Multimodal General Anesthesia: Theory and Practice.
Multimodal General Anesthesia: Theory and Practice.
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DOI：
10.1213/ane.0000000000003668
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发表时间：
2018-11
影响因子：
5.7
通讯作者：
Naranjo M
中科院分区：
文献类型：
--
作者：
Brown EN;Pavone KJ;Naranjo M
平衡全身麻醉是麻醉护理中最常用的管理策略，它需要联合使用不同的药物来产生麻醉状态。麻醉医师开发这种方法是为了避免在全身麻醉维持过程中仅仅依赖乙醚。与单独使用某种药物相比，平衡全身麻醉使用每种药物的剂量更少，从而增加了获得预期效果的可能性，并降低了产生副作用的可能性。为了在术中控制伤害性感受以及在术后控制疼痛，目前平衡全身麻醉的实践几乎完全依赖阿片类药物。虽然阿片类药物是最有效的抗伤害性感受药物，但它们有不良副作用。此外，对阿片类药物的过度依赖导致了美国的阿片类药物滥用流行。由于担心阿片类药物的过度使用，平衡全身麻醉策略现在使用更多的药物来产生麻醉状态。在这些被称为“多模式全身麻醉”的方法中，额外使用的药物可能包括作用于特定中枢神经系统靶点的药物，如右美托咪定，以及作用靶点不太特异的药物，如镁剂。据推测，使用更多小剂量的药物能进一步使预期效果最大化，同时使副作用最小化。尽管这种方法似乎使效益 - 副作用比最大化，但对于选择药物组合尚未提供合理的策略。手术引起的伤害性感受是使患者处于全身麻醉状态的主要原因。因此，任何合理的策略都应侧重于术中控制伤害性感受以及术后控制疼痛。在这篇专题文章中，我们回顾了伤害性感受和觉醒回路的解剖学和生理学，以及常用麻醉剂和麻醉辅助药物在这些系统中起作用的机制。我们提出了一种多模式全身麻醉的合理策略，该策略基于选择作用于伤害性感受系统中不同靶点的药物组合，以控制术中伤害性感受和术后疼痛。因为这些药物也会降低觉醒程度，所以控制无意识所需的催眠药和/或吸入性乙醚的剂量会减少。有效使用这种策略需要同时监测抗伤害性感受和无意识水平。我们通过总结4种代表性手术的麻醉管理来说明这种策略的应用。
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.