Jonathan W. Tanner

A Randomized, Controlled, Double-Blind Trial of Patient-Controlled Sedation with Propofol/Remifentanil Versus Midazolam/Fentanyl for Colonoscopy

BACKGROUND:Patient-controlled sedation (PCS) with propofol has been advocated as a method for dealing with the narrow therapeutic window for moderate sedation, but previous studies have methodologic limitations. We hypothesized that, by using remifentanil in conjunction with propofol and using PCS in both arms of the study, we could demonstrate marked improvements in facility use compared with fentanyl plus midazolam. METHODS:Fifty patients undergoing elective colonoscopy were randomized (with concealed allocation) to midazolam/fentanyl (group MF) or propofol/remifentanil (group PR) administered via PCS. Time intervals for sedation and recovery, perceptions by patient, nurse, and gastroenterologist, and need for anesthesiologist intervention were assessed. RESULTS:Group PR patients were sedated and recovered significantly more rapidly than did group MF (P < 0.0001). In the group PR, recovery room time was actually shorter than procedure room time. Patient, nurse, and gastroenterologist perceptions were equivalent between the groups. Two patients in group PR required anesthesiologist intervention for arterial desaturation exceeding the primary safety end point. CONCLUSIONS:PCS with propofol/remifentanil yields superior facility throughput compared with midazolam/fentanyl when used in an appropriate care setting.

Transients in orientation of a fluorescent cross-bridge probe following photolysis of caged nucleotides in skeletal muscle fibres

In muscle fibres labelled with iodoacetamidotetramethylrhodamine at Cys707 of the myosin heavy chain, the probes have been reported to change orientation when the fibre is activated, relaxed or put into rigor. In order to test whether these motions are indications of the cross-bridge power stroke, we monitored tension and linear dichroism of the probes in single glycerol-extracted fibres of rabbit psoas muscle during mechanical transients initiated by laser pulse photolysis of caged ATP and caged ADP. In rigor dichroism is negative, indicating average probe absorption dipole moments oriented more than 54.7 degrees away from the fibre axis. During activation from rigor induced by photoliberation of ATP from caged ATP in the presence of calcium, the dichroism reversed sign promptly (half-time 12.5 ms for 500 microM-ATP) upon release of ATP, but then changed only slightly during tension development 20 to 100 milliseconds later. During the onset of rigor following transfer of the fibre from an ATP-containing relaxing solution to a rigor medium lacking ATP, force generation preceded the change in dichroism. The dichroism change occurred slowly (half-time 47 s), because binding of ADP to sites within the muscle fibre limited its rate of diffusion out of the fibre. When ADP was introduced or removed, the dichroism transient was similar in time course and magnitude to that obtained after the introduction or removal of ATP. Neither adding nor removing ADP produced substantial changes in force. These results demonstrate that orientation of the rhodamine probes on the myosin head reflects mainly structural changes linked to nucleotide binding and release, rather than rotation of the cross-bridge during force generation.

Bound volatile general anesthetics alter both local protein dynamics and global protein stability.

BACKGROUND Recent studies have demonstrated that volatile general anesthetic agents such as halothane and isoflurane may bind to discrete sites on protein targets. In the case of bovine serum albumin, the sites of halothane and chloroform binding have been identified as being located in the IB and IIA subdomains. This structural information provides a foundation for more detailed studies into the potential mechanisms of anesthetic action. METHODS The effect of halothane and isoflurane and the nonimmobilizer 1,2-dichlorohexafluorocyclobutane on the mobility of the indole ring in the tryptophan residues of albumin was investigated using measurements of fluorescence anisotropy. Myoglobin served as a negative control. In addition, the effect of bound anesthetic agents on global protein stability was determined by thermal denaturation experiments using near-ultraviolet circular dichroism spectroscopy. RESULTS The fluorescence anisotropy measurements showed that halothane and isoflurane decreased the mobility of the indole rings in a concentration-dependent manner. The calculated dissociation constants were 1.6+/-0.4 and 1.3+/-0.3 mM for isoflurane and halothane, respectively. In contrast, both agents failed to increase the fluorescence anisotropy of the tryptophan residues in myoglobin, compatible with lack of binding. The nonimmobilizer 1,2-dichlorohexafluorocyclobutane caused no change in the fluorescence anisotropy of albumin. Binding of the anesthetic agents stabilized the native folded form of albumin to thermal denaturation. Analysis of the thermal denaturation data yielded dissociation constant values of 0.98+/-0.10 mM for isoflurane and 1.0+/-0.1 mM for halothane. CONCLUSIONS Attenuation of local side-chain dynamics and stabilization of folded protein conformations may represent fundamental modes of action of volatile general anesthetic agents. Because protein activity is crucially dependent on inherent flexibility, anesthetic-induced stabilization of certain protein conformations may explain how these important clinical agents change protein function.

HALOTHANE, AN INHALATIONAL ANESTHETIC AGENT, INCREASES FOLDING STABILITY OF SERUM ALBUMIN

Inhalational anesthetic agents are known to alter protein function, but the nature of the interactions underlying these effects remains poorly understood. We have used differential scanning calorimetry to study the effects of the anesthetic agent halothane on the thermally induced unfolding transition of bovine serum albumin. We find that halothane (0.6-10 mM) stabilizes the folded state of this protein, increasing its transition midpoint temperature from 62 to 71 degrees C. Binding of halothane to the native state of serum albumin thus outweighs any non-specific interactions between the thermally unfolded state of serum albumin and halothane in this concentration range. Based on the average enthalpy change DeltaH for unfolding of 170 kcal/mol, the increase from 62 to 71 degrees C corresponds to an additional Gibbs energy of stabilization (DeltaDeltaG) due to halothane of more than 4 kcal/mol. Analysis of the dependence of DeltaDeltaG on halothane concentration shows that thermal unfolding of a bovine serum albumin molecule is linked to the dissociation of about one halothane molecule at lower halothane concentrations and about six at higher halothane concentrations. Serum albumin is the first protein that has been shown to be stabilized by an inhalational anesthetic.

Differential halothane binding and effects on serum albumin and myoglobin.

To understand further the weak molecular interactions between inhaled anesthetics and proteins, we studied the character and dynamic consequences of halothane binding to bovine serum albumin (BSA) and myoglobin using photoaffinity labeling and hydrogen-tritium exchange (HX). We find that halothane binds saturably and with submillimolar affinity to BSA, but either nonspecifically or with considerably lower affinity to myoglobin. Titration of halothane binding with guanidine hydrochloride suggested more protection of binding sites from solvent in BSA as compared with myoglobin. Protection factors for slowly exchanging albumin hydrogens are increased in a concentration-dependent manner by up to 27-fold with 10 mM halothane, whereas more rapidly exchanging groups of albumin hydrogens have either unaltered or decreased protection factors. Protection factors for slowly exchanging hydrogens in myoglobin are decreased by halothane, suggesting destabilization through binding to an intermediate or completely unfolded conformer. These results demonstrate the conformation dependence of halothane binding and clear dynamic consequences that correlate with the character of binding in these model proteins. Preferential binding and stabilization of different conformational states may underlie anesthetic-induced protein dysfunction, as well as provide an explanation for heterogeneity of action.

Guidelines for the use of local anesthesia in office-based dermatologic surgery

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Cooperative binding of inhaled anesthetics and ATP to firefly luciferase.

Firefly luciferase is considered a reasonable model of in vivo anesthetic targets despite being destabilized by anesthetics, as reflected by differential scanning calorimetry (DSC). We examined the interaction between two inhaled anesthetics, ATP, luciferase, and temperature, using amide hydrogen exchange, tryptophan fluorescence, and photolabeling in an attempt to examine this apparent discrepancy. In the absence of ATP/Mg2+, halothane and bromoform cause destabilization, as measured by hydrogen exchange, suggesting nonspecific interactions. In the presence of ATP/Mg2+ and at room temperature, the anesthetics produce considerable stabilization with a negative ΔH, indicating population of a conformer with a specific anesthetic binding site. Stabilizing interactions are lost, however, at unfolding temperatures. We suggest that preferential binding to aggregated forms of luciferase explain the higher temperature destabilization detected with DSC. Our results demonstrate a cooperative binding equilibrium between native ligands and anesthetics, suggesting that similar interactions could underlie actions at biologically relevant targets. Proteins 2001;42:436–441.

Volatile anesthetics alter protein stability

1. We have used differential scanning calorimetry to measure the halothane induced change in stability of five lipid-free proteins in aqueous solution. 2. The temperature at peak heat capacity (Tm) as the sample is heated provides a measure of stability. 3. Addition of halothane increases Tm for bovine and human serum albumin, but decreases Tm for hen egg white lysozyme, bovine pancreatic ribonuclease A, and horse skeletal muscle myoglobin. 4. A shift of Tm in either direction may model the action of inhaled anesthetics on relevant proteins in the central nervous system.

Airway Trauma in a High Patient Volume Academic Cardiac Electrophysiology Laboratory Center

BACKGROUND:Providing anesthesia and managing airways in the electrophysiology suite can be challenging because of its unique setting outside of the conventional operating room. We report our experience of several cases of reported airway trauma including tongue and pharyngeal hematoma and vocal cord paralysis in this setting. METHODS:We analyzed all of the reported airway trauma cases between December 2009 and January 2011 in our cardiac electrophysiology laboratories and compared these cases with those without airway trauma. Data from 87 cases, including 16 cases with reported airway trauma (trauma group) and 71 cases without reported airway trauma from the same patient population pool at the same period (control group), were collected via review of medical records. RESULTS:Airway trauma was reported for 16 patients (0.7%) in 14 months among 2434 anesthetic cases. None of these patients had life-threatening airway obstruction. The avoidance of muscle relaxants during induction in patients with a body mass index less than 30 was found to be a significant risk factor for airway trauma (P = 0.04; odds ratio, 10; 95% confidence interval, 1.1–482). Tongue or soft tissue bite occurred in 2 cases where soft bite block was not used during cardioversion. No statistically significant difference was found between the trauma and the control groups for preprocedure anticoagulation, anticoagulation during the procedure, or reversal of heparin at the end of the procedure. CONCLUSIONS:The overall incidence of reported airway trauma was 0.7% in our study population. Tongue injury was the most common airway trauma. The cause seems to have been multifactorial; however, airway management without muscle relaxant emerged as a potential risk factor. Intubation with muscle relaxant is recommended, as is placing a soft bite block and ensuring no soft tissue is between the teeth before cardioversion.