Shanker Akshay, Abel John H, Narayanan Shilpa, Mathur Pooja, Work Erin, Schamberg Gabriel, Sharkey Aidan, Bose Ruma, Rangasamy Valluvan, Senthilnathan Venkatachalam, Brown Emery N, Subramaniam Balachundhar
Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States.
Front Med (Lausanne). 2021 Oct 14;8:719512. doi: 10.3389/fmed.2021.719512. eCollection 2021.
Multimodal general anesthesia (MMGA) is a strategy that utilizes the well-known neuroanatomy and neurophysiology of nociception and arousal control in designing a rational and clinical practical paradigm to regulate the levels of unconsciousness and antinociception during general anesthesia while mitigating side effects of any individual anesthetic. We sought to test the feasibility of implementing MMGA for seniors undergoing cardiac surgery, a high-risk cohort for hemodynamic instability, delirium, and post-operative cognitive dysfunction. Twenty patients aged 60 or older undergoing on-pump coronary artery bypass graft (CABG) surgery or combined CABG/valve surgeries were enrolled in this non-randomized prospective observational feasibility trial, wherein we developed MMGA specifically for cardiac surgeries. Antinociception was achieved by a combination of intravenous remifentanil, ketamine, dexmedetomidine, and magnesium together with bupivacaine administered as a pecto-intercostal fascial block. Unconsciousness was achieved by using electroencephalogram (EEG)-guided administration of propofol along with the sedative effects of the antinociceptive agents. EEG-guided MMGA anesthesia was safe and feasible for cardiac surgeries, and exploratory analyses found hemodynamic stability and vasopressor usage comparable to a previously collected cohort. Intraoperative EEG suppression events and postoperative delirium were found to be rare. We report successful use of a total intravenous anesthesia (TIVA)-based MMGA strategy for cardiac surgery and establish safety and feasibility for studying MMGA in a full clinical trial. www.clinicaltrials.gov; identifier NCT04016740 (https://clinicaltrials.gov/ct2/show/NCT04016740).
多模式全身麻醉（MMGA）是一种策略，它利用众所周知的伤害感受和唤醒控制的神经解剖学和神经生理学知识，设计出一种合理且临床实用的模式，以在全身麻醉期间调节意识丧失和抗伤害感受水平，同时减轻任何单一麻醉剂的副作用。我们试图测试对接受心脏手术的老年人实施MMGA的可行性，这些老年人是血流动力学不稳定、谵妄和术后认知功能障碍的高危人群。20名年龄在60岁及以上、接受体外循环冠状动脉搭桥术（CABG）或CABG/瓣膜联合手术的患者被纳入这项非随机前瞻性观察性可行性试验，在此试验中我们专门为心脏手术开发了MMGA。通过静脉注射瑞芬太尼、氯胺酮、右美托咪定和镁，以及作为胸肋筋膜阻滞给药的布比卡因的联合使用来实现抗伤害感受。通过脑电图（EEG）引导丙泊酚给药以及抗伤害感受药物的镇静作用来实现意识丧失。EEG引导的MMGA麻醉对心脏手术是安全可行的，探索性分析发现血流动力学稳定性和血管升压药的使用与先前收集的队列相当。术中EEG抑制事件和术后谵妄很少见。我们报告了基于全静脉麻醉（TIVA）的MMGA策略在心脏手术中的成功应用，并确立了在全面临床试验中研究MMGA的安全性和可行性。 临床试验.gov网站；标识符NCT04016740（https://clinicaltrials.gov/ct2/show/NCT04016740）。
