Anestesia combinada

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Abstract

Resumen La combinación de anestesia general con anestesia regional central o periférica se denomina anestesia combinada. La técnica de anestesia combinada fue muy popular en los años 80's y 90's. Se ha empleado con resultados satisfactorios en procedimientos prolongados y dolorosos tales como cirugía de tórax y cirugía de abdomen mayor, brindando una sumatoria de beneficios con un perfil adecuado se seguridad. Presenta algunas ventajas en relación a la anestesia general, principalmente disminución de los requerimientos anestésicos y posibilita de implantación de una estrategia analgésica postoperatoria adecuada. Se observa menor índice de dolor postoperatorio y menor morbimortalidad, la respuesta neuroendocrina al estrés es menor y mejora la respuesta inmunológica.

Translated abstract

Abstract The combination of general anesthesia with central or peripheral regional anesthesia is called combined anesthesia. The combined anesthesia technique was very popular in the years 80's and 90's. It has been used with satisfactory results in prolonged and painful procedures such as chest surgery and major abdominal surgery, providing a sum of benefits with a suitable profile is security. It has some advantages in relation to general anesthesia, mainly reduced anesthetic requirements and enables a proper postoperative analgesic strategy implementation. Lower rate of postoperative pain and lower morbidity and mortality is observed, the neuroendocrine response to stress less and improves immune response.

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Most cited references 19

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Neuraxial analgesia in neonates and infants: a review of clinical and preclinical strategies for the development of safety and efficacy data.

T L Yaksh, Dilys Walker (2012)

Neuraxial drugs provide robust pain control, have the potential to improve outcomes, and are an important component of the perioperative care of children. Opioids or clonidine improves analgesia when added to perioperative epidural infusions; analgesia is significantly prolonged by the addition of clonidine, ketamine, neostigmine, or tramadol to single-shot caudal injections of local anesthetic; and neonatal intrathecal anesthesia/analgesia is increasing in some centers. However, it is difficult to determine the relative risk-benefit of different techniques and drugs without detailed and sensitive data related to analgesia requirements, side effects, and follow-up. Current data related to benefits and complications in neonates and infants are summarized, but variability in current neuraxial drug use reflects the relative lack of high-quality evidence. Recent preclinical reports of adverse effects of general anesthetics on the developing brain have increased awareness of the potential benefit of neuraxial anesthesia/analgesia to avoid or reduce general anesthetic dose requirements. However, the developing spinal cord is also vulnerable to drug-related toxicity, and although there are well-established preclinical models and criteria for assessing spinal cord toxicity in adult animals, until recently there had been no systematic evaluation during early life. Therefore, in the second half of this review, we present preclinical data evaluating age-dependent changes in the pharmacodynamic response to different spinal analgesics, and recent studies evaluating spinal toxicity in specific developmental models. Finally, we advocate use of neuraxial drugs with the widest demonstrable safety margin and suggest minimum standards for preclinical evaluation before adoption of new analgesics or preparations into routine clinical practice.

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Regional anaesthesia versus general anaesthesia, morbidity and mortality.

Jane Ballantyne, Mina Nishimori, Padma Gulur (2006)

The regional versus general anaesthesia debate is an age-old debate that has brought about few clear answers. Most concur that multiple factors including the patient, the surgery, the method of regional and general anaesthesia, and the quality of perioperative care, all influence surgical outcome. In this age of evidence-based medicine, the heterogenous data available need to be reconciled with the advances in perioperative care and the significant decline in complications associated with the surgical process as a whole. This review considers general issues such as the type of available evidence, and its limitations, particularly with regard to the relatively broad question of neuraxial versus general anaesthesia. It then assesses current evidence on regional versus general anaesthesia for specific scenarios such as hip fracture surgery, carotid endarterectomy, Caesarean section, ambulatory orthopaedic surgery, and postoperative cognitive dysfunction in elderly patients after non-cardiac surgery.

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Combined epidural and general anesthesia for abdominal aortic surgery.

C Her, G Kizelshteyn, V. Walker … (1990)

The hypothesis that combined epidural and light general anesthesia for infrarenal abdominal aortic surgery is associated with a more stable intraoperative course and less postoperative morbidity than general anesthesia alone was tested. The authors compared intraoperative hemodynamic variables and postoperative morbidity between a group with combined epidural and general anesthesia (n = 30) and a group with general anesthesia (n = 19). Patients who had combined epidural and general anesthesia were given epidural bupivacaine intraoperatively and epidural morphine postoperatively. After cross-clamping of the aorta, cardiac index and pulmonary capillary wedge pressure did not change in the group with combined epidural and general anesthesia, whereas cardiac index decreased (mean change, 0.30 L/min/m2; P = 0.0006) and pulmonary capillary wedge pressure increased (mean change, 1 mm Hg; P = 0.007) in the group with general anesthesia. After unclamping, cardiac index increased in both groups (mean change, 0.26 L/min/m2, P = 0.002, and 0.30 L/min/m2, P = 0.001, respectively). Postoperatively, the necessity for ventilatory support and the incidence of respiratory failure were lower in the combined epidural and general anesthesia group than in the general anesthesia group (P = 0.0002 and P = 0.018, respectively). In addition, vasodilator therapy was required less frequently in the group with combined epidural and general anesthesia (P = 0.002). Duration of intensive care unit stay was shorter in the combined epidural and general anesthesia group (2.7 days v 3.8 days, P = 0.003). These data indicate that for infrarenal abdominal aortic surgery, combined epidural and general anesthesia is associated with more stable intraoperative hemodynamics and significantly less postoperative morbidity than general anesthesia alone.