Michael J. Laster

Biotransformation of halothane, enflurane, isoflurane, and desflurane to trifluoroacetylated liver proteins: association between protein acylation and hepatic injury.

In susceptible patients, halothane, enflurane, isoflurane, and desflurane can produce severe hepatic injury by an immune response directed against reactive anesthetic metabolites covalently bound to hepatic proteins.The incidence of hepatotoxicity appears to directly correlate with anesthetic metabolism catalyzed by cytochrome P450 2E1 to trifluoroacetylated hepatic proteins. In the present study, we examined whether the extent of acylation of hepatic proteins in rats by halothane, enflurane, isoflurane, and desflurane correlated with reported relative rates of metabolism. After pretreatment with the P450 2E1 inducer isoniazid, five groups of 10 rats breathed 1.25 minimum alveolar anesthetic concentration (MAC) of halothane, enflurane, isoflurane, or desflurane in oxygen, or oxygen alone, each for 8 h. Immunochemical analysis of livers harvested 18 h after anesthetic exposure showed tissue acylation (greatest to least) after exposure to halothane, enflurane, or isoflurane. Reactivity was not different between isoflurane as compared to desflurane or oxygen alone. An enzyme-linked immunosorbent assay showed halothane reactivity was significantly greater than that of enflurane, isoflurane, desflurane, or oxygen, and that enflurane reactivity was significantly greater than desflurane or oxygen. Sera from patients with a clinical diagnosis of halothane hepatitis showed antibody reactivity against hepatic proteins from rats exposed to halothane or enflurane. No reactivity was detected in rats exposed to isoflurane, desflurane, or oxygen alone. These results indicate that production of acylated proteins may be an important mediator of anesthetic-induced hepatotoxicity. (Anesth Analg 1997;84:173-8)

Polyhalogenated and perfluorinated compounds that disobey the meyer-overton hypothesis

Fourteen polyhalogenated, completely halogenated (perhalogenated), or perfluorinated compounds were examined for their anesthetic effects in rats. Anesthetic potency or minimum alveolar anesthetic concentration (MAC) was quantified using response/nonresponse to electrical stimulation of the tail as the end-point. For compounds that produced excitable behavior, and/or did not produce anesthesia when given alone, we determined MAC by additivity studies with desflurane. Nine of 14 compounds had measurable MAC values with products of MAC x oil/gas partition coefficient ranging from 3.7 to 24.8 atm. Because these products exceed that for conventional inhaled anesthetics (1.8 atm), they demonstrate a deviation from the Meyer-Overton hypothesis. Five compounds (CF3CCIFCF3, CF3CCIFCCIFCF3, perfluorocyclobutane, 1,2-dichloroperfluorocyclobutane, and 1,2-dimethylperfluorocyclobutane) had no anesthetic effect when given alone, had excitatory effects when given alone, and tended to increase the MAC for desflurane. These five compounds had no anesthetic properties in spite of their abilities to dissolve in lipids and tissues, to penetrate into the central nervous system, and to be administered at high enough partial pressures so that they should have an anesthetic effect as predicted by the Meyer-Overton hypothesis. Such compounds will be useful in identifying and differentiating anesthetic sites and mechanisms of action. Any physiologic or biophysical/biochemical change produced by conventional anesthetics and deemed important for the anesthetic state should not be produced by nonanesthetics.

Carbon Monoxide Production from Degradation of Desflurane, Enflurane, Isoflurane, Halothane, and Sevoflurane by Soda Lime and Baralyme@

Anecdotal reports suggest that soda lime and Baralyme Registered Trademark brand absorbent can degrade inhaled anesthetics to carbon monoxide (CO).We examined the factors that govern CO production and found that these include: 1) The anesthetic used: for a given minimum alveolar anesthetic concentration (MAC)-multiple, the magnitude of CO production (greatest to least) is desflurane >or=to enflurane > isoflurane much greater than halothane = sevoflurane. 2) The absorbent dryness: completely dry soda lime produces much more CO than absorbent with just 1.4% water content, and soda lime containing 4.8% or more water (standard soda lime contains 15% water) generates no CO. In contrast, both completely dry Baralyme Registered Trademark and Baralyme Registered Trademark with 1.6% water produce high concentrations of CO, and Baralyme Registered Trademark containing 4.7% water produces concentrations equaling those produced by soda lime containing 1.4% water. Baralyme Registered Trademark containing 9.7% or more water and standard Baralyme Registered Trademark (13% water) do not generate CO. 3) The type of absorbent: at a given water content, Baralyme Registered Trademark produces more CO than does soda lime. 4) The temperature: an increased temperature increases CO production. 5) The anesthetic concentration: more CO is produced from higher anesthetic concentrations. These results suggest that CO generation can be avoided for all anesthetics by using soda lime with 4.8% (or more) water or Baralyme Registered Trademark with 9.7% (or more) water, and by using inflow rates of less than 2-3 L/min. Such inflow rates are low enough to ensure that the absorbent does not dry out. (Anesth Analg 1995;80:1187-93)

Comparison of kinetics of sevoflurane and isoflurane in humans.

The low solubility of sevoflurane in blood suggests that this agent should enter and leave the body more rapidly than isoflurane. However, the closeness of sevoflurane and isoflurane tissue/blood partition coefficients suggests that the rates of equilibration with and elimination from tissues should be similar. We tested both predictions, comparing sevoflurane with isoflurane and nitrous oxide in seven volunteers. We measured the rate at which the alveolar (end-tidal) (FA) concentration of nitrous oxide increased toward an inspired (FI) concentration of 65%–70%, then measured the concurrent rise in FA and mixed expired concentrations (FM) of sevoflurane and isoflurane at respective FI values of 1.0% sevoflurane and 0.6% isoflurane for 30 min. Minute ventilation (V E) was measured concurrently with the measurements of anesthetic concentrations. For the potent agents, we also measured V E, FA and FM for 6–7 days of elimination. FA/FI values at 30 min of administration were as follows: nitrous oxide, 0.986 ± 0.003 (mean ± SD); sevoflurane, 0.850 ± 0.018; and isoflurane, 0.733 ± 0.027. FA/FA0 (FA0 = the last FA during administration) values after 5 min of elimination were as follows: sevoflurane, 0.157 ± 0.020; isoflurane, 0.223 ± 0.024. Recovery (volume of anesthetic recovered during elimination/volume taken up) of sevoflurane (101% ± 7%) equaled recovery of isoflurane (101% ± 6%). Time constants for a five-compartment mammillary model for sevoflurane were smaller than those for isoflurane for the lungs but were not different from isoflurane for the other compartments. In summary, we found (a) that FA/FI of sevoflurane increases and FA/FA0 decreases more rapidly than do these variables with isoflurane in humans; but (b) that elimination from tissues did not differ between sevoflurane and isoflurane; and (c) that the metabolism of sevoflurane did not differ from that estimated for isoflurane.

Toxicity of compound A in rats : effect of a 3-hour administration

BackgroundSoda lime converts sevoflurane to CF2 == C(CF3)OCH2F, an olefin called compound A, whose toxicity raises concerns regarding the safe administration of sevoflurane via rebreathing circuits. The present report extends the findings of a previous investigation by others of the toxicity of this olefin, and establishes concentration-response relationships for such toxicity. MethodsEighteen groups of ten Wistar rats breathed 0, 25, 50, 100, 200, 300, 350, and 400 ppm of the olefin in oxygen for 3 h. The olefin concentrations were developed in a square-wave manner by injection of saturated vapor followed by a continuous delivery of dilute vapor. The lethal concentration in 50% (LC50) of animals was estimated by logistic regression. Rats were killed on day 1 or day 4 after breathing the olefin, and specimens of brain, kidney, lung, liver, and small intestine were obtained from all rats for examination using light microscopy. ResultsThe LC50 equaled 331 ppm (95% confidence limits ± 13 ppm). No injury resulted to lung or small intestine in either the experimental or the control group (those breathing only oxygen for 3 h). Renal injury (necrosis of the outer strip of the outer medulla, defined in this report as corticomedullary tubular necrosis) occurred at 50 ppm and greater; hepatic injury at 350 ppm and greater; and cerebral injury only at 400 ppm. ConclusionThe lethal concentration and the threshold for toxicity of the olefin are less than previously reported. The threshold for nephrotoxicity reaches the range of values for the olefin that have been attained in clinical practice. Further studies are required to determine whether these results in rats can be extrapolated to patients.

Toxicity of Compound A in Rats: Effect of Increasing Duration of Administration

BackgroundAn olefin called compound A (CF2 == C(CF3)OCH2F) results from the action of soda lime or Baralyme on sevoflurane. We have demonstrated that rats exposed to the olefin for 3 h died at or were injured by olefin concentrations lower than those previously reported to produce these effects. The present report examines the impact of duration of exposure to the olefin on such effects. MethodsTwenty-three groups of ten Wistar rats breathed 0, 12.5, 25, 50, 75, 100, 125, 150, 175, 200, 225, and 250 ppm of the olefin in oxygen for 6 or 12 h. Rats that survived were killed on day 1 or day 4 after breathing the olefin, and specimens of brain, kidney, lung, liver, and small intestine were obtained from all rats for examination by microscopy using hematoxylin and eosin stain and a stain (proliferating cell nuclear antigen) for cell growth (regeneration). ResultsThe lethal concentrations in 50% of rats equaled 203 ± 4 ppm (mean ± SE) for a 6-h exposure period and 127 ± 9 ppm for a 12-h exposure period, and both values were less than the previously determined value of 331 ± 7 ppm for a 3-h exposure period. Compared with results from control rats (those breathing oxygen for 6 h or 12 h), only renal and pulmonary injury were found. Pulmonary injury only occurred at near-lethal concentrations. Renal injury (defined as necrosis of the outer stripe of the outer medullary layer or corticomedullary junction necrosis) occurred at and above 25–50 ppm for 6-h and 12-h exposures, respectively, a result similar to that previously obtained with a 3-h exposure. Exposure to 25–50 ppm stimulated cell regeneration in a dose-related manner. ConclusionsIn rats, lethal concentrations of the olefin and concentrations producing severe renal injury are inversely related to the duration of exposure to the olefin, exceeding by two- to fourfold peak concentrations that can be obtained in clinical practice. The threshold concentrations for nephrotoxicity (i.e., minimal toxicity) equal concentrations that can be produced in clinical practice. However, even if these threshold effects in rats apply to humans, they probably would not alter renal function. Although dose-related, neither the lethal nor the toxic effects are simply a function of cumulative dose (concentration-time).

What solvent best represents the site of action of inhaled anesthetics in humans, rats, and dogs ?

The correlation between the potency of inhaled anesthetics and their solubility in a hydrophobic phase provides an opportunity to define better the characteristics of the anesthetic site of action. The correlation implies that inhaled anesthetics act in a hydrophobic site and that the solvent used has properties representative of the true site of anesthetic action. We sought to characterize this site more accurately by testing for the solvent that provided the best correlation for a diverse group of anesthetics. We determined the solubility of halothane, enflurane, cyclopropane, fluroxene, isoflurane, sevoflurane, and desflurane in benzene, olive oil, Intralipid, n-octanol, and lecithin. We used established MAC values for rats, dogs, and humans for all but sevoflurane and desflurane, for which we determined MAC in rats to be 2.80% ± 0.24% (mean ± standard deviation) and 7.71% ± 0.65%, respectively. Lecithin gave the lowest coefficient of variation for the product of potency (MAC) × solubility, but the difference was statistically significant only for a comparison of the products for lecithin and olive oil. The values for lecithin were within the range of values produced by biological variation. More important, the correlation of log MAC and log solubility had an average slope of unity (−1.04 ± 0.07) for lecithin, but a slope differing from unity for benzene (−0.82 ± 0.05) and olive oil (−0.87 ± 0.05). We conclude that lecithin is probably more representative of the site of action of these anesthetics than the other solvents.

No correlation between quantitative electroencephalographic measurements and movement response to noxious stimuli during isoflurane anesthesia in rats.

A meaningful use of the electroencephalogram (EEG) for monitoring depth of anesthesia has proven elusive. Although changes in the EEG with changing anesthetic dose or concentration have been noted for 60 yr, it has been difficult to demonstrate reliable, quantitative correlation between the EEG and other physiologic measures of anesthetic depth. We attempted to correlate several quantitative EEG measurements in rats, including average amplitude, spectral edge frequency, and burst suppression ratio, with the movement response to supramaximal noxious stimulation. We anesthetized 21 Sprague-Dawley rats with isoflurane 1.5% and allowed them to breathe spontaneously. After equilibration, EEG was recorded for off-line analysis; then a noxious stimulation was delivered with a tail clamp and the somatic response noted. Isoflurane concentration was adjusted up and down, and the EEG and movement response to tail clamp were assessed at each level until the minimum alveolar concentration was determined in each rat. We found no EEG dose response to increasing inspired concentrations of isoflurane, except for an increasing degree of burst suppression. We found no difference in any parameter between rats that responded and those that did not respond to stimuli at a given concentration of isoflurane. Finally, we found that the presence of burst suppression did not predict lack of response.

Recovery and kinetic characteristics of desflurane and sevoflurane in volunteers after 8-h exposure, including kinetics of degradation products.

Background Desflurane and sevoflurane permit speedier changes in anesthetic partial pressures than do older halogenated anesthetics. The authors determined the kinetic characteristics of desflurane and sevoflurane and those of compound A [CH2 F-O-C(= CF2)(CF3)], a nephrotoxic degradation product of sevoflurane. Methods Volunteers received 1.25 minimum alveolar concentration of desflurane or sevoflurane, each administered for 8 h in a fresh gas inflow of 2 l/min. Inspired (FI) and end-tidal (FA) concentrations of anesthetic and compound A were measured during administration, and FA relative to FAO (the last end-tidal concentration during administration) during elimination. The indices of recovery were also measured. Results The ratio FI /FA rapidly approached 1.0, with values greater for sevoflurane (desflurane 1.06 +/- 0.01 vs. sevoflurane 1.11 +/- 0.02, mean +/- SD). The ratio FA /FI for compound A was approximately 0.8. The FA /FAO ratio decreased slightly more rapidly with desflurane than with sevoflurane, and objective measures indicated faster recovery with desflurane: The initial response to command (14 +/- 4 min vs. 28 +/- 8 min [means +/- SD]) and orientation (19 +/- 4 vs. 33 +/- 9 min) was quicker, and recovery was faster as defined by results of the Digit Symbol Substitution, P-deletion, and Trieger tests. Desflurane produced less vomiting (1 [0.5, 3]; median [quartiles] episodes) than did sevoflurane (5 [2.5, 7.5] episodes). The FA /FAO ratio for compound A decreased within 5 min to a constant value of 0.1. Conclusions These anesthetics have kinetics consistent with their solubilities. Sevofluranes greater biodegradation probably increases F sub I /FA differences during anesthetic administration and decreases FA /FAO differences during elimination. The FA for compound A differs from FI by 20% (FA /FI = 0.8) because of substantial degradation. Recovery from anesthesia proceeds nearly twice as fast with desflurane than with sevoflurane. Differences in ventilation, or alveolar or tissue elimination, do not completely explain the slower recovery with sevoflurane.

Minimum alveolar concentrations of noble gases, nitrogen, and sulfur hexafluoride in rats: helium and neon as nonimmobilizers (nonanesthetics)

We assessed the anesthetic properties of helium and neon at hyperbaric pressures by testing their capacity to decrease anesthetic requirement for desflurane using electrical stimulation of the tail as the anesthetic endpoint (i.e., the minimum alveolar anesthetic concentration [MAC]) in rats. Partial pressures of helium or neon near those predicted to produce anesthesia by the Meyer-Overton hypothesis (approximately 80-90 atm), tended to increase desflurane MAC, and these partial pressures of helium and neon produced convulsions when administered alone. In contrast, the noble gases argon, krypton, and xenon were anesthetic with mean MAC values of (+/- SD) of 27.0 +/- 2.6, 7.31 +/- 0.54, and 1.61 +/- 0.17 atm, respectively. Because the lethal partial pressures of nitrogen and sulfur hexafluoride overlapped their anesthetic partial pressures, MAC values were determined for these gases by additivity studies with desflurane. Nitrogen and sulfur hexafluoride MAC values were estimated to be 110 and 14.6 atm, respectively. Of the gases with anesthetic properties, nitrogen deviated the most from the Meyer-Overton hypothesis. Implications: It has been thought that the high pressures of helium and neon that might be needed to produce anesthesia antagonize their anesthetic properties (pressure reversal of anesthesia). We propose an alternative explanation: like other compounds with a low affinity to water, helium and neon are intrinsically without anesthetic effect. (Anesth Analg 1998;87:419-24)