Emergence Electroencephalography in an Unresponsiveness Geriatric Patient in the Postanesthesia Care Unit: A Case Report.

Incomplete neurological awakening manifested as aberrant patterns of electroencephalography (EEG) at emergence may be responsible for an unresponsive patient in the postanesthesia care unit (PACU). We describe a case of an individual who remained unresponsive but awake in the PACU. Retrospective, intraoperative EEG analysis showed low alpha power and a sudden shift from deep delta to arousal preextubation. We explored parallels with diminished motivation disorders and anesthesia-induced sleep paralysis due to imbalances in anesthetic drug sensitivity between brain regions. Our findings highlight the relevance of end-anesthesia EEG patterns in diagnosing delayed awakening.

Preliminary pharmacokinetics and patient experience of jet-injected dexmedetomidine in healthy adults.

Jet injection is a drug delivery system without a needle. A compressed liquid drug formulation pierces the skin, depositing the drug into the subcutaneous or intramuscular tissues. We investigated the pharmacokinetics and patient experience of dexmedetomidine administered using jet injection in six healthy adult study participants. This needleless jet injection device was used to administer dexmedetomidine 0.5 µg/kg to the subcutaneous tissues overlying the deltoid muscle. Serum concentrations of dexmedetomidine were assayed at approximately 5 minutes, 15 minutes, 30 minutes, 1 hour and 4 hours after administration. Pharmacokinetic interrogation of concentration time profiles estimated an absorption half time for jet-injected dexmedetomidine of 21 minutes (coefficient of variation 69.4%) with a relative bioavailability assumed unity. In our samples the measured median peak (range) concentration was 0.164 µg/l (0.011-0.325 µg/l), observed in the sample taken at a median (range) of 13.5 minutes (11-30 minutes). The Richmond agitation sedation scale was used to assess the sedative effect, and scored 0 (alert and calm) or -1 (drowsy) in all participants. Five of the six participants stated they would prefer jet injection to needle injection in the future and one had no preference. The findings suggest that the use of a larger dose (>2 µg/kg) would be required to achieve the clinically relevant target concentration of 1 µg/l necessary to achieve deeper sedation (Richmond agitation sedation scale ≤3).

Seeing is Believing: Chasing Sevoflurane Vapor Trails.

PURPOSE: Sevoflurane is an inhalational general anesthetic that has been used recently to treat chronic, painful lesions, reportedly supporting analgesia and wound healing. The potential for repeated exposure to off-gassed sevoflurane vapor, especially outside the air-conditioned operating theatre environment, is of some concern. DESIGN: This paper explores the qualitative and quantitative pathing of off-gassed sevoflurane from a topically applied liquid source. METHODS: Using a small, unventilated test-box (total volume 0.5 m3) with infra-red imaging and gas-analysing, we investigated the spatial distribution of sevoflurane vapor following complete vaporization of a 20 mL liquid sample. Utilizing the infra-red absorption of sevoflurane, it was possible to visualize (as an apparent reduction in temperature) the streaming path of the sevoflurane vapor. Sevoflurane levels (%) in the test-box were measured using an infra-red gas analyzer. FINDINGS: In keeping with its higher density than air, sevoflurane vapor was seen to "waterfall" from the liquid source and accumulate in the bottom of the test-box. Sevoflurane vapor concentration was minimal above the liquid source. When extrapolated to a larger (unventilated) room, we estimate that the sevoflurane concentration would be less than 10 ppm one centimetre above the liquid pool. With vacuum extraction, these levels would be even lower. CONCLUSIONS: Due to sevoflurane's tendency to accumulate on the floor, it is concluded that topical application of liquid sevoflurane posses virtually no risk to off-gas exposure in unventilated spaces.

Tissue oxygen partial pressure as a viability metric for ex vivo brain tissue slices.

BACKGROUND: Despite the prevalent use of the ex vivo brain slice preparation in neurophysiology research, a reliable method for judging tissue viability - and thus suitability of a slice for inclusion in an experiment - is lacking. The utility of indirect electrophysiological measures of tissue health is model-specific and needs to be used cautiously. In this study, we verify a more direct test of slice viability, based on tissue oxygen consumption rate. NEW METHOD: We hypothesised that the minimum intra-slice partial pressure of oxygen (pO2min) would correlate with tissue oxygen consumption rate, providing an accessible method for reliably assessing tissue viability status. Using mouse brain cortex slices, we measured tissue oxygen consumption rate using a Fick's law diffusion-consumption model applied to full intra-tissue pO2 profiles and compared this to pO2min and 2,3,5-triphenol tetrazolium chloride (TTC) viability staining. RESULTS: Tissue pO2min correlated strongly with oxygen consumption rate in both neurophysiological active and quiescent tissue (in "no-magnesium" and "normal" artificial cerebrospinal fluid, respectively) (R2 =49.7% and 42.1%, respectively). Both correlated with TTC viability stain. Oxygen consumption rate was positively related to the frequency of seizure-like event activity in no-magnesium artificial cerebrospinal fluid (R2 = 44.8%). COMPARISON WITH EXISTING METHODS: While measurement of tissue oxygen levels and oxygen consumption is not new, intra-tissue pO2min is a novel approach to assess brain slice viability. CONCLUSION: The results confirm that tissue oxygen minimum pO2min is a robust metric for estimating tissue viability status - the lower the pO2min, the healthier the tissue.

Determination of Krogh Coefficient for Oxygen Consumption Measurement from Thin Slices of Rodent Cortical Tissue Using a Fick's Law Model of Diffusion.

To investigate the impact of experimental interventions on living biological tissue, ex vivo rodent brain slices are often used as a more controllable alternative to a live animal model. However, for meaningful results, the biological sample must be known to be healthy and viable. One of the gold-standard approaches to identifying tissue viability status is to measure the rate of tissue oxygen consumption under specific controlled conditions. Here, we work with thin (400 µm) slices of mouse cortical brain tissue which are sustained by a steady flow of oxygenated artificial cerebralspinal fluid (aCSF) at room temperature. To quantify tissue oxygen consumption (Q), we measure oxygen partial pressure (pO2) as a function of probe depth. The curvature of the obtained parabolic (or parabola-like) pO2 profiles can be used to extract Q, providing one knows the Krogh coefficient Kt, for the tissue. The oxygen trends are well described by a Fick's law diffusion-consumption model developed by Ivanova and Simeonov, and expressed in terms of ratio (Q/K), being the rate of oxygen consumption in tissue divided by the Krogh coefficient (oxygen diffusivity × oxygen solubility) for tissue. If the fluid immediately adjacent to the tissue can be assumed to be stationary (i.e., nonflowing), one may invoke conservation of oxygen flux K·(∂P/∂x) across the interface to deduce (Kt/Kf), the ratio of Krogh coefficients for tissue and fluid. Using published interpolation formulas for the effect of salt content and temperature on oxygen diffusivity and solubility for pure water, we estimate Kf, the Krogh coefficient for aCSF, and hence deduce the Kt coefficient for tissue. We distinguish experimental uncertainty from natural biological variability by using pairs of repeated profiles at the same tissue location. We report a dimensionless Krogh ratio (Kt/Kf)=0.562±0.088 (mean ± SD), corresponding to a Krogh coefficient Kt=(1.29±0.21)×10-14 mol/(m·s·Pa) for mouse cortical tissue at room temperature, but acknowledge the experimental limitation of being unable to verify that the fluid boundary layer is truly stationary. We compare our results with those reported in the literature, and comment on the challenges and ambiguities caused by the extensive use of 'biologically convenient' non-SI units for tissue Krogh coefficient.

Encapsulation Dynamics of Neuromuscular Blocking Drugs by Sugammadex.

BACKGROUND: The clinical actions of sugammadex have been well studied, but the detailed molecular mechanism of the drug encapsulation process has not been systematically documented. The hypothesis was that sugammadex would attract rocuronium and vecuronium via interaction with the sugammadex side-chain "tentacles," as previously suggested. METHODS: Computational molecular dynamics simulations were done to investigate docking of sugammadex with rocuronium and vecuronium. To validate these methods, strength of binding was assessed between sugammadex and a heterogeneous group of nine other drugs, the binding affinities of which have been experimentally determined. These observations hinted that high concentrations of unbound sugammadex could bind to propofol, potentially altering its pharmacokinetic profile. This was tested experimentally in in vitro cortical slices. RESULTS: Sugammadex encapsulation of rocuronium involved a sequential progression down a series of metastable states. After initially binding beside the sugammadex molecule (mean ± SD center-of-mass distance = 1.17 ± 0.13 nm), rocuronium then moved to the opposite side to that hypothesized, where it optimally aligned with the 16 hydroxyl groups (distance, 0.82 ± 0.04 nm) before entering the sugammadex cavity to achieve energetically stable encapsulation by approximately 120 ns (distance, 0.35 ± 0.12 nm). Vecuronium formed fewer hydrogen bonds with sugammadex than did rocuronium; hence, it was less avidly bound. For the other molecules, the computational results showed good agreement with the available experimental data, showing a clear bilogarithmic relation between the relative binding free energy and the association constant (R2 = 0.98). Weaker binding was manifest by periodic unbinding. The brain slice results confirmed the presence of a weak propofol-sugammadex interaction. CONCLUSIONS: Computational simulations demonstrate the dynamics of neuromuscular blocking drug encapsulation by sugammadex occurring from the opposite direction to that hypothesized and also how high concentrations of unbound sugammadex can potentially weakly bind to other drugs given during general anesthesia.

Deconstructing delirium in the post anaesthesia care unit.

The course of neuro-cognitive recovery following anaesthesia and surgery is distinctive and poorly understood. Our objective was to identify patterns of neuro-cognitive recovery of the domains routinely assessed for delirium diagnosis in the post anaesthesia care unit (PACU) and to compare them to the cognitive recovery patterns observed in other studies; thereby aiding in the identification of pathological (high risk) patterns of recovery in the PACU. We also compared which of the currently available tests (3D-CAM, CAM-ICU, and NuDESC) is the best to use in PACU. This was a post hoc secondary analysis of data from the Alpha Max study which involved 200 patients aged over 60 years, scheduled for elective surgery under general anaesthesia lasting more than 2 h. These patients were assessed for delirium at 30 min following arrival in the PACU, if they were adequately arousable (Richmond Agitation Sedation Score ≥ -2). All tests for delirium diagnosis (3D-CAM, CAM-ICU, and NuDESC) and the sub-domains assessed were compared to understand temporal recovery of neurocognitive domains. These data were also analysed to determine the best predictor of PACU delirium. We found the incidence of PACU delirium was 35% (3D-CAM). Individual cognitive domains were affected differently. Few individuals had vigilance deficits (6.5%, n = 10 CAM-ICU) or disorganized thinking (19% CAM-ICU, 27.5% 3D-CAM), in contrast attention deficits were common (72%, n = 144) and most of these patients (89.5%, n = 129) were not sedated (RASS ≥ -2). CAM-ICU (27%) and NuDESC (52.8%) detected fewer cases of PACU delirium compared to 3D-CAM. In conclusion, return of neurocognitive function is a stepwise process; Vigilance and Disorganized Thinking are the earliest cognitive functions to return to baseline and lingering deficits in these domains could indicate an abnormal cognitive recovery. Attention deficits are relatively common at 30 min in the PACU even in individuals who appear to be awake. The 3D CAM is a robust test to check for delirium in the PACU.

The general anaesthetic propofol prevents cerebrocortical potentiation in neocortical mouse brain slices.

Propofol is well known to cause amnesia independent of its sedative effect. Memory consolidation processes in the hippocampus have been proposed as a target - however the neural substrates for propofol's amnesic actions remain understudied and poorly described. In particular, the potential role of the cerebral cortex has not been investigated. As an in vitro experimental model of cortical memory consolidation, potentiated cerebral cortex evoked responses were generated in mouse neocortical slices using high frequency (20 Hz) stimulation to layer IV cortical grey matter or subcortical white matter. In separate experiments, slices were pretreated with propofol at two concentrations, 2 µg/mL and 4 µg/mL, to determine the effect of clinically relevant propofol levels on the potentiation response. Only grey matter stimulation induced a significant and lasting increase in cortical evoked potential amplitude in the drug-free condition. Propofol at 2 µg/mL completely inhibited cortical evoked response potentiation, while the 4 µg/mL concentration caused a small but significant depressant effect consequent to the high frequency stimulation. These findings support the hypothesis that propofol disrupts memory consolidation and actively facilitates memory decay in the cerebral cortex. The results further highlight the importance of the cerebral cortex in the early phase of long term memory consolidation.

Non-NMDA Mechanisms of Analgesia in Ketamine Analogs.

Despite 50 years of clinical use and experimental endeavor the anesthetic, analgesic, and psychomimetic effects of ketamine remain to be fully elucidated. While NMDA receptor antagonism has been long held as ketamine's fundamental molecular action, interrogation of bespoke ketamine analogs with known absent NMDA binding, yet profound anesthetic and analgesia fingerprints, suggests alternative targets are responsible for these effects. Herein we describe experimental findings utilizing such analogs as probes to explore ketamine-based analgesic molecular targets. We have focused on two-pore potassium leak channels, identifying TWIK channels as a rational target to pursue further. While the totality of ketamine's mechanistic action is yet to be fully determined, these investigations raise the intriguing prospect of separating out analgesia and anesthetic effects from ketamine's undesirable psychomimesis-and development of more specific analgesic medications.

A systematic exploration of local network state space in neocortical mouse brain slices.

The ex vivo cortical slice is an extremely versatile preparation, but its utility ultimately depends on understanding its limitations and functional constraints. A question for experimentalists new to the field of cortical slice electrophysiology might be - what are the different network dynamical states available to a cortical slice as a function of excitatory drive? The purpose of this study is to provide a coherent answer to this question, within the context of extracellularly recorded population field potentials. Cortical slices (400 µm) were prepared from adult male or female C57 mice. Evoked responses were recorded within cortical layer III/IV using extracellularly positioned metal electrodes. In the first part of the study, slice excitatory drive was increased by reducing the concentration of magnesium ions in the artificial cerebrospinal fluid - and the evoked responses categorized during the transition. In the second part, each of the identified functional states were explored in greater detail with tissue perfusion conditions and excitatory drive optimised for the requisite response state. As expected, rodent cortical slices did not generate spontaneous, persistent EEG-like field potential activity. However, distinct response states (spontaneous and evoked) characterized by intermittent population bursts could be differentiated as a function of excitatory drive. Each state reflected different modes of neocortical activation: "monosynaptic" responses were brief, non-propagating activations, reflecting an inhibited cortex with sensory processing blocked; polysynaptic and epileptiform activity propagated intra-cortically, the latter reflecting a hyperactivated, hypersynchronous "seizing" cortex. Polysynaptic activity most closely resembled sensory "up states" associated with intracortical sensory processing. Understanding the functional distinction between the different cortical slice response states is the starting point for designing experiments that maximise the utility of this ex vivo model. The results and descriptions in this study should help slice experimentalists less experienced in the nuances of cortical slice neurophysiology to make informed choices about how to tailor the parameters of the model to suit the specific aims of their research.

The molecular dynamics of possible inhibitors for SARS-CoV-2.

The novel coronavirus SARS-CoV-2, responsible for the present COVID-19 global pandemic, is known to bind to the angiotensin converting enzyme-2 (ACE2) receptor in human cells. A possible treatment of COVID-19 could involve blocking ACE2 and/or disabling the spike protein on the virus. Here, molecular dynamics simulations were performed to test the binding affinities of nine candidate compounds. Of these, three drugs showed significant therapeutic potential that warrant further investigation: SN35563, a ketamine ester analogue, was found to bind strongly to the ACE2 receptor but weakly within the spike receptor-binding domain (RBD); in contrast, arbidol and hydroxychloroquine bound preferentially with the spike RBD rather than ACE2. A fourth drug, remdesivir, bound approximately equally to both the ACE2 and viral spike RBD, thus potentially increasing risk of viral infection by bringing the spike protein into closer proximity to the ACE2 receptor. We suggest more experimental investigations to test that SN35563-in combination with arbidol or hydroxychloroquine-might act synergistically to block viral cell entry by providing therapeutic blockade of the host ACE2 simultaneous with reduction of viral spike receptor-binding; and that this combination therapy would allow the use of smaller doses of each drug.Communicated by Ramaswamy H. Sarma.

Microalgae-based photosynthetic strategy for oxygenating avascularised mouse brain tissue - An in vitro proof of concept study.

Hypoxic brain injury is a leading cause of loss of quality of life globally for which there are currently no effective treatments. There has been increasing interest in incorporating photosynthesising agents into hypoxic tissue as a mechanism for in situ oxygen delivery, independent of vascular perfusion. To date this has not been tested in the brain. The oxygen production capacity of Chlamydomonas reinhardtii microalgal cultures was measured in artificial cerebrospinal fluid (aCSF) in benchtop assays and in cortical slices in situ. Cortical slice function was quantified by measuring the length, frequency and amplitude of seizure-like event (SLE) activity - in conventionally oxygenated aCSF, C. reinhardtii cultures, unoxygenated and deoxygenated aCSF. The possibility of direct toxic algal effects was investigated by exposing slices to cultures for 5 h. An oxygen level of 25 mg.L-1 was achieved with C. reinhardtii in no-Mg aCSF. Slice SLE function was preserved in C. reinhardtii, without the need for supplemental oxygen. In contrast, functional parameters deteriorated in unoxygenated and deoxygenated aCSF. In the former, there was a 66% reduction in SLE frequency and a 37% reduction in event amplitude. In the latter, SLE activity ceased completely. No toxic algae effects were seen in slices exposed to cultures for 5 h. These results confirm that C. reinhardtii oxygenation of aCSF can sustain cortical network activity - without tissue toxicity for the normal lifespan of an acute cortical slice. This study shows promise for the concept of photosynthesis as a mechanism for providing oxygen to rescue ischaemic avascularised brain tissue.

Electrophysiological field potential identification of an intact GABAergic system in mouse cortical slices.

In brain slice experiments there's currently no validated electrophysiological method for differentiating viability between GABAergic and glutamatergic cell populations. Here we investigated the neurophysiology of high frequency field potential activity - and its utility for probing the functional state of the GABAergic system in brain slices. Field potentials were recorded from mouse cortical slices exposed to 50 mM potassium ("elevated-K") and the induced high frequency (>20 Hz) response characterized pharmacologically. The elevated-K responses were also related to the high frequency activity imbedded in no-magnesium seizure-like events (SLE) from the same slices. The elevated-K response, comprising a transient burst of high frequency activity, was strongly GABAA-dependent. The size of the high frequency response was reduced by 71% (p = 0.001) by picrotoxin, but not significantly attenuated by either APV or CNQX. High frequency activity embedded in no-magnesium SLEs correlated with the elevated-K response. The success rate for generating an elevated-K response - and high frequency SLE activity - declined rapidly with increasing time since slicing. These findings support the hypothesis that in cortical slices, a functioning synaptic GABAergic system is evidenced by a strong high frequency component to no-magnesium SLE activity - and that the integrity of the GABAergic system degrades quicker than the excitatory glutamatergic system in this preparation.

Application of a benchtop colorimetric method for quantification of blood propofol levels.

Quantification of plasma propofol (2,6-diisopropylphenol) in the context of clinical anaesthesia is challenging because of the need for offline blood sample processing using specialised laboratory equipment and techniques. In this study we sought to refine a simple procedure using solid phase extraction and colorimetric analysis into a benchtop protocol for accurate blood propofol measurement. The colorimetric method based on the reaction of phenols (e.g. propofol) with Gibbs reagent was first tested in 10% methanol samples (n = 50) containing 0.5-6.0 µg/mL propofol. Subsequently, whole blood samples (n = 15) were spiked to known propofol concentrations and processed using reverse phase solid phase extraction (SPE) and colorimetric analysis. The standard deviation of the difference between known and measured propofol concentrations in the methanol samples was 0.11 µg/mL, with limits of agreement of - 0.21 to 0.22 µg/mL. For the blood-processed samples, the standard deviation of the difference between known and measured propofol concentrations was 0.09 µg/mL, with limits of agreement - 0.18 to 0.17 µg/mL. Quantification of plasma propofol with an error of less than 0.2 µg/mL is achievable with a simple and inexpensive benchtop method.