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Dexmedetomidine and Cognitive Dysfunction After Critical Illness What Can (And Cannot) Be Extrapolated from Rodent Models

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Dexmedetomidine and Cognitive Dysfunction After Critical Illness What Can (And Cannot) Be Extrapolated from Rodent Models EDITORIAL Dexmedetomidine and Cognitive Dysfunction after Critical Illness What Can (and Cannot) Be Extrapolated from Rodent Models Cameron W. Paterson, M.D., Craig M. Coopersmith, M.D. istorically, success in the inflammatory products in the cen- Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/133/2/258/514466/20200800.0-00009.pdf by guest on 30 September 2021 Hintensive care unit (ICU) has tral nervous system. been measured in easily quantifi- Cognition alterations often able metrics such as mortality and occur early in the course of an length of stay. While these met- ICU stay necessitating pharmaco- rics have significant value, they logic sedation to either assure that do not take into account what a a patient can synchronize with a patient’s life is like after ICU dis- ventilator or to prevent a patient charge. By understanding that from self-harm. Multiple different success is not simply measured by sedating agents are available target- leaving the ICU, the recent iden- ing different neural pathways. One tification of post–intensive care commonly used sedation agent is syndrome has revolutionized the dexmedetomidine, an α2 agonist manner in which we think of suc- that also has activity for the imid- cessful outcomes after critical ill- azoline receptor, as well as the α1 ness.1 Unfortunately, a significant receptor. Dexmedetomidine has proportion of patients suffer from “Understanding how to numerous clinical benefits includ- post–intensive care syndrome, in prevent (or at least minimize) ing a short half-life and minimal which they have long-term cogni- effects on respiratory drive, allow- tive, physical, and emotional issues post–intensive care syndrome ing patients to interact while on for extended periods of time—or thus represents a new frontier mechanical ventilation in a man- permanently—after discharge in critical care.” ner that is often not possible with from the ICU. Understanding how other sedating agents. Preclinical to prevent (or at least minimize) work has demonstrated that dex- post–intensive care syndrome thus represents a new frontier medetomidine decreases cognitive decline in mice in the in critical care. postoperative setting via resolution of systemic and neuroin- Neurocognitive dysfunction occurs in 70% of sepsis flammation. In a complementary set of studies presented in survivors with chronic critical illness.2 A critical driver of this issue of Anesthesiology, Li et al. sought to determine sepsis-associated encephalopathy is uncontrolled neuroin- the impact of dexmedetomidine on cognitive decline in a flammation, which is precipitated by loss of blood–brain rodent model, and more similar to medical than surgical barrier function, as well as dysregulated peripheral-to-cen- illness.4 The authors examined a variety of endpoints in tral signaling through vagal pathways.3 Key cellular medi- young (12 week) mice subjected to a sterile inflammatory ators of this neuroinflammation include monocytes, insult with lipopolysaccharide, a component of the cell wall macrophages, and microglial cells, and their activation in Gram-negative bacteria. Mice were then treated with is associated with the development and persistence of dexmedetomidine in combination with blockers. At 3 days, Image: J. P. Rathmell. This editorial accompanies the article on p. 393. Accepted for publication April 30, 2020. Published online first on June 18, 2020. From the Department of Surgery and Emory Critical Care Center, Emory University School of Medicine (C.W.P., C.M.C.); and Lieutenant Medical Corps, United States Navy, Naval Reserve Officer Training Corps (C.W.P.), Atlanta, Georgia. The views expressed in this article reflect the results of research conducted by the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the United States Government. Dr. Paterson is a military service member or federal/contracted employee of the United States Government. This work was prepared as part of his official duties. Title 17 U.S.C. 105 provides that “copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. Anesthesiology 2020; 133:258–61. DOI: 10.1097/ALN.0000000000003391 258 AUGUST 2020 ANESTHESIOLOGY, V 133 • NO 2 Editorial the authors demonstrated that dexmedetomidine reversed long-term changes in cognition, especially considering that cognitive dysfunction measured by decreased “freezing the adrenergic nervous system is often altered and pharma- time” behavior. Mechanistically, this was mediated through cologically targeted in critical illness. α2 receptors as the reversal in cognitive decline was abro- This begs the larger question, however, of how useful gated by α2 antagonists yohimbine and atipamezole, but animal models of critical illness are. A long-standing debate was unaffected by theα 1 antagonist prazosin. At 6 h, the regarding how well rodent models of critical illness mimic authors also demonstrated that dexmedetomidine attenu- human illness has led to conflicting results even when ated systemic and hippocampal release of macrophage-de- analyzing the identical data set.8,9 What is unfortunately rived interleukin-1β through a α2-dependent mechanism. unquestionable is that the overwhelming number of ran- Similar findings were noted in the blood–brain barrier, domized controlled trials in the ICU fail to show benefit.10 where lipopolysaccharide-induced increased leakage was This lack of efficacy is especially glaring in sepsis, a disease Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/133/2/258/514466/20200800.0-00009.pdf by guest on 30 September 2021 reversed by dexmedetomidine, a finding that was prevented responsible for nearly 20% of all deaths worldwide, which by administering α2 inhibitors. costs more than $60 billion annually in the United States A common critique of preclinical studies of critical ill- alone.11,12 Historically, much (if not most) sepsis research ness is that young mice are typically used despite the fact has utilized mouse models of sepsis. While this has resulted that the majority of patients in the ICU are aged. There are in a massive amount of mechanistic data, this approach has clear data that the host response changes significantly with not yet been successfully translated into changes of treat- age (so-called “inflam-aging”), which is a limitation in the ment at the bedside, and multiple clinical trials based on utility of young mice to model older patients.5 Cognizant of successful therapies in mice have proven to be unsuccess- this disconnect, Li et al. took the unusual step of repeating ful in the ICU. The causes of these failures are multiple. many of their experiments in 12-month-old mice, which For instance, it is easy to see conceptually how translating are middle aged based on murine life tables. Importantly, findings in young, healthy, genetically homogenous mice they found similar findings in freezing time and systemic to aged genetically diverse human patients with multiple and hippocampal inflammation in 12-month-old mice. comorbidities might be difficult. This represents a notable (and unusual) experimental design Since sepsis impacts multiple organs, funding for research in that strengthens the data presented. this syndrome comes from multiple institutes at the National However, above and beyond the noble pursuit of mecha- Institutes of Health (NIH). Of these, the National Institute of nistic insights for the sake of scientific understanding alone, General Medical Sciences (NIGMS) provides the most fund- a key goal of translational research is that these insights ing for the field. Driven by a desire to translate discoveries ultimately play a role in improving human health. In this to the bedside, NIGMS recently released “Priorities for Sepsis context, there are a few key experimental decisions that Research” for researchers submitting applications related to must be taken into account when determining the potential sepsis.13 The purpose of the notice was to explicitly notify relevance of the study of Li et al. to the bedside of criti- applicants of NIGMS’s focus on areas that would “provide new cally ill patients. First, while lipopolysaccharide is a model knowledge of the mechanistic complexity of sepsis in humans of a short-term proinflammatory state that rapidly returns and… [to] test strategies for translating this knowledge into to baseline (or results in a similarly rapid death in more improved diagnostics and therapies for sepsis patients.” This severe models), it does not closely mimic any disease seen official guidance lists 12 topics of interest to NIGMS that in the ICU. While historically lipopolysaccharide was used cover a remarkably wide range of potential research direc- as a model of sepsis since it is an integral part of Gram- tions. In contrast, it only lists two areas of low priority: rodent negative bacteria, there is expansive literature demonstrat- models, “unless uniquely well justified in terms of potential ing the differences between lipopolysaccharide and more for providing novel insights into human sepsis,” and clinical authentic models of sepsis,6 which has resulted in inter- trials. While the low priority of clinical trials is not a surprise national consensus guidelines explicitly recommending given NIGMS’s overall mission,
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