Wintermeeting 2024:Francisco Lobo

Multimodal anesthesia and multimodal sedation: is two times one more than two?

Francisco Lobo

Friday 19 January 10:30-11:00

The state of General Anesthesia comprises unconsciousness, amnesia, analgesia/antinociception and immobility accompanied by physiological stability. Classically, this drug-induced reversible state has been achieved with the use of basic interactions between hypnotic drugs, opioids and muscular relaxants; the current balanced general anesthesia is  usually based on an hypnotic drug for induction, volatile agent of intravenous drug for maintenance and opioids administered by boluses or as an infusion while muscle relaxation and paralysis may be achieved with the interaction between these drugs or supplemented by muscle relaxants.

A new paradigm has been suggested involving more drugs than this basic triple cocktail. This multimodal general anesthesia approach is based on the ideas that:

  • additional drugs acting in multiple neuronal pathways by different mechanisms may contribute to optimize the nociception-antinociception balance;
  • the synergic and additive interactions between  different drugs at lower doses will decrease the side effects and maximize the desired effects.

Adherence of anesthesiologists to this novel strategy and implementation in the daily clinical practice must start with a comprehensive review of its neuropharmacological rational.

A proposed outline for this comprehensive review includes:

  1. Neural circuits underlying general anesthesia and sleep
  2. Ascending and descending nociception pathways
  3. Antinociceptive drugs and respective sites and mechanisms of action
  • Opioids
  • Ketamine
  • Magnesium
  • Dexmedetomidine
  • Lidocaine
  • NSAIDs
  1. Hypnotic drugs and respective sites and mechanisms of action
  • Propofol
  • Volatile agents
  1. Role of peripheral nerve blocks
  2. Assessment of level of anesthesia: unconsciousness and antinociception monitoring

Suggested references

PMID 37724595
PMID 30252709
PMID 33857967
PMID 21190458
PMID 21513454
PMID 17620835
PMID 18425091

Francisco A Lobo
Anesthesiology Institute
Cleveland Clinic Abu Dhabi
Abu Dhabi, UAE