12Balanced anaesthesia today
Section snippets
Definition of balanced anaesthesia
The concept of combining several compounds with different actions—such as amnesia, analgesia, or diminution of autonomic reflexes—was first conceived by George W. Crile in 1910 with a theory called anociassociation.1 Crile suggested the use of a light general anaesthesia together with local anaesthesia for blocking painful stimuli. The term balanced anaesthesia was introduced by John S. Lundy in 1926.2 Lundy's idea was to utilize a balance of agents and techniques (e.g. premedication, regional
Induction of anaesthesia
Whereas sevoflurane can be administered at a high concentration via face-mask, thus enabling the anaesthesiologist to induce anaesthesia by a mask induction technique, desflurane cannot be given in a similar fashion because of its pungency and the related side-effects such as coughing and laryngospasm.4, 5 Although traditionally most general anaesthetics are induced by injection of an intravenous anaesthetic, the so-called vital capacity induction with sevoflurane may offer an alternative
Recovery from anaesthesia
The use of anaesthetics with fast pharmacokinetics, such as the intravenous anaesthetic propofol or the newer volatile anaesthetics desflurane and sevoflurane, speeds up the recovery process from general anaesthesia. In particular, volatile anaesthetics offer a rapidly dissipating action, thus enabling even inexperienced anaesthesiologists to optimize the perioperative workflow. ‘Fast-track’ anaesthesia may offer significant cost savings without compromising patient safety and comfort. Patients
Intraoperative analgesia
Economical aspects require a rapid turnover of patients, and quite often there is no or only limited capacity in the recovery area for patients who require postoperative observation. However, the necessity for monitoring a patient in a PACU is not only dependent on the choice of anaesthetic but also on adjuvants that are co-administered. An important aspect for the continuing improvement of balanced anaesthesia was the development of anaesthetic adjuvants such as opioids and neuromuscular
Postoperative nausea and vomiting
Currently, the use of a TIVA technique is preferred if a patient is at risk of PONV (see Chapter 13 for a detailed discussion). Propofol offers an excellent action as an antiemetic even at subhypnotic doses.26 In a study comparing the antiemetic effect of propofol with that of ondansetron in women undergoing breast surgery, propofol was found to be more effective.27 The findings regarding the incidence of PONV after a propofol-based anaesthesia and a sevoflurane-based balanced anaesthesia
Organ protection
There is accumulating evidence from experimental and clinical studies that volatile anaesthetics protect different organ systems against ischaemic injuries (see Chapters 9–11 for details). Currently, most research focuses on myocardial ischaemia. Although it was initially demonstrated that isoflurane distributes coronary blood flow away from ischaemic areas,29, 30 consecutive studies did not support this finding and even demonstrated the opposite.31, 32 In addition to beneficially altering
Balanced anaesthesia in the future: is xenon a new choice?
The anaesthetic properties of xenon have now been recognized for more than 50 years (see Chapter 4).41 Xenon has been reported to exert minimal effects on cardiac or vascular function in either healthy or sick subjects, as demonstrated in humans and in animals.41 The rapid induction and emergence render xenon a nearly ideal anaesthetic gas. However, the anaesthetic potency of xenon is too weak for its use as a single anaesthetic. One cannot deliver more than one MAC of xenon at an FiO2 of 0.3,
Economics
Costs may be an important argument contributing to the fact that many anaesthesiologists prefer balanced anaesthesia to TIVA (see also Chapter 7). In a study comparing the effects of propofol administered via target-controlled infusion (TCI) and sevoflurane, the cost of a TIVA was higher than that of a balanced anaesthesia.46 Similar results were found in a multicentre study comparing the costs of a propofol anaesthesia, sevoflurane maintenance after propofol induction, or a completely
Postoperative pain management
Up to today, pain management after the administration of anaesthetics with extremely rapid pharmacokinetics such as desflurane, sevoflurane and remifentanil needs optimization. It is of paramount importance that the anaesthesiologist who uses these substances is aware of the type of procedure performed, the amount of postoperative pain the surgery will provoke, and the type of personality of the patient with respect to pain perception. With these factors in mind, an adequate strategy of pain
Summary
Balanced anaesthesia today has reached new dimensions with the use of less soluble anaesthetics in combination with short-acting anaesthetic adjuvants. Careful weighing of the risks—but also of the benefits—of balanced anaesthesia shows that this technique is an important asset in the anaesthesiologist's clinical routine. At present, balanced anaesthesia is the closest step towards an ideal anaesthetic. (Box 1 Box 2)
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