CORTISOL AND BLOOD GLUCOSE AT THE STAGES OF COMBINED ANESTHESIA WITH VENTILATOR AND EXTRACURRICULAR BLOCKADES WITH MORPHINE
Анестезиология
UDC 617-089
CORTISOL AND BLOOD GLUCOSE AT THE STAGES
OF COMBINED ANESTHESIA WITH VENTILATOR
AND EXTRACURRICULAR BLOCKADES WITH MORPHINE
V.A. Fomichev, MD, PhD, Professor
Novosibirsk State Medical University
(630091, Russia, Novosibirsk, Krasny Prospekt, 52)
E-mail: fomichev.va@med54.ru
A.Y. Maloletneva, MD, Assistant Professor
Novosibirsk State Medical University
(630091, Russia, Novosibirsk, Krasny Prospekt, 52)
E-mail: malolet67@mail.ru
A.S. Busin, Anesthesiologist
Clinical Hospital at Novosibirsk station
(630003, Russia, Novosibirsk, Vladimirovsky descent, 2a)
E-mail: kms.novosibirsk1989@yandex.ru
Abstract. Cortisol and blood glucose indicators are markers of anti-stress protection. The dynamics of cortisol and blood glucose were determined in 162 patients with surgical diseases of the abdominal cavity with various variants of combined general anesthesia with ventilator and extracurricular morphine blockades in comparable groups. In group 1 (control) (n=64), patients were operated under combined general anesthesia with ventilator and NLA preparations, in group 2 (comparison), patients (n=54) were operated on the background of combined general anesthesia with ventilator and epidural analgesia with morphine; in group 3 patients (n=46), combined general anesthesia with a ventilator was performed under conditions of paravertebral morphine analgesia. Changes in the concentration of cortisol and blood glucose were analyzed in the groups. It was revealed that the technology of anesthetic protection of patients with abdominal surgical interventions using paravertebral morphine administration is not accompanied by deviations of cortisol and blood glucose beyond the stress norm
Keywords: surgical diseases of the abdominal cavity, cortisol and blood glucose indicators, extracurricular morphine analgesia.
Introduction
The process of implementing most variants of endotracheal anesthesia with a ventilator is inevitably accompanied by clinically unfavorable stimulation of the pituitary-adrenal system with subsequent hormone production [1, 9]. Therefore, among the criteria for the adequacy of antinociceptive protection, the determination of the concentration of cortisol in the blood plasma is a marker of the manifestation of the stress reaction of the body [2, 5]. Since glucose is one of the main components of the energy "raw material" of the body, the determination of its level at the stages of surgical treatment under various anesthesia options serves as one of the criteria for assessing the degree of anesthetic protection.
The task of the study. To assess the adequacy of anesthetic protection based on the dynamics of cortisol and plasma glucose levels in the perioperative period in patients with various variants of combined general anesthesia with ventilator and extracurricular morphine blockades.
Material and method
To solve this problem, 162 patients with various surgical diseases of the abdominal cavity were examined. The patients were operated on as planned, underwent the necessary training and examination.
The patients were divided into 3 groups depending on the method of anesthesia: group 1 – patients who were operated under general combined anesthesia with ventilator and NLA preparations – 64 people;
Group 2 – patients in whom general combined anesthesia with ventilator was performed against the background of epidural morphine analgesia – 54 people;
Group 3 – patients who underwent general combined anesthesia with a ventilator under conditions of paravertebral morphine blockade – 46 people.
Of the 162 patients examined at the stages of surgical operations and in the first three days of the postoperative period, there were 118 women (78.8%) and 44 men (21.2%). The groups were comparable by gender, age, weight of talus, height, volume of surgical interventions and severity of surgical and anesthetic risk on the MNOAR scale.
Combined general anesthesia with ventilator and NLA drugs represented a modification of the classical technique. Premedication: atropine in usual dosages of 0.1 mg / kg, diphenhydramine 10-20 mg, 1/2-1/3 doses of droperidol at the rate of 0.2 mg / kg of body weight, depending on the condition, age, blood pressure. Introductory anesthesia with sodium thiopental at a dose of 6-8 mg /kg.Myoplegia was supported by arduan in conventional doses (0.05 mg/kg). Ventilation with nitrous-oxygen mixture 2:1. Analgesia and vegetative protection were provided by fentanyl at a dose of 0.01 mg / kg h and droperidol at a dose of 0.2 mg / kg h. Drug-induced sleep was further deepened by seduxen and ketamine at doses of 0.17 mg/kg hour and 1 mg/kg hour.
To perform combined general anesthesia with a ventilator in the conditions of epidural analgesia, the epidural space was catheterized according to the generally accepted method at the appropriate level of the operation. Morphine hydrochloride was used at a dose of 0.08-0.1 mg/kg, taking into account the age and condition of the patient (on average 5-8 mg) in 6-8 ml of saline solution.
During catheterization of the paravertebral space after anesthesia of the interstitial space, the needle moved in the segital direction with a deviation from the midline of 10-20 degrees maximum with simultaneous administration of 0.25% novocaine ( if another anesthetic is intolerant) until the appearance of the "loss of resistance" test in the nearest cellular paravertebral space. Since the movement of the needle was necessarily preceded by the introduction of a local anesthetic, slight signs of irritation of the spinal roots appear before the moment when further manipulations can damage the structure of the spinal nerves. If it was necessary to identify the position of the needle, the spinal roots were blocked with a local anesthetic or ultrasound control, as with the ESP block. The fiber in the paravertebral space is denser than in the epidural, which will require a lot of effort. After fixing the catheter, morphine hydrochloride was injected at a dose of 8 mg in 6-8 ml of saline solution.
In the future, the scheme was as follows: premedication – atropine in normal dosages, diphenhydramine 10-20 mg, droperidol 0.05-0.1 mg / kg of weight. Introductory anesthesia and intubation are similar to group 1 patients. Anesthesia was maintained by inhalation of nitrous oxide with oxygen in a ratio of 2:1, if necessary, the hypnotic effect was potentiated by bolus administration of seduxen 0.12 mg / kg hour or ketamine at a dose of 0.7 mg / kg hour.
When using general combined anesthesia with a ventilator against the background of epidural analgesia with morphine, analgesia and vegetative protection were enhanced with fentanyl and droperidol at doses of 0.004 mg/kg hour and 0.07 mg/kg hour. When using general combined anesthesia with a ventilator against the background of paravertebral analgesia with morphine, the doses of fentanyl and droperidol were 0.005 mg / kg hour and 0.07 mg / kg hour.
Considering that cortisol levels in the blood reflect the degree of stress and are recognized as markers of stress severity, we conducted studies of the dynamics of this indicator with the Amerlight Cortisol kit. For our region, the normal concentration of cortisol in the serum of a healthy person at 9 o'clock in the morning corresponds to about 140-790 nM/l.
Serum sampling was carried out in 30 people, 10 people in each group, differing in options for anesthetic support of operations at 8 stages: stage 1 – before surgery, stage 2 – after induction into anesthesia, stage 3 after skin incision, stage 4 – the main, most traumatic, stage 5 – the end of the operation, stage 6 – 1 hour after surgery, stage 7 – a day after surgery, stage 8 – 3 days after surgery.
The calculations were carried out on the basis of the hormonal laboratory of the Road Clinical Hospital at art. Novosibirsk.
For an indirect assessment of the adequacy of anesthetic protection, we used a glucose oxidant method for determining glucose in whole blood, serum and human blood plasma with "Novogluk" kits.
Studies were conducted in 59 patients at 8 stages: stage 1 – before surgery, stage 2 – after induction into anesthesia, stage 3 – after a skin incision, stage 4 – the main, most traumatic, stage 6 – 1 hour after surgery, stage 7 – a day after surgery, stage 8 – after 3 days after the operation. That is, a total of 472 studies of blood samples were conducted in 3 groups of patients, where group 1 consisted of 22 patients, 2 – 19 patients and 3 – 18 patients.
The results and its discussion
The dynamics of cortisol content in blood plasma in patients operated in various versions of the anesthetic manual are presented in Table 1.
The analysis of the data in Table 1 shows that the initial data of cortisol concentrations in all 3 groups are in the upper limit of the norm, which indicates adaptation to emotional stress.Further, the results of the study demonstrate that in patients of the control group, plasma cortisol levels increased in the operational and postoperative periods. So at stage 2, the cortisol level was 23.4% higher than the initial one. There was a significant increase in cortisol by 36.39% at stage 3, 97.7% at stage 4, 116.7% at stage 5 and 116.57% at stage 5 above the preoperative level. Moreover, the maximal increase was noted at the 5th and 6th stages of the nearest postoperative period. 1 day after the operation, a decrease in this indicator was registered and it became 35.4% more (p<0.05) in relation to stage 1. Only on the 3rd day after surgery, the cortisol level was 366.38±23.8 nmol/l
Table 1
Dynamics of cortisol content in blood plasma at the stages
of the study in patients operated under conditions of various variants of the anesthetic manual
Nmol \ l
Groups |
Stage 1 |
Stage 2 |
Stage 3 |
Stage 4 |
Stage 5 |
Stage 6 |
Stage 7 |
Stage 8 |
1 п=10 |
458,5± 50,64 |
565,8± 27,62 |
625,4± 64,67* |
906,5± 42,92* |
993,9± 22,17* |
978,9± 23,41* |
620,9± 53,1* |
366,4± 23,79 |
2 п=10 |
565,6± 38,30 |
467,4± 40,98 |
538,5± 38,44 |
556,3± 40,58 |
523,2± 42,67 |
495,5± 59,87 |
488,3± 36,7 |
377,9± 37,14 |
3 п=10 |
535,9± 63,99 |
452,3± 53,36 |
408,5± 43,99 |
657,2± 22,34 |
560,2± 62,92 |
504,9± 57,32 |
514,9± 47,87 |
441,4± 52,68 |
*p<0.05 differences between the initial and subsequent stages are significant
In group 2 of patients, there were no significant changes in the dynamics of cortisol levels (Table 1). There was a decrease in the concentration of the hormone at stage 2 by 17.4% in comparison with the initial data. Then, during the operation (3,4,5 stages), an increase in hormone levels was noted by 15.2%, 19% and 11.9% in relation to stage 2, but they remained 4.9%, 1.64% and 7.6% below the baseline level.
After surgery (stages 6.7 and 8), there was again a decrease in the concentration of cortisol in the blood by 12.4%, 13.7% and 32.2%, respectively, in comparison with preoperative values.
When analyzing the dynamics of cortisol in the blood of patients of group 3, a decrease in the level of 25.5% and 23.8% was noted at the 2nd and 3rd stages of the study. At stages 4 and 5, the cortisol content in blood plasma increased by 22.65 and 4.53%, compared with the baseline data, but these differences were not statistically significant. Then, in the postoperative period, a decrease in the level of cortisol in blood plasma was recorded, which corresponded to a decrease in the concentration of cortisol by 5.9%, 4.0% and 24.3% compared with the 1st stage of the study (p>0.05).
Thus, the results obtained allow us to conclude that in patients with operations under general combined anesthesia against the background of extradural blockades, there are no significant shifts in the content of cortisol in blood plasma, whereas in operations performed under combined general anesthesia with ventilators and NLA preparations, the dynamics of the hormone at the study stages indicated a reliable manifestation of a stress reaction.
Studies of the dynamics of glucose in the blood were conducted in 59 patients operated on abdominal organs. The patients were divided into 3 groups depending on the anesthetic allowance. The data is presented in table 2.
Table 2
The dynamics of glucose concentration levels at the studied stages
in the conditions of various variants of the anesthesiological manual
Groups |
Stage 1 |
Stage 2 |
Stage 3 |
Stage 4 |
Stage 5 |
Stage 6 |
Stage 7 |
Stage 8 |
1 п=22 |
4,99± 0,10 |
4,79± 0,17 |
5,65± 0,15* |
7,17± 0,97* |
6,82± 0,16* |
6,84± 0,14* |
4,73± 0,21 |
4,73± 0,21 |
2 п=19 |
4,62± 0,12 |
4,75± 0,13 |
4,94± 0,12 |
6,17± 0,14* |
5,04± 0,12* |
4,95± 0,22 |
4,81± 0,10 |
4,80± 0,11 |
3 п=18 |
4,94± 0,12 |
4,64± 0,39 |
4,95± 0,39 |
6,35± 0,09* |
5,52± 0,08* |
5,10± 0,24 |
4,74± 0,07 |
4,83± 0,11 |
*p<0.05 differences between the initial and subsequent stages are significant
In group 1, postoperative analgesia was provided by systemic administration of analgesics, in group 2, postoperative analgesia was carried out by epidural analgesia with morphine, in group 3, the postoperative period was provided by paravertebral analgesia with morphine.
The data given in Table 2 inform about a constant increase in glucose levels in patients of group 1 (control). So at stage 2, the level of this indicator was already 6.6% higher than the initial one. At stage 3, there was a significant increase in the level of glycemia by 25.8%, although the average values of the level of glycemia did not exceed the upper limit of the norm. The most traumatic moment of the operation and the immediate postoperative period (stages 4.5 and 6) were characterized by hyperglycemia and it significantly exceeded the baseline data by 59.7%, 51.0% and 54.5%. Then (stages 7 and 8) there was a decrease in glucose levels, but it exceeded the value of stage 1 by 5.0%. This information confirms the opinion that under general anesthesia, surgical intervention is accompanied by excess catabolic processes and significant stress in the carbohydrate metabolism system.
The increase in blood glucose concentration in group 2 patients was recorded only at the most traumatic moment of the operation and was leveled only after its completion. The average values were 33.5% and 9.2% higher than the glucose level at stage 1 (p<0.05), although the average value did not exceed the average values of the norm. At 5,7,8 stages, there was a decrease in the concentration of glucose in the blood, but the values of these indicators remained 7.1%, 4.1% and 3.8% higher than the initial one.
In group 3 of the study, a significant increase in glucose by 28.5% and 11.7% was also recorded at stages 4 and 5 (p<0.05). In the postoperative period, the concentration of glucose in the blood decreased and was lower than the baseline level by 4.1% and 2.2%.
Thus, taking into account the dynamics of the described indicators, it can be reasonably assumed that general combined anesthesia with a ventilator in the conditions of extradural blockades provides more adequate protection against surgical aggression than traditional endotracheal anesthesia with NLA preparations, while maintaining a rational manifestation of adaptive mechanisms of adaptive exchange.
Our studies of the dynamics of the postoperative period in patients operated under conditions of different variants of combined anesthesia with a ventilator revealed more favorable reliable differences in the dynamics of responses of the pituitary-adrenal system and carbohydrate metabolism of patients operated under conditions of variants of combined general anesthesia with a ventilator against the background of extradural blockades compared with changes in similar indicators against the background of endotracheal anesthesia with NLA drugs
Conclusion
The use of paravertebral analgesia of opiates and the technology of anesthetic protection of patients with abdominal surgical interventions reduces the negative manifestations of stress reactions, which is expressed by deviations of cortisol and glucose, the values of which do not exceed the stress norm.
REFERENCES
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REFERENCES
1. Cortisol and ACTH responses to psychosocial stress are modulated by corticosteroid binding globulin levels. R. Kumsta [et al.]. Psychoneuroendocrinol. 2007 Sep-Nov. Vol. 32. No. 8/10. Pp. 1153-1157.
2. Cortisol stress response and in vivo pet imaging of human brain serotonin 1A receptor binding. L. J. Steinberg [et al.]. Int. J. Neuropsychopharmacol. 2019 May. Vol. 22. No. 5. Pp. 329-338.
3. Endocrinology. National leadership. Short edition. Edited by I.I. Dedov, G.A. Melnichenko. Moscow. GEOTAR-Media, 2011.
4. Fleisher L.A. Mythen M. Anesthetic implications of concurrent diseases. In: Miller R.D., Eriksson L., Fleisher L., et al. Miller´s Anesthesia. 8th ed. Vol. 1. Philadelphia: Elsevier Churchill Livingstone, 2015: 1172–1174.
5. Glucocorticoid response to acute stress in elderly patients with cardiovascular diseases. L. N. Argvliani [et al.]. Modern. problems of science and education [Electronic resource]. 2013.
6. Intensive therapy. National leadership. Short edition. Edited by B.R. Gelfand, I.B. Zabolotskikh. 2nd ed., reprint. and additional. Moscow. GEOTAR-Media, 2019.
7. Okorokov, A.N. Emergency endocrinology. Moscow. Med. lit., 2011.
8. Perioperative management of patients with concomitant diseases. A guide for doctors. Edited by I.B. Zabolotskikh. Moscow. Practical Medicine, 2019.
9. Yoon-Mi L., Byeng C., Kyung-Jin Y. Impact of volatile anesthetics on oxidative stress and inflammation. Biomed Res Int. 2015; 2015: 242709.
Материал поступил в редакцию 01.09.24
ДИНАМИКА КОРТИЗОЛА И ГЛЮКОЗЫ КРОВИ
НА ЭТАПАХ КОМБИНИРОВАННОЙ АНЕСТЕЗИИ
С ИВЛ И ЭКСТРАДУРАЛЬНЫМИ БЛОКАДАМИ МОРФИНОМ
В.А. Фомичев, доктор медицинских наук, профессор
Новосибирский государственный медицинский университет
(630091, Россия, Новосибирск, Красный просп., 52)
E-mail: fomichev.va@med54.ru
А.Ю. Малолетнева, кандидат медицинских наук, ассистент профессора
Новосибирский государственный медицинский университет
(630091, Россия, Новосибирск, Красный просп., 52)
E-mail: malolet67@mail.ru
А.С. Бусин, Врач- анестезиолог
Дорожная клиническая больница на ст. Новосибирск
(630003, Россия, Новосибирск, Владимировский спуск, д. 2а)
E-mail: kms.novosibirsk1989@yandex.ru
Аннотация. Показатели кортизола и глюкозы крови являются маркерами антистрессовой защиты. Определение динамики показателей кортизола и глюкозы крови для оценки адекватности анестезиологической защиты у изучаемых вариатов анестезиологических пособий. Определяли динамику кортизола и глюкозы крови у 162 больных с хирургическими заболеваниями брюшной полости при различных вариантах комбинированной общей анестезии с ИВЛ и экстрадуральными блокадами морфином в сопоставимых группах. В 1 группе (п=64) больные оперированы в условиях комбинированной общей анестезии с ИВЛ и препаратами НЛА, во 2 группе больные (п=54) оперированы на фоне комбинированной общей анестезии с ИВЛ и эпидуральной аналгезией морфином; в 3 группе больных (п=46) комбинированную общую анестезию с ИВЛ проводили в условиях паравертебральной аналгезии морфином. В группах анализировали изменения концентрации кортизола и глюкозы крови. Определено, что комбинированная общая анестезия с ИВЛ на фоне экстрадуральных блокад морфином обеспечивает большую стрессоустойчивость, чем комбинированная анестезия с ИВЛ препаратами НЛА. Выявлено, что технология анестезиологической защиты больных с абдоминальными хирургическими вмешательствами с использованием паравертебрального введения морфина не сопровождается отклонениями кортизола и глюкозы крови за пределы стресс-нормы
Ключевые слова: хирургические заболевания органов брющной полости, показатели кортизола и глюкозы крови, экстрадуральная аналгезия морфином.