What is the recommended anesthetic technique for patients undergoing surgical procedures, specifically combining general anesthesia (GA) with regional techniques?

Combining General Anesthesia with Regional Techniques

For most surgical procedures, combining general anesthesia with regional techniques does not reduce mortality or major cardiovascular complications, but does provide modest improvements in pulmonary outcomes and superior postoperative pain control compared to general anesthesia with opioid analgesia alone. 1

Evidence for Combined GA + Regional Techniques

Cardiovascular Outcomes

• Seven randomized trials in vascular surgery patients demonstrated no differences in mortality or major morbidity when comparing regional anesthesia techniques to general anesthesia alone 1
• The MASTER trial (915 patients undergoing major abdominal surgery) found that combined general and epidural anesthesia/analgesia did not decrease death or cardiovascular outcomes 1
• One subgroup analysis showed reduced MI incidence in aortic surgery patients (7.9% with GA/opioid vs 2.7% with GA/epidural, p<0.05), though beta blocker use was not controlled 1

Pulmonary Benefits

• Combined general and epidural anesthesia modestly improved pulmonary outcomes compared to general anesthesia alone 1
• Thoracic epidural analgesia after coronary artery bypass surgery decreased postoperative pulmonary complications but did not influence MI incidence or overall mortality 1

Pain Management Advantages

• Epidural anesthesia/analgesia provides superior pain control with lower opiate dosages, better ablation of catecholamine response, and less hypercoagulable state compared to IV opioids 1
• Multimodal analgesia combining regional techniques with non-opioid medications (acetaminophen, NSAIDs) reduces opioid consumption and provides superior analgesia compared to either agent alone 2, 3, 4, 5

Recommended Approach by Procedure Type

Open Abdominal Surgery

• Use combined general anesthesia with thoracic epidural for major open abdominal procedures (colorectal, aortic surgery) 1
• Epidural provides superior pain control and facilitates early mobilization and enteral intake 1
• Maintain epidural with local anesthetics; consider adding clonidine as adjunct 1, 3

Laparoscopic Surgery

• Alternative regional techniques may be equally effective to epidural for laparoscopic procedures 1
• Consider spinal anesthesia, intravenous lidocaine infusion, or patient-controlled analgesia as alternatives 1
• Peripheral nerve blocks or TAP blocks (0.2-0.5 mL/kg per side) provide effective analgesia 3

Orthopedic Procedures (Lower Extremity)

• Peripheral nerve blocks are preferred over neuraxial techniques to avoid sympathetic blockade 1
• Femoral nerve block or fascia iliaca compartment block using 0.2-0.4 mL/kg of long-acting local anesthetic with clonidine adjunct 4
• Continuous peripheral nerve blocks provide extended postoperative analgesia for major procedures 4

Infrainguinal Vascular Procedures

• Spinal or epidural anesthesia can be performed with minimal hemodynamic changes if neuraxial blockade is limited to appropriate dermatomes 1
• No outcome differences demonstrated between regional and general techniques 1

Multimodal Analgesia Protocol

Core Components (Unless Contraindicated)

• Acetaminophen: IV 15-20 mg/kg loading dose (pediatric) or standard adult dosing 2, 3, 5
• NSAID or COX-2 inhibitor: Ketorolac 0.5-1 mg/kg IV or alternative NSAID 2, 4, 5
• Dexamethasone: 0.15-0.25 mg/kg (maximum 0.5 mg/kg) or ≥8 mg in adults to reduce postoperative swelling and inflammation 1, 3, 6
• Regional technique: Procedure-specific nerve block or neuraxial anesthesia 5, 7
• Local anesthetic infiltration: Surgical site infiltration when regional block not feasible 2, 5

Adjunctive Medications

• Ketamine: Low-dose infusion as co-analgesic for complex procedures 1, 2, 3, 6
• Alpha-2 agonists (clonidine, dexmedetomidine): As adjunct to regional blocks or systemic administration 1, 2, 3, 4
• IV lidocaine infusion: Alternative or adjunct to regional techniques in laparoscopic surgery 1, 6
• Magnesium: May be considered as part of multimodal approach 8, 6

Opioid Use

• Administer opioids only as rescue adjuncts after multimodal non-opioid regimen established 4, 5
• Short-acting opioids preferred: fentanyl 1-2 mcg/kg or remifentanil infusion 0.05-0.3 mcg/kg/min 3

Critical Safety Considerations

Neuraxial Block Precautions

• Avoid neuraxial blocks in patients with coagulopathy due to risk of epidural hematoma 1
• High dermatomal levels (thoracic epidural, high lumbar/spinal) can cause significant hypotension from sympathetic blockade and preload compromise 1
• Maintain blood flow to gut using vasopressors once normovolemia established when using epidural 1

Regional Technique Selection

• Peripheral nerve blocks do not exacerbate hemodynamic instability unlike neuraxial techniques 1
• Use amide local anesthetics (bupivacaine, ropivacaine) rather than esters for regional blocks 1, 9
• Maximum ropivacaine dose: 3 mg/kg with epinephrine, 2 mg/kg without 3

Local Anesthetic Systemic Toxicity Prevention

• Have 20% lipid emulsion immediately available when administering local anesthetics 3
• Aspirate frequently before injection to avoid intravascular administration 3
• Monitor for early toxicity signs: CNS excitation/depression, circumoral numbness, metallic taste, cardiac depression 3

Common Pitfalls and How to Avoid Them

Overreliance on Opioids Alone

• Always use multimodal approach combining non-opioid analgesics with regional techniques 4, 5, 7
• Opioid monotherapy leads to inadequate pain control, respiratory depression, nausea, vomiting, and delayed mobilization 2, 4, 7

Inadequate Non-Opioid Administration

• Real-world data shows foundational analgesics are frequently underdosed 3
• Administer acetaminophen AND NSAID together for synergistic effect 2, 3, 5
• Start non-opioid medications preoperatively and continue throughout perioperative period 2, 5

Inappropriate Regional Technique Selection

• Do not use single-shot blocks for major procedures when continuous catheters would provide superior extended analgesia 4
• Avoid neuraxial blocks when peripheral nerve blocks would suffice and avoid sympathetic blockade 1

Monitored Anesthesia Care Limitations

• Monitored anesthesia care was associated with highest 30-day mortality in large-scale study, likely due to selection bias 1
• Provides poor blockade of stress response unless local anesthetic provides profound anesthesia 1
• General or regional anesthesia may be preferable to monitored anesthesia care 1