This forum needs to get more clinical, so here's a CA-1 level thread. So as a resident I see two schools of thought when a scalpel gets put to skin or organ and the HR and BP shoot up. Let's assume MAC is 1.2 or so. Some- probably most- give narcotics in this spot. The "pain" or stimulation resulting in these vasoactive changes is mediated by nociceptor pathways and amenable to attenuation by opioids. More and more though, I'm working with people who think that these changes are best managed with vasoactive drugs (i.e. esmolol, nitro, etc). They save administration of long-active narcs for the end of the case, and use vasoactive agents in the beginning and the middle during periods of stimulation. As a believer in pre-emptive analgesia I tend to fall into the first camp, but because I'm seeing more of the second, I'm interested in hearing other opinions on this.