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2018 ; 127
(5
): 1246-1258
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Multimodal General Anesthesia: Theory and Practice
#MMPMID30252709
Brown EN
; Pavone KJ
; Naranjo M
Anesth Analg
2018[Nov]; 127
(5
): 1246-1258
PMID30252709
show ga
Balanced general anesthesia, the most common management strategy used in
anesthesia care, entails the administration of different drugs together to create
the anesthetic state. Anesthesiologists developed this approach to avoid sole
reliance on ether for general anesthesia maintenance. Balanced general anesthesia
uses less of each drug than if the drug were administered alone, thereby
increasing the likelihood of its desired effects and reducing the likelihood of
its side effects. To manage nociception intraoperatively and pain
postoperatively, the current practice of balanced general anesthesia relies
almost exclusively on opioids. While opioids are the most effective
antinociceptive agents, they have undesirable side effects. Moreover,
overreliance on opioids has contributed to the opioid epidemic in the United
States. Spurred by concern of opioid overuse, balanced general anesthesia
strategies are now using more agents to create the anesthetic state. Under these
approaches, called "multimodal general anesthesia," the additional drugs may
include agents with specific central nervous system targets such as
dexmedetomidine and ones with less specific targets, such as magnesium. It is
postulated that use of more agents at smaller doses further maximizes desired
effects while minimizing side effects. Although this approach appears to maximize
the benefit-to-side effect ratio, no rational strategy has been provided for
choosing the drug combinations. Nociception induced by surgery is the primary
reason for placing a patient in a state of general anesthesia. Hence, any
rational strategy should focus on nociception control intraoperatively and pain
control postoperatively. In this Special Article, we review the anatomy and
physiology of the nociceptive and arousal circuits, and the mechanisms through
which commonly used anesthetics and anesthetic adjuncts act in these systems. We
propose a rational strategy for multimodal general anesthesia predicated on
choosing a combination of agents that act at different targets in the nociceptive
system to control nociception intraoperatively and pain postoperatively. Because
these agents also decrease arousal, the doses of hypnotics and/or inhaled ethers
needed to control unconsciousness are reduced. Effective use of this strategy
requires simultaneous monitoring of antinociception and level of unconsciousness.
We illustrate the application of this strategy by summarizing anesthetic
management for 4 representative surgeries.
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