Sparing Effect for Balanced Anesthesia

Core Principle of Balanced Anesthesia

The American Society of Anesthesiologists recommends combining small doses of multiple agents, including a hypnotic, an opioid, and optionally a benzodiazepine, to maximize therapeutic benefits while minimizing dose-related adverse effects of any single agent 1
The fundamental concept is pharmacologic synergy, allowing reduction of individual drug doses, thereby decreasing side effects while maintaining adequate anesthesia depth 1

The use of a hypnotic agent, such as propofol or volatile anesthetics, for unconsciousness is recommended 2, 3, 4, 5
The use of an opioid analgesic, such as remifentanil or fentanyl, for analgesia and blunting of nociceptive responses is recommended 6, 7
The optional use of a benzodiazepine, such as midazolam, for anxiolysis and amnesia is recommended 1

The American Society of Anesthesiologists notes that reduced side effects from lower individual drug doses, including lower propofol doses decreasing hypotension, bradycardia, and respiratory depression, are a benefit of balanced anesthesia 6, 1
Opioid-sparing techniques reduce postoperative nausea/vomiting and respiratory depression 2, 3, 4, 5
Combination therapy provides better pain control with fewer adverse events 6

The British Journal of Anaesthesia recommends selecting core agents based on procedure, including hypnotic, opioid, and optional benzodiazepine 6, 1
The use of local/regional anesthesia is mandatory for opioid sparing, and non-opioid analgesics reduce total opioid requirements by 30-50% 2, 3, 4, 5, 7
The American Society of Anesthesiologists recommends titrating to effect using monitoring, including depth of anesthesia monitoring to limit total anesthetic load 2, 3, 4, 5

The Anaesthesia journal notes that obese patients require an aggressive opioid-sparing strategy, including the use of short-acting agents and maximization of local anesthetics and multimodal non-opioid analgesia 2, 3, 4, 5, 7
The Anesthesiology journal recommends caution when using ketamine as an alternative balanced agent, as it can produce deeper sedation and more respiratory depression when combined with propofol 6