The general versus regional anaesthesia debate: time to re-examine the goals.

New justification for the use of regional anaesthesia, either alone or in combination with general anaesthesia, has been provided with reports of some unexpected influences on outcome. A reduction in the incidence of postoperative thrombotic episodes and vascular graft occlusion is strongly suggested in patients with generalized vascular disease. Application of a variety of drugs, including local anaesthetics, opioids and adrenergic agonists, in the region of the spinal cord reduces afferent input during surgery and also the metabolic stress response. Evidence is increasing that this multi-modal approach to anaesthesia has important consequences in the spinal cord which result in modification of the postoperative requirement for analgesia. Premedication with opioid and other analgesics may also enhance this pre-emptive effect. New general anaesthetic and analgesic drugs are available that are more suited to these combined techniques. They have shorter duration of action so that plasma concentration can be rapidly adjusted to match a variable surgical stimulus.