Are opioids indispensable for general anaesthesia?

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Presentation transcript:

Are opioids indispensable for general anaesthesia? Talmage D. Egan British Journal of Anaesthesia Volume 122, Issue 6, Pages e127-e135 (June 2019) DOI: 10.1016/j.bja.2019.02.018 Copyright © 2019 British Journal of Anaesthesia Terms and Conditions

Fig 1 A triangle representing the conventional goals of general anaesthesia. Amnesia is another essential outcome that is presumed to be achieved when a patient is unconscious. ANS, autonomic nervous system. Adapted from Egan and Svensen.2 British Journal of Anaesthesia 2019 122, e127-e135DOI: (10.1016/j.bja.2019.02.018) Copyright © 2019 British Journal of Anaesthesia Terms and Conditions

Fig 2 An idealised, graphical representation of the concentration-effect relationships of inhaled anaesthetic agents in terms of MAC, MAC-awake, and MAC-BAR. The trio of anaesthetic outcomes (deliverables) depicted follow the colour scheme introduced in Figure 1. See text for complete explanation. MAC, minimum alveolar concentration. Adapted from Egan and Svensen.2 British Journal of Anaesthesia 2019 122, e127-e135DOI: (10.1016/j.bja.2019.02.018) Copyright © 2019 British Journal of Anaesthesia Terms and Conditions

Fig 3 An idealised, highly schematised representation of the neuroanatomical targets of general anaesthesia. The trio of anaesthetic outcomes (deliverables) depicted follow the colour scheme introduced in Figure 1. British Journal of Anaesthesia 2019 122, e127-e135DOI: (10.1016/j.bja.2019.02.018) Copyright © 2019 British Journal of Anaesthesia Terms and Conditions

Fig 4 An idealised, graphical representation of the concept of MAC reduction by opioids. The trio of anaesthetic outcomes (deliverables) depicted follow the colour scheme introduced in Figure 1. BAR, block of adrenergic response. British Journal of Anaesthesia 2019 122, e127-e135DOI: (10.1016/j.bja.2019.02.018) Copyright © 2019 British Journal of Anaesthesia Terms and Conditions

Fig 5 An idealised, highly schematised representation of the nociceptive-medullary-autonomic (NMA) circuit. The ascending nociceptive (pain) pathway begins with A-delta and C peripheral afferent fibres that synapse in the dorsal horn on projection neurones. These projection neurones synapse at multiple sites in the brainstem including the nucleus of the tractus solitarius (NTS) in the medulla. The autonomic response to a nociceptive stimulus is initiated from the NTS which mediates sympathetic output through the rostral ventral lateral medulla (RVLM) and the caudal ventral lateral medulla (CVLM) to the heart and peripheral blood vessels via projections to the thoracolumbar sympathetic ganglia and the adrenal medulla (which is essentially a sympathetic ganglion releasing sympathomimetics to the blood stream). The NTS also projects to the periventricular nucleus (PVN) and supraoptic nucleus (SON) in the hypothalamus. The parasympathetic output is mediated through the nucleus ambiguous (NA) which projects through the vagus nerve to the sino-atrial node of the heart. Adapted from Brown and colleagues.11 British Journal of Anaesthesia 2019 122, e127-e135DOI: (10.1016/j.bja.2019.02.018) Copyright © 2019 British Journal of Anaesthesia Terms and Conditions