Strong Early Phase Parasympathetic Inhibition Followed by Sympathetic Withdrawal During Propofol Induction: Temporal Response Assessed by Wavelet-Based Spectral Analysis and Photoplethysmography

Hsin-Yi Wang, Men-Tzung Lo, Kun-Hui Chen, Susan Mandell, Wen-Kuei Chang, Chen Lin, Chien-Kun Ting, Hsin-Yi Wang, Men-Tzung Lo, Kun-Hui Chen, Susan Mandell, Wen-Kuei Chang, Chen Lin, Chien-Kun Ting

Abstract

Background: Induction of anesthesia with propofol is associated with a disturbance in hemodynamics, in part due to its effects on parasympathetic and sympathetic tone. The impact of propofol on autonomic function is unclear. In this study, we investigated in detail the changes in the cardiac autonomic nervous system (ANS) and peripheral sympathetic outflow that occur during the induction of anesthesia. Methods: Electrocardiography and pulse photoplethysmography (PPG) signals were recorded and analyzed from 30 s before to 120 s after propofol induction. The spectrogram was derived by continuous wavelet transform with the power of instantaneous high-frequency (HFi) and low-frequency (LFi) bands extracted at 1-s intervals. The wavelet-based parameters were then divided into the following segments: (1) baseline (30 s before administration of propofol), (2) early phase (first minute after administration of propofol), and (3) late phase (second minute after administration of propofol) and compared with the same time intervals of the Fourier-based spectrum [high-frequency (HF) and low-frequency (LF) bands]. Time-dependent effects were explored using fractional polynomials and repeated-measures analysis of variance. Results: Administration of propofol resulted in reductions in HFi and LFi and increases in the LFi/HFi ratio and PPG amplitude, which had a significant non-linear relationship. Significant between-group differences were found in the HFi, LFi, and LFi/HFi ratio and Fourier-based HF and LF after dividing the segments into baseline and early/late phases. On post hoc analysis, changes in HFi, LFi, and the LFi/HFi ratio were significant starting from the early phase. The corresponding effect size (partial eta squared) was > 0.3, achieving power over 90%; however, significant decreases in HF and LF were observed only in the late phase. The PPG amplitude was increased significantly in both the early and late phases. Conclusion: Propofol induction results in significant immediate changes in ANS activity that include temporally relative elevation of cardiac sympathovagal balance and reduced sympathetic activity. Clinical Trial Registration: The study was approved by the Institutional Review Board of Taipei Veterans General Hospital (No. 2017-07-009CC) and is registered at ClinicalTrials.gov (https://ichgcp.net/clinical-trials-registry/NCT03613961).

Keywords: autonomic nervous system; heart rate variability; propofol anesthesia; pulse photoplethysmography; wavelet-based spectral analysis.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Wang, Lo, Chen, Mandell, Chang, Lin and Ting.

Figures

FIGURE 1
FIGURE 1
Temporal changes in (B) R-R interval, (A) its corresponding wavelet-based spectrogram, and (C) the Fourier spectrum in a representative individual after a bolus of propofol. The wavelet-based spectrogram in (A) shows the change in the frequency content of signals over time and a decrease in HFi and LFi power in response to propofol at the start of induction. Frequency is plotted on the y-axis and time on the x-axis. The amount of energy or power in the signal is indicated in color. The spectrogram shows the power content in the range of 0.01–0.40 Hz. (C) The corresponding RR interval signal obtained during the different phases after induction of propofol. HF and LF power derived by the traditional Fourier-based method shows decreases only in the late phase after induction. HF, high-frequency power; HFi, instantaneous high-frequency power; LF, low-frequency power; LFi, instantaneous low-frequency power.
FIGURE 2
FIGURE 2
Results of the fractional polynomials with 95% confidence interval and goodness-of-fit in (A) normalized HFi (R squared = 0.9828), (B) normalized LFi (R squared = 0.999), (C) normalized LFi/HFi ratio (R squared = 0.8635), and (D) heart rate (R squared = 0.8273). The black circles represent the averaged value for each derived parameter for all subjects over time and the red line illustrates the fitted result for the fractional polynomial model with the 95% confidence interval (shadowed area). HFi, instantaneous high-frequency power; LFi, instantaneous low-frequency power.
FIGURE 3
FIGURE 3
Temporal changes in (A) normalized HFi, (B) normalized LFi, (C) normalized LFi/HFi ratio, (D) Fourier-based HF, (E) Fourier-based LF, and (F) Fourier-based LF/HF ratio at baseline and in the early and late phases. The main effect was assessed by repeated-measures analysis of variance. Baseline phase, 30 seconds before induction; early phase, the first minute of propofol induction; late phase, the second minute of propofol induction. The data are presented as the mean ± the standard error of the mean. *P < 0.05 vs. baseline, post hoc test. ANOVA, analysis of variance; HF, high-frequency power; HFi, instantaneous high-frequency power; LF, low-frequency power; LFi, instantaneous low-frequency power.
FIGURE 4
FIGURE 4
Fractional polynomials with 95% confidence interval and goodness-of-fit of normalized pulse photoplethysmography amplitude (PPGA) changes (R squared = 0.992) (A) and the corresponding PPGA assessed by repeated-measures analysis of variance (B). Baseline, 30 s before induction; early phase, the first minute of propofol induction; late phase, the second minute of propofol induction. The data are presented as the mean ± the standard error of the mean. *P < 0.05 vs. baseline, post hoc test; †P < 0.05 vs. early phase, post hoc test. A continued dilatation response of PPGA was clearly demonstrated. ANOVA, analysis of variance.

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