Hypothalamic CRH Neurons Modulate Sevoflurane Anesthesia and The Post-anesthesia Stress Responses

Joint Public Review:

This study describes a group of CRH-releasing neurons, located in the paraventricular nucleus of the hypothalamus, which, in mice, affects both the state of sevoflurane anesthesia and a grooming behavior observed after it. PVH-CRH neurons showed elevated calcium activity during the post-anesthesia period. Optogenetic activation of these PVH-CRH neurons during sevoflurane anesthesia shifts the EEG from burst-suppression to a seemingly activated state (an apparent arousal effect), although without a behavioral correlate. Chemogenetic activation of the PVH-CRH neurons delays sevoflurane-induced loss of righting reflex (another apparent arousal effect). On the other hand, chemogenetic inhibition of PVH-CRH neurons delays recovery of the righting reflex and decreases sevoflurane-induced stress (an apparent decrease in the arousal effect). The authors conclude that PVH-CRH neurons are a common substrate for sevoflurane-induced anesthesia and stress. The PVH-CRH neurons are related to behavioral stress responses, and the authors claim that these findings provide direct evidence for a relationship between sevoflurane anesthesia and sevoflurane-mediated stress that might exist even when there is no surgical trauma, such as an incision. In its current form, the article does not achieve its intended goal.

Strengths
The manuscript uses targeted manipulation of the PVH-CRH neurons, and is technically sound. Also, the number of experiments is substantial.

Weaknesses
The most significant weaknesses are a) the lack of consideration and measurement of GABAergic mechanisms of sevoflurane anesthesia, b) the failure to use another anesthetic as a control, c) a failure to document a compelling post-anesthesia stress response to sevoflurane in humans, d) limitations in the novelty of the findings. These weaknesses are related to the primary concerns described below:

Concerns about the primary conclusion, that PVH-CRH neurons mediate "the anesthetic effects and post-anesthesia stress response of sevoflurane GA".

1. Just because the activity of a given neural cell type or neural circuit alters an anesthetic's response, this does not mean that those neurons play a role in how the anesthetic creates its anesthetic state. For example, sevoflurane is commonly used in children. Its primary mechanism of action is through enhancement of GABA-mediated inhibition. Children with ADHD on Ritalin (a dopamine reuptake inhibitor) who take it on the day of surgery can often require increased doses of sevoflurane to achieve the appropriate anesthetic state. The mesocortical pathway through which Ritalin acts is not part of the mechanism of action of sevoflurane. Through this pathway, Ritalin is simply increasing cortical excitability making it more challenging for the inhibitory effects of sevoflurane at GABAergic synapses to be effective. Similarly, here, altering the activity of the PVHCRH neurons and seeing a change in anesthetic response to sevoflurane does not mean that these neurons play a role in the fundamental mechanism of this anesthetic's action. With the current data set, the primary conclusions should be tempered.

2. It is important to compare the effects of sevoflurane with at least one other inhaled ether anesthetic. Isoflurane, desflurane, and enflurane are ether anesthetics that are very similar to each other, as well as being similar to sevoflurane. It is important to distinguish whether the effects of sevoflurane pertain to other anesthetics, or, alternatively, relate to unique idiosyncratic properties of this gas that may not be a part of its anesthetic properties.

For example, one study cited by the authors (Marana et al.. 2013) concludes that there is weak evidence for differences in stress-related hormones between sevoflurane and desflurane, with lower levels of cortisol and ACTH observed during the desflurane intraoperative period. It is not clear that this difference in some stress-related hormones is modeled by post-sevoflurane excess grooming in the mice, but using desflurane as a control could help determine this.

Concerns about the clinical relevance of the experiments
In anesthesiology practice, perioperative stress observed in patients is more commonly related to the trauma of the surgical intervention, with inadequate levels of antinociception or unconsciousness intraoperatively and/or poor post-operative pain control. The authors seem to be suggesting that the anesthetic itself is causing stress, but there is no evidence of this from human patients cited. We were not aware that this is a documented clinical phenomenon. It is important to know whether sevoflurane effectively produces behavioral stress in the recovery room in patients that could be related to the putative stress response (excess grooming) observed in mice. For example, in surgeries or procedures that required only a brief period of unconsciousness that could be achieved by administering sevoflurane alone (comparable to the 30 min administered to the mice), is there clinical evidence of post-operative stress?

Patients who receive sevoflurane as the primary anesthetic do not wake up more stressed than if they had had one of the other GABAergic anesthetics. If there were signs of stress upon emergence (increased heart rate, blood pressure, thrashing movements) from general anesthesia, the anesthesiologist would treat this right away. The most likely cause of post-operative stress behaviors in humans is probably inadequate anti-nociception during the procedure, which translates into inadequate post-op analgesia and likely delirium. It is the case that children receiving sevoflurane do have a higher likelihood of post-operative delirium. Perhaps the authors' studies address a mechanism for delirium associated with sevoflurane, but this is not considered. Delirium seems likely to be the closest clinical phenomenon to what was studied.

Concerns about the novelty of the findings
CRH is associated with arousal in numerous studies. In fact, the authors' own work, published in eLife in 2021, showed that stimulating the hypothalamic CRH cells leads to arousal and their inhibition promotes hypersomnia. In both papers, the authors use fos expression in CRH cells during a specific event to implicate the cells, then manipulate them and measure EEG responses. In the previous work, the cells were active during wakefulness; here- they were active in the awake state that follows anesthesia (Figure 1). Thus, the findings in the current work are incremental.

The activation of CRH cells in PVN has already been shown to result in grooming by Jaideep Bains (cited as reference 58). Thus, the involvement of these cells in this behavior is expected. The authors perform elaborate manipulations of CRH cells and numerous analyses of grooming and related behaviors. For example, they compare grooming and paw licking after anesthesia with those after other stressors such as forced swim, spraying mice with water, physical attack, and restraint. However, the relevance of these behaviors to humans and generalization to other types of anesthetics is not clear.