Prof. John P. McDonough
Prof. John P. McDonough
University of North Florida, USA
Title: General anesthesia without opioids or vapors
Problem Statement
Although effective for pain-management, opioid analgesic drugs are associated with adverse side effects including respiratory depression, nausea with and without vomiting, increased lethargy and post-operative ileus. Additionally, negative side effects of pain include shallow breathing, retention of secretions and atelectasis. These side-effects prevent the initiation of oral intake and may also contribute to prolonged ambulation times. 
Notwithstanding these facts, in the United States, 99% of surgical patients receive opioids for postsurgical pain and many receive opioids as part of the anesthetic regime. Heroine is an illegal drug in the U.S., yet 80% of new heroin users stated out by misusing prescribed opioid pain treatment, while 99% of surgical patients who are prescribed opioids progress to long term opioid use or abuse.
Proposed Solution
It has long been known that non-opioid agents can provide effective analgesia through the administration of multi-modal therapy. Benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), centrally acting non-opioid non-NSAIDs such as acetaminophen, gabapentinoids, magnesium, lidocaine, and NMDA antagonists such as ketamine just in combination with inhalation anesthetic supplementation with nitrous oxide and supplemental nerve block as indicated, have been shown to provide an anesthetic that provides for physiological stability, excellent operating conditions, and patient comfort in the postoperative period.
Implementation Strategy 
Prior to the induction of general anesthesia the patient should receive 1 gm IV acetaminophen, midazolam 0.03 mg/kg, ketamine 0.5 mg/kg, and lidocaine 1.0 mg/kg. Induction should be accomplished with propofol at a reduced dose consistent with the patient’s state of wakefulness. Three in fusions should then be started: Lidocaine 1 mg/kg/hr, Ketamine 0.1 mg/kg/hr and propofol 75-100 mics/kg/min. After endotracheal begin intubations nitrous 50-70%. Magnesium 2 gm may be given either preoperatively or during the first 45 minutes of the operation. All infusions should be continued until the operation, including dressing application, is fully completed. At that point the nitrous oxide should be discontinued and the muscle relaxant reversed.
Dr. McDonough is a tenured Full Professor of Nursing, Director of Graduate Studies and Program Director of the Nurse Anesthetist Program at the School of Nursing, University of North Florida. He received his nursing education at Greenfield Community College (Mass.) and St Anselm College (NH), and his certificate in nurse anesthesia from the School of Anesthesia, VA Medical Center in Des Moines, IA. Later, he completed his first MS degree and a doctorate in psychotherapy at Drake University in Des Moines. He also has an MSN degree from the University of Tennessee and a Certificate of Advanced Graduate Specialization in Family Practice from the School of Nursing, State University of New York at Stony Brook. He also has the post-doctoral doctorate (Doktor Habilitatus) from the medical University of Salzburg, Austria with a major in Anesthesiology. In addition to being a CRNA, he is also a Diplomate and Fellow of the American Board of Medical Psychotherapists. He has practiced in the military including and assignment as the Chief Anesthetist at the United States Military Academy, West Point, and the Director of Clinical Education for Nurse Anesthesia at the Uniformed Service University of the Health Sciences. In the civilian world he has practiced in rural hospitals as a sole provider, at major urban medical centers and now as an academic with an active clinical practice at a major trauma, and a private office based practice. Dr. McDonough is a past President of Florida Association of Nurse Anesthetists, a member of the American Association of Nurse Anesthetists, has served on the national Education Committee and Chair of Advanced Practice of the Florida Board of Nursing. He is appointed as Editor-in-Chief, International Journal of Advanced Nursing Studies and holds appointment as a Full Professor, Medical University of Salzburg, Austria, and a Fellow of the Royal Society of Medicine. He is a frequent presenter at major conferences throughout North America and Europe.