Multimodal General Anesthesia in Practice

Motivated by the opioid crisis in the United States, multimodal general anesthesia builds on the practices established in balanced general anesthesia.



Definition of General Anesthesia


“General anesthesia” is a drug-induced reversible behavioral state consisting of antinociception, unconsciousness, amnesia and akinesia with maintenance of physiologic systems stability.1,2When anesthesiology was first practiced, the definition was not as clear as stated here, and a single agent, namely ether, was relied upon to produce the state that we now call general anesthesia.


Today, balanced general anesthesia is one of the most common management approaches to delivering general anesthesia.3 It consists of using different drugs to achieve at least approximately each of the separate characteristics of the anesthetic state: for example, opioids to produce antinociception, propofol or sevoflurane to produce unconsciousness and amnesia, and rocuronium or other neuromuscular blocking agents to achieve akinesia. Balanced general anesthesia is predicated on the idea that using combinations of agents makes it possible to use less of each drug and thereby achieve more of the desired effects and fewer of the undesired side effects.4,5


Multimodal General Anesthesia

Multimodal general anesthesia builds on the practices established in balanced general anesthesia and, at least in the United States, is also motivated by the opioid crisis.2 To explain multimodal general anesthesia, we must first draw the distinction between nociception and pain. Nociception is the transmission through the central nervous system of responses to noxious and likely harmful stimuli, whereas pain is the conscious perception of nociceptive information.2During surgery, when the patient is unconscious, analgesic medications are given to control nociception, whereas during the postoperative period, when the patient has recovered consciousness, analgesics are administered to treat pain.


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Emery N. Brown, MD, PhD (1,2)

Laura A. Santa Cruz, MD (1)

Sandya Subramanian, MPhil (2)


1 Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Boston


2 Institute for Medical Engineering and Science Picower Institute for Learning and Memory Department of Brain and Cognitive Sciences Harvard–MIT Health Sciences and Technology Program Massachusetts Institute of Technology Cambridge, Mass.


Financial disclosures: Massachusetts General Hospital has licensed intellectual property for EEG monitoring, developed by Dr. Brown, to Masimo. Dr. Brown holds interests in PASACALL, a company developing EEG-based anesthetic state control systems for anesthesiology. Dr. Brown and Ms. Subramanian have applied for a patent on a system and method for intraoperative monitoring of nociception. This research has been supported in part by NIH grant P01 GM118269 and by funding from the JPB Foundation.

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