Perioperative Multimodal General Anesthesia Focusing on Specific CNS Targets in Patients Undergoing Cardiac Surgeries: The Pathfinder Feasibility Trial
Akshay Shanker, John H Abel, Shilpa Narayanan, Pooja Mathur, Erin Work, Gabriel Schamberg, Aidan Sharkey, Ruma Bose, Valluvan Rangasamy, Venkatachalam Senthilnathan, Emery N Brown, Balachundhar Subramaniam, Akshay Shanker, John H Abel, Shilpa Narayanan, Pooja Mathur, Erin Work, Gabriel Schamberg, Aidan Sharkey, Ruma Bose, Valluvan Rangasamy, Venkatachalam Senthilnathan, Emery N Brown, Balachundhar Subramaniam
Abstract
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. Clinical Trial Number: www.clinicaltrials.gov; identifier NCT04016740 (https://ichgcp.net/clinical-trials-registry/NCT04016740).
Keywords: EEG; analgesia; cardiac; multimodal; neuroanesthesia; nociception; regional; suppression.
Conflict of interest statement
Masimo Corporation has licensed and paid royalties on intellectual property to Massachusetts General Hospital created by EB. He is also a cofounder of PASCALL, a company developing closed loop physiological control systems for anesthesiology. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Copyright © 2021 Shanker, Abel, Narayanan, Mathur, Work, Schamberg, Sharkey, Bose, Rangasamy, Senthilnathan, Brown and Subramaniam.
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