warm ischemia time.

Evaluation of bispectral index (BIS) as an indicator of central nervous system depression in horses anesthetized with propofol

The bispectral index (BIS) was evaluated as an indicator of central nervous system (CNS) depression in horses anesthetized with propofol. Five non-premedicated horses were anesthetized with 7 mg/kg, IV propofol and the minimum infusion rate (MIR) of propofol required to maintain anesthesia was determined during intermittent positive pressure ventilation in each horse. The BIS was determined 20 min later and after stabilization at 2.0 MIR, 1.5 MIR, and 1.0 MIR. The BIS was also recorded after the cessation of propofol infusion when the horses regained spontaneous breathing and swallowing reflex. The MIR and plasma concentration (Cp) of propofol were 0.20 +/- 0.03 mg/kg/min and 17.5 +/- 4.0 microg/ml, respectively. The BIS value and Cp were 59 +/- 13 and 26.7 +/- 8.6 microg/ml at 2.0 MIR, 63 +/- 9 and 22.9 +/- 9.7 microg/ml at 1.5 MIR, 64 +/- 13 and 20.1 +/- 5.9 microg/ml at 1.0 MIR, 64 +/- 24 and 13.0 +/- 2.8 microg/ml at return of spontaneous breathing, and 91 +/- 4 and 11.0 +/- 3.4 microg/ml when the swallowing reflex returned, respectively. The BIS value was significantly less in anesthetized horses compared to horses once swallowing returned (p=0.025). The BIS value was significantly correlated with the propofol Cp (r=-0.625, p=0.001). There was not a significant difference in the BIS values during the MIR multiples of propofol. The BIS was a useful indicator of awakening but did not indicate the degree of CNS depression during propofol-anesthesia in horses.

Effects of premedication with tiletamine/zolazepam/medetomidine during general anesthesia using sevoflurane/fentanyl in swine undergoing pancreas transplantation

OBJECTIVE

To assess cardiac and hemodynamic responses and body temperature during long-term general anesthesia using sevoflurane/fentanyl after premedication with a tiletamine/zolazepam/medetomidine combination in swine undergoing experimental pancreas transplantation.

MATERIALS AND METHODS

Twelve Landrace female pigs of means weight 46.4 +/- 5.1 kg were premedicated by intramuscular administration of tiletamine/zolazepam (3.5 mg/kg), medetomidine (0.03 mg/kg), and atropine (0.02 mg/kg), before anesthesia with 0.75 minimum alveolar concentration sevoflurane and continuous intravenous fentanyl infusion (5.7 +/- 0.7 microg/kg/h). Assessment of heart rate, arterial blood pressure, and temperature in pigs undergoing allogenic pancreas transplant surgery were registered at the start of anesthesia (T0), as well as at 60 (T60), 120 (T120), and 180 (T180) minutes after T0, and finally at the end of anesthesia (T anesthesia end), when we switched off the sevoflurane vaporizer. Analysis of variance was used to determine differences between times with P < .05 considered significant. Results are given as mean values +/- standard deviations.

RESULTS

Arterial blood pressure significantly decreased from T120 to the end of anesthesia, while a significantly decreased heart rate was only evident at T60. Body temperature decreased significantly from T60 to the end of anesthesia. These decreases, however, lacked clinical relevance; all parameters were within normal range. No major anesthetic complications were observed in this study.

CONCLUSIONS

The administration of a tiletamine/zolazepam/medetomidine combination as premedication in swine subjected to pancreas transplantation allowed for a safe reduction of sevoflurane/fentanyl requirements during long-term general anesthesia. Despite arterial blood pressure and body temperature evidencing a decrease during anesthetic maintenance, all parameters remained within normal range values.

Effect of inhalation of isoflurane at end-tidal concentrations greater than, equal to, and less than the minimum anesthetic concentration on bispectral index in chickens

OBJECTIVE

To determine the effect of inhalation of isoflurane at end-tidal concentrations greater than, equal to, and less than the minimum anesthetic concentration (MAC) on bispectral index (BIS) in chickens. Animals-10 chickens.

PROCEDURES

For each chicken, the individual MAC of isoflurane was determined by use of the toe-pinch method. After a 1-week interval, chickens were anesthetized with isoflurane at concentrations 1.75, 1.50, 1.25, 1.00, and 0.75 times their individual MAC (administered from higher to lower concentrations). At each MAC multiple, a toe pinch was performed and BIS was assessed and correlated with heart rate, blood pressure, and an awareness score (derived by use of a visual analogue scale).

RESULTS

Among the chickens, mean +/- SD MAC of isoflurane was 1.15 +/- 0.20%. Burst suppression was detected at every MAC multiple. The BIS and awareness score were correlated directly with each other and changed inversely with increasing isoflurane concentration. Median (range) BIS values during anesthesia at 1.75, 1.50, 1.25, 1.00, and 0.75 MAC of isoflurane were 25 (15 to 35), 35 (25 to 45), 35 (20 to 50), 40 (25 to 55), and 50 (35 to 65), respectively. Median BIS value at extubation was 70 +/- 9. Values of BIS correlated with blood pressure, but not with heart rate. Blood pressure changed with end-tidal isoflurane concentrations, whereas heart rate did not.

CONCLUSIONS AND CLINICAL RELEVANCE

Assessment of BIS can be used to monitor the electrical activity of the brain and the degree of unconsciousness in chickens during isoflurane anesthesia.

Bispectral index, spectral edge frequency 95% and median frequency recorded at varying desflurane concentrations in pigs

The objective of this study is to evaluate the usefulness of bispectral index (BIS), spectral edge frequency 95% (SEF) and median frequency (MED) in relation to a simple descriptive scale (SDS) as indicators of anaesthetic depth at different desflurane concentrations in swine. Sixteen pigs were randomly allocated to four groups. Electroencephalograms (EEG) were recorded during desflurane anaesthesia, and BIS, SEF and MED were calculated from the EEG. The agent was administered in pure oxygen at 1, 1.25, 1.5 and 1.7 MAC in randomized order. Anaesthetic depth was evaluated on a SDS. BIS decreased significantly (P<0.001) at the different anaesthetic dosages used. SEF decreased significantly (P<0.001) from basal to 1 MAC of desflurane. MED decreased significantly (P<0.001) from basal to 1 MAC and from 1 to 1.75 MAC. Good correlation was seen between SDS scores and BIS values and between SDS scores and MED values. BIS appeared to be useful to predict changes in anaesthetic depth at clinically used dosages of inhalant anaesthesia.

Investigation of changes in the middle latency auditory evoked potential during anesthesia with sevoflurane in dogs

OBJECTIVE

To investigate the middle latency auditory evoked potential (MLAEP) in awake dogs and dogs anesthetized with 2 concentrations of sevoflurane.

ANIMALS

10 adult Beagles.

PROCEDURE

The MLAEP was recorded while dogs were awake and anesthetized with sevoflurane (end-tidal concentration, 2.7% or 3.5%). Three needle electrodes were inserted SC, and click stimuli were delivered biaurally. Signal acquisition, averaging, and analysis were performed by use of computer software developed in-house. Signals were recorded for 128 milliseconds, and the responses to 1,024 stimuli were averaged. Waveforms from 10 recordings in each dog were averaged, and latencies of peaks were measured. Data acquired for awake dogs and dogs anesthetized with high and low sevoflurane concentrations were compared statistically.

RESULTS

Sevoflurane anesthesia attenuated the MLAEP so that only peaks P0, Na, and Pa could be identified. The MLAEP changes were maximal at the lower concentration of sevoflurane evaluated. The latencies of these peaks were significantly shorter in awake dogs, compared with values in anesthetized dogs. No difference in the peak latency was detected between the sevoflurane concentrations.

CONCLUSIONS AND CLINICAL RELEVANCE

In terms of CNS responsiveness, the effects of anesthesia with sevoflurane are similar to those of anesthesia with isoflurane. Data suggest that sevoflurane is not the inhalant agent of choice in a research setting where electroencephalographic measurements are to be recorded during anesthesia. The depression of the MLAEP waveform by sevoflurane also suggests that the MLAEP is not a suitable tool with which to monitor anesthetic depth during sevoflurane anesthesia in dogs.