Daily Anesthesiology Research Analysis

BACKGROUND: Anaesthesia-induced burst suppression signifies profound cerebral inactivation. Although considerable efforts have been directed towards elucidating the electroencephalographic manifestation of burst suppression, the neuronal underpinnings that give rise to isoflurane-induced burst suppression are unclear. METHODS: Electroencephalography combined with micro-endoscopic calcium imaging was used to investigate the neural mechanisms of isoflurane-induced burst suppression. Synchronous activities of pyramidal neurones in the auditory cortex and medial prefrontal cortex and inhibitory neurones in the auditory cortex (including parvalbumin [PV], somatostatin [SST], and vasoactive intestinal peptide [Vip]) and subcortical regions (including the medial geniculate body, locus coeruleus, and thalamic reticular nucleus) were recorded during isoflurane anaesthesia. In addition, the effects of chemogenetic manipulation inhibitory neurones in the auditory cortex on isoflurane-induced burst suppression were studied. RESULTS: Isoflurane-induced burst suppression was highly correlated with the synchronous activities of excitatory neurones in the cortex (∼65% positively and ∼20% negatively correlated neurones). Conversely, a minimal or absent correlation was observed with the neuronal synchrony of inhibitory interneurones and with neuronal activities within subcortical areas. Only activation or inhibition of PV neurones, but not SST or Vip neurones, decreased (P<0.0001) or increased (P<0.0001) isoflurane-induced neuronal synchrony. CONCLUSIONS: Isoflurane-induced burst suppression might be primarily driven by the synchronous activities of excitatory pyramidal neurones in the cortex, which could be bidirectionally regulated by manipulating the activity of inhibitory PV interneurones. Our findings provide new insights into the neuronal mechanisms underlying burst suppression.

Anaesthetic gases account for ∼3% of the carbon footprint of the entire healthcare sector and up to 63% of the emissions originating from surgical care. Transitioning to predominant use of total intravenous anaesthesia (TIVA) has been proven a safe and effective strategy to reduce this footprint, yet its adoption has been slow in most countries. Interventions at the national level have been limited to regulatory action (e.g. banning of desflurane) and publication of nonbinding recommendations and best practices. We describe a new approach that we used to drive sustainable change and apply it to the debate between TIVA and inhalation anaesthesia at the national level. The Dutch Approach is founded on a bottom-up, self-regulatory model grounded in evidence-based practices. Patient safety studies, a national inventory of anaesthetic drug use, and in-depth interviews with anaesthetists were combined in developing a national guideline. Meeting the two main concerns among anaesthetists, patient safety and professional autonomy, the guideline requires all Dutch anaesthetic practices to adopt a local protocol whose main message is 'TIVA when possible, inhalation anaesthesia when necessary'. Central to the approach was the integration within the national quinquennial quality control audits. Adoption and implementation will be monitored and evaluated in an ongoing research project.

BACKGROUND: Malignant hyperthermia (MH) susceptibility is associated with variants in RYR1, the gene encoding the skeletal muscle ryanodine receptor-1 (RyR1), in 70-75% of patients. Functional characterisation demonstrating an increased sensitivity to RyR1 agonists is necessary among other criteria for inclusion in the European Malignant Hyperthermia Group list of MH susceptibility diagnostic variants. METHODS: Seven variants in the RYR1 gene, p.Glu342Lys, p.Leu2288Ser, p.Phe2340Leu, p.Arg2676Trp, p.Val3324Ala, p.Phe4076Leu, and p.Trp5020Cys, identified in MH-susceptible individuals were introduced into the cDNA for the human RYR1 gene. These variants were tested in cultured human embryonic kidney HEK293 cells for their effect on calcium release in response to the RyR1 agonist 4-chloro-m-cresol. Calcium release of each variant was compared with wild-type and benign and pathogenic controls. Each variant was subjected to curation using the European Malignant Hyperthermia Group scoring matrix and ClinGen RYR1 Variant Curation Expert Panel guidelines. RESULTS: Six of seven RYR1 variants (p.Glu342Lys, p.Leu2288Ser, p.Phe2340Leu, p.Arg2676Trp, p.Val3324Ala, p.Phe4076Leu) showed hypersensitivity to 4-chloro-m-cresol compared with wild-type. The p.Trp5020Cys variant did not release calcium in response to 4-chloro-m-cresol. All variants had minor allele frequencies <0.1%. Rare exome variant ensemble learner scores of p.Glu342Lys, p.Leu2288Ser, p.Phe4076Leu, and p.Trp5020Cys were >0.85, supporting pathogenicity. CONCLUSIONS: The variants p.Glu342Lys, p.Leu2288Ser p.Phe2340Leu, and p.Arg2676Trp are pathogenic or likely pathogenic for MH and can be used for presymptomatic testing for MH susceptibility. As current knowledge on the p.Val3324Ala, p.Phe4076Leu, and p.Trp5020Cys variants remains insufficient, they are still classified as variants of uncertain significance.