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Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions. Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that 'perioperative neurocognitive disorders' be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder)., (Copyright © 2018 Jointly by the British Journal of Anaesthesia, American Society of Anesthesiologists Inc, Wolters Kluwer Health Inc, International Anesthestic Research Society, Canadian Anesthesiologist’s Society, Acta Anaesthesiologica Scandinavica Foundation, and IOS Press., Jointly by the British Journal of Anaesthesia, American Society of Anesthesiologists Inc, International Anesthesia Research Society, Canadian Anesthesiologist’s Society, Acta Anaesthesiologica Scandinavica Foundation, and IOS Press. Published by Elsevier Ltd.. All rights reserved.)

The inhaled anesthetics were officially introduced to American medicine more than 160 years ago and rank among the most important medical advances in our time. These drugs are used to render patients insensible over twenty million times each year and are the most dangerous of all drugs that physicians currently use. An entire medical specialty, anesthesiology, has arisen out of the need for the special training to administer them safely. Nevertheless, side effects, toxicity, and long-term cognitive problems continue to plague their use, especially in the very sick or aged. Hence, it is essential that we develop an understanding of their molecular pharmacology so that safer alternatives can be developed.

Previous evidence suggests multiple anesthetic binding sites on human serum albumin, but to date, we have only identified Trp-214 in an interdomain cleft as contributing to a binding site. We used a combination of site-directed mutagenesis, photoaffinity labeling, amide hydrogen exchange, and tryptophan fluorescence spectroscopy to evaluate the importance to binding of a large domain III cavity and compare it to binding character of the 214 interdomain cleft. The data show anesthetic binding in this domain III cavity of similar character to the interdomain cleft, but selectivity for different classes of anesthetics exists. Occupancy of these sites stabilizes the native conformation of human serum albumin. The features necessary for binding in the cleft appear to be fairly degenerate, but in addition to hydrophobicity, there is evidence for the importance of polarity. Finally, myristate isosterically competes with anesthetic binding in the domain III cavity and allosterically enhances anesthetic binding in the interdomain cleft.

There is a distinct possibility that general anesthetics exert their action on the postsynaptic receptor channels. The structural requirements for anesthetic binding in transmembrane channels, however, are largely unknown. High-resolution (1)H nuclear magnetic resonance and direct photoaffinity labeling were used in this study to characterize the volatile anesthetic binding sites in gramicidin A (gA) incorporated into sodium dodecyl sulfate (SDS) micelles and into dimyristoylphosphatidylcholine (DMPC) bilayers, respectively. To confirm that the structural arrangement of the peptide side chains can affect anesthetic binding, gA in nonchannel forms in methanol was also analyzed. The addition of volatile anesthetic halothane to gA in SDS with a channel conformation caused a concentration-dependent change in resonant frequencies of the indole amide protons of W9, W11, W13, and W15, with the most profound changes in W9. These frequency changes were observed only for gA carefully prepared to ensure a channel conformation and were absent for gA in methanol. For gA in DMPC bilayers, direct [(14)C]halothane photolabeling and microsequencing demonstrated dominant labeling of W9, less labeling of W11 and W13, and no significant labeling of W15. In methanol, gA showed much less labeling of any residues. Inspection of the 3-D structure of gA suggests that the spatial arrangements of the tryptophan residues in the channel form of gA, combined with the amphiphilic regions of lipid, create a favorable anesthetic binding motif.

The structural features of volatile anesthetic binding sites on proteins are being examined with the use of a defined model system consisting of a four-alpha-helix bundle scaffold with a hydrophobic core. Previous work has suggested that introducing a cavity into the hydrophobic core improves anesthetic binding affinity. The more polarizable methionine side chain was substituted for a leucine, in an attempt to enhance the dispersion forces between the ligand and the protein. The resulting bundle variant has an improved affinity (K(d) = 0.20 +/- 0.01 mM) for halothane binding, compared with the leucine-containing bundle (K(d) = 0.69 +/- 0.06 mM). Photoaffinity labeling with (14)C-halothane reveals preferential labeling of the W15 residue in both peptides, supporting the view that fluorescence quenching by bound anesthetic reports both the binding energetics and the location of the ligand in the hydrophobic core. The rates of amide hydrogen exchange were similar for the two bundles, suggesting that differences in binding affinity were not due to changes in protein stability. Binding of halothane to both four-alpha-helix bundle proteins stabilized the native folded conformations. Molecular dynamics simulations of the bundles illustrate the existence of the hydrophobic core, containing both W15 residues. These results suggest that in addition to packing defects, enhanced dispersion forces may be important in providing higher affinity anesthetic binding sites. Alternatively, the effect of the methionine substitution on halothane binding energetics may reflect either improved access to the binding site or allosteric optimization of the dimensions of the binding pocket. Finally, preferential stabilization of folded protein conformations may represent a fundamental mechanism of inhaled anesthetic action.

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.

The fundamental interactions of inhalational anesthetics with proteins have been considered in some detail, using specific examples where appropriate to illustrate these interactions and demonstrate progress. It is now clear that these low-affinity volatile molecules with rapid kinetics can specifically bind to discrete sites in some proteins at reasonable pharmacological concentrations, and some general features of these sites are beginning to emerge. The structural or dynamic consequences of anesthetic binding, however, are still vague at best. The remaining challenge is to define which interactions produce anesthetic binding to relevant targets and what the features of this relevant anesthetic binding site are. Finally, and most importantly, how does the occupancy of these pockets, patches, or cavities result in the subtle alterations in protein conformation and dynamics that confound their function and ultimately produce the behavioral response that we term "anesthesia"?

The activity of various Ca2+-ATPases is affected by volatile anesthetics, such as halothane, commonly used in clinical practice. The effect on the enzyme in skeletal muscle sarcoplasmic reticulum (SR) is biphasic, including stimulation at clinical anesthetic concentrations and subsequent inhibition at higher concentrations. We have previously proposed that the action of a volatile anesthetic on Ca2+-ATPases results from its binding in the interior of the enzyme molecule [Lopez, M.M. and Kosk-Kosicka, D. (1995) J. Biol. Chem. 270, 28239-28245]. Presently, we investigated whether the anesthetic interacts directly with the skeletal muscle SR Ca2+-ATPase (SERCA1) as evidenced by binding. Photoaffinity labeling with [14C]halothane demonstrated that the anesthetic binds saturably to SR membranes, and that approximately 80% of the binding is specific, with a KI of 0.6 mM. The KI value agrees well with the concentration at which halothane half-maximally activates SERCA1. SDS gel electrophoresis of labeled membranes indicates that 38-56% of [14C]halothane incorporates into SERCA1, and 38-53% in lipids. Distribution of label among the three fragments produced by controlled tryptic digestion of SERCA1 suggests heterogeneous halothane binding presumably in discrete sites in the enzyme. The results provide the first direct evidence that halothane binds to SERCA1. Potentially this binding could be related to anesthetic effect on enzyme's function.

We have shown previously that inhalation anaesthetics inhibit dopamine transport in rat synaptosomes. In order to determine if this inhibition is associated with occupancy of the cocaine site, we examined binding of [3H] (2 beta-carbomethoxy-3 beta-(4-fluorophenyl)-tropane) (3H-CFT) in the presence of halothane or isoflurane 0.01-5 mmol litre-1 in rat brain synaptosomes. Both anaesthetics inhibited 3H-CFT binding (mean Ki 0.61 (SEM 0.12) and 0.75 (0.21) mmol litre-1, respectively), by increasing Kd (13.8 (0.6) and 29.8 (12.8) nmol litre-1, respectively) compared with control (8.02 (0.5) nmol litre-1) (P < 0.01). Halothane did not change Bmax, but isoflurane increased it significantly. Cocaine protected CFT sites from N-ethylmaleimide alkylation, but neither anaesthetic did. Photoaffinity labelling with halothane significantly inhibited 3H-CFT binding compared with UV-exposed controls. We conclude that clinically relevant concentrations of both anaesthetics inhibit high-affinity CFT binding, and the data suggest overlapping sites for halothane and CFT.

Background: Recently, halothane and isoflurane have been shown to bind in a saturable manner to serum albumin using NMR and gas chromatography methods. To validate a novel direct photoaffinity labeling method developed in our laboratory, the authors also determined the binding characteristics of halothane to serum albumin, and then extended this approach to other soluble proteins in an initial attempt to understand the interaction of volatile anesthetics and proteins., Methods: Serum albumin (BSA), bacterial luciferase (BL), poly-(L-lysine)(PLL), and poly-(L-glutamate)(PLG) were dissolved in 0.154 M NaCl containing 14C-halothane with or without other volatile anesthetics or ligands, and exposed to 254 nm UV light for 10 s. Covalently bound label was quantitated by scintillation counting after precipitation, filtration, and washing. Binding parameters were calculated by nonlinear least-squares fitting of rectangular hyperbolas or logistic equations., Results: Serum albumin bound halothane in a saturable manner at an apparent KD between 0.3 and 0.5 mM. Other volatile anesthetics inhibited binding (KI, in mM): halothane (0.36), chloroform (1.26), methoxyflurane (2.66), isoflurane (1.47), diethyl ether (45.5), and ethanol (1,040). Oleate and BSA conformational changes (low pH) also inhibited label incorporation. Binding to BL and PLL at pH 7 was nonsaturable and not displaced by unlabeled halothane or the BL substrate decanal. Conversion of PLL to an alpha-helical conformation (pH > 10) increased binding and created a saturable component with an apparent KD of 0.55 mM. Alkaline conditions decreased binding to PLG consistent with the loss of alpha-helical domains., Conclusions: Photoaffinity labeling produced results in close agreement with more conventional methods for studying halothane binding, and should be a useful tool for the study of volatile anesthetic binding sites. Halothane binding to soluble proteins depended on their type and conformation, and, in some cases, was saturable within the clinical concentration range, increasing the tenability of discrete proteinaceous sites of action for the inhalational anesthetics.