ART OF MEDICINE 2017
THE DYNAMICS OF SERUM CORTISOL AND INSULIN IN HIP JOIT ARTHROPLASTY
Abstract. The hip joint arthroplasty has high risk of perioperative stress-response and insulin-resistance. The analgesia technics differ in terms of anti-nociceptive and anti-stress protection. The aim of our study was to analyze the serum cortisol and insulin dynamics during perioperative period in patients undergone total hip arthroplasty according to the anaesthesia and analgesia techniques.
Materials and methods. The study included 150 patients undergone primary total hip joint replacement. We analyzed the dynamics of serum cortisol, insulin and cortisol/insulin (C/I) index in relation to four variants of intraoperative anaesthesia and three variants of postoperative analgesia techniques, pathology type and patients’ gender. Dates were taken before, during and at the first postoperative day.
Results and Discussion. The average serum cortisol level among all patients was at the reference values all stages of the study, but there was some increase after the onset of anesthesia followed by a decrease during the operation. In the morning of the first postoperative day the level of cortisol returned to baseline. When analyzing the level of cortisol depending on the methods of intraoperative anesthesia, its insignificant growth at the beginning of anesthesia prior to surgery in all groups was found to be within the range of 20-40 nmol/L from the baseline level. At the traumatic moment of surgery, in comparison with the previous stage, cortisol decreased in all groups of regional anesthesia: in the group of spinal anesthesia by 71 nmol/L, in the group of paravertebral+caudal anesthesia – by 53 nmol/L, in the group of nerve blocks – by 13 nmol/L, whereas in the group of general anesthesia cortisol increased by 47 nmol/L. This may indicate a more powerful antinociceptive protection from regional methods. In the morning of the first postoperative day, the level of cortisol recovered to baseline in the group of spinal anesthesia, in the group of nerve blocks and general anesthesia – was by 15 nmol/L higher than the baseline, and in the group of paravertebral+caudal anesthesia – by 38 nmol/L lower than the baseline level. Among the methods of postoperative analgesia, the following thing was observed: in the systemic opioid analgesia group, the level of cortisol in the morning of the first postoperative period was by 31 nmol/L higher than the baseline level before the operation, in the group of epidural analgesia – lower by 73 nmol/L, and in the group paravertebral analgesia – lower by 13 nmol/L. This may indicate a more adequate analgesia from prolonged epidural and paravertebral analgesia compared with systemic opioid analgesia. In analyzing the dynamics of cortisol in gender groups, there was a significant increase in its level at the beginning of anesthesia in men, by 61 nmol/L. Patients with coxarthrosis had higher levels of cortisol in the plasma than patients with fractures, although this difference was statistically significant only at the beginning of anesthesia before surgery (p = 0,02).
The analysis of the level of insulin, depending on the methods of intraoperative analgesia showed the foolowing: the lowest level of insulin on the traumatic stage of the operation in the group of spinal anaesthesia was found to be by 2,61 mIU/L higher compared to the level prior to the operation, and the date of this group significantly differed from other groups at this stage of the study (p <0,05). At all other stages of the study, the level of insulin between intraoperative anesthesia groups did not differ significantly (p>0,05). The difference in insulin levels between postoperative analgesia groups at any stage of the study was not statistically significant (p>0,1).
The C/I index among all patients before surgery was 50,37. On the base of anesthesia before the operation, this index slightly increased, during the operation returned to the baseline level, and in the morning of the first postoperative day was lower by 10 compared with the baseline. Such dynamics may indicate some increased expression of antistress mechanisms in the intraoperative period, and the decrease of such stress after surgery. The analysis of the C/I index in relation to intraoperative anesthesia technics showed a more pronounced increase in the group of spinal anesthesia at the beginning of anesthesia by 14, while in other groups, C/I increased by 5 in comparison with the baseline. During the operation, in all groups of regional anesthesia methods, C/I returned to the baseline, while in the general anesthesia group it continued to grow and was higher by 7 than at the initial stage. In the first postoperative morning in all groups C/I index was lower compared to the baseline. Among the groups of postoperative analgesia in the first postoperative morning, patients in the group of epidural analgesia had significantly higher index, but the rate of this group was high in the previous stages of the study. Men had a significant increase in C/I before and during surgery, which was not observed in women. In patients with coxarthrosis at the beginning of anesthesia, the C/I index increased by 10, while in patients with fractures – by 5. Thus, the dynamics of the C/I, which characterizes the expression of compensatory anti-stress responses, suggests that all methods of pain relief provide sufficient anti-stress protection. But on the basis of the peripheral regional methods, such protection is more stable compared with general anesthesia and neuraxial methods.
Conclusions: Regional analgesia provides a positive effect on the serum cortisol and insulin level in patients undergone hip joint arthroplasty. The expression of compensatory responses by index of cortisol/insulin is more stable in patients having peripheral regional anesthesia, in comparison with neuraxial methods and general anesthesia.
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