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SPINAL ANESTHESIA AND THE STRESS/IMMUNE RESPONSE (CROSBI ID 278206)

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Šakić, Kata SPINAL ANESTHESIA AND THE STRESS/IMMUNE RESPONSE // Regional anesthesia and pain medicine, 40 (2015), 5; 65-67. doi: 10.1097/AAP.0000000000000308

Podaci o odgovornosti

Šakić, Kata

engleski

SPINAL ANESTHESIA AND THE STRESS/IMMUNE RESPONSE

Stress response is a significant risk factor for an unsatisfactory outcome in surgical patients. This is part of the systemic reaction to injury which encompasses a wide range of endocrinological, immunological and hematological effects (1). The reduction and modulation of stress response during the operation can significantly reduce the incidence of post- operative complications and morbidity (2). Regional anesthesia with local anesthetic agents inhibits the stress response to surgery and can also influence postoperative outcome by beneficial effects on organ function (1). Different anesthesia methods do not have the same effect on clinical outcome regarding their efficacy in suppressing this stress. A combination of the analgesic methods could be more effective while having fewer adverse effects of the anesthetics. The results of the current study suggested that spinal anesthesia plus intravenous patient-controlled analgesia have the most favorable cardiac effects regarding postoperative levels of pro-BNP (3). Spinal anesthesia administered for laparoscopic cholecystectomy alone maintained comparable hemodynamics compared to general anesthesia (GA) and did not produce any ventilatory depression. It also produced less neuroendocrine stress response as seen by reduction in the level of serum cortisol in ASA physical status I patients scheduled for laparoscopic cholecystectomy (4). Spinal anesthesia in addition to GA compared to epidural anesthesia (EA) in addition to GA may reduce postoperative morbidity in laparoscopic cholecystectomy. Intraoperative cortisol, noradrenaline and total catecholamine levels were significantly lower in the SA group compared with the EA group. When pre- and intraoperative values were compared, the SA group showed a decrease in adrenaline, noradrenaline and total catecholamine levels, and the EA group showed an increase in ACTH and noradrenaline levels (5). Another study demonstrated effectiveness of spinal anesthesia in suppressing stress response in elective surgical patients. Serum cortisol and glucose levels were significantly higher in the general anesthesia group compared to the spinal anesthesia group (p<0.01). There was a statistically significant, positive correlation between serum cortisol levels and glycemia at all times observed (p<0.01) (2). Gottschalk et al. also demonstrated in a well designed prospective, randomized controlled study that spinal anesthesia attenuates the hyperglycemic response to surgical stimuli in diabetics and nondiabetic patients (6). It is well established that normal response to stress is immunosuppressive, which seems at the first glance protective, but can be harmful in the perioperative setting if prolonged and severe (7, 8, 9). Inflammation in the surgical setting is primarily a product of the innate immune system masked by activation of blood monocytes, neutrophils and tissue macrophages, complement activation, release of proinflammatory cytokines and chemokines and upregulation of endothelial adhesion molecules. Decreased function of the adaptive immunity in the early days following surgery is often due to a decrease in total lymphocyte counts, altered T-cell subsets, diminished lymphocyte proliferation and a shift to the T-helper type 2 (Th2) cytokine profile (10, 11). The immunomodulatory effects of surgery, anesthesia and other therapy are difficult to define in a surgical patient. Danger immune patterns and pattern recognition receptors have been targets of the recent investigations. It is interesting observation that aseptic trauma primes the innate immune system for the posttraumatic release of LBP and sCD14. In a recent reported study the authors reported the physiological reactions to LBP and sCD14 after total hip replacement surgery during spinal/epidural anesthesia. IL-6 levels peaked 24 h after the operation, whereas IL-1β and IL-10 levels remained unchanged. Systemic levels of LBP were increased 24 h after surgery, whereas sCD14 remained steady. However, the dilution-corrected sCD14 values increased significantly, and the levels of both LBP and sCD14 peaked at day 3 after surgery (12). Indeed it seems that spinal anesthesia results in less immunosupression compared to general anesthesia, i.e. maintains the number of Th1 cells, thus stimulating the cell immunology. Cytokines are significant mediators of the immune response to surgery (13). Žura et al. showed on a case series an increase of pro-inflammatory cytokine IL-6 on first postoperative day after spinal anesthesia for transurethral resection of the prostate (14). Another study of the same authors on more significant number of patients confirmed surgery-related postoperative release of the pro-inflammatory cytokine IL-6 was increased in patients after spinal and general anesthesia. In addition, increased levels of the typical Th1 cytokine IL-2 were found in patients anesthetized by general anesthesia compared to spinal anesthesia. Serum concentrations of other pro- inflammatory cytokines, anti-inflammatory cytokines and cytokines which are secreted by Th1 helper lymphocytes showed no statistical difference before and after surgery under general and spinal anesthesia (15). Recent study, that evaluated the effect of epidural analgesia on postoperative pain, endocrine- metabolic and inflammatory stress response and cellular immune responses during major corrective spine surgery, demonstrated significantly less plasma levels of glucose, cortisol, CRP, IL-lβ, IL-6, IL-10 at various stages in group with epidural anesthesia (EA) compared to general anesthesia (GA). The ratio of CD4/CD8 (p=0.001) and B cells (p=0.01) have increased by postoperative day 3 in group EA compared to GA. NK-cells (CD16/56+) have decreased significantly by day 3 after surgery (p=0.001) compared to the group 2. T-lymphocytes, (CD3) have decreased in all patients, but they were significantly lower in patients receiving opioids, compared with EA. The authors concluded that EA reduces the surgical stress response, prevents postoperative lymphocyte apoptosis and thus, increases stress and infectious resistance (16). Hemostasis changes can be considered as a component of the surgical stress-response too. Liuboshevskiĭ et al. claimed that the role of intraoperative regional anesthesia was much more significant, than postoperative analgesia. Both spinal and epidural anesthesia show comparable correction of surgical stress-response markers. Also both types of regional anesthesia reduced hypercoagulation expression and prevented fibrinolysis activation. This resulted in a reduction in the hemotransfusion frequency (17). Administration of local anesthetics was designed to provide intraoperative anesthesia and analgesia. However, in recent years it has become evident and clear that regionally administrated local anesthetics have benefits far beyond anesthesia and pain relief ; indeed the technique has significant impact on outcome of major surgical procedures by modulating stress/immune response (13, 18). References 1. Desborough JP. The stress response to trauma and surgery.Br J Anaesth. 2000 ; 85(1):109–17. 2. Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD. Influence of spinal and general anesthesia on the metabolic, hormonal, and hemodynamic response in elective surgical patients. Med Sci Monit. 2014 ; 20:1833–40. doi: 10.12659/MSM.890981. 3. Mirkheshti A, Heidari Farzan M, Nasiri Y, Mottaghi K, Dabbagh A. The effect of anesthesia method on serum level of pro-brain natriuretic Peptide in patients undergoing orthopedic surgery. Anesth Pain Med. 2015 Apr 20 ; 5(2):e19707. doi: 10.5812/aapm.19707. eCollection 2015. 4. Das W, Bhattacharya S, Ghosh S, Saha S, Mallik S, Pal S. Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial. Saudi J Anaesth. 2015 Apr-Jun ; 9(2):184–8. doi: 10.4103/1658- 354X.152881. 5. Calvo-Soto P, Martínez-Contreras A, −Hernández BT, And FP, Vásquez C. Spinal-general anaesthesia decreases neuroendocrine stress response in laparoscopic cholecystectomy. J Int Med Res. 2012 ; 40(2):657–65. 6. Gottschalk A, Rink B, Smektala R, Piontek A, Ellger B, Gottschalk A. Spinal anesthesia protects against perioperative hyperglycemia in patients undergoing hip arthroplasty. J Clin Anesth. 2014 Sep ; 26(6):455–60. doi: 10.1016/j.jclinane.2014.02.001. Epub2014 Sep 8. 7. Beilin B, Shavit Y, Trabekin E, Mordashev B, Maybard E, Zeidel A, Bessler H. The effects of postoperative pain management on immune respose to surgery. Anesth Analg 2003 ; 97:822–7. 8. Schneemilch CE, Bank U. Release of pro- and anti-inflammatory cytokines during different anesthesia procedures. Anaesthesiol Reanim 2001 ; 26: 4–10. 9. Elenkov IJ, Chrousos GP. Stress hormones, pro- inflammatory and anti-inflammatory cytokines and autoimmunity. Ann N. Y. Acad Sci 2002 ; 966: 290– 303. 10. Sheeran P, Hall GM. Cytokines and anaesthesia. Brit J Anaesth 1997 ; 78: 201–19. 11. Hensler Th, Hecker H, Heeg K, Heidecke CD, Bartels H, Brthlen W, Wagner H, Siewert JR, Holzmann B. Distinct mechanisms of immunosuppression as a consequence of major surgery. Infect Immun 1997 ; 65: 2283–91. 12. Bastian D, Tamburstuen MV, Lyngstadaas SP, Reikerås O. LBP and sCD14 patterns in total hip replacement surgery performed during combined spinal/epidural anaesthesia. Scand J Clin Lab Invest. 2011 Oct ; 71(6):486–91. doi:10.3109/00365513.2011.587529. Epub 2011 Jul 4. 13. Šakić K, Žura M, Šakić L, Malenica B, Bagatin D, Šturm, D. Anaestethic technique and cytokine response . Periodicum Biologorum 2011 ; 113: 151– 156. 14. Žura M, Šakić K, Malenica B, Vrbanović V. Immune response to surgical stress in spinal anaesthesia. Periodicum Biologorum 2009 ; 111: 193- 196 15. Žura M, Kozmar A, Šakić K, Malenica B, Hrgovic Z. Effect of spinal and general anesthesia on serum concentration of pro-inflammatory and anti- inflammatory cytokines. Immunobiology. 2012 ; 217(6):622–7. doi: 10.1016/j.imbio.2011.10.018. Epub 2011 Nov 3. 16. Ezhevskaia AA, Prusakova ZhB, Maksimova LP, Sholkina MN, Balmusova EA, Ovechkin AM. Effects of epidural anesthesia on stress-induced immune supression during major corrective spine surgery. Anesteziol Reanimatol. 2014 ; 59(6):4–9. 17. Liuboshevskiĭ PA, Artamonova NI, Ovechkin AM. Haemostasis disturbances as the component of the surgical stress-response and possibilities of their correction]. Anesteziol Reanimatol. 2012 ; (3):44–8. 18. Piegeler T, Votta-Velis EG, Bakhshi FR, Mao M, Carnegie G, Bonini MG, Schwartz DE, Borgeat A, Beck-Schimmer B, Minshall RD. Endothelial barrier protection by local anesthetics: ropivacaine and lidocaine block tumor necrosis factor-α-induced endothelial cell Src activation. Anesthesiology. 2014 Jun ; 120(6):1414–28. doi: 10.1097/ALN.0000000000000174.

spinal anaesthesia ; stress

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Podaci o izdanju

40 (5)

2015.

65-67

objavljeno

1098-7339

10.1097/AAP.0000000000000308

Povezanost rada

nije evidentirano

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