Multimodal General Anesthesia: Theory and Practice
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 gene...
| Main Authors: | , , |
|---|---|
| Other Authors: | |
| Format: | Article |
| Language: | English |
| Published: |
Ovid Technologies (Wolters Kluwer Health)
2020
|
| Online Access: | https://hdl.handle.net/1721.1/126701 |
| _version_ | 1811089382385385472 |
|---|---|
| author | Brown, Emery Neal Pavone, Kara Naranjo, Marusa |
| author2 | Massachusetts Institute of Technology. Institute for Medical Engineering & Science |
| author_facet | Massachusetts Institute of Technology. Institute for Medical Engineering & Science Brown, Emery Neal Pavone, Kara Naranjo, Marusa |
| author_sort | Brown, Emery Neal |
| collection | MIT |
| description | 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. |
| first_indexed | 2024-09-23T14:18:17Z |
| format | Article |
| id | mit-1721.1/126701 |
| institution | Massachusetts Institute of Technology |
| language | English |
| last_indexed | 2024-09-23T14:18:17Z |
| publishDate | 2020 |
| publisher | Ovid Technologies (Wolters Kluwer Health) |
| record_format | dspace |
| spelling | mit-1721.1/1267012022-09-29T08:32:49Z Multimodal General Anesthesia: Theory and Practice Brown, Emery Neal Pavone, Kara Naranjo, Marusa Massachusetts Institute of Technology. Institute for Medical Engineering & Science Picower Institute for Learning and Memory Massachusetts Institute of Technology. Department of Brain and Cognitive Sciences Massachusetts Institute of Technology. Institute for Data, Systems, and Society 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. National Institutes of Health (Grants R01 GM104948 and P01GM118269) 2020-08-20T13:53:03Z 2020-08-20T13:53:03Z 2018-11 2019-09-30T15:36:21Z Article http://purl.org/eprint/type/JournalArticle 0003-2999 https://hdl.handle.net/1721.1/126701 Brown, Emery N. et al. "Multimodal General Anesthesia: Theory and Practice." Anesthesia and Analgesia 127, 5 (November 2018): 1246-1258. © 2018 The Author(s) en http://dx.doi.org/10.1213/ane.0000000000003668 Anesthesia and Analgesia Creative Commons Attribution-NonCommercial-NoDerivs License http://creativecommons.org/licenses/by-nc-nd/4.0/ application/pdf Ovid Technologies (Wolters Kluwer Health) Anesthesia & Analgesia |
| spellingShingle | Brown, Emery Neal Pavone, Kara Naranjo, Marusa Multimodal General Anesthesia: Theory and Practice |
| title | Multimodal General Anesthesia: Theory and Practice |
| title_full | Multimodal General Anesthesia: Theory and Practice |
| title_fullStr | Multimodal General Anesthesia: Theory and Practice |
| title_full_unstemmed | Multimodal General Anesthesia: Theory and Practice |
| title_short | Multimodal General Anesthesia: Theory and Practice |
| title_sort | multimodal general anesthesia theory and practice |
| url | https://hdl.handle.net/1721.1/126701 |
| work_keys_str_mv | AT brownemeryneal multimodalgeneralanesthesiatheoryandpractice AT pavonekara multimodalgeneralanesthesiatheoryandpractice AT naranjomarusa multimodalgeneralanesthesiatheoryandpractice |