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Concept: Local anesthetic

169

General anesthetics are used during medical and surgical procedures to reversibly induce a state of total unconsciousness in patients. Here, we investigate, from a dynamic network perspective, how the cortical and cardiovascular systems behave during anesthesia by applying nonparametric spectral techniques to cortical electroencephalography, electrocardiogram and respiratory signals recorded from anesthetized rats under two drugs, ketamine-xylazine (KX) and pentobarbital (PB). We find that the patterns of low-frequency cortico-cardio-respiratory network interactions may undergo significant changes in network activity strengths and in number of network links at different depths of anesthesia dependent upon anesthetics used.

Concepts: Pharmacology, Surgery, Anesthesia, General anaesthesia, Chloroform, Local anesthetic, Anesthetic, EEG measures during anesthesia

168

Lubeluzole, which acts on various targets in vitro, including voltage-gated sodium channels (NaChs), was initially proposed as neuroprotectant. Lubeluzole structure contains a benzothiazole moiety (R-like) related to riluzole and a phenoxy-propranol-amine moiety (A-core) recalling propranolol. Both riluzole and propranolol are efficient NaCh blockers. We studied in detail the effects of lubeluzole (racemic mixture and single isomers), aforementioned lubeluzole moieties, and riluzole on NaChs to increase our knowledge about drug-channel molecular interactions. Compounds were tested on hNav1.4 NaChs, and F1586C or Y1593C mutants functionally expressed in HEK293 cells, using patch-clamp. Lubeluzole blocked NaChs with a remarkable effectiveness. No stereoselectivity was found. Compared to mexiletine, dissociation constant for inactivated channels was ≈600 times lower (≈11 nM), conferring to lubeluzole a huge use-dependence of great therapeutic value. The F1586C mutation impaired use-dependent block only partially, suggesting that additional amino acids are critically involved in high-affinity binding. Lubeluzole moieties were modest NaCh blockers. Riluzole blocked NaChs efficiently but lacked use-dependence, similarly to R-like. F1586C fully abolished A-core use-dependence, suggesting that A-core binds to the local anesthetic receptor. Thus lubeluzole likely binds to the local anesthetic receptor through its phenoxy-propranol-amine moiety, with consequent use-dependent behavior. Nevertheless, compared to other known NaCh blockers, lubeluzole adds a third pharmacophoric point through its benzothiazole moiety, that greatly enhances high-affinity binding and use-dependent block. If sufficient isoform specificity can be attained, the huge use-dependent block may help in the development of new NaCh inhibitors to provide pharmacotherapy for membrane excitability disorders, such as myotonia, epilepsy, or chronic pain.

Concepts: Protein, Acid, Amine, Functional group, Ion channel, Local anesthetic, Racemic mixture, Adderall

39

The neurophysiological mechanisms by which anesthetic drugs cause loss of consciousness are poorly understood. Anesthetic actions at the molecular, cellular, and systems levels have been studied in detail at steady states of deep general anesthesia. However, little is known about how anesthetics alter neural activity during the transition into unconsciousness. We recorded simultaneous multiscale neural activity from human cortex, including ensembles of single neurons, local field potentials, and intracranial electrocorticograms, during induction of general anesthesia. We analyzed local and global neuronal network changes that occurred simultaneously with loss of consciousness. We show that propofol-induced unconsciousness occurs within seconds of the abrupt onset of a slow (<1 Hz) oscillation in the local field potential. This oscillation marks a state in which cortical neurons maintain local patterns of network activity, but this activity is fragmented across both time and space. Local (<4 mm) neuronal populations maintain the millisecond-scale connectivity patterns observed in the awake state, and spike rates fluctuate and can reach baseline levels. However, neuronal spiking occurs only within a limited slow oscillation-phase window and is silent otherwise, fragmenting the time course of neural activity. Unexpectedly, we found that these slow oscillations occur asynchronously across cortex, disrupting functional connectivity between cortical areas. We conclude that the onset of slow oscillations is a neural correlate of propofol-induced loss of consciousness, marking a shift to cortical dynamics in which local neuronal networks remain intact but become functionally isolated in time and space.

Concepts: Nervous system, Neuron, Brain, Cognition, Cerebral cortex, Anesthesia, Local anesthetic, Anesthetic

28

Venipuncture and intravenous cannulation are the most common painful procedures performed on children. The most widely used topical anesthetic is eutectic mixture of local anesthetics (EMLA). EMLA use is associated with a transient cutaneous vasoconstriction which can make it difficult to identify veins. We assessed with a prospective, multicenter, observational study whether EMLA interferes with venipuncture and intravenous cannulation. The primary study outcome was a success at first attempt in the course of venipuncture or venous cannulation. The study enrolled 388 children; 255 of them received EMLA and 133 did not. Eighty-six percent of procedures were successful at the first attempt in the EMLA group and 76.7 % in the no EMLA group. Conclusion: In this study, EMLA use did not interfere with the success of venipuncture or venous cannulation in children.

Concepts: Anesthesia, Topical anesthetic, Local anesthetic, Lidocaine, Local anesthetics, Prilocaine, Lidocaine/prilocaine

28

Profound pulpal anesthesia in posterior mandibular teeth with irreversible pulpitis usually requires administering an inferior alveolar nerve block (IANB) plus other supplemental injections. The purpose of this prospective, randomized, double-blind study was to compare the anesthetic success rate of buccal infiltration injections of articaine and lidocaine when supplemented with an IANB.

Concepts: Cranial nerves, Mandibular nerve, Local anesthetic, Inferior alveolar nerve, Mandibular canal

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We hypothesize that isoflurane and ketamine impact ventilatory pattern variability (VPV) differently. Adult Sprague-Dawley rats were recorded in a whole-body plethysmograph before, during and after deep anesthesia. VPV was quantified from 60-s epochs using a complementary set of analytic techniques that included constructing surrogate data sets that preserved the linear structure but disrupted nonlinear deterministic properties of the original data. Even though isoflurane decreased and ketamine increased respiratory rate, VPV as quantified by the coefficient of variation decreased for both anesthetics. Further, mutual information increased and sample entropy decreased and the nonlinear complexity index (NLCI) increased during anesthesia despite qualitative differences in the shape and period of the waveform. Surprisingly mutual information and sample entropy did not change in the surrogate sets constructed from isoflurane data, but in those constructed from ketamine data, mutual information increased and sample entropy decreased significantly in the surrogate segments constructed from anesthetized relative to unanesthetized epochs. These data suggest that separate mechanisms modulate linear and nonlinear variability of breathing.

Concepts: Fundamental physics concepts, Anesthesia, Randomness, Surrogate, Information theory, Ketamine, Local anesthetic, Anesthetic

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BACKGROUND: Interscalene nerve blocks provide adequate analgesia, but there are no objective criteria for early assessment of correct catheter placement. In the present study, pulse oximetry technology was used to evaluate changes in the perfusion index (PI) in both blocked and unblocked arms, and changes in the plethysmographic variability index (PVI) were evaluated once mechanical ventilation was instituted. METHODS: The PI and PVI values were assessed using a Radical-7™ finger pulse oximetry device (Masimo Corp., Irvine, CA, USA) in both arms of 30 orthopedic patients who received an interscalene catheter at least 25 min before induction of general anesthesia. Data were evaluated at baseline, on application of local anesthetics; five, ten, and 15 min after onset of interscalene nerve blocks; after induction of general anesthesia; before and after a 500 mL colloid fluid challenge; and five minutes thereafter. RESULTS: In the 25 patients with successful blocks, the difference between the PI values in the blocked arm and the PI values in the contralateral arm increased within five minutes of the application of the local anesthetics (P < 0.05) and increased progressively until 15 min. After induction of general anesthesia, the PI increased in the unblocked arm while it remained relatively constant in the blocked arm, thus reducing the difference in the PI. A fluid challenge resulted in a decrease in PVI values in both arms. CONCLUSION: The perfusion index increases after successful interscalene nerve blockade and may be used as an indicator for successful block placement in awake patients. The PVI values before and after a fluid challenge can be useful to detect changes in preload, and this can be performed in both blocked and unblocked arms. (ClinicalTrials.gov number: NCT 01389011).

Concepts: Anesthesia, Local anesthesia, Catheter, Pulse oximetry, Local anesthetic, Block, Blocking, Masimo

28

The nonselective sodium channel blocker lidocaine is widely used as a local anesthetic but also systemically for treatment of postoperative and neuropathic pain. Voltage-gated sodium channels are crucial for action potential generation and conduction, and their availability controls the amount of activity-dependent conduction velocity slowing. This important axonal property, as assessed by microneurography, is used to differentiate human mechanoinsensitive (silent) nociceptors from the classical polymodal nociceptors. In the current study, microneurography was used to assess axonal properties of the 2 main nociceptor classes in humans, before and after intradermal injection of lidocaine .1% or control saline solution in the receptive field. In mechanosensitive nociceptors, lidocaine reduced baseline conduction velocity and turned activity-dependent slowing into speeding of conduction. In contrast, mechanoinsensitive fibers were not affected in their baseline conduction velocity or their activity-dependent slowing, but probability of conduction block with repetitive stimulation increased. Recovery cycles showed reduced hyperpolarization in all C-fiber classes after lidocaine injections. These results support our hypothesis that sodium channel subtypes are differentially expressed in the 2 nociceptor classes of mechanosensitive C-fibers (CMs) and mechanoinsensitive C-fibers (CMis). PERSPECTIVE: This study reveals that microneurography can be used to assess pharmacological effects on single C-fibers directly in humans.

Concepts: Pharmacology, Neuron, Action potential, Pain, Sodium channel, Sodium channel blocker, Local anesthetic, Lidocaine

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BACKGROUND: /st>Dexmedetomidine is an α-2-receptor agonist which might be used as an additive to local anaesthetics for various regional anaesthetic techniques. We therefore designed this prospective, double-blinded, controlled volunteer study to investigate the effects of dexmedetomidine as an adjuvant to ropivacaine on peripheral nerve block. METHODS: /st>Ultrasound-guided ulnar nerve block (UNB) was performed in 36 volunteers with either 3 ml ropivacaine 0.75% ®, 3 ml ropivacaine 0.75% plus 20 µg dexmedetomidine (RpD), or 3 ml ropivacaine 0.75% plus systemic 20 µg dexmedetomidine (RsD). UNB-related sensory and motor scores were evaluated. RESULTS: /st>Sensory onset time of UNB was not different between the study groups, whereas motor onset time was significantly faster in Group RpD when compared with the other study groups [mean (sd)] [21 (15) vs 43 (25) min in Group RsD and 47 (36) min in Group R, P<0.05 Group RpD vs other groups]. The duration of sensory block was 350 (54) min in Group R, 555 (118) min in Group RpD, and 395 (40) min in Group RsD (P<0.01 Group RpD vs other groups, P<0.05 Group RsD vs Group R). Motor block duration was similar to the duration of sensory block. CONCLUSIONS: /st>A profound prolongation of UNB of ∼60% was detected with perineural dexmedetomidine when added to 0.75% ropivacaine. The systemic administration of 20 µg dexmedetomidine resulted in a prolongation of ∼10% during UNB with 0.75% ropivacaine.Eudra-CT No.: 2012-000030-19.

Concepts: Time, Anesthesia, Local anesthetic, Regional anesthesia

27

Lidocaine vaginal bioadhesive gel is being developed as a local anesthetic for use in minimally invasive outpatient gynecological procedures and was investigated in single-dose and multiple-dose studies in healthy, young, adult women. Lidocaine doses of 2.5, 5 and 10% (w/w) were administered and parent drug and metabolites, monoethylglycinexylidide and glycinexylidide, were measured in plasma. Lidocaine was absorbed through vaginal tissue and into the systemic circulation in a dose-proportional manner and there was little systemic accumulation. Plasma concentrations were 10 to 20-fold lower than concentrations obtained after administration of intravenous lidocaine used to treat arrhythmic activity, thus demonstrating a wide safety margin for a vaginal lidocaine product. This article is protected by copyright. All rights reserved.

Concepts: Blood, Heart, Minimally invasive, Woman, All rights reserved, Local anesthetic, Lidocaine, Copyright