A Randomized, Double-Blinded, Placebo-Controlled Study to Determine if Caffeine Citrate Accelerates Emergence From Anesthesia
Phase: PHASE4
Conditions: Anesthesia
Sponsor: University of Chicago

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[TITLE PAGE – REVISED IRB PROTOCOL] 
 
PROTOCOL TITLE: A Randomized, Double-Blinded, Placebo-Controlled 
Study to Determine if Caffeine Citrate Accelerates Emergence from 
Anesthesia  
 
PI:   
 
Name: Aaron Fox, Ph.D. 
 
 
Telephone: (773) 702-2667 
 
 
Fax: 
 
 
E-mail: aaronfox@uchicago.edu 
 
 
CO-I(S):  
Name: Zheng (Jimmy) Xie, M.D., Ph.D. 
 
   
Telephone: (773) 702-2667 
 
 
 Fax: 
 
   
E-mail: JXie@dacc.uchicago.edu  
 
FUNDING:  
NIH 
 
     
1R01GM116119 – 01  
 
 
09/01/2015 – 08/30/2019 
PI: Fox 
 
 
 
 
Reversing Anesthesia with Caffeine 
 
Patients who are anesthetized, wake after their bodies clear the anesthetic. Our 
preliminary studies found that in rodents that caffeine could dramatically accelerate 
emergence from anesthesia. Preliminary data from a Pilot study in human subjects 
suggest that humans show a similar response to caffeine. The goal in this application is to 
determine the mechanism for the emergence and to test whether caffeine can accelerate 
emergence from anesthesia in human subjects. 
 
 
SPONSOR:  
Name: Principal Investigator, Aaron Fox, Ph.D. 
 
     
Address:  
The University of Chicago 
Neurobiology, Pharmacology and Physiology 
 
 
 
 
947 E. 58th Street 
 
     
Telephone: (773) 702-2667  
 
 
TYPE OF RESEARCH:  Interventional, drug studies 
 
INTERVENTION: Study Drug Caffeine Citrate  
 
MANUFACTURER OF INTERVENTION (if applicable): Bedford Labs 
 
 
IND OR IDE # (applicable for IND/IDE-regulated studies): 127863 
 
 
NAME OF PERSON WHO HOLDS IND OR IDE (if applicable): Aaron Fox, Ph.D. 
 

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PROTOCOL NUMBER:   
 
 
PROTOCOL VERSION: 2.0 
 
PROTOCOL VERSION DATE: 

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TABLE OF CONTENTS                                                                                                                           PAGE 
 
1. INTRODUCTION ………………………………………………………………… 
1.1   
Background and Rationale…………………………………………    
1.2  
 Objectives …………………………………………………………. 
2. STUDY DESIGN 
2.1   
Type of Study ………………………………………………………  
2.2   
Duration of Study ………………………..………………………… 
2.3   
Schedule of Events………………………………………………….  
2.4   
Sequence and Duration of all Study Periods……………………….. 
2.5   
Method for Assigning Subjects to Treatment Groups……………… 
2.6   
Blinding…………………………………………………………….. 
2.7   
Primary Study Endpoints…………………………………………... 
2.8   
Secondary Study Endpoints………………………………………… 
2.9   
Primary Safety Endpoints…………………………………………... 
3. SUBJECT SELECTION AND WITHDRAWAL………………………………………. . 
 
3.1   
Number of Subjects…………………………………………………. 
3.2   
Gender, Age, Racial and Ethnic Origin of Subjects………………… 
3.5   
Inclusion Criteria……………………………………………………. 
3.6   
Exclusion Criteria…………………………………………………… 
3.7   
Vulnerable Subjects…………………………………………………. 
3.8   
Subject Identification & Recruitment………………………………..  
3.9   
Location……………………………………………………………... 
3.10  Payment to Subjects…………………………………………………. 
3.11   Informed Consent Process…………………………………………... 
3.12   Subject Withdrawal Following Study Completion..…………………  
3.13   Subject Withdrawal Before Completion (i.e., early termination)…….  
3.14    Data Collection and Follow-up on Early Withdrawal Subjects……...  
4. STUDY DRUG……………………………………………………………. 
A.  Drug Study: 
4.1A   Formulation of Study Drug………………………………………….. 
4.2A   Treatment Regimen………………………………………………….. 
4.3A   Preparation and Administration of Study Drug……………………… 
4.4A  Subject Compliance Monitoring…………………………………….. 
4.5A  Concomitant Medications and Therapies……………………………. 
4.6A   Packaging and Labeling……………………………………………... 
4.7A   Receipt of Drug Supplies……………………………………………. 
4.8A   Product Storage and Stability………………………………………... 
4.9A   Dispensing of Study Drug…………………………………………… 
4.10A Return or Destruction of Study Drug……………………………….. 
5. STUDY PROCEDURES 
5.1   
Screening Session 1…………………………………….…………… 
5.2   
Anesthesia Sessions 2-3..……………………………………………….. 
6. STATISTICAL PLAN 
6.1   
Sample Size Determination………………………………………….  
6.2   
Statistical Methods………………………………………………….. 

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6.3   
Subject Population(s) for Analysis………………………………….. 
7. RISKS AND BENEFITS 
7.1   
Risks and Likelihood of Occurrence ………………………………. 
7.2   
Potential Direct Benefits to Subject…………………………………. 
8. SAFETY AND ADVERSE EVENTS …………………………………………………. 
8.1   
Safety……………………………………………………………….. 
8.2   
Adverse Events…………………………………………………....... 
8.3   
Responsibilities………………………………………………………  
8.4   
Documenting and Reporting Adverse Events……………………… 
8.5   
Classifying Adverse Events………………………………………… 
8.6   
Unblinding procedures……………………………………………… 
8.7   
Data Safety Monitoring Plan……………………………………….. 
9. DATA HANDLING AND RECORD KEEPING ………………………………………. 
9.1   
Data Management Responsibilities………………………………… 
9.2   
Data Capturing Methods………………………………………….... 
9.3   
Source Documents…………………………………………………. 
9.4   
Records Retention………………………………………………….. 
9.5  
Confidentiality……………………………………………………… 
10. STUDY MONITORING, AUDITING AND INSPECTION……………………………… 
10.1   Study Monitoring Plan……………………………………………… 
10.2   Auditing and Inspecting……………………………………………. 
11. FINANCIAL CONSIDERATIONS………………………………………………….. 
12. ETHICAL CONSIDERATIONS ……………………………………………………. 
12.1  
Institutional Review Board (IRB) approval………………………… 
12.2 
Ethical and Scientific Conduct of the Clinical Study……………… 
12.3 
Subject Informed Consent…………………………………………. 
13. CONFLICT OF INTEREST ………………………………………………………... 
14. PUBLICATION PLAN ……………………………………………………………. 
15. REFERENCES …………………………………………………………………… 
16. APPENDIXES ……………………………………………………………………. 
             A.  INFORMED CONSENT FORM …………………………………………….. 
             B.  SCHEDULE OF EVENTS (SCHEMA) ………………………………………. 
             C.  DATA SAFETY MONITORING PLAN ……………………………………… 
 

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STUDY SUMMARY (DRUGS) 
TITLE  
A Randomized, Double-Blinded, Placebo-Controlled Study 
to Determine if Caffeine Citrate (caffeine) Accelerates 
Emergence from Anesthesia 
OBJECTIVES 
To determine if caffeine will accelerate emergence from 
anesthesia. 
PRIMARY OBJECTIVE 
Determine whether subjects wake more rapidly from 
anesthesia after administration of caffeine as measured by the 
time between terminating anesthetic and the reinstatement of 
the gag reflex.  
SECONDARY 
OBJECTIVES 
Determine whether subjects wake more rapidly from 
anesthesia after administration of caffeine as measured by the 
time between terminating anesthetic and responding to 
simple commands (“squeeze my hand”). 
 
Normally patients show cognitive impairments for hours after 
waking from anesthesia. We wish to determine whether 
caffeine administration ameliorates the cognitive impairment. 
STUDY CENTER(S) 
Single-center at University of Chicago 
NUMBER OF SUBJECTS  
Up to 8 
DIAGNOSIS AND MAIN 
INCLUSION CRITERIA 
Healthy male, ages 25-40 with no systematic diseases or 
conditions, metabolic equivalents of functional capacity, low 
risk for Obstructive Sleep Apnea, no history of arrhythmia, 
BMI < 30 kg/m2, no personal or family history of malignant 
hyperthermia, no history of any mental illness, no history of 
drugs or alcohol abuse, no history of seizure disorders or 
head trauma  
DURATION OF SUBJECT 
PARTICIPATION AND 
DURATION OF STUDY  
Subjects will be on study for up to 10 weeks 
 
INVESTIGATIONAL 
PRODUCT 
Caffeine Citrate 
DOSE, ROUTE, REGIMEN  15 mg/kg body weight, given intravenously 10 min before 
the end of 1 hour isoflurane anesthesia 

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DURATION OF 
ADMINISTRATION  
 
Study drug given intravenously across a  10 min time 
window 
STATISTICAL 
METHODOLOGY  
In this crossover study volunteers will serve as their own 
controls. The data will be analyzed with a paired t-test. 
 

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LIST OF ABBREVIATIONS 
 
EXAMPLES   
 
UCMC  
 
UNIVERSITY OF CHICAGO MEDICAL CENTER 
UC 
 
 
UNIVERSITY OF CHICAGO 
OCR  
 
OFFICE OF CLINICAL RESEARCH 
IRB 
 
 
INSTITUTIONAL REVIEW BOARD 
URA 
 
 
UNIVERSITY RESEARCH ADMINISTRATION 
ORS 
 
 
OFFICE OF RESEARCH SERVICES 
CRSO  
 
CLINICAL RESEARCH SUPPORT OFFICE 
UCCRC 
 
UNIVERSITY OF CHICAGO CANCER CLINICAL RESEARCH CENTER 
CRC 
 
 
CLINICAL RESOURCE CENTER (FORMERLY GCRC) 
DSMB  
 
DATA SAFETY AND MONITORING BOARD 
FDA 
 
 
FOOD AND DRUG ADMINISTRATION 
CDER  
 
CENTER FOR DRUG EVALUATION AND RESEARCH 
CBER  
 
CENTER FOR BIOLOGICS EVALUATION AND RESEARCH 
NIH 
 
 
NATIONAL INSTITUTES OF HEALTH 
NCI 
 
 
NATIONAL CANCER INSTITUTE 
CTSA  
 
CLINICAL AND TRANSLATIONAL SCIENCE AWARD 
ITM 
 
 
INSTITUTE FOR TRANSLATIONAL MEDICINE 
 
 
 
 
 
 

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1.  INTRODUCTION  
1.1 BACKGROUND AND RATIONALE 
 
1.1.1 Background: Disease and current understanding of disease  
Our lab has studied anesthetics for almost fifteen years. We, as well as other labs, 
found that anesthetics inhibit neurotransmitter release (Crowder et al.; van Swinderen et 
al., 1999; Winegar & MacIver, 2006; Herring et al., 2009; Herring et al., 2011; Saifee et 
al.).  We thought that if we could reverse this action that we would be able to reverse 
aspects of anesthesia. In our preliminary studies, several drugs were studied that normally 
facilitate neurotransmitter release. If inhibiting neurotransmitter release is part of the 
mechanism leading to anesthesia (Crowder et al.; van Swinderen et al., 1999; Winegar & 
MacIver, 2006; Herring et al., 2009; Herring et al., 2011; Saifee et al.) then drugs that 
facilitate neurotransmitter release may aid in reversing anesthesia. Elevating intracellular 
cAMP, with drugs like forskolin or caffeine, is well known to facilitate neurotransmitter 
release (Byrne & Kandel, 1996; Trudeau et al., 1996; Fujita-Yoshigaki, 1998; Fujita-
Yoshigaki et al., 1998; Lonart et al., 1998; Trudeau et al., 1998; Takahashi et al., 1999; 
Trudeau et al., 1999; Kuromi & Kidokoro, 2000; Hilfiker et al., 2001; Machado et al., 
2001; Sakaba & Neher, 2001; Burgoyne & Morgan, 2003; Kuromi & Kidokoro, 2003; 
Lonart et al., 2003; Sakaba & Neher, 2003; Seino & Shibasaki, 2005; Kasai et al.). We 
found that drugs that elevate intracellular cAMP levels reversed the inhibition of 
neurotransmitter release caused by anesthetics in in vitro studies. In addition, the cAMP 
elevating drugs caused rats to wake up very quickly from anesthesia. 
Normally recovery from anesthesia is passive. Anesthetic is terminated and people 
wake up. Some do so slowly. Age, genetics, gender and other factors come into play with 
regards to waking time (Solt et al., 2011). But currently there is nothing that a clinician 
can do to hurry the process. Additionally, there are cognitive impairments that last for 
hours following anesthesia (Nathanson et al., 1995; Larsen et al., 2000; Chen et al., 
2001). Reaction times and memory are impaired following anesthesia (Nathanson et al., 
1995; Larsen et al., 2000; Chen et al., 2001). People (outpatients) are being released from 
surgery/ anesthesia on an ever shortening time scale to save money. It would be 
significant if clinicians could wake the patients safely, rapidly and completely with no 
cognitive issues.   
Anesthesia is thought to work similarly in humans and rodents. In our preliminary 
studies we found that drugs that elevate intracellular cAMP, like caffeine, dramatically 
accelerated recovery from anesthesia in rats.  The question that we hope to address is the 
following: Do drugs that elevate cAMP levels work the same way in humans? Do these 
drugs accelerate emergence from anesthesia? Preliminary data from a Pilot study 
suggests that this is in fact the case. 
 
1.1.2 Investigational Agent  
The drug that will be used in this study is caffeine citrate. 
 
In August of 2013 the FDA was sent an application for IND exemption for caffeine. The 
exemption was not granted. Our next step was to obtain NIH funding for the project, 
which we obtained. Next we sent off a formal IND application for caffeine citrate. That 

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IND was approved with (IND #127863). The University of Chicago IRB also approved 
our protocol (IRB 15-0897).   
 
 
 
 
 
 
 
  1.1.3 Preclinical data 
Previously my lab has shown that clinically relevant concentrations of anesthetics inhibit 
neurotransmitter release from both secretory cells and neurons. We tested isoflurane, 
propofol, etomidate and ketamine. All four anesthetics efficiently inhibited 
neurotransmitter release (Herring BE, Xie Z, Marks J and Fox AP (2009); Herring BE, 
McMillan, K., Pike, C. Marks, J, Fox AP., Xie Z (2011); Xie Z, McMillan, K., Pike, 
CM., Cahill, AL., Herring BE., Wang, Q., & Fox AP., (2013)). 
 
We hypothesized that inhibition of neurotransmitter release plays a key role in how 
anesthetics produce anesthesia in animals and humans.  Furthermore we hypothesized 
that drugs that reverse the inhibitory effects of anesthetics on the release machinery 
may help accelerate recovery from anesthesia.  Historically, cAMP signaling has been 
shown to play a key role in synaptic function and plasticity. Elevating cAMP facilitates 
neurotransmitter release (Byrne & Kandel, 1996; Trudeau et al., 1996; Fujita-Yoshigaki, 
1998; Fujita-Yoshigaki et al., 1998; Lonart et al., 1998; Trudeau et al., 1998; Takahashi 
et al., 1999; Trudeau et al., 1999; Kuromi & Kidokoro, 2000; Hilfiker et al., 2001; 
Machado et al., 2001; Sakaba & Neher, 2001; Burgoyne & Morgan, 2003; Kuromi & 
Kidokoro, 2003; Lonart et al., 2003; Sakaba & Neher, 2003; Seino & Shibasaki, 2005; 
Kasai et al.). We posited that elevating intracellular cAMP might alter anesthetic action 
by restoring neurotransmitter release. Drugs that elevate [cAMP]i levels, were tested; 
these drugs were found to completely reverse the inhibitory effects of anesthetics on 
neurotransmitter release in in vitro studies. When tested, these same cAMP elevating 
drugs dramatically accelerated recovery from anesthesia in rats.  So far we have tested 
three cAMP elevating drugs (forskolin, theophylline and caffeine) in rats. All accelerate 
recovery from anesthesia in rats.  The Pilot study that was just completed suggests that 
caffeine appears to accelerate emergence from anesthesia in humans. 
There are two studies that bear directly on the cAMP accelerating emergence from 
anesthesia hypothesis. In the 1970’s Cohn et al showed that direct inject of cAMP into 
the brain reduced the duration of narcosis for a series of sedative, hypnotic, tranquilizer 
and anesthetic drug tested {Cohn, 1975 #152}. They tested 8 different drugs. It appears 
that cAMP effectively reduced the waking times for all 8 drugs. More recently, the Solt 
lab has shown that activation of D1 dopamine receptors accelerates emergence from 
anesthesia {Taylor, 2013 #68}. D1 receptors are always coupled to the cAMP machinery 
i.e. activation of this class of receptor always produces an elevation of cAMP in cells that 
express the receptor. 

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Some of the preliminary results are shown below: 
 
Isoflurane Blocks Neurotransmitter Release in PC12 Cells: Forskolin, Theophylline 
and Caffeine Reverse this Block 
Anesthetics modulate the activity of various channels and receptors, thereby altering 
neurotransmitter release. For this experiment, PC12 cells were permeabilized with 
digitonin, and then cells were stimulated by exposing them to Ca2+. Permeabilization 
disrupts the cell’s resting potential and equilibrates the intracellular and extracellular Ca2+ 
levels. Under these conditions, modulation of channels or receptors should have no effect 
on neurotransmitter release. In earlier studies, PC12 cells were also dialyzed with known 
Ca2+ concentrations, via a patch pipette from a constant holding potential of -65 mV; 
these studies validated the digitonin methodology. Exocytosis was elicited in the presence 
and absence of isoflurane (0.5 mM). Basal (Ca2+-independent) neurotransmitter release is 
virtually non-existent in digitonin permeabilized PC12 cells in Ca2+-free conditions, but 
robust release is observed upon 
exposing cells to Ca2+-containing 
solutions. Physiologically, release is 
evoked by the activation of voltage-
gated Ca2+ channels. The proximity 
of Ca2+ channels to synaptic release 
sites suggests that [Ca2+]i may rise 
to levels above 100 M at the 
vesicle.  To mimic these levels in 
our 
experiments, 
evoked 
neurotransmitter release was elicited 
by 
exposing 
digitonin-
permeabilized cells to 100 M Ca2+, 
for 2 min, in the absence or 
presence of isoflurane.   
In previous studies we have 
shown that 0.5 mM (~1.5 MAC) 
isoflurane 
inhibits 
neurotransmitter release by ~39% 
(Herring et al., 2009; Herring et 
al., 2011).  Fig 1 shows that 
isoflurane (0.5 mM) significantly 
inhibited neurotransmitter release 
by ~36% (p < .05) in this study.  
Three drugs that elevate intracellular cAMP were then tested for their ability to reverse 
the inhibition produced by isoflurane. Fig. 1 shows that all three drugs, forskolin (5 M) 
or theophylline (50 M) or caffeine (50 M), reversed the isoflurane-mediated inhibition 
of neurotransmitter release. 
Fig. 1 – Forskolin, theophylline and caffeine reversed the inhibition of 
neurotransmitter release produced by isoflurane. PC12 cells were 
permeabilized with digitonin (20 M) and then stimulated by exposing 
cells to a solution containing 100 M Ca2+. Neurotransmitter release was 
monitored with an amperometric electrode which gently touched the cell. 
Under these conditions, isoflurane (0.5 mM) significantly inhibited 
neurotransmitter release by ~36% (p < 0.05, relative to control and all other 
conditions). The number of events recorded from control PC12 cells were 
about the same as those from PC12 cells exposed to isoflurane + forskolin 
(5 M) or isoflurane and theophylline (50 M) or isoflurane and caffeine 
(50 M)   (Control 81.28 ± 5.1 (n=36), isoflurane 52.29 ± 6.31 (n=17),  
isoflurane + forskolin 83.4 ± 6.1 (n=17), isoflurane + theophylline 79.75 ± 
7.07 (n=12), isoflurane + caffeine 79.43 ± 12.12 (n=7) events per 
stimulation). 
Number of Events Per Stimulus
100
80
60
40
20
0
Control
0.5mM Iso
0.5mM Iso &
Forskolin
0.5mM Iso &
Theophylline
0.5mM Iso &
Caffeine
*

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 Caffeine Accelerates Recovery from Isoflurane Anesthesia 
The results in Fig. 1 suggest that 
elevating 
intracellular 
cAMP 
reverses 
the 
inhibition 
of 
neurotransmitter 
release 
produced by isoflurane in vitro. 
Does 
elevating cAMP alter 
recovery from anesthesia in 
animals?  To address this 
question, 
we 
examined 
emergence from anesthesia in 
rats.  First, we assessed waking 
from anesthesia in the absence 
of any other drug to assess 
population 
variability. 
Rats, 
weighing 420-510 gm, were 
placed 
in 
an 
anesthetizing 
apparatus consisting of a gas-
tight box where they were 
exposed to 3% isoflurane (in 3 
L/min 
O2) 
for 
8 
minutes.  
Isoflurane 
levels 
were 
then 
decreased to 2% (in 2L/ min O2) 
for an additional 45 minutes. 
The rats were then removed 
from the anesthetizing chamber 
and placed on their backs in the 
middle 
of 
a 
large 
table. 
Recovery time from anesthesia 
for rats is defined as the time 
from when the animals are 
removed 
from 
the 
anesthesthetizing 
chamber 
to 
when they stand upright with 4 
paws on the table. Caffeine 
elevates intracellular cAMP by 
inhibiting 
phosphodiesterase. 
Caffeine 
is 
of 
particular 
practical interest as it is such a 
widely 
used 
and 
largely 
innocuous drug. Fig. 2A shows 
a graph of recovery times from 
isoflurane anesthesia for control 
rats (■) or for animals injected 
with caffeine (●), 25 mg/kg, 5 minutes prior to discontinuing the isoflurane. Caffeine 
dramatically sped recovery from anesthesia. Fig. 2B shows the average recovery time at 
0
20
40
60
80
100
*
*
*
1E-3
0.01
0.1
1
10
0
30
60
Percent Reduction in Recovery Time
Caffeine Concentration (mg/kg)
Recovery Time Normalized to % Control
Caffeine Concentration (mg/kg)
Control         0.1              1               5              25
A.
B.
0
500
1000
191
477
Caffeine
(25 mg/kg)
Control
p = 7.6546 x 10-7
reduced 60%
Recovery Time From Anesthesia (Sec)
IC =0.8934 mg/kg
50
Fig. 2 - Caffeine accelerated recovery from isoflurane anesthesia. A, Adult 
rats were anesthetized as described.  Five minutes prior to discontinuing the 
isoflurane the animals received an intravenous injection of either saline 
(control ■) or saline with 25 mg/kg caffeine (●). The isoflurane was 
terminated and the animals were allowed to recover.  B, Average waking 
time normalized to the Control value, set to 100%, at different caffeine 
concentrations (n=13; control, n=8; 0.1 mg/kg, n=13; 1 mg/kg, n=12; 5 
mg/kg, n=12; 25 mg/kg).   Inset plots the percent reduction in waking time as 
a function of the caffeine concentration. The midpoint was at ~0.9 mg/ kg 
caffeine and the maximal reduction of waking time was ~60.5%. 

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different concentrations of caffeine. The inset shows a plot of the dose response curve fit 
to the data showing that the midpoint occurs at approximately 0.9 mg/kg. Of note, an 
average person consumes more than 0.9 mg/ kg of caffeine in a cup of coffee.  
Methods: Adult rats were anesthetized with 3% isoflurane for 8 minutes and were then 
exposed to 2% isoflurane for 45 minutes. During the anesthesia an I-V was inserted into a 
tail vein, while anesthesia was maintained with a nose cone. Five minutes prior to 
discontinuing the anesthetic the animals received an I-V injection of either saline 
(control, ■) or saline with drug (●). The anesthetic was then terminated and the animals 
were allowed to wake up breathing room air.  The rats were placed on their backs on a 
table. Waking time was defined as the time between terminating the anesthetic and the 
rats were standing with 4 paws on the table. 
 
Caffeine Does not Alter Heart Rate, Blood Pressure or Breathing Rate 
 
Fig. 3 plots vital signs immediately 
before or 10 minutes after injection of 
caffeine in isoflurane anesthetized 
rats. 
Anesthetic 
conditions 
were 
similar to those in figure 2. No 
significant changes in heart rate, blood 
pressure (BP) or breathing rate (BR) 
were observed as a result of caffeine 
application (25 mg/kg). In all cases O2 
blood saturation was at either 99% or 
100%.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Caffeine Accelerates Recovery from Propofol Anesthesia  
 
Fig. 4 plots recovery times from propofol anesthesia from control rats (■) or from rats 
injected with 25 mg/kg of the drug (●). Adult rats were anesthetized in the following 
manner. Rats were placed in a gas tight anesthesia box where they were exposed to 3% 
isoflurane for 8 minutes. IVs were inserted into a tail vein and the rats were allowed to 
wake. The rats then received a bolus inject of propofol (4 mg/kg) and either saline 
(Control) or drug in saline (25 mg/Kg). The rats were placed on their backs on a table 
Fig. 3 - No significant change in blood 
pressure, heart rate or respiratory rate in rats 
exposed to drug. Rats were anesthetized as 
described in Fig. 2.  Drug, 25 mg/ kg, was 
injected into each animal. Just prior to drug 
injection blood pressure, heart rate and 
respiratory rate was measured with an IITC   
Life science Multi Channel Blood Pressure 
system, using a tail cuff.  10 minutes after 
drug, the parameters were re-measured. HR= 
Heart Rate, BR = Breathing Rate. Pre = Pre 
drug application. Post = 10 minutes after drug 
application.
mm Hg or Number/ Minute 
400
200
0
Systolic
Diastolic
HR
BR
Pre
Pre
Pre
Pre
Post
Post
Post
Post

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and allowed to wake with room air. As 
before, waking was defined as 4 paws on 
the table. Note that the caffeine was applied 
at the same time as the propofol which may 
not have been optimal. 
 
    This last result opens the possibility 
that caffeine accelerates recovery from 
anesthesia for all anesthetics.  
 
1.1.4 Clinical Data to Date 
Work Done By Others:  
There are two clinical trials that have 
tested caffeine in anesthetized patients. Both 
trials were carefully vetted. In a recent 
clinical 
trial 
in 
anesthetized 
children, 
caffeine was found to be safe (the trial was 
to determine whether caffeine could reduce 
the number of children who experience 
adverse post-extubation respiratory events 
(Khalil et al., 2008) – caffeine helped 
significantly). Note that the concentration of 
caffeine used in this study was quite high. 
Caffeine has been shown safe to use in anesthetized adults. In a clinical trial, to 
determine whether caffeine ameliorated post anesthesia nausea and vomiting, patients 
were given 500 mg caffeine during anesthesia. This combination, anesthesia and caffeine, 
was found to be safe (Steinbrook et al.). Note that 500 mg in that trial is similar to the low 
end of the range that we propose for our trial. 
 
 
 
 
Preliminary Data from Pilot Study: 
A: Safety of Administering Caffeine to Test Subjects Anesthetized with Isoflurane 
 
Safety: 
The good news, is that neither subject experienced any cardiac or respiratory effects due 
to caffeine.  Their hemodynamic responses were unaffected during the trial. No 
differences in vital signs were observed between sessions.  
Subject 1 and 2: 
The graphs below plot heart rate and blood pressure throughout the anesthesia session. 
No significant difference was observed when comparing placebo and caffeine injections. 
There were also no difference in blood O2 saturation (always close to 100%) or 
respiratory rates.  
0
500
1000
p=0.000001234
reduced 38.8%
587 sec
359 sec
Drug (25mg/kg)
Recovery Time from Propofol (Sec)
Control
Fig. 4 - Drug accelerates recovery from propofol 
anesthesia.  Adult rats were anesthetized with 
3% isoflurane for 8 minutes at which time an I-V 
was inserted. The animals were allowed to wake 
and then a bolus of propofol (4 mg/ kg) was 
injected along with either saline (Control, black 
squares) or with 25 mg/kg drug in saline (red 
circles). The animals were allowed to wake.  The 
same animals were used as controls and to test 
drug (n=16 per group).
 

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There were two minor medical incidents during the trial. 
1.  Subject #1 had a mild sore throat immediately following the anesthesia. The sore 
throat was resolved pretty quickly. It was gone soon after he had a chance to take a drink 
following the anesthesia procedure. It appeared to be mainly due to the dryness of his 
mouth during anesthesia. In any case it was very mild since it disappeared so quickly. 
Sore throats are very common during anesthesia since the doctors insert a tube into the 
throat to ensure that the airway stays open. It is equivalent to having a sore arm after an 
injection. This one disappeared after a drink. 
2. Subject #2 had a headache that started 8 hours after the caffeine was administered. He 
was fine at his departure from UC. The subject attempted to study in the afternoon.  At 
approximately 5 pm (caffeine was given at 9 am) he started to have a headache.  He went 
to bed and his headache resolved after a brief rest. The headache could have been due to 
the caffeine, but we are not sure. Caffeine has a half-life of ~5 hours in the body. This 
was 8 hours after he received the caffeine. Most of the caffeine should have been gone by 
that time. A more likely scenario is that he had studied very late the night before and had 
slept little. Then he started to study again. He had similar headaches before although not 
frequently. In any case, the headache disappeared after a brief rest. 
 
 
 
 
 
Analysis of Efficacy.  
 
Below is shown an analysis of 2 subjects that were anesthetized with and without caffeine 
(10 mg/ kg caffeine citrate with corresponds to 5 mg/ kg of pure caffeine). This analysis 
was done blind. The codes were broken after the data had been analyzed and plotted.  
 
 
 
Section 1 - Waking Times 
Section 2 - Estimate of isoflurane Concentration at waking 
Section 3 - Memory Test 
Section 4 - VAS Test 
 
 
 
 

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1 – Waking Times - It turns out that we made a mistake on visit 1 of subject 2. We 
forgot to change the oxygen flow rate after turning off the isoflurane at the end of the 
hour.  Normally during the anesthesia itself 2 liters per minute of O2 were used.  At the 
end of the hour of anesthesia the isoflurane is turned off and the O2 flow rate is turned to 
8 L/ min. If you leave the anesthesia machine at 2 L/ min of O2 the machine keeps 
recirculating the gases thereby giving recycled isoflurane to the test subject. So the 
isoflurane goes down much more slowly. When the isoflurane is stopped the 2L/ min of 
O2 should be stopped as well.  Instead 8 L/ min of O2 needs to be given.  On visit 1 of 
subject #2, this was not done. When the time course of isoflurane’s drop in concentration 
in the lungs, after turning off the isoflurane, in anesthesia session #1 was compared with 
that on anesthesia session 2 (which had a correct procedure) they were very different. But 
they should have been similar. The difference is that for session #2 we used a flow rate of 
8 L/ minute of O2 while for session #1 we used 2 L/ minute of O2, at least at first. So no 
good comparison between sessions is possible. Below is plotted the waking times for 
subject #1, where no mistakes were made. Three different parameters are plotted. Time to 
Gag, Time to Open Eyes and Time to Respond to Commands. 
 
 
 
Best Estimate for Subject 2 – In Visit 1 he gagged in 14 minutes 18 seconds (with 
caffeine). In visit 2 he gagged at 14 minutes and 10 seconds (with placebo). The two 
waking times were very similar. But the O2 flow rate of 2 L/ min O2 was maintained for 2 
to 3 minutes after the isoflurane was turned off. So a simple correction would be that 
subject 2 would have woken 2 to 3 minutes earlier if the flow rate had been administered 
correctly in visit 1. No adjustment is needed for visit 2. This is simply an estimate.

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2 - Estimate of isoflurane concentration for subject 1 waking times: 
 
Note that EPIC takes data once per minute and only stores a single digit of the isoflurane 
concentration. That limits our precision. 
 
Subject 1 came in twice. Below is plotted the end tidal isoflurane concentration as a 
function of time. The first visit is plotted in black squares and the second visit in green 
circles. Note that the data from both visits fall along the same curve. We fit the data with 
a double exponential. It may be that we would have needed 3 exponentials to fit the data 
perfectly all the way to 0 % isoflurane, but for the range we explored, 2 exponentials was 
fine. Using the fit we can obtain an estimate of the isoflurane concentration during each 
visit. In visit 1 Subject 1 woke (gagged) in 34 minutes, 3 seconds (2043 sec). In visit 2 he 
woke (gagged) in 13 minutes, 17 seconds (797 sec). From the fit this corresponds to 
waking at 0.202% isoflurane in visit 1 and 0.317% isoflurane in visit 2. 
That’s a pretty big difference. 
 
 
 
 
There are far fewer green circles because the subject emerged from anesthesia so 
much more rapidly when he received the caffeine injection. The isoflurane measuring 
probe is removed when the subjects wakes. Green data points that look square 
represent data point where the black squares and green circles overlay each other.

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Estimate of isoflurane concentration for subject 2 waking time: 
 
Note that EPIC takes data once per minute and only stores a single digit of the isoflurane 
concentration. That limits our precision. 
 
Subject 2 came in twice. Unfortunately in the first visit the O2 levels were left at 2 L/ min 
for several minutes after the isoflurane was shut off. This means that the time course was 
distorted for visit 1.  Below is plotted the end tidal isoflurane concentration as a function 
of time. The second visit is plotted in black squares and the first visit is not plotted. We 
fit the data with a double exponential. We are somewhat skeptical of the fit since there 
was not a lot of data to fit, since he woke quickly. We are pretty sure that the fit here is 
not accurate. But this is the best we could do. Using the fit we can obtain an estimate of 
the isoflurane concentration during visit 2. In visit 2 Subject 2 woke (gagged) in 14 
minutes, 10 seconds (850 sec). From the fit this corresponds to waking at 0.22% 
isoflurane. Thus the isoflurane concentration that subject 2 woke at is similar to that 
of subject 1. Although we don’t know the exact isoflurane concentration at waking for 
visit 1, it was ~0.3% (reading directly from EPIC). Again not so different than subject 1.  
 
 
 
Note that the black squares corresponds to the visit with the placebo injection. 
Data from the caffeine injection is not plotted.

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 3 – Memory Test – Here we made a choice that was not optimal. Originally we had 
planned on giving the memory test at 30 minutes after turning off isoflurane. This 
original plan assumed that a typical person would wake from 1 hour of isoflurane 
anesthesia in about 15 minutes. But then reality stepped in. Subject 1 woke in visit 1 
(placebo) at 34 minutes. In addition, he was not ready to complete the memory test at 45 
minutes. He was still disoriented. So he took the memory test at 60 minutes and was 
clearly impaired. But we used an identical timing paradigm for subject #2. He took his 
memory test at 60 minutes as well. He woke at ~15 minutes and was mostly recovered at 
60 minutes. Now we understand that we need multiple memory tests. The first memory 
test should take place soon after emerging from anesthesia and then additional tests 
should be spaced every 15 minutes afterwards.  
 
 
 
 
 
 
 
Memory Test – Anesthesia # 1 was with placebo, while anesthesia #2 was with 
caffeine. 

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Memory Test – Anesthesia # 1 was with caffeine, while anesthesia #2 was placebo. 
This subject needed to be tested earlier in the anesthesia. 
 
 
 
 
 
 
4 – VAS Test – In this test we ask the subject how they feel. This test takes advantage 
of the difference between a human and a rodent i.e. you can ask what is happening. 
 
 
 

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Summary of the Data from the Pilot Study: 
This Pilot Study used an intermediate concentration of caffeine. In rats when we used an 
intermediate concentration of caffeine, the rats that emerged rapidly from anesthesia 
woke up more rapidly after caffeine, but the largest effect was observed with animals that 
emerged slowly from anesthesia. In this human trial, subject 1 woke with a placebo 
injection in 34 minutes and in 13 minutes after caffeine. This was a subject that emerged 
slowly from anesthesia. Subject 2 emerged from anesthesia in 14 minutes after receiving 
either caffeine or placebo injections. But due to a mistake with the anesthesia machine, 
we believe that he would have emerged 2-3 minutes more rapidly. This modest difference 
is what we saw in rats that emerged quickly from anesthesia, without any help from 
caffeine.  
The isoflurane concentration where waking occurred was ~0.3% when caffeine was 
injected and ~0.2% when the subjects received a saline injection. This is already a large 
difference. The rat data suggests that as the caffeine concentration is increased, it works 
to antagonize the isoflurane more effectively. Thus increasing the caffeine from 10 mg/ 
kg of the Pilot study to the 15 mg/ kg requested in this study, we should see an even 
larger effect. That is the human subjects should wake from the isoflurane more rapidly 
with an even higher concentration of the anesthetic remaining in their bodies. 
Although we do not have a time course for the memory test, anesthetics clearly impair 
memory. In fact, Subject 1 completed a test soon after emerging from anesthesia and then 
telling us that he had never completed the test. He became argumentative even after we 
showed him the completed test. Our best estimate at present is that complete restitution of 
memory took place 15-30 minutes more rapidly in the presence of caffeine. But this is 
anecdotal. We need better testing to demonstrate this effect. 
Similarly when we asked the subjects how they felt, they clearly felt much better after 
caffeine. They came back to normal 30 – 60 minutes faster in every negative category 
(such as “I Feel Lightheaded” or “I feel Confused” or “I Feel Dreamy”). 
 
1.1.5 Rationale for Conducting this Research 
Our lab has studied anesthetics for over fifteen years. We have spent considerable time 
studying the inhibition of neurotransmitter release produced by anesthetics (Herring et 
al., 2009; Herring et al., 2011; Xie et al., 2012; Xie et al., 2013).  We thought that if we 
could reverse this action that we would be able to reverse aspects of anesthesia. Several 
drugs were studied; these drugs normally facilitate neurotransmitter release. If inhibiting 
neurotransmitter release causes anesthesia then drugs that facilitate neurotransmitter 
release should aid in reversing anesthesia. Elevating intracellular cAMP, with drugs like 
caffeine, is well known to facilitate neurotransmitter release. We found that drugs that 
elevate intracellular cAMP levels caused rats to wake up very quickly from anesthesia.  
A variety of drugs are used during general anesthesia that are reversed 
pharmacologically afterwards. For example opioid drugs, frequently used to suppress 
pain, can be reversed pharmacologically following surgery.  Other drugs like 
anticoagulants and muscle relaxants are used in a similar manner. General anesthetics 
induce a coma-like state; unfortunately recovery from anesthesia induced loss of 
consciousness cannot be reversed (Solt et al., 2011). Recovery is passive and is due to the 

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discontinuation of anesthetic. Problematically, recovery is somewhat random, dependent 
upon a variety of genetic, age, physical condition and gender related factors that are 
beyond the clinician's control (Solt et al., 2011; Chemali et al., 2012; Taylor et al.). 
Cognitive impairments persist for hours following anesthesia. Outpatients are released 
from hospital after anesthesia/ surgery after an ever diminishing recovery period in order 
to constrain hospital costs. This is a recipe for increasing anesthesia-induced accidents. It 
would be extremely beneficial to be able to time recovery from anesthesia in a 
reproducible manner and to have that recovery be complete. Anesthesia in rodents is 
thought to be very similar to that in humans (Thurman et al., 2008). We have tested a 
variety of drugs in rats and we have identified four different drugs that appear to wake 
animals rapidly and reproducibly after terminating anesthesia. We have chosen one of the 
four drugs and would like to test it in humans. These studies have the potential to impact 
medicine in an important way and in a relatively short time frame.   
 
1.1.6 Dose Rationale and Risks/Benefits  
The drug that will be used in this study is caffeine which is commonly consumed by 
millions of people daily. It is the most popular drug used worldwide found in more than 
60 plants. It is classified by the FDA as "Generally Recognized as Safe". This was a 
critical consideration for our study. To be able to find a drug that would be considered 
safe. An IV formulation of caffeine is in clinical use, for treating apnea of prematurity in 
neonates. The dosages of caffeine in this study are within the range used for the above 
clinical conditions. For example, the recommended loading dosage for premature infants 
being treated for apnea of prematurity is 20 mg/ kg, a 33% higher dosage that we propose 
in adult male volunteers. The dosage that we have chosen is not associated with serious 
side effects (“caffeine has few unwanted side effects and is safe even in very large 
doses”. This quote is from (Rang et al., 2001) the most widely used pharmacology 
textbook in medical schools. We hypothesize that injection of caffeine at the end of 
anesthesia at clinically relevant dosages will facilitate the emergence of a subject from 
general anesthesia. Additionally, caffeine may improve cognitive function recovery after 
general anesthesia. 
 
 
1.2.  OBJECTIVES  
a) Hypothesis 
Anesthesia is thought to work similarly in humans and animals (Thurman et al., 2008). In 
our preliminary studies we found that drugs that elevate intracellular cAMP, like 
forskolin or caffeine, dramatically accelerated recovery from anesthesia in rats. Caffeine 
appeared to have a similar effect in two human test subjects. We hypothesize that drugs 
that elevate intracellular cAMP will dramatically accelerate recovery from anesthesia in 
humans. 
 
Objectives  
Primary Objective 
To determine whether drugs that elevate cAMP levels accelerate recovery from 
anesthesia. 
 

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Secondary Objective(s) 
To determine whether drugs that elevate cAMP help ameliorate the cognitive problems 
that persist for hours following anesthesia. 
 
2.  STUDY DESIGN  
2.1 Type of Study  
This is a Randomized, Double-Blinded, Placebo Controlled Study. 
 
2.2 Duration of Study  
Screening:  1 week 
Intervention: 6 weeks total 
Follow-up: 2 weeks 
 
Part 1:  We will enroll up to 8 test subjects in a full scale trial. The estimated duration of 
this trial will be approximately 16 weeks followed by a 2 week follow up period. 
 
Week 1: Explanation of the trial and signature of informed consent form. Detailed 
medical exam and physical exam. Toxicology screen and acceptance into trial. Training 
with psychomotor tests. 
 
Week 2: Volunteers will be exposed to isoflurane anesthesia as described below and then 
receive and injection of either a saline solution or caffeine citrate (both investigators and 
subjects will be blind to composition of injection).  Psychomotor tests will be carried out.  
There will be a toxicology screen. Later that day and then the day after the session, there 
will be a telephone follow-up with the subject. 
 
Week 3: There will be a telephone follow-up with both volunteers. 
 
Week 4-6: Volunteers will be exposed to isoflurane anesthesia as described below and 
then receive and injection of either a saline solution or Caffeine (both investigators and 
subjects will be blind to composition of injection). Psychomotor tests will be carried out. 
There will be a toxicology screen. Later that day and then the day after the session, there 
will be a telephone follow-up with the subject. 
 
Weeks 6: There will be telephone follow-ups with both volunteers. 
 
 
Week 7: There will be a final series of telephone follow-up with both volunteers. If there 
are no issues identified, this will be the last contact with the volunteers. 
 
We are suggesting that the trial take place over 16 weeks due to scheduling conflicts i.e. 
the possibility that subjects are not available. We hope to anesthetize 2 subjects per single 
lab day. 
 
 

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We are asking to be allowed to enroll up to 8 additional volunteers, but we will only 
require 6-8 to complete the study. If we need additional subjects due to dropout from the 
trial, we will ask the IRB for additional subjects. After 6 subjects are completed we will 
submit a continuing review after enrolling 6 additional subjects in order to inform the 
IRB of the study progress, how subjects tolerated the dosing changes, and if there were 
any subject safety issues.  
 
If we are given IRB approval, the next set of test subjects will take 4-6 weeks to complete 
the trial. There will also be a two week follow-up period.  
 
For the full trial, we are asking for extra time up to 26 weeks in the trial to allow for 
expected dropouts.  
 
 
2.3 Schedule of Events  
Each subject will attend 3 sessions to complete the study. In the first session, an 
anesthesiologist will explain the purpose of the trial and carefully go over the consent 
form. If the subject is willing to enroll the consent form will be signed. Then the 
anesthesiologist will take a detailed medical history and perform a physical examination 
of the subject.  A baseline EKG and urine toxicology screen text will be obtained. If the 
subject meets the criteria for the study, the subject will be enrolled in the trial. At this 
point a pre-study training session will be provided to familiarize the subject with the 
psychomotor tests.  In the following two sessions, each subject will receive general 
anesthesia in one session (with a saline injection as a placebo control) and receive general 
anesthesia plus an injection containing caffeine citrate (15 mg/ kg) in the other session in 
a randomized manner.  For each subject, each session involving anesthesia will be at least 
2 weeks apart. Detailed study procedure will be described in section 5 below. 
Please Note: We will try to process two subjects on a single anesthesia day. One at 7:00 
AM and another at 1:00 PM. In the Pilot study we tested one subject per day. The 
subjects arrived at UC at 7:00 AM and the entire anesthesia procedure including recovery 
was finished by 11:00 AM. That was wasteful, in terms of time. Normally 
anesthesiologists put multiple people to sleep per day. They don't finish their days at 
11:00 AM. That is why we would like to have one subject in the morning and a second 
subject in the afternoon. 
 
2.4 Sequence and Duration of all Study Periods 
The total time of each study session, including the pre-anesthesia preparation, testing and 
recovery from anesthesia, will be ~4 hours.  
 
2.5 Method for Assigning Subjects to Treatment Groups 
The University of Chicago Investigational Drug Service (IDS) will prepare the injectable 
solutions for our trial. They will provide us with either saline or with caffeine citrate, 15 
mg/ kg. They will not inform the research team of their preparations. There is no way to 
identify whether caffeine is present in a solution by looking at the solution (caffeine 
citrate is colorless and odorless). The entire experiment will be done blind by the research 
team and by the volunteer. The only requirement will be that at the end of the test the 

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subject will receive one round of anesthesia without caffeine and one round with caffeine. 
The assignment of which drug to use will be carried out with a random number sequence 
generated by random.org.  
 
 
2.6 Blinding 
This is a double-blinded study. Neither the experimenter nor the subject will know 
whether they are giving or receiving caffeine. The code will be broken only after the 
study is complete. At this point all the research team will be made aware of the results as 
will the IRB. During the study the blind may be broken only in emergencies when 
knowledge of the subject’s treatment group is necessary for further subject management.  
When possible, the Investigator will discuss the emergency with the monitor (the IRB) 
prior to unblinding.   
 
2.7 Primary Study Endpoint 
The goal of the study is to determine whether caffeine speeds emergence from anesthesia. 
The primary endpoint will be a measurement made following termination of anesthesia in 
the human volunteers.  This will be the time between terminating delivery of anesthetic 
and the subject opening his eyes. This measurement will constitute the “waking” time for 
each subject.   
 
2.8 Secondary Study Endpoints 
As a secondary endpoint for this study we will measure the time between terminating 
anesthetic and the subject being able to respond to a simple command (“squeeze my 
hand”). 
Normally patients receiving anesthesia exhibit significant cognitive problems for hours 
after anesthesia is terminated (references are provided below). Our goal is to determine 
whether caffeine helps ameliorate the cognitive issues.  After waking, each subject will 
be asked to complete a series of psychomotor tests (described below), that will assess his 
reaction times, his memory and his motor control (ability to move his limbs). Details of 
the test are provided below. 
 
2.9 Primary Safety Endpoints 
Throughout each anesthesia visit, the subject’s vital signs will be monitored and there 
will be two experienced anesthesiologists present throughout the anesthesia session. Both 
anesthesiologists will be present for the first hour of the recovery time following the 
anesthesia. Once the test subject is awake, oriented with regards to time and space, and 
showing stable vital signs, typically about an hour after terminating the isoflurane, one of 
the anesthesiologists may leave the room. There will be one anesthesiologist present at all 
times until the subject is discharged. 
 
At the conclusion of each “anesthesia” visit, we will discharge the subject based on the 
criteria used in our post anesthesia care unit in the hospitals. In general, the subject 
should be awake and alert with the stable vital signs. He should be able to drink clear 
liquid, void and ambulate before discharge home.  We will call a car service for him 
without cost to the subject. The subject will be expected to live within 30 miles of The 
University of Chicago to make sessions easily accessible.  Upon discharge from the 

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hospital, the subject will be required to be accompanied by a responsible adult. Each 
session for any given subject will be at least 2 weeks apart. The total time of each 
session, including the pre-anesthesia preparation, testing and recovery from anesthesia, 
will be ~4 hours.  We will call the subject later the same day and then again the next day 
to make sure the subject fully recovers without any adverse event. The subject will get 
another call a week after the procedure. In some cases we may use emails or text 
messages rather than phone calls. 
 
After the 2nd and final anesthesia session the subject will receive phone calls for the next 
two weeks to ensure complete recovery and no adverse effects. 
 
3.  SUBJECT SELECTION AND WITHDRAWAL  
 
 
3.1 Number of Subjects 
For this study of up to 8 subjects will be tested. There will be a progress report to the IRB 
after 6 subjects.  
 
 
3.2 Gender, Age, Racial and Ethnic Origin of Subjects 
Healthy male, ages 25 – 40, all race and ethnic origin inclusive. 
Our animal studies were carried out in adult male rats equivalent to the age range listed 
above. At present we would like to reproduce our animal studies in humans, introducing 
as few new variables as possible. The effects of anesthesia and the study drug on fetuses 
are not entirely known. The tests for early pregnancy are not 100% reliable.  In males, 
pregnancy is not a possibility. Children can have adverse reactions to anesthetics, and 
they will not be recruited.  Therefore, male volunteers are selected in this study. In order 
to further reduce the variables and minimize the risks for the subjects, exclusion criteria 
are used to select the subjects who are most suitable for this primary study.  
 
3.5 Inclusion Criteria 
1. Age 25-40 
2. Male 
3. Normal healthy subject without systematic diseases or conditions 
4. Metabolic Equivalents of Functional Capacity ≥ 5 
5. Low risk for Obstructive Sleep Apnea (OSA) based on the screening test (STOP-bang 
score established by American Society of Sleep Apnea): Yes to > 3 items- high risk 
of OSA 
6. No History of Arrhythmia (Baseline EKG will be obtained during the history and 
physical session), seizure, liver and kidney diseases 
7. BMI  <  30 kg/m2 
8. No prior difficulty with anesthesia 
9. No personal or family history of malignant hyperthermia 
10. No history of any mental illness 
11. No history of drugs or alcohol abuse (urine drug screens required).  
12. Subjects capable of giving consent. 
13. Living less than 30 miles away from UC. 
14.  No history of seizure disorders. 

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15.  No history of head trauma. 
 
3.6 Exclusion Criteria 
1. Age <25 or >40 
2. Female 
3. ASA physical status > 1 (normal healthy subject without systematic diseases or 
conditions) 
4. Metabolic Equivalents of Functional Capacity (METs) < 5 
5. High risks for Obstructive Sleep Apnea (OSA) based on the screening test (STOP-
bang score established by American Society of Sleep Apnea): Yes to > 3 items- high 
risk of OSA 
6. History Arrhythmia (Baseline EKG will be obtained during the history and physical 
session), seizure, liver and kidney diseases 
7. BMI > 30 kg/m2 
8. Prior difficulty with anesthesia 
9. Personal or family history of malignant hyperthermia 
10.  History of any mental illness 
11.  History of drugs or alcohol abuse (urine drug screens required) 
12.  Subjects capable of giving consent 
13. Living more than 30 miles away. 
14.  History of seizure disorders. 
15.  History of head trauma. 
 
3.7 Vulnerable Subjects 
No vulnerable subjects will be used. 
 
3.8 Subject Identification & Recruitment  
Brochures, flyers and posters will be distributed throughout Chicago (at malls, stores, 
community clubs, minority centers etc).  
 
Women will not be recruited to this study. The effects of anesthesia and the study drug on 
fetuses are not entirely known. The tests for early pregnancy are not 100% reliable.  In 
males, pregnancy is not a possibility. Therefore, male volunteers are selected in this 
study. In order to further reduce the variables and minimize the risks for the subjects, 
exclusion criteria are used to select the subjects who are most suitable for this primary 
study.  
Children can have adverse reactions to anesthetics and they will not be recruited.  
Minorities will be actively recruited.   
 
3.9 Location 
The University of Chicago CCD recovery room. This facility is outfitted with all the 
necessary emergency and equipment required to maximize safety. The isolation recovery 
room that we use is perfect for our purposes since it is soundproof.  
 
3.10 Payment to Subjects 

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$500 will be given to each subject for every day they are anesthetized. $1000 will be 
provided to each subject for completing the entire trial. Since the subjects will be in the 
trial for 2 full days, the payments reflect an average salary for a working day of $500/ 
day. The subject will receive $500 after each anesthesia session. 
 
3.11 Informed Consent Process 
One of the anesthesiologists will provide a verbal explanation of the study to the subject 
and answer all questions regarding this study. Then, a written description of the study 
will be provided to the subject. Afterwards the subject will be required to describe the 
study in their own words showing that they understand the purpose of the study, the risks 
involved and their own role in the study.  If any risks are not well understood, the 
members of our team will explain them, in detail. The subject and the person who 
administered the informed consent must sign and date the document.  A copy of the 
informed consent form will be given to the subject and the original will be kept in the 
subject’s record. 
 
3.12 Subject Withdrawal Following Study Completion  
The final “anesthesia” visit will be no different than the previous one. After the subject 
wakes from anesthesia and completes the psychomotor tests, he will be released to home, 
in company with another adult, once he meets the safety criteria for release. This will be 
followed up by phone calls for the subsequent 2 weeks to ensure that the subject has not 
suffered any adverse effects from the treatment. 
 
All subjects will be asked, upon completion of the study, to help us identify ways to make 
the study better. The idea for combining the informed consent and the history and 
physical sessions arose from complaints from test subjects. 
 
3.13 Subject Withdrawal Before Study Completion (i.e., early termination)  
All subjects are free to withdraw from participation in the trial at any time, for any 
reason, specified or unspecified, and without prejudice. 
 
Not uncommon side effects of anesthesia are nausea and vomiting, mild to moderate sore 
throat, transient hypoxia (low oxygen level), transient blood pressure and heart rate 
changes (sinus arrhythmia). Most people do not experience any of these events. They are 
reversible and have no long-term consequence. But they can be unpleasant to the 
volunteer. Thus, the volunteers may decide not to complete the 2 rounds of anesthesia. 
Our expectation is that there will be significant drop out. 
If there is a more serious event associated with the trial, then the IRB will be informed 
immediately and the subject will be monitored until the issue is resolved. 
If we observe that the subject does not easily tolerate anesthesia, as indicated by changes 
in vital signs, or alternatively if the toxicology screen comes back positive for drugs or 
alcohol or alternatively if the subject does not bring a responsible adult with him to the 
session, they will be asked to leave the trial. Termination will have no adverse health 
consequences, but if the subject had previously received anesthesia there will be follow-
up phone calls identical to those received by subjects who complete the trial.  

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3.14 Data Collection and Follow-up on Early Withdrawal Subjects 
Most people suffer no adverse effects of any sort related to anesthesia. The adverse 
effects that are typically experienced like sore throat or vomiting are transient in nature 
and subjects will have no long-term consequence. These events will be monitored by the 
follow-up phone calls. More serious events will be monitored closely until the event is 
resolved, by clinicians associated with this project or alternatively by other clinicians at 
UC. No follow-ups on efficacy will be carried out, as the point of the research trial is to 
determine whether caffeine can cause a rapid emergence from anesthesia. 
 
We ask the IRB for approval to recruit an additional 8 volunteers.  
 
4.  STUDY DRUG 
A.  Drug Study: 
4.1A Formulation of Study Drug 
 
Caffeine citrate (caffeine), is available commercially.  It is manufactured by Bedford 
Labs.   
 
Placebo control will be a sterile saline solution.  
 
4.2A Treatment Regimen 
The study drug (caffeine citrate) or the placebo (a saline solution) will be given 
intravenously 10 min before the end of 1 hour isoflurane anesthesia. Caffeine will be 
administered at a dose of 15 mg/ kg. There will be a single injection of either caffeine or 
a saline placebo control solution in the anesthetized test subjects. The drug will be 
injected slowly across a 10-minute interval, in order to prevent concentration spikes in 
the subject. A pump infuser will be used to introduce the drug.  The subjects will be told 
not to eat or drink for 8 hours prior to anesthesia (see below for a more detailed 
description).  
 
An example of the method of administration may be illustrative. The drug, caffeine 
citrate and comes in a single dosage of 20 mg caffeine per ml of solution. Let’s say a 
volunteer weighs 65 kg. The dose we propose for this trial is 15 mg/ kg. Therefore the 
volunteer will get a 48.75 ml injection of caffeine citrate. This amount of solution (48.75 
ml) can be injected as a bolus via an IV line in under a minute. This rapid infusion of 
drug is what we call a bolus injection. We plan on introducing the 48.75 ml of caffeine 
citrate more slowly, across a 10-minute time window, to prevent spikes in the circulating 
caffeine concentration. The caffeine will be introduced via a pump infuser. In this case 
the subject will get 975 mg of caffeine citrate that is equivalent to 487.5 mg of pure 
caffeine. 
 
 
4.3A Preparation and Administration of Study Drug 
All drugs will be stored and/ or prepared by the IDS group and provided to the research 
team on the day of each session.  

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The IDS office is located in the Wyler Pavilion, room C286, but is in the process of 
moving to CCD. The area has equipment necessary to store, prepare, and dispense all 
categories and dosage forms of drugs and biologics. IDS pharmacists and technicians 
along with other supporting pharmacy personnel provide services to faculty, 
investigators, pharmacy staff, nursing staff, and subjects enrolled in research protocols. 
The IDS office is open up to 10 hours per day on weekdays or a staff member is on call 7 
days per week. Key staff members in the central pharmacy provide dispensing support 
twenty-four hours a day when IDS staff is not present  
 
Required documents for every research study are placed in designated binders. They 
contain sections for: Randomization schedule, Drug Accountability Records, Drug 
Receipt Records, Subject scripts and consent signature pages, Drug Order Forms (if 
applicable) or information on how to get a re-supply of drug, and any other miscellaneous 
forms needed. For all studies, a protocol specific procedure sheet is prepared. Each 
subject's order is verified with the protocol assigned and with the subject's dispensing 
history prior to dispensing any study medications. Discrepancies are discussed with the 
study nurse or physician, as appropriate. The presence of the subject’s signed inform 
consent is verified by the pharmacist. The protocol is reviewed for all pharmaceutical 
information prior to attempting to prepare a study medication. A pharmacy protocol 
specific procedure sheet is reviewed before drug preparation is set up by the pharmacist 
processing the order. The Central Pharmacy area maintains all investigational drug 
supplies handled by the inpatient pharmacy. The IDS provides training to essential staff 
to provide service to protocols that require continuous service 24 hours per day, 7 days 
per week, and 365 days per year. 
 
IDS maintains drug accountability records in compliance with state and federal 
regulations and the specific requirements of each protocol. At study termination when 
study drug has been either returned to the sponsor or destroyed, all drug accountability 
records and study-related documents are transferred to the investigator.  
 
IDS Information  
Main Office: Room C286, Wyler Pavilion  
Phone: 773-834-7466  
Fax: 773-834-7461 
 
4.4A Subject Compliance Monitoring 
Compliance will be monitored with a toxicology screen. Data from the screen will be 
included in the study database containing recovery from anesthesia data. Any subjects 
that do not meet compliance guidelines (no drugs or alcohol) will be asked to leave the 
study.  If they do not bring a responsible adult to the anesthesia sessions they will be 
asked to leave.  
 
4.5A Concomitant Medications and Therapies 
Our goal is to identify a relatively young cohort of healthy volunteers. Thus patients 
taking drugs for chronic conditions will not be chosen.  
 

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Propofol is the preferred agent for the induction phase because it does not cause airway 
irritation. Isoflurane will be used as the main anesthetic agent as it is an extremely safe 
anesthetic that has been used for decades. During this study, we do not plan to use other 
anesthetic agents, such as midazolam, fentanyl, and muscle relaxants to minimize the 
interactions of these drugs to our study drug. However, propofol and muscle relaxants are 
available at the bedside in case they are needed for the management of unexpected airway 
situations, such as laryngeal spasm.  If an unexpected airway emergency occurs, the ASA 
difficult airway algorithm will be applied for airway management. The subject will be 
allowed to breathe spontaneously unless the tidal volume is less than 3 ml/kg. We will 
optimize the tidal volume at around 5 ml/kg to make sure each subject receives similar 
amount of isoflurane for an hour. Pressure support mode may be applied to optimize the 
tidal volume if necessary.  The study drug (caffeine citrate) or the placebo control will be 
given intravenously 10 min before the end of 1-hour isoflurane anesthesia.  The 
anesthesiologists will be blinded to the medication injected to the subject since the drug 
or normal saline is prepared by the pharmacists in the OR pharmacy. When isoflurane is 
turned off, the subject will eliminate isoflurane passively via breathing.  
 
There will be at least two anesthesiologists present during the entire period that 
anesthesia is administered.  Each subject will be given a dose of antiemetic medication, 
zofran (4 mg) 20 minutes before the end of the anesthesia to minimize the incidence of 
post anesthesia nausea and vomiting.  During the period of anesthesia, we will keep the 
subject's BP within 20% of its pre-anesthesia value. If the BP falls more than 20% of the 
baseline, we will first give IV fluid to replete the fluid deficit due to the restriction of 
fluid intake prior to the study.  If that is not sufficient to raise the BP, we will reduce the 
concentrations of isoflurane by 0.1% at a time until we can maintain the BP close to the 
normal range. Vasoactive medications will be given only if absolutely necessary but they 
will be available. Volunteer safety is our first priority.  
 
[Intraoperative hypotension is not well defined (see (Bijker et al., 2007)).  In clinical 
practice, changes of 20 - 30% of the baseline mean MP or SBP are well accepted. 
Transient change of BP in this range is usually clinically insignificant. Healthy volunteers 
tolerate these changes better than sick surgical patients.  In general, lowering of blood 
pressure by an anesthetic is also dose dependent. Hemodynamic changes are very fluid 
during anesthesia. It is important not to overcorrect the minor transient change of BP and 
heart rate. Nonetheless, in this trial with healthy volunteer, we will use a change of 
20% from the baseline (MBP or SBP) for more than 5 min as our trigger for 
intervention]. 
  
4.6A Packaging and Labeling 
The drug will arrive at UC packaged by the manufacturer, Bedford Labs Inc. It will be 
prepared for use by our IDS group as will be the placebo control. The drugs will be 
labeled with a numeric code that will be unknown to the research team and the research 
subjects.  The code will be included in the database with the volunteer data. The study 
will be unblinded after completing the Pilot program. 
 
4.7A Receipt of Drug Supplies 

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Caffeine is inexpensive and stable. The IDS group will be instructed to place an order 
sufficient for the entire Pilot Project and they will be required to store the drug. The 
placebo will be prepared as needed. It too should be stable for a period of time. 
 
 
4.8A Product Storage and Stability 
Caffeine is stable for months in the vials shipped by the manufacturer if stored at room 
temperature (15 – 30 degrees C). Caffeine is preservative free. 
 
4.9A Dispensing of Study Drug 
Caffeine or placebo will be injected via and intravenous line by one of the two attending 
anesthesiologists. Only a certified anesthesiologist will be allowed to dispense either the 
drug (caffeine citrate) or the IDS prepared placebo. 
 
4.10A Return or Destruction of Study Drug 
Any remaining caffeine will be discarded as will be any remaining saline. 
 
 
5.  STUDY PROCEDURES 
 
Each subject will attend 4 sessions to complete the study. 
 
5.1 Screening Session 1  
In the first screening session, an anesthesiologist will explain the purpose of the trial and 
carefully go over the consent form. If the subject is willing to enroll the consent form will 
be signed. Next, the anesthesiologist will take a detailed medical history and perform a 
physical examination of the subject.  A baseline EKG and urine toxicology screen text 
will be obtained. If the subject meets the criteria for the study, the subject will be enrolled 
in the trial. At this point a pre-study training session will be provided to familiarize the 
subject with the psychomotor tests.   
 
5.2 Study sessions 2 – 3 
In the following two sessions, each subject will receive general anesthesia in one session 
(with a saline injection as a placebo control) and receive general anesthesia and caffeine 
citrate (15 mg/ kg equal to 7.5 mg/ kg of pure caffeine) in the other session in a 
randomized manner. For each subject, each session involving anesthesia will be at least 2 
weeks apart.  
 
For each session, subjects will be asked not to eat and drink 8 hours prior to the study in 
order to minimize the potential risk for aspiration during anesthesia.  They will be asked 
to refrain from alcohol or drug use for 24 hours prior to the sessions. A toxicology screen 
will be used for each session. Once the subject is checked in, a peripheral intravenous 
catheter (IV) will be inserted on one of the arms by the anesthesiologist (Xie, Fong or 
Apfelbaum).  The IV is used to administer medications during the course of the study.  
After the IV insertion, American Society of Anesthesiologists (ASA) standard 
monitoring, including EKG, blood pressure (BP), respiratory rate, end tidal CO2, pulse 

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oximetry, BIS monitor and temperature, will be used to assess the subject (see below for 
further details).  The subject will then be asked to breathe 100% O2 via a facemask for 
two minutes.  After the lungs are filled with 100% O2, the subject will be given propofol 
(2mg/kg), as an IV bolus, to induce anesthesia.  Within 1-2 minutes, the subject will 
become unconscious. If the subject is still conscious, an extra dose of propofol (0.5 to 1 
mg/kg) will be given until the subject is in a deeper stage of anesthesia.  A Laryngeal 
Mask Airway (LMA), a rubber airway device, will be inserted via the mouth into the 
larynx. This device will help to optimize the patency of the airway while the subject is 
completely anesthetized. This allows the subject to breathe easier without the help of a 
ventilator.  This is the induction phase of anesthesia. After induction, the subject will be 
given isoflurane (1.0 MAC, as adjusted by age and weigh by the anesthesia machine) for 
60 minutes. This period is called the maintenance phase of anesthesia. 60 minutes will 
ensure that each subject reaches anesthetic equilibrium. Oxygen flow will be kept at 2 
L/min during the maintenance phase. Ten minutes before terminating the isoflurane, 
volunteers will be infused with a solution containing saline (control) or with caffeine 
(test).  After the termination of isoflurane, the subject will be allowed to wake up.  This 
phase is called the emergence phase of anesthesia. During the emergence phase, Oxygen 
flow will go up to 8 L/min to avoid rebreathing. We will test whether the caffeine 
shortens the emergence phase of anesthesia.   
 
[EKG, respiratory rate, end tidal CO2, pulse oximetry and temperature are monitored 
continuously, once the volunteer is connected to the monitoring machines. A bispectral 
index (BIS) monitor, will continuously measure depth of anesthesia. Prior to starting the 
procedure, blood pressure will be measured every 5 minutes; this measurement of blood 
pressure will provide the baseline for subsequent BP measurements. Blood pressure will 
be measured every 2 minutes during the first 10 min of the anesthesia, which includes the 
induction period. BP will be measured every 5 min throughout the course of anesthesia 
and the first 30 min in the PACU. After that, BP will be measured every 10 min until the 
subject is discharged. This data is stored automatically for each patient in our hospital’s 
Epic database]. 
Propofol is the preferred agent for the induction phase because it does not cause airway 
irritation. Additionally, propofol is normally used for anesthesia induction in human 
patients.   There are several advantages to use isoflurane as the main anesthetic agent. 
Most importantly, it is an extremely safe anesthetic that has been used for decades. All 
our preliminary animal data was generated with isoflurane.  Because it takes slightly 
longer to "wake up" from isoflurane anesthesia, compared to other volatile anesthetics 
like sevoflurane, it will allow us to better differentiate the actions of the caffeine.  During 
this study, we do not plan to use other anesthetic agents, such as midazolam, fentanyl, 
and muscle relaxants to minimize the interactions of these drugs to our study drug. 
However, propofol and muscle relaxants are available at the bedside in case they are 
needed for the management of unexpected airway situations, such as laryngeal spasm.  If 
an unexpected airway emergency occurs, the ASA difficult airway algorithm will be 
applied for airway management. The subject will be allowed to breathe spontaneously 
unless the tidal volume is less than 3 ml/kg. We will optimize the tidal volume at around 
5 ml/kg to make sure each subject receives similar amount of isoflurane for an hour. 
Pressure support mode may be applied to optimize the tidal volume if necessary.  The 

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study drug (caffeine citrate) or the placebo (saline) will be given intravenously 10 min 
before the end of 1 hour isoflurane anesthesia.  The anesthesiologists will be blinded to 
the medication injected to the subject since the pharmacists in the IDS GROUP prepare 
the drug or the placebo control. When isoflurane is turned off, the subject will eliminate 
isoflurane passively via breathing.  We will measure the time between when the 
isoflurane is stopped to the awakening of the subject.  We will record the time to 
recovery of the gag reflex, until the subject’s eyes open, until the subject’s mouth opens, 
and the time until the subject can respond to the command to grip the hand of the 
attending physician and the removal of the laryngeal mask.   After the subject is awake 
and relatively alert, he will perform psychomotor tests to measure his cognitive function. 
The subject will be required to complete a simple set of cognitive tests to determine if 
they are still impaired by anesthetic. Both "control" and test subjects will be required to 
complete the same tests. In total there are 3 different tests. The tests will be repeated 
every 15 minutes in order to obtain a recovery time course. 
 
There will be at least two anesthesiologists present during the entire period of anesthesia.  
Each subject will be given a dose of antiemetic medication, zofran (4 mg) 20 minutes 
before the end of the anesthesia to minimize the incidence of post anesthesia nausea and 
vomiting.  During the period of anesthesia, we will keep the subject's BP within 20% of 
its pre-anesthesia value. If the BP falls more than 20% of the baseline, for more than 5 
minutes, we will first give IV fluid to replete the fluid deficit due to the restriction of 
fluid intake prior to the study.  Vasoactive medications will be given if necessary. 
One hour after the isoflurane is stopped, if the subject is awake, oriented and showing 
stable vital signs, one of the anesthesiologists may leave the room to prepare for the 
afternoon session. There will always be at least one anesthesiologist with the test subject 
at all times. Most of the time there will be two anesthesiologists. 
At the conclusion of the study, we will discharge the subject based on the criteria used in 
our post anesthesia care unit in the hospitals. In general, the subject should be awake and 
alert with the stable vital signs. He should be able to drink clear liquid, void and ambulate 
before discharge home.  We will call a car service for him without cost to the subject. 
The subject will be expected to live within 30 miles of The University of Chicago to 
make sessions easily accessible.  Upon discharge, the subject will be required to be 
accompanied by a responsible adult. Each session for any given subject will be at least 2 
weeks apart. The total time of each session, including the pre-anesthesia preparation, 
testing and recovery from anesthesia, will be ~4 hours.  We will call the subject on the 
same day and the next day after each session to make sure the subject fully recovers 
without any adverse event. The subject will get another call a week after the procedure. 
 
Subjects will be tested in this manner a total of two times. In one of the tests they will be 
anesthetized with isoflurane and injected with a saline solution and in one test they will 
be anesthetized with isoflurane and then injected with caffeine citrate (15 mg/ kg).  
 
After terminating anesthesia, the subject will perform psychomotor tests to measure his 
cognitive function. The subject will be required to complete a simple set of cognitive 
tests to determine if they are still impaired by anesthetic. Both "control" (saline injection) 
and test subjects (those that obtain caffeine) will be required to complete the same tests. 

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Memory will be tested with 20 words, after which the subject will be asked to recall the 
words, order not being important. Two hours later the subject will be asked for the same 
words. The Digit Symbol Substitution Test asks subjects to substitute symbols for 
numbers for 60 seconds. Each time there will be different symbol number codes. The 
subjects will also be asked to estimate a period of time, typically 30 seconds. Blood 
pressures, heart rate and O2 saturation will be monitored. The entire suite of tests will be 
repeated two hours later. This latter test will allow us to assess whether the drugs allow 
recovery of cognitive ability. 
 
*Please note: We may recruit one or two additional anesthesiologists to our team. We 
will only recruit attending clinicians. They would take all the human clinical trial 
coursework and then we would have training sessions related to our protocol. The IRB 
should be aware that our protocol was designed to be as similar as possible to a standard 
surgical session with anesthesia, so that our research protocol will be instantly familiar to 
any experienced anesthesiologist. 

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Schema: 
Procedure 
Screening 
Session 1 
Study 
Session 1 
Study 
Session 2 
Time 
1 week 
prior to 
study 
Start of 
Study: 
week 0 
Week 2-4 
Explain 
Trial to 
subject 
Obtain 
Consent 
X 
 
 
Medical 
History 
X 
 
 
Physical 
exam 
X 
 
 
Vital signs 
X 
X 
X 
EKG 
X 
X 
X 
Urine 
Toxicology 
screen 
X 
X 
X 
Enroll 
Subject in 
Trial 
X 
 
 
Psychomotor 
Training 
session 
X 
 
 
Propofol 
Induction – 
Isoflurane 
maintenance 
 
X 
X 
**Saline 
Control 
injection 
 
X 
 
**caffeine 
(15 mg/ kg) 
injection 
 
 
X 
Psychomotor 
session 1 + 2 
 
X 
X 
Adverse 
Event report 
 
X 
X 
 
**Please note that the drugs will be applied in a double-blind manner and will be 
prepared by a hospital pharmacist. 
 
6.  STATISTICAL PLAN AND CONSIDERATIONS 
6.1 Sample Size Determination  

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Members of the IRB should understand that the sample size described above is an 
estimate, since we could not find good data on human “waking” times from isoflurane 
anesthesia in the literature. Thus we used our own animal studies to estimate sample size. 
There are at least three reasons why our sample size might be in error. First, rats are not 
people. They may get rid of isoflurane differently than do humans due to their higher 
respiration rates. In addition, rats are genetically more similar to each other than are 
humans. That would tend to increase human variance relative to that of the rat. On the 
other hand, the equipment used to anesthetize rats is less sophisticated than that in 
humans. In humans, the expired anesthetic concentration is measured, thereby allowing 
for precise anesthetic concentration, in the lungs. This is not possible in rats and so the 
anesthetic dose applied is less precise. This will tend to lower human variance. This is a 
long-winded way to say that our sample size estimate may be wrong. In these studies rats 
were used 4 times (twice with a saline injection twice with an injection of saline 
containing caffeine), a strategy that reduced variance. 
 
Additional caveats: The 15 mg caffeine citrate that we propose is equivalent to 7.5 mg/ 
kg of pure caffeine. We have never tested 7.5 mg/ kg caffeine in rats, nor have we ever 
studied isoflurane at a concentration of 1 MAC. 
 
We use the following stringent criteria to determine sample size: Power will be set to 
95% and p ≤ 0.01.  
 
Rats waking from isoflurane anesthesia with 5 mg/ kg caffeine (isoflurane ~ 1.5 MAC): 
(Control - saline injection)  
 
 
 
- Mean = 540 sec, SD = 159.04 
(Test - 5 mg/ kg caffeine in saline injection)   
- Mean = 269.67 sec, SD = 103.69 
At this concentration of caffeine we would need n=12 measurements for control and 
n=12 measurements for caffeine to meet our stated stringent criteria. If each person were 
used for one control and one caffeine measurements we would need 12 people for the 
study. 
 
We are using human volunteers twice, not four times like the rat population, we expect 
higher variance. Nonetheless, we expect 8 total volunteers will satisfy our study. This is 
because we are using a higher concentration of caffeine (7.5 mg/ kg), which should 
produce a larger response than the 5 mg/ kg shown above, and we will employ a lower 
concentration of isoflurane (1 MAC), which should be easier to antagonize. 
 
6.2 Statistical Methods 
 
We hope to use a simple paired t-test to analyze the data, using volunteers as their own 
controls. 
 
Crossover study - Each volunteer receives anesthesia 2 times: once without drug (control) 
and once with caffeine (test). Our animal studies suggest that variance is dramatically 
minimized when test subjects can be used as their own controls, in this manner. If 
humans recapitulate the rodent studies then 8 volunteers should provide an adequately 

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sized sample to answer the research question. The study was originally divided into two 
parts. The first part, the Pilot study has been completed. 
 
Part 1: In order to demonstrate feasibility and safety, we carried out a pilot study of 2 
healthy human volunteers to assess whether caffeine aids these subjects in recovering 
from isoflurane anesthesia. Recovery times were measured in three ways: as the time 
between the time when anesthetic is terminated until the subject starts to gag, can open 
his eyes, and the subject is able to respond to simple commands (like squeeze the 
clinician’s hand). Each of the three endpoints was monitored and plotted separately. In 
this pilot study caffeine citrate (caffeine) was used at 10 mg/kg. By comparing subjects 
that wake from anesthesia who are injected with a saline solution to subjects that are 
injected with caffeine we were able to show that caffeine is as efficient in humans as in 
rodents.  Now that we have demonstrated safety and feasibility, if the IRB gives us 
permission, we will continue to Part 2 of our study. Time from the end of anesthesia to 
eye opening will be analyzed, as will be the time from the end of anesthesia to response 
to a simple command. Each parameter (gagging, eye opening and response to command) 
will be analyzed and plotted separately. 
 
There are cognitive impairments that last for hours following anesthesia (Nathanson et 
al., 1995; Larsen et al., 2000; Chen et al., 2001). Reaction times and memory are 
impaired following anesthesia (Nathanson et al., 1995; Larsen et al., 2000; Chen et al., 
2001). Outpatients are being released from surgery/ anesthesia on an ever shortening time 
scale to save money. It would be significant if clinicians could wake the patients safely, 
rapidly and completely with no cognitive issues.  The psychomotor studies will allow us 
to assess whether caffeine helps ameliorate the cognitive problems associated with 
anesthesia.  Subjects will be required to carry out a series of simple psychomotor tests 
thirty minutes after anesthesia and then again two hours later. By comparing results, 
memory and reaction times we will determine whether Caffeine helps ameliorate 
cognitive problems, relative to the saline treated controls. Data from each test will be 
analyzed and plotted separately. 
 
Part 2: Up to 8 additional healthy human males will be recruited for this part of the study.  
If the effects of caffeine in humans mirror that of the rat, we will need ~8 more 
volunteers to complete the trial assuming that each volunteer attends all 4 anesthesia 
sessions.  We anticipate some dropout. This is the part we are asking for permission to 
start.  
 
6.3 Subject Population(s) for Analysis 
The data from all subjects will be analyzed without knowledge of whether the data comes 
from a control or test condition. After breaking the code, data will be grouped 
accordingly. All data will be analyzed in two different ways. Using a paired t-test data 
from subjects that have completed the two anesthesia sessions of the study will be 
analyzed and plotted. Separately, using an unpaired t-test all data will be grouped 
together including that from subjects who did not finish the trial. In this way the data will 
be compared.  Only data from subjects that failed the toxicology screen will be excluded. 
 

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7.  RISKS AND BENEFITS 
7.1 Risks and Likelihood of Occurrence 
 
Anesthesia risks:  
Overall, anesthesia is extremely safe.  Our hospital administers anesthesia thousands time 
every year with minimal complications directly related to anesthesia.  However, there are 
potential risks for general anesthesia.  The likely risks in patients of the general 
population include, but are not limited to, post anesthesia nausea and vomiting (up to 
30%), mild to moderate sore throat, transient hypoxia (low oxygen level), transient blood 
pressure and heart rate changes (sinus arrthymia). Most people do not experience any of 
these events. They are reversible and have no long term consequence.  
The more severe risks, but less likely, are awareness, under anesthesia, aspiration 
pneumonia (up to 0.03% - that is the reason that you are told not to eat and drink for 8 
hours prior to the anesthesia so that your stomach can be as empty as possible), severe 
hypoxia due to aspiration or difficult airway, severe hyper or hypotension, sustained 
arrthymia, dental damage, vocal cord damage and reactions to drugs we administrate. 
There events do not commonly occur in the healthy population. With the screening tests 
in this study, these events are very unlikely to occur. If they occur, they will be very 
unlikely to cause long term consequences with proper treatments. 
 
The most severe risks are unexpected difficult airway, including difficult mask 
ventilation and difficult intubation, and malignant hyperthermia (MH), a genetic 
associated reaction to anesthesia (0.002-0.005%). These are considered rarely events in 
Anesthesia although severe consequences, such as organ damage or even death may 
occur.  We will carefully screen the subjects based on our exclusion criteria to minimize 
these risks. Therefore, these risks will be further reduced in the population of our study 
because of careful screening carried out prior to the administration of anesthesia.  In 
addition, our anesthesia location and anesthesiologists are well-equipped to handle these 
situations so that the damage will be as minimal as possible.  
 
Assessing risks for this trial are somewhat complicated. We will be recruiting healthy 
volunteers for this trial, while most of the available data comes from the pool of people 
receiving anesthesia for surgery. Most of these surgical patients are quite sick and are 
therefore susceptible in ways that healthy people are not. 
 
As an example: A common number used in anesthesia related deaths in ~1 per hundred 
thousand (see Fig. 1 in ref (Haller et al., 2011)). Different recent studies have different 
numbers. Some studies have higher numbers of deaths (~2 per hundred thousand 
(Kawashima et al., 2003)) while others have lower number of deaths (~4 per million, 
(Aitkenhead, 2005)). The problem with these numbers is that they include all anesthesia’s 
including those in sick patients. Sick patients have most of the adverse reactions. I have 
only found a single study that examined ASA-1 patients by themselves (ASA-1 patients 
are healthy and are similar to those we hope to enroll). This study, which covered a span 
of 14 years found zero anesthesia related deaths in this 14 year interval in ASA-1 patients 
(Khan & Khan, 2011). This is why anesthesia studies in healthy human volunteers have 
been allowed in the past. There were ~22,000 ASA-1 patients tracked. 

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Definition of ASA categories: 
 
ASA-1:  No organic, physiologic, or psychiatric disturbance; excludes the very young 
and very old; healthy with good exercise tolerance 
 
ASA-2: No functional limitations; has a well-controlled disease of one body system; 
controlled hypertension or diabetes without systemic effects, cigarette smoking without 
chronic obstructive pulmonary disease (COPD); mild obesity, pregnancy 
 
ASA-3: Some functional limitation; has a controlled disease of more than one body 
system or one major system; no immediate danger of death; controlled congestive heart 
failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid 
obesity, chronic renal failure; bronchospastic disease with intermittent symptoms 
 
ASA-4: Has at least one severe disease that is poorly controlled or at end stage; possible 
risk of death; unstable angina, symptomatic COPD, symptomatic CHF, hepatorenal 
failure 
 
ASA-5:  Not expected to survive > 24 hours without surgery; imminent risk of death; 
multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, poorly 
controlled coagulopathy 
 
Risks of Caffeine: 
 Caffeine is very safe and commonly used in the household and also used clinically in 
certain conditions, such as post-dural puncture headache in post-partum women and sleep 
apnea in premature infants.  The doses used in this study are lower than those used in 
infants for sleep apnea.  The FDA categorizes caffeine as "Generally Recognized as 
Safe".  However, caffeine can have side effects, such as palpitation, seizure, sleepless or 
nervousness.  Seizures are exceptionally rare and occur at much higher concentrations 
than will be used in the current study.  We don't expect caffeine's effects to be any 
different with or without anesthesia.  Two clinical trials, one in adults and another in 
children, showed that it was safe to administer caffeine to anesthetized patients (Khalil et 
al., 2008; Steinbrook et al.). Both these trials used caffeine and sodium benzoate. 
 
In this protocol we describe a procedure where anesthetized healthy human volunteers 
would be given 15 mg/ kg caffeine citrate, 10 minutes before terminating anesthesia. The 
caffeine is to be administered slowly across a 10-minute time window so as to prevent a 
large spike in circulating caffeine levels.  We propose using healthy, low body mass male 
volunteers exclusively in this trial. In these low body mass, low weight volunteers 15 mg/ 
kg caffeine and citrate will translate to 750-1200 mg caffeine citrate in total. Normalizing 
for the weight of the volunteers represents a more rigorous pharmacological approach 
than simply giving everyone the same amount of caffeine citrate. Note that 15 mg/ kg 
caffeine citrate is equivalent to ~7.5 mg/ kg of caffeine base. Thus 750-1200 mg caffeine 
citrate corresponds to 375-600 mg of pure caffeine. 

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The New Scientist website states that caffeine is the most commonly used psychoactive 
drug and in the United States more than 90% of adults use it daily. Caffeine has been 
used by humans at least since Roman times and has been found to be safe. Hundreds of 
millions of Americans drink caffeinated beverages every day. Worldwide the number is 
in the billions. In some cases the drinks contain large amounts of caffeine. For instance, a 
large cup (20 oz) of Starbuck’s coffee contains over 415 mg of caffeine, an amount not so 
different than the low end of the range of caffeine that we propose to use in our study.  
Death Wish coffee is even more extreme in that it has 660 mg caffeine in a 12 oz cup. 
Most extreme is chameleon cold brew coffee, which has over 2000 mg in a 32 oz 
container. Caffeine is also used in medicine on a daily basis. Caffeine is used to treat 
neonatal apnea as well as certain types of headaches. It is a popular additive for drugs 
that treat pain, like Excedrin. 
 
Citrate is used as a food additive in beverages, soda, ice cream, candy, fruit juice, wine, 
juice, jam, canned fruit and vegetables, frozen fruit, cheese spreads, dressings, preserves, 
cheese, mayonnaise etc. E numbers are codes for substances that can be safely used as 
food additives for use within the European Union and Switzerland. The E number for 
sodium citrate is E331. Caffeine and citrate are found in variety of energy drinks. For 
instance, Xtreme Shock Energy drink contains caffeine citrate, while drinks like RedBull, 
Monster and Full throttle contain caffeine and sodium citrate.  Both caffeine and citrate 
are consumed by millions of people on a daily basis. Sodium citrate is generally 
considered inert.  
 
Thousands and thousands of preterm infants have been given IV injections of caffeine 
citrate to treat apnea of prematurity (Reference 1 - (Parikka et al., 2015)). Caffeine is a 
neonatal success story. It is one of the most commonly prescribed drugs in neonatal 
medicine. And it has been used successfully for about 40 years. See below for a more 
complete description.  
 
In our trial we propose using caffeine in anesthetized patients. We found two studies 
where caffeine has been tested in anesthetized patients (Khalil et al., 2008; Steinbrook et 
al., 2013). In the Khalil et al study, 20 mg/ kg caffeine was given to anesthetized children 
(Khalil et al., 2008). This dosage is 33% higher than what we propose in our trial. The 
duration of the caffeine application is difficult to determine from the study. But it is 
important to note that no adverse effects were reported in the 36 children that received an 
injection of 20 mg/ kg caffeine with sodium benzoate. 
 
The study that is most relevant to our proposed trial is that of Steinbrook et al. 
(Steinbrook et al., 2013). In this study, anesthetized adult patients were given a bolus of 
caffeine (500 mg), 15 minutes before emergence from anesthesia. Both the dosage and 
the method of application were similar to what we propose. 65 patients received this 
treatment without adverse effect. 
 
Caffeine and sodium benzoate has been used to treat post-dural puncture headaches for 
decades. In the Sechzer and Abel study (Sechzer & Abel, 1978), dozens of women were 

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treated for post-dural puncture headache with 500 mg caffeine and sodium benzoate, 
applied as a single 2 ml bolus. Both the dosage and the method of application were 
similar to what we propose in the IRB protocol. No adverse effects were reported, but the 
caffeine successfully treated most of the headaches. 
 
Caffeine and sodium benzoate has been used in psychiatric studies. In one such study, 
caffeine and sodium benzoate was used in psychiatric patients at concentrations much 
higher than we plan to give to our volunteers. In this study 8 patients received IV caffeine 
sodium benzoate in the range of 500 – 2000 mg. The patients received the drug on 
multiple occasions at multiple concentrations (between 500 – 2000 mg). The drug was 
always applied as a single bolus. No adverse effects of the caffeine sodium benzoate were 
reported (Shapira et al., 1987). In this study, the methodology, a bolus application and the 
concentration (up to 2000 mg), are more extreme than are proposed in our IRB protocol.  
 
In a different psychiatric study, McCall (McCall, 1992) gave 10 patients caffeine sodium 
benzoate (500 mg) IV during amobarbital interviews to keep them from falling asleep. 
The caffeine was administered as a single bolus. This combination of caffeine 
concentration and bolus administration were similar to what we propose.   
 
Thousands and thousands of preterm infants have been given IV injections of caffeine to 
treat apnea of prematurity (Parikka et al., 2015). Caffeine is a neonatal success story. It is 
one of the most commonly prescribed drugs in neonatal medicine. And it has been used 
successfully for about 40 years. A brief excerpt from (Kreutzer & Bassler, 2014) - 
Kreutzer & Bassler, where they discuss caffeine in neonates: “Until 2006, it had only a 
few relatively small and short-term studies supporting its use. It is thanks to the efforts of 
Barbara Schmidt and the Caffeine for Apnea of Prematurity (CAP) Trial Group that we 
now have high-quality and reliable data not only on short-term but also long-term 
outcomes of caffeine use for apnea of prematurity. CAP was an international, 
multicenter, placebo-controlled randomized trial designed to determine whether survival 
without neurodevelopmental disability at a corrected age of 18 months is improved if 
apnea of prematurity is managed without methylxanthines in infants at a high risk of 
apneic attacks. CAP was kept simple and pragmatic in order to allow for maximum 
generalizability and applicability……… However, recent data suggest that the 
administration of prophylactic methylxanthine by neonatologists is now common 
practice”.  
 
Caffeine citrate is functionally identical to caffeine and sodium benzoate. It has been used 
for decades as an injectable drug, with great success.  
 
It is true that in none of the studies listed above have any subjects been given caffeine 
with a 10-minute injection, in a manner similar to what we propose. We would like to do 
this to prevent spikes in the circulating caffeine concentration. In several of the studies 
listed above caffeine was administered as a single bolus. Our preference, though, is a 10-
minute infusion of caffeine applied via a pump. That is how we administered the caffeine 
in the Pilot study. 
 

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In infants and in some psychiatric patients higher concentrations of caffeine were tested 
than what we propose (see references 2 and 6 for examples). In all cases the drug was 
applied as an IV injection. No adverse responses were observed. 
Finally, if there is a problem, the anesthesiologists are well trained to manage any 
unexpected events associated with anesthesia and the study drug.  The area of the study 
will be well equipped to handle any unexpected events as well. For the most common 
side effects, such as nausea/vomiting, we will hydrate the subjects and administer 
antiemetic medications.  There are rarely any long-term effects with post anesthesia 
nausea and vomiting.  Mild or moderate sore throat usually goes away in a day or two.  If 
any severe complications, such as aspiration, arrhythmia, persistent hypoxia, occur, the 
patient will be excused from the study.  The anesthesiologists will manage the situation 
until the subject's conditions return to normal.  Anesthesiologists are experts dealing with 
these situations in the operating rooms.  The area of the study is adjacent to the operating 
rooms where airway management equipment, code cart (defibrillator, pacemaker and 
emergency drugs) and malignant hyperthermia cart are immediately available. 
 
Risk of Data Loss: 
There is also a risk that confidentiality will be lost.  However, subject identity and data 
will be locked up in the PI's office. Only the investigators in this project have access to 
the data. The identity will not be included in the publication. The subject's identities will 
be destroyed once the analysis is completed for publication. 
 
7.2 Potential Direct benefits to subject 
Although the risks involved are more than minimal, the benefits to the general medical 
community are significant. Why is recovery from anesthesia important? Isn’t recovery 
pretty fast normally? Recovery is rapid in most patients, but not in all. Small subsets of 
patients “wake” slowly. Even after “waking” from anesthesia patients can still exhibit 
cognitive impairment that can last for hours.  This is especially true in the elderly. If 
drugs like caffeine were able to accelerate cognitive recovery in addition to accelerating 
“waking” times that would be extremely useful. Also, a large percentage of children 
(>20%) develop emergence agitation, a form of delirium, following anesthesia. Rather 
than re-anesthetize the child, the current practice, or use a variety of pre-medications, a 
safe and effective way to reverse the anesthesia, like caffeine, would be useful. If caffeine 
reverses anesthesia and calms the children, that would be extremely useful. Although we 
will not test any children, if the drug works in adults there will be a strong chance it will 
work in children.  
Seniors are especially vulnerable to anesthesia. As more elderly undergo surgeries, it is 
apparent that recovery can take a long time (days). Memory especially appears to be 
labile. It would be very beneficial to have a drug that could reverse the effects of 
anesthesia in this population. 
What is the goal of this trial? Our goal is to determine whether caffeine helps patients 
emerge from anesthesia quickly and reproducibly and to find out whether caffeine helps 
with the cognitive deficits that persist following anesthesia. Normally, recovery from 
anesthesia is somewhat random, dependent upon a variety of factors, like genetics or age 

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that are beyond the clinician’s control. It would be extremely beneficial to be able to time 
recovery from anesthesia in a reproducible manner and to have that recovery be 
complete.  Even though patients “wake” from anesthesia, there are still cognitive 
problems that persist for hours. Patient’s reaction rates are slowed and memory can be 
impaired. Accidents may occur due to cognitive problems following anesthesia, which 
include problems with balance and with walking. And then there are outliers; patients that 
wake very slowly after anesthesia.  None of this would be a problem, if there were a 
reliable drug that could speed recovery from anesthesia. Ideally you would design the 
drug to be almost completely innocuous and very inexpensive. If one had a really safe 
drug and one that was almost free, it might be possible to give it to everyone. Caffeine 
may be such a drug. It is the most commonly used psychoactive drug in the world, used 
by billions of people. If caffeine were to reverse cognitive deficits associated with 
anesthesia that would be valuable.  
An additional benefit of caffeine is that it may reduce pain. Caffeine and sodium 
benzoate is used to reduce pain in post dural puncture headaches. Caffeine also magnifies 
the pain killing power of aspirin, ibuprophen and narcotics. That is why caffeine is an 
active ingredient in Excedrin Extra Strength or prescription drugs like Darvon 
Compound-65 or Triaminicin with Codeine.   There may be several different 
mechanisms that enable caffeine to relieve pain of different kinds and differing 
intensities; intense pain may be directly sensitive to caffeine. It is possible that caffeine 
will be beneficial in reducing post-operative pain. 
In a recent clinical trial in anesthetized children, caffeine was found to be safe (the trial 
was to determine whether caffeine could reduce the number of children who experience 
adverse post-extubation respiratory events – caffeine helped significantly). 
Caffeine has been shown safe to use in anesthetized adults. In a clinical trial, to determine 
whether caffeine ameliorated post anesthesia nausea and vomiting, patients were given 
500 mg caffeine during anesthesia. This combination, anesthesia and caffeine, was found 
to be safe. That trial used a dosage not too dissimilar to that we propose for our trial. 
Unfortunately, caffeine did not help with nausea and vomiting. 
We hope that the IRB takes into account the potential benefit to medicine in a relatively 
short time frame.  
The benefits to the subject are small, perhaps nonexistent. First, they will obtain a 
physical exam free of charge. Many people do not avail themselves of regular medical 
attention or don't have access. Identification of health-related issues may be important to 
the subject. Although the subjects will not be enrolled in the study, they will be informed 
of any issues identified by the clinicians. Second, is that many people have anesthesia 
during their lifetimes. Any beneficial changes to clinical standards will help them, but at 
an unidentified time in the future. 
 
8.  SAFETY AND ADVERSE EVENTS  
8.1 Safety 
Prior to induction of anesthesia and throughout the application of anesthetic, up until the 
anesthetic is discontinued and the subject opens their eyes, there will be two 
anesthesiologists with each subject continuously. After waking, there will be an 

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anesthesiologist present for the next 2 hours until the subject is released and the second 
anesthesiologist will be present for the first hour of recovery and then available but not 
necessarily in the room afterwards.  
The exclusion criteria will eliminate any subject with high risks for this study.  The study 
will be carried out adjacent to the adult operating rooms that are fully equipped with 
monitors, resuscitation equipment, oxygen, suction, airway and cardiac code carts etc.  
Note that having two accredited anesthesiologists present throughout the anesthesia is a 
standard higher than that used in a typical operating room. This is done to minimize risk. 
If we can use each subject as their own control, that will lead to the fewest total number 
of anesthesias due to reduced population variance. 
 
8.2 Adverse Events 
Definitions 
Adverse Event (AE): 
Any problematic or unfavorable medical occurrence in a human subject, including 
any abnormal sign (e.g. abnormal physical exam or laboratory finding), symptom, 
or disease, temporally associated with the subject’s involvement in the research, 
whether or not considered related to participation in the research. 
 
Serious Adverse Event (SAE): 
• 
Any adverse event that: 
• 
Results in death 
• 
Is life threatening, or places the subject at immediate risk of death from 
the event as it occurred 
• 
Requires or prolongs hospitalization 
• 
Causes persistent or significant disability or incapacity 
• 
Results in congenital anomalies or birth defects 
• 
Causes cancer 
• 
Is an important medical event  
Important medical events are those that may not be immediately life threatening, 
but are clearly of major clinical significance.  They may jeopardize the subject, 
and may require intervention to prevent one of the other serious outcomes noted 
above.  For example, drug overdose or abuse, a seizure that did not result in in-
patient hospitalization, or intensive treatment of bronchospasm in an emergency 
department would typically be considered serious. 
 
Unanticipated Problem: 
Any incident, experience, or outcome that meets all of the following criteria: 
• 
Unexpected, in terms of nature, severity, or frequency, given (a) the 
research procedures that are described in the protocol-related documents, 
such as the IRB approved research protocol and informed consent 
document; and (b) the characteristics of the study population; 
• 
Related or possibly related to participation in the research (in this 
guidance document, possibly related means there is a reasonable 
possibility that the incident, experience, or outcome may have been caused 
by the procedures involved in the research); 

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• 
Suggests that the research places subjects or others at a greater risk of 
harm (including physical, psychological, economic, or social harm) than 
was previously known or recognized. 
 
8.3 Responsibilities    
Investigators 
Investigators conducting clinical research are responsible for: 
•  Assurance that their protocols are conducted in compliance with these 
guidelines. 
•  Submission of protocol to IRB and FDA. The protocol must include a 
DSM Plan (data & safety monitoring, section 8.6) that is commensurate 
with the study risk and reflects this guideline. 
- DSM plan describes plans for monitoring and reporting adverse events, 
serious adverse events, and unanticipated problems commensurate with 
nature and complexity of study. 
- Recipients of Serious Adverse Event and Unanticipated Problem reports 
must include IRBs, DSMB (data & safety monitoring board) and the FDA. 
•  Adherence to the DSM with respect to timely submission of adverse 
events, serious adverse events, and unanticipated problems. 
 
 
Sponsors 
Sponsors are responsible for: 
•  Following FDA Adverse Event Reporting guidelines and regulations for 
IND (investigational new drug) & IDE (investigational device exemption) 
-regulated trials through the Medwatch Program. 
•  Assistance to extramural investigators in understanding and applying 
adverse event and serious adverse event guidelines and for ensuring 
compliance with OHRP guidance. 
•  Oversight of these guidelines, which includes periodic review and revision 
as relevant rules and regulations change. 
•  Assurance that the Data and Safety Monitoring Plan (DSM Plan) 
addresses reporting of adverse events, serious adverse events, and 
unanticipated problems (if a DSMP is required). 
•  Verification that all corrective action plans have been adequately 
implemented. 
•  Assurance that the study has an independent data and safety monitoring 
body commensurate with study risk (Data and Safety Monitoring Board or 
Safety Officer). 
•  Ongoing oversight of the safety reporting process to ensure that potential 
safety issues are addressed. 
 
Sponsor - Investigators 
•  Implement and adhere to all items cited for both investigators and sponsors. 
 
8.4 Documenting and Reporting Adverse Events 
8.4.1 Adverse Event Reporting 

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Data will be reviewed after each session and all Adverse Events will be summarized and 
reported to the IRB at the time of IRB Continuing Review. 
 
8.4.2 Serious Adverse Event Reporting 
All SAEs will be reported according to FDA guidelines for receipt of Adverse Event 
reporting: 
• 
Unexpected fatal or life threatening experiences associated with the use of 
the drug (21 CFR 312[.32[c] [ii] [2]) - must be reported to the FDA by 
telephone or by facsimile transmission as soon as possible but no later 
than seven calendar days after the sponsor’s initial receipt of the 
information if the intervention is under an Investigative New Drug (IND) 
application. 
If an adverse drug experience was not initially determined to be reportable 
but the results of an investigation show that the experience is reportable 
under the above paragraph, the experience should be submitted to the FDA 
in a written safety report as soon as possible, but in no event later than 15 
calendar days after the determination is made. 
• 
Other adverse experiences associated with the use of the drug that are both 
serious and unexpected must be reported to the FDA within 15 calendar 
days after the sponsor’s initial receipt of the information. 
• 
If the drug is marketed and not under an IND (21 CFR 314.80[(c) (1) (i)], 
a serious and unexpected adverse drug experience must be reported to the 
FDA within 15 calendar days of initial receipt of the information by the 
applicant. 
 
8.4.3 Unanticipated Problems (UP) Reporting 
All Unanticipated Problems that meet the stated criteria (section 8.2) will be 
reported within 10 days using the Unanticipated Problem Report Form to the 
IRB.  For Internal Fatal/Life-Threatening Unanticipated Problems, the 
PI should notify the IRB Chair by phone immediately and consider 
voluntarily halting subject enrollment. 
 
Table1.  Time Line for Reporting Events 
 
Fatal/Life Threatening 
– Changing Risk-
Benefit 
Serious, Unexpected, 
& Related – Changing 
Risk-Benefit 
All Other Events & 
Minor Protocol 
Deviations 
IRB 
Immediately by phone. 
Follow-up written notice 
within 10 days 
10 working days 
Continuing Review  
FDA 
7 days by IND/IDE 
holder 
15 days by IND/IDE 
holder 
Annual Report  
 
 
8.5 Classifying Adverse Events 
The Adverse Events will be classified according to severity, expectedness and potential 
relatedness to the study drug. 

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1. Severity 
Classifications often include the following: 
 
Mild: Awareness of signs or symptoms, but easily tolerated and are of minor 
irritant type causing no loss of time from normal activities. Symptoms do not 
require therapy or a medical evaluation; signs and symptoms are transient.  
•  Moderate: Events introduce a low level of inconvenience or concern to the 
subject and may interfere with daily activities, but are usually improved by 
simple therapeutic measures; moderate experiences may cause some 
interference with functioning.  
 
 Severe: Events interrupt the subject’s normal daily activities and generally 
require hospitalization. 
 
2. Expectedness 
AEs must be assessed as to whether they were expected to occur or unexpected, 
meaning not anticipated based on current knowledge found in the protocol, informed 
consent form, investigator brochure, product insert, or label. Categories are:  
•  Unexpected - nature or severity of the event is not consistent with information 
about the condition under study or intervention in the protocol, consent form, 
product brochure, or investigator brochure.  
•  Expected - event is known to be associated with the intervention or condition 
under study. 
 
3.  Relationship to the Study Drug 
The potential event relationship to the study intervention and/or participation must be 
assessed by the site investigator. A comprehensive scale in common use to categorize 
an event is:  
•  Definitely Related: The adverse event is clearly related to the investigational 
agent/procedure – i.e. an event that follows a reasonable temporal sequence 
from administration of the study intervention, follows a known or expected 
response pattern to the suspected intervention, that is confirmed by 
improvement on stopping and reappearance of the event on repeated exposure 
and that could not be reasonably explained by the known characteristics of the 
subject’s clinical state.  
•  Possibly Related: An adverse event that follows a reasonable temporal 
sequence from administration of the study intervention and follows a known or 
expected response pattern to the suspected intervention, but that could readily 
have been produced by a number of other factors.  
•  Not Related: The adverse event is clearly not related to the investigational 
agent/procedure - i.e. another cause of the event is most plausible; and/or a 
clinically plausible temporal sequence is inconsistent with the onset of the event 
and the study intervention and/or a causal relationship is considered biologically 
implausible. 

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8.6 Unblinding procedures 
The safety of the subject always comes first. If a serious event occurs, although very 
unlikely to result from caffeine, we will unblind study for the subject in order to ensure 
the subject’s safety.  This procedure is covered in the consent from. The unblinding will 
be part of managing an SAE, and will be reported with the SAE. We will use the same 
timeline requirements for investigator reporting of SAEs. 
 
 
8.7 Data Safety Monitoring Plan 
A final analysis will be done at the end of the study. However, data will be reviewed after 
each session with a volunteer (excluding the screening sessions). Particularly, any safety 
issues, such as unexpected vitals signs change or adverse events, will be recognized 
immediately. Therefore, corrections can be made quickly.  
Any serious/unexpected adverse events will be immediately reported to the IRB. An 
investigation will be carried out immediately.  If the adverse events are observed, then the 
caffeine dosage will be reduced.  If similar adverse events keep being caused by the study 
drug, we will stop the study unless we can find a solution to avoid these events.   
We will review each session every day so that we can deal with any adverse events in a 
timely manner.    We will have follow up phone calls to the subject to make sure that no 
adverse effects occur away from UC. 
The team that evaluates subject safety will include three anesthesiologists (Apfelbaum, 
Wong and Xie) all of whom are faculty at UC and all are experienced anesthesiologists. 
Data quality will be monitored by the three anesthesiologists and by Fox, the PI.  
Our protocol is designed to be conservative in order to prevent any unexpected or adverse 
effects. The concentrations anesthetics and caffeine used in this study are safe based on 
the data in the literature. Even so, unexpected events can occur.  For example, seizure or 
arrhythmia will be reported immediately to the IRB. Similarly a fall in BP that triggers a 
response (see above), but which does not respond quickly to treatment will be reported. If 
any of these events, seizure or arrhythmia or prolonged depression of BP, occurs in more 
than 1 subject the study will be stopped. 
 
 
9.  DATA HANDLING AND RECORD KEEPING  
9.1 Data Management Responsibilities 
 
Fox will carry out data handling and record-keeping. All data will be stored in a 
password-protected computer in a locked room in the Fox office. A backup of the data 
will be kept on a password-protected thumbdrive. Another backup is kept on a second 
password-protected computer in the Fox office. (Note that password-protected means that 
all data is kept in an encrypted form in a military grade 256 bit AES encrypted container).  
All paperwork will be kept in a locked file cabinet in the Fox lab. There will be no 
grouping of data until the study is complete and unblinding occurs. The IDS group will 

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prepare the injectable solution for use in each volunteer in a randomized manner. 
Members of our study group will not know what is being injected. At the end of each 
section of the trial the IDS group will provide to us the information required to unblind 
the trial. At this time data will be grouped into a “control” and “caffeine” group. The data 
will be analyzed with a t-test and then graphed, using Origin software. This data will then 
be sent off for publication. 
Clinical data related to the anesthesia procedure will be stored in our hospital’s hipaa-
compliant Epic database.  
 
9.2 Data Capturing Methods 
The data from the trial will be stored in a computer file. The file will be updated 
following each volunteer session. Analysis will not take place until all the the trial is 
complete. 
 
9.3 Source Documents 
All trial data (findings, pharmacy information, vital signs, lab notes, clinical notes etc) 
will be entered by Fox into a computer. This data will be kept on a password protected 
computer in a locked room in the Fox office. The data will be encrypted. Only members 
of the research team (Fox, Xie, Apfelbaum and Fong) will have access to the data. The 
data from the trial will be kept indefinitely. After the study is complete all identifiers to 
the subjects will be eliminated, as they are not required. Any documents i.e. signed, 
consent forms, original lab notes, clinical notes, will be kept in a locked file cabinet in the 
same locked room in the Fox lab. Only Fox will have a key.  
 
Please note that all the clinical data generated during the procedure itself (BP, heart rate, 
respiratory rate etc.) will be stored in The University of Chicago’s hipaa compliant, Epic 
database. 
  
 
9.4 Records Retention 
It is the investigator’s responsibility to retain study essential documents for at least 2 years 
after the last approval of a marketing application in their country and until there are no 
pending or contemplated marketing applications in their country or at least 2 years have 
elapsed since the formal discontinuation of clinical development of the investigational 
product.   
Institutional policy requires that all study records be kept for a minimum of seven years.  
  
 
9.5 Confidentiality 
All study data will be kept on a password protected computer in a locked room in the Fox 
lab. The data will be encrypted. Only members of the research team (Fox, Xie, 
Apfelbaum and Fong) will have access to the data. The data from the trial will be kept 
indefinitely. After the study is complete all identifiers to the subjects will be eliminated, 

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as they are not required. Any documents i.e. signed consent forms, will be kept in a 
locked file cabinet in the same locked room in the Fox office. 
 
 
10.  STUDY MONITORING, AUDITING AND INSPECTING  
10.1 Study Monitoring Plan 
There are two aspects that will be tightly monitored. Subject safety will be monitored by 
Dr. Xie while data quality will be monitored by Drs. Fox and Xie. Dr. Xie is an 
experienced clinician well versed in patient care as well as in data collection/ analysis. 
Dr. Fox has been running a lab at UC for over 25 years, collecting different types of 
scientific data. 
 
After each session with a subject our research team will meet to go over any subject 
safety issues. Any serious issues will be immediately reported to the IRB. At the same 
session the team will examine the data collected to ensure that our protocols were 
carefully followed. This will be done in a blinded fashion. 
 
Our plan is to publish our results as soon as humanly possible. The referees provided by 
the journal as well as the editor will provide an objective outside review of the data. 
 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the 
OCR, IRB, the sponsor, government regulatory bodies, and University compliance and 
quality assurance groups of all study related documents (e.g. source documents, 
regulatory documents, data collection instruments, study data etc.).  The investigator will 
ensure the capability for inspections of applicable study-related facilities (e.g. pharmacy, 
diagnostic laboratory, etc.). 
 
 
11.  FINANCIAL CONSIDERATIONS 
The single largest cost in the study is the time of the three clinicians. For this study, lab 
days, kindly donated by their department (Anesthesia and Critical Care) will be used for 
some subject sessions. Other will be paid for by the NIH grant that supports this study. 
Equipment for the study will be loaned as well (Anesthesia and Critical Care). The other 
costs (payments to subjects, car service, supplies, drugs, IDS costs, light refreshments) 
are to be paid by a NIH grant. 
 
12.  ETHICAL CONSIDERATIONS  
 
12.1 Institutional Review Board (IRB) approval   
The investigator-sponsor will obtain, from the University of Chicago Institutional Review 
Board (IRB), prospective approval of the clinical  protocol and corresponding informed 
consent form(s); modifications to the clinical protocol and corresponding informed 
consent forms, and advertisements (i.e., directed at potential research subjects) for study 
recruitment.    
 

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The only circumstance in which a deviation from the current IRB-approved clinical 
protocol/consent form(s) may be initiated in the absence of prospective IRB approval is 
to eliminate an apparent immediate hazard to the research subject(s).  In such 
circumstances, the investigator-sponsor will promptly notify the University of Chicago 
IRB of the deviation.  
 
The University of Chicago IRB operates in compliance with FDA regulations at 21 CFR 
Parts 50 and 21 CFR 56, and in conformance with applicable International Conference on 
Harmonization (ICH) Guidelines on Good Clinical Practice (CGP).  
 
In the event that the University of Chicago IRB requires, as a condition of approval, 
substantial changes to a clinical protocol submitted under an FDA-accepted IND 
application, or in the event of an investigator-sponsor’s decision to modify the previously 
accepted clinical protocol: 
 
 for a Pilot clinical study: The investigator-sponsor will submit (i.e., in advance 
of implementing the change) a Protocol Amendment to the IND describing 
any change to the Phase 1 clinical protocol  that significantly affects the safety 
of the subjects.  For changes that do not affect critical safety assessments, the 
revisions to the clinical protocol will be addressed in the Annual Report to the 
IND.  
 
12.2  Ethical and Scientific Conduct of the Clinical Study  
The clinical study will be conducted in accordance with the current IRB-approved 
clinical protocol; ICH Guidelines on GCP; and relevant policies, requirements, and 
regulations of the University of Chicago IRB, University of Chicago and UCMC, State of 
Illinois, and applicable federal agencies. 
 
 
12.3  Subject Informed Consent 
The sponsor-investigator will make certain that an appropriate informed consent process 
is in place to ensure that potential research subjects, or their authorized representatives, 
are fully informed about the nature and objectives of the clinical study, the potential risks 
and benefits of study participation, and their rights as research subjects.  The investigator-
sponsor, or a sub-investigator(s) designated by the investigator-sponsor, will obtain the 
written, signed informed consent of each subject, or the subject’s authorized 
representative, prior to performing any study-specific procedures on the subject. The date 
and time that the subject, or the subject’s authorized representative, signs the informed 
consent form and a narrative of the issues discussed during the informed consent process 
will be documented in the subject’s case history.  The investigator-sponsor will retain the 
original copy of the signed informed consent form, and a copy will be provided to the 
subject, or to the subject’s authorized representative. 
 
The investigator-sponsor will make certain that appropriate processes and procedures are 
in place to ensure that ongoing questions and concerns of enrolled subjects are adequately 
addressed and that the subjects are informed of any new information that may affect their 
decision to continue participation in the clinical study.  In the event of substantial 

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changes to the clinical study or the risk-to-benefit ratio of study participation, the 
investigator-sponsor will obtain the informed consent of enrolled subjects for continued 
participation in the clinical study 
 
 
13.  CONFLICT OF INTEREST  
The investigators responsible for this study does not have any Conflict of Interests with 
regard to this Clinical Study. 
 
14.  PUBLICATION PLAN  
Data from the trial will be published as soon as the trial is complete regardless of whether 
the results confirm our working hypothesis. All subject identifiers will be removed as 
they are not required for publication. In addition to the primary endpoints (eye, opening 
and response to command) and secondary endpoints (psychomotor results), we will also 
publish vital sign information in the presence and absence of caffeine. 
 
15.  REFERENCES  
 
To aid the IRB review I have included brief descriptions of a few references. References 
1 and 2 were studies where caffeine was given to anesthetized patients. 
 
3-9 were all carried out at The University of Chicago in healthy human volunteers and 
are similar to the studies we propose. Similar studies from other institutions are included 
below from elsewhere in the USA or other countries (references 10-18). Note that our 
literature search yielded thousands of similar studies. At the end are included a small 
number of crossover studies where healthy human volunteers were given drugs that 
carried more than minimal risk (19-23). The final reference (number 24) is from a review 
that covers 3323 healthy volunteers used in a variety of phase 1 trials to test new 
experimental drugs. The review covers a variety of single-dose studies as well as 
crossover studies where volunteers were exposed to drugs multiple times. Afterward are a 
compilation of all the references used to prepare this application, in alphabetical order. 
 
1) Khalil, S. N., Maposa, D., Ghelber, O., Rabb, M. F., Matuszczak, M., Ganesan, B. A., 
Tabrizi, H. K., & Chuang, A. Z. (2008), Caffeine in children with obstructive sleep 
apnea. Middle East J Anesthesiol  19(4), 885-99. 
 
In this clinical trial in anesthetized children, caffeine was found to be safe. 
The trial was carried out in order to determine whether caffeine reduced the 
number of children who experience adverse post-extubation respiratory 
events – caffeine helped significantly. 
 
2) Steinbrook, R. A., Garfield, F., Batista, S. H., & Urman, R. D. (2013), Caffeine 
for the prevention of postoperative nausea and vomiting. J Anaesthesiol Clin 
Pharmacol  29(4), 526-9. 
 
This clinical trial was carried out to determine whether caffeine ameliorated 
post anesthesia nausea and vomiting.  Patients were given 500 mg caffeine 

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during anesthesia. This combination, anesthesia and caffeine, was found to 
be safe. Note that 500 mg in that trial is what we propose for our trial. 
Unfortunately, the caffeine did not help with the nausea or vomiting. 
 
 
3) Galinkin JL, Janiszewski D, Young CJ, Klafta JM, Klock PA, Coalson DW, 
Apfelbaum JL & Zacny JP. (1997). Subjective, psychomotor, cognitive, and 
analgesic effects of subanesthetic concentrations of sevoflurane and nitrous oxide. 
Anesthesiology 87, 1082-1088. 
 
In this study, a cohort of 12 healthy human volunteers was exposed multiple rounds 
of sevoflurane or nitrous oxide anesthesia. This was done to test efficacy of 
sevoflurane. Sevoflurane is a volatile anesthetic similar to isoflurane. This study was 
carried out at The University of Chicago. 
 
 
4) Young CJ, Coalson D, Klock PA, Klafta JM, Goldsher G, Apfelbaum JL, Zacny JP. 
Analgesic and psychomotor effects of thiopental at subanesthetic concentrations in 
human volunteers. Acta Anaesthesiol Scand. 1997 Aug;41(7):903-10. 
 
In this study, a cohort of 12 healthy human volunteers was exposed multiple rounds 
of thiopental to test effects on pain. This study was carried out at The University of 
Chicago. 
 
5) Zacny JP, Janiszewski D, Sadeghi P, Black ML. Reinforcing, subjective, and 
psychomotor effects of sevoflurane and nitrous oxide in moderate-drinking 
healthy volunteers. Addiction. 1999 Dec;94(12):1817-28. 
 
A cohort of 14 healthy volunteers were exposed to sevoflurane and nitrous oxide. 
This study was carried out at The University of Chicago. 
 
 
 
6) Zacny JP, Paice JA, Coalson DW. Separate and combined psychopharmacological 
effects of alprazolam and oxycodone in healthy volunteers. Drug Alcohol Depend. 2012 
Aug 1;124(3):274-82. doi: 10.1016/j.drugalcdep.2012.01.023. Epub 2012 Feb 25. 
 
A cohort of 20 healthy volunteers were given restricted drugs. This study was 
carried out at The University of Chicago. 
 
 

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7) Zacny JP, Paice JA, Coalson DW. Characterizing the subjective and psychomotor 
effects of carisoprodol in healthy volunteers. Pharmacol Biochem Behav. 2011 
Nov;100(1):138-43. doi: 10.1016/j.pbb.2011.08.011. Epub 2011 Aug 23. 
 
A cohort of 15 healthy volunteers were given carisoprodol. This study was carried 
out at The University of Chicago. 
 
 
8) Weafer J, de Wit H. Inattention, impulsive action, and subjective response to d-
amphetamine. Drug Alcohol Depend. 2013 Jun 18. pii: S0376-8716(13)00196-8. doi: 
10.1016/j.drugalcdep.2013.05.021. [Epub ahead of print] 
 
A cohort of 165 healthy adults were exposed to d-amphetamine. This study was 
carried out at The University of Chicago. 
 
 
9) Baggott MJ, Childs E, Hart AB, de Bruin E, Palmer AA, Wilkinson JE, de Wit H. 
Psychopharmacology of theobromine in healthy volunteers. Psychopharmacology 
(Berl). 2013 Jul;228(1):109-18. doi: 10.1007/s00213-013-3021-0. Epub 2013 Feb 19. 
 
A cohort of 80 healthy volunteers were exposed to a variety of theobromine 
concentrations. In addition, they were exposed to caffeine. Theobromine is a drug 
that is similar to caffeine. This study was carried out at The University of Chicago. 
 
10) Holaday, Duncan A.,  Smith, Frederick R.,  Anesthesiology. 1981 Feb;54(2):100-6. 
Clinical Characteristics and Biotransformation of Sevoflurane in Healthy Human 
Volunteers. 
 
The anesthetic sevoflurane was tested in healthy human volunteers. Volunteers were 
anesthetized for an hour. This study was carried out at the University of Miami. 
 
11) Saxena N, Muthukumaraswamy SD, Diukova A, Singh K, Hall J, Wise R. PLoS 
One. 2013;8(3):e57685. doi: 10.1371/journal.pone.0057685. Epub 2013 Mar 6.  
Enhanced stimulus-induced gamma activity in humans during propofol-induced sedation. 
 
In this study, the general anesthetic propofol was administered to 15 healthy human 
volunteers while their brain waves were monitored. This study was carried out at 
Cardiff University, Great Britain. 
 
12) Russo SG, Cremer S, Eich C, Jipp M, Cohnen J, Strack M, Quintel M, Mohr A. Br J 
Anaesth. 2012 Dec;109(6):996-1004. doi: 10.1093/bja/aes314. Epub 2012 Sep 25. 

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Magnetic resonance imaging study of the in vivo position of the extraglottic airway 
devices i-gel™ and LMA-Supreme™ in anaesthetized human volunteers. 
 
Magnetic resonance study in a cohort of 12 healthy human volunteers that were 
anesthetized as part of the study. This study was carried out at Gottingen 
University, Germany. 
 
 
13) Långsjö JW, Alkire MT, Kaskinoro K, Hayama H, Maksimow A, Kaisti KK, Aalto 
S, Aantaa R, Jääskeläinen SK, Revonsuo A, Scheinin H. J Neurosci. 2012 Apr 
4;32(14):4935-43. doi: 10.1523/JNEUROSCI.4962-11.2012. Returning from oblivion: 
imaging the neural core of consciousness. 
 
A cohort of 20 healthy volunteers were anesthetized with a variety of anesthetics 
including propofol while their brain activity was monitored. This study was carried 
out at University of Turku, Finland. 
 
14) Neukirchen M, Hipp J, Schaefer MS, Brandenburger T, Bauer I, Winterhalter 
M, Kienbaum P, Werdehausen R. Br J Anaesth. 2012 Dec;109(6):887-96. doi: 
10.1093/bja/aes303. Epub 2012 Sep 3. Cardiovascular stability and unchanged muscle 
sympathetic activity during xenon anaesthesia: role of norepinephrine uptake inhibition. 
 
A cohort of 8 healthy volunteers were anesthetized with Xenon while physiological 
measurements were obtained. This study was carried out at Heinriche-Heine 
University, Germany. 
 
15)  Schlünzen L, Juul N, Hansen KV, Cold GE. Acta Anaesthesiol Scand. 2012 
Feb;56(2):248-55. doi: 10.1111/j.1399-6576.2011.02561.x. Epub 2011 Oct 19. Regional 
cerebral blood flow and glucose metabolism during propofol anaesthesia in healthy 
subjects studied with positron emission tomography. 
 
A cohort of 8 healthy volunteers were anesthetized with propofol while brain 
activity measurements were obtained.  This study was carried out at Aarhus 
University, Denmark. 
 
16) Hines CS, Fujita M, Zoghbi SS, Kim JS, Quezado Z, Herscovitch P, Miao N, Ferraris 
Araneta MD, Morse C, Pike VW, Labovsky J, Innis RB. 
J Nucl Med. 2013 Jan;54(1):64-9. doi: 10.2967/jnumed.112.106872. Epub 2012 Nov 12. 

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Propofol decreases in vivo binding of 11C-PBR28 to translocator protein (18 kDa) in 
the human brain. 
 
A cohort of 10 healthy human volunteers were anesthetized with propofol and then 
had PET scans. This study was carried out at The National Institutes if Health, 
USA. 
 
17) Alkire MT, Gruver R, Miller J, McReynolds JR, Hahn EL, Cahill L. Proc Natl Acad 
Sci U S A. 2008 Feb 5;105(5):1722-7. doi: 10.1073/pnas.0711651105. Epub 2008 Jan 28. 
Neuroimaging analysis of an anesthetic gas that blocks human emotional memory. 
 
A cohort of 39 volunteers were exposed to the general anesthetic sevoflurane. 
Memory tests were given. This study was carried out at The University of California 
at Irvine.  
 
18) Shiratsuchi H, Kouatli Y, Yu GX, Marsh HM, Basson MD. Am J Physiol Cell 
Physiol. 2009 Jun;296(6):C1400-10. doi: 10.1152/ajpcell.00345.2008. Epub 2009 Apr 8. 
Propofol inhibits pressure-stimulated macrophage phagocytosis via the GABAA receptor 
and dysregulation of p130cas phosphorylation. 
 
In this study volunteers were anesthetized with propofol; blood was drawn 30 
minutes after anesthesia was started and measurements were made. This study was 
carried out at Wayne State University, Detroit. 
 
19) Hull JH, Findlay JW, Rogers JF, Welch RM, Butz RF, Bustrack JA. Drug Intell Clin 
Pharm. 1982 Nov;16(11):849-54. An evaluation of the effects of smoking on codeine 
pharmacokinetics and bioavailability in normal human volunteers. 
 
In this study 12 healthy volunteers were given codeine two times at one week 
intervals.  
 
20) Donny EC, Bigelow GE, Walsh SL. Drug Alcohol Depend. 2003 Apr 1;69(3):289-
301. Choosing to take cocaine in the human laboratory: effects of cocaine dose, inter-
choice interval, and magnitude of alternative reinforcement. 
 
In this study human volunteers (in this case cocaine-dependent volunteers) were 
given multiple dosages of cocaine. 
 

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21) Liu X, Chen D, Zhang R. Drug Dev Ind Pharm. 2003 Aug;29(7):813-9. Evaluation of 
monolithic osmotic tablet system for nifedipine delivery in vitro and in vivo. 
 
In this study 11 healthy human volunteers were given nifedipine, a calcium channel 
blocker, multiple times in a new delivery system. 
 
 
22) Hawkey CJ, Jones JI, Atherton CT, Skelly MM, Bebb JR, Fagerholm U, Jonzon 
B, Karlsson P, Bjarnason IT. Gut. 2003 Nov;52(11):1537-42. Gastrointestinal safety of 
AZD3582, a cyclooxygenase inhibiting nitric oxide donator: proof of concept study in 
humans. 
 
In this study 31 human volunteers were exposed to a variety of drugs at different 
concentrations including a new experimental drug. This is not an uncommon way to 
test new drugs.  
 
23) la Porte C, Verweij-van Wissen C, van Ewijk N, Aarnoutse R, Koopmans P, Reiss 
P, Stek M Jr, Hekster Y, Burger D. J Clin Pharmacol. 2005 Feb;45(2):211-8. 
Pharmacokinetic interaction study of indinavir/ritonavir and the enteric-coated capsule 
formulation of didanosine in healthy volunteers. 
 
In this study a variety of drugs used to treat HIV were given to 8 healthy volunteers. 
Each volunteer received multiple drugs.  
 
24) Buoen C, Bjerrum OJ & Thomsen MS. (2005). How first-time-in-human studies are 
being performed: a survey of phase I dose-escalation trials in healthy volunteers 
published between 1995 and 2004. J Clin Pharmacol 45, 1123-1136. 
 
This review covers a subset of studies carried out in the 1995-2004 time frame. It 
examines data from 3323 healthy human volunteers in multiple studies where the 
subjects were given escalating doses of drugs. Some studies used single-dose 
methodologies while other studies used crossover studies where subjects were given 
multiple doses of drugs. 
 
 
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Bijker JB, van Klei WA, Kappen TH, van Wolfswinkel L, Moons KG & Kalkman CJ. 
(2007). Incidence of intraoperative hypotension as a function of the chosen 
definition: literature definitions applied to a retrospective cohort using automated 
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Burgoyne RD & Morgan A. (2003). Secretory granule exocytosis. Physiol Rev 83, 581-
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Byrne JH & Kandel ER. (1996). Presynaptic facilitation revisited: state and time 
dependence. J Neurosci 16, 425-435. 
 
Chemali JJ, Van Dort CJ, Brown EN & Solt K. (2012). Active emergence from propofol 
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Chen X, Zhao M, White PF, Li S, Tang J, Wender RH, Sloninsky A, Naruse R, Kariger 
R, Webb T & Norel E. (2001). The recovery of cognitive function after general 
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Crowder CM, Metz LB & Dasgupta N. UNC-13 is necessary for isoflurane sensitivity in 
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Ford CD, Ford DC & Koenigsberg MD. (1989). A simple treatment of post-lumbar-
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Fujita-Yoshigaki J. (1998). Divergence and convergence in regulated exocytosis: the 
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Fujita-Yoshigaki J, Dohke Y, Hara-Yokoyama M, Furuyama S & Sugiya H. (1998). 
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Haller G, Laroche T & Clergue F. (2011). Morbidity in anaesthesia: today and tomorrow. 
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Herring BE, McMillan K, Pike CM, Marks J, Fox AP & Xie Z. (2011). Etomidate and 
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Herring BE, Xie Z, Marks J & Fox AP. (2009). Isoflurane inhibits the neurotransmitter 
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Hilfiker S, Czernik AJ, Greengard P & Augustine GJ. (2001). Tonically active protein 
kinase A regulates neurotransmitter release at the squid giant synapse. J Physiol 
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Kasai H, Takahashi N & Tokumaru H. (2012). Distinct initial SNARE configurations 
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Kawashima Y, Takahashi S, Suzuki M, Morita K, Irita K, Iwao Y, Seo N, Tsuzaki K, 
Dohi S, Kobayashi T, Goto Y, Suzuki G, Fujii A, Suzuki H, Yokoyama K & 
Kugimiya T. (2003). Anesthesia-related mortality and morbidity over a 5-year 
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Khalil SN, Maposa D, Ghelber O, Rabb MF, Matuszczak M, Ganesan BA, Tabrizi HK & 
Chuang AZ. (2008). Caffeine in children with obstructive sleep apnea. Middle 
East J Anesthesiol 19, 885-899. 
 
Khan MU & Khan FA. (2011). Anaesthesia related mortality in ASA-1 and 2 patients as 
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Kreutzer K & Bassler D. (2014). Caffeine for apnea of prematurity: a neonatal success 
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16.  APPENDIXES 
 
A. INFORMED CONSENT FORM 
 
B. SCHEDULE OF EVENTS (SCHEMA) 

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        C.  DATA SAFETY AND MONITORING PLAN  
Our research group (Fox and three anesthesiologists) will monitor patient vital signs and 
any adverse results immediately following each session. Any problems will immediately 
be reported to the IRB. Our research team will also track data quality.