Isolated Forearm Test: Replicated, Relevant, and Unexplained

End-tidal Anesthetic Concentration: Monitoring, Interpretation, and Clinical Application

Age-adjusted fraction of minimum alveolar concentration derived from end-tidal anesthetic partial pressure measurement remains a useful drug advisory display to help prevent awareness if interpreted with proper understanding of the quantal and probabilistic nature of minimum alveolar concentration, semantics, drug interactions, and hysteresis.

Are opioids indispensable for general anaesthesia?

The drug-induced, reversible coma of anaesthesia requires three clinical outcomes: unconsciousness, immobility, and the control of autonomic nervous system (ANS) responses to surgical stimulation. Producing the anaesthetised state with a single anaesthetic agent, such as an inhaled vapour or propofol, is challenging, primarily because suppressing ANS responses requires very high anaesthetic concentrations, resulting in haemodynamic depression and prolonged recovery. The antinociceptive effects of opioids (i.e. minimum alveolar concentration reduction) are thus central to the well-entrenched 'balanced anaesthesia' concept. In recent years, the notion of 'multimodal general anaesthesia' has extended the concept of balanced anaesthesia to include more drugs that target different neuroanatomical circuits and multiple neurophysiologic mechanisms. The opioid epidemic has provided some of the motivation to move away from opioids toward other adjunct drugs. Persistent opioid use after surgery is a component of the opioid epidemic and is a major concern for perioperative physicians. Potential solutions to the problem of persistent opioid use after surgery have focused on proper 'opioid stewardship' after operation, wherein opioids are used conservatively in combination with other analgesic adjuncts, and excessive opioid prescribing for home use is avoided. But there is a paucity of data on how intraoperative opioid usage patterns may be contributing to persistent opioid use after surgery. There are cogent reasons to moderate perioperative opioid use, including intraoperative opioids, but whether these changes in practice integral to the multimodal general anaesthesia concept will improve anaesthesia outcomes, including persistent opioid use after surgery, is unknown. Studies investigating these issues are an important research priority.