Surgical stress response following hip arthroplasty regarding choice of anesthesia and postoperative analgesia

  • Mirjana L Kendrišić General Hospital Sremska Mitrovica, Department of Anesthesiology, Reanimatology and Intensive care, Sremska Mitrovica, Serbia
  • Maja Šurbatović Military Medical Academy, Clinic of Anesthesiology and Intensive Therapy, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
  • Dragan Djordjević Military Medical Academy, Clinic of Anesthesiology and Intensive Therapy, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
  • Jasna Jevdjić Clinical Center Kragujevac, Anesthesiology and Reanimation Department, Kragujevac, Serbia; University of Kragujevac, Faculty of Medical Sciences, Kragujevac, Serbia
Keywords: anesthesia, general, analgesia, spinal, conduction, intraoperative period, hydrocortisone, insulin, biological markers,


Background/Aim. Significant surgical stress response consisting of hormonal, metabolic and inflammatory changes can be initiated by the hip replacement surgery. Appropriate choice of anesthesia and postoperative analgesia should provide diminution of surgical stress response and may reduce number of perioperative complications. Surgical stress response after peripheral nerve blocks has not been studied extensively in patients who underwent hip replacement. The aim of the study was to investigate whether continuous lumbar plexus block can significantly reduce surgical stress response in comparison to other types of postoperative analgesia – continuous epidural analgesia and intravenous patient controlled analgesia (PCA) with morphine. Methods. Prospective study included 60 patients, scheduled for total hip arthroplasty. The patients were randomized into 4 groups: group CNB (central nerve block - epidural), group PNB (Peripheral nerve block - lumbar plexus block), SAM (Spinal anesthesia- PCA (anesthesia) morphine) and GAM (General anesthesia + PCA with Morphine). Serum levels of cortisol, thyroid hormones (T3, T4) and thyroid stimulating hormone (TSH), insulin, glucose and C-reactive protein (CRP) were measured in all groups – preoperatively, as well as 4 h, 12 h and 24 h after surgery. Results. The study showed that average serum cortisol levels were significantly lower 4 h after the operation in the groups where methods of regional anesthesia were performed intraoperatively (SAM, CNB, PNB); (F = 19.867; p < 0.01). Groups with postoperative continuous catheter analgesia (CNB, PNB) had significantly lower serum cortisol levels 12 h after the operation (F = 8.050; p < 0.01). The highest serum insulin levels were detected 4 h postoperatively in the CNB and PNB group, while the lowest were in the GAM group (F = 5.811; p < 0.05). Twelve hours after the operation, the lowest values of insulin were measured in the SAM group (F = 5.052; p < 0.05), while 24 h postoperatively, the lowest values were found in the SAM and GAM group (F = 6.394; p < 0.05). T3, T4 and TSH levels showed slight reduction in comparison to preoperative values without statistical significance. Blood glucose levels were significantly different among the groups 4 h after surgery with the highest values recorded in the GAM group and the lowest ones in the SAM group (F = 10.084; p < 0.01). On the other hand, 12 h after the operation significant rise in blood glucose levels was detected in the SAM group (F = 7.186; p < 0.01) Levels of CRP increased remarkably 12 h and 24 h after the surgery, but without significant difference among the groups. Conclusion. Administration of postoperative analgesia using continuous lumbar plexus block following hip arthroplasty reduces significantly stress response in comparison to postoperative PCA with morphine and has comparable effects on hormone release to epidural analgesia. Spinal anesthesia provides the best diminution of surgical stress response in the early postoperative period in comparison with other types of intraoperative analgesia.

Author Biographies

Mirjana L Kendrišić, General Hospital Sremska Mitrovica, Department of Anesthesiology, Reanimatology and Intensive care, Sremska Mitrovica, Serbia
lekar specijalista anesteziologije sa reanimatologijom
Dragan Djordjević, Military Medical Academy, Clinic of Anesthesiology and Intensive Therapy, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Clinic of Anesthesiology and Intensive therapy


Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85(1): 109−17.

Singh M. Stress response and anaesthesia. Indian J Anaesth 2003; 47(6): 427−34.

Hall GM, Peerbhoy D, Shenkin A, Parker CJ, Salmon P. Hip and knee arthroplasty: a comparison and the endocrine, metabolic and inflammatory responses. Clin Sci (Lond) 2000; 98(1): 71−9.

Sapin R, Schlienger JL. Thyroxine (T4) and tri-iodothyronine (T3) determinations: techniques and value in the assessment of thyroid function. Ann Biol Clin (Paris) 2003; 61(4): 411−20. (French)

Ljunggren S, Hahn RG, Nyström T. Insulin sensitivity and beta-cell function after carbohydrate oral loading in hip replacement surgery: a double-blind, randomised controlled clinical trial. Clin Nutr 2014; 33(3): 392−8.

Zhou Y, Liu H. Perioperative blood glucose control. Zhonghua Wei Chang Wai Ke Za Zhi 2012; 15(6): 544−5. (Chinese)

Pili-Floury S, Mitifiot F, Penfornis A, Boichut N, Tripart MH, Chris-tophe JL, et al. Glycaemic dysregulation in nondiabetic patients after major lower limb prosthetic surgery. Diabetes Metab 2009; 35(1): 43−8.

Tomás T. Patient: related risk factors for infected total arthro-plasty. Acta Chir Orthop Traumatol Cech 2008; 75(6): 451−6.(Czech)

Lattermann R, Belohlavek G, Wittmann S, Füchtmeier B, Gruber M. The anticatabolic effect of neuraxial blockade after hip surgery. Anesth Analg 2005; 101(4): 1202−8, table of contents.

Lattermann R, Carli F, Wykes L, Schricker T. Epidural blockade modifies perioperative glucose production without affecting protein catabolism. Anesthesiology 2002; 97(2): 374−81.

Yombi JC, Schwab PE, Thienpont E. Serum C-reactive protein distribution in minimally invasive total knee arthroplasty do not differ with distribution in conventional total knee arthro-plasty. PLoS One 2015; 10(4): e0124788.

Zhu F, Lee A, Chee YE. Fast-track cardiac care for adult cardiac surgical patients. Cochrane Database Syst Rev. 2012; 10: CD003587.

Ahmed J, Khan S, Lim M, Chandrasekaran TV, Macfie J. Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis 2012; 14(9): 1045−51.

Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011; 16(2): CD007635.

Rosencher N, Llau JV, Mueck W, Loewe A, Berkowitz SD, Homering M. Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin). Acta Anaesthesiol Scand 2013; 57(5): 565−72.

Højer Karlsen AP, Geisler A, Petersen PL, Mathiesen O, Dahl JB. Postoperative pain treatment after total hip arthroplasty: a sys-tematic review. Pain 2015; 156(1): 8−30.

Amiri HR, Zamani MM, Safari S. Lumbar plexus block for management of hip surgeries. Anesth Pain Med 2014; 4(3): e19407.

Martin F, Martinez V, Mazoit JX, Bouhassira D, Cherif K, Gentili ME, et al. Antiinflammatory effect of peripheral nerve blocks after knee surgery: Clinical and biologic evaluation. Anesthesi-ology 2008; 109(3): 484−90.

Luger TJ, Kammerlander C, Gosch M, Luger MF, Kammerlander-Knauer U, Roth T, et al. Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter? Oste-oporos Int 2010; 21(Suppl 4): S555−72.

Guay J, Parker MJ, Gajendragadkar PR, Kopp S. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2016; 2(22): CD000521. .

Kehlet H, Aasvang EK. Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence? F1000Res 2015; 4. pii: F1000 Faculty Rev-1449.

Hip Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK)Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ 2014; 186(1): E52−60.

Helwani MA, Avidan MS, Ben Abdallah A, Kaiser DJ, Clohisy JC, Hall BL, et al. Effects of regional versus general anesthesia on outcomes after total hip arthroplasty. Bone Joint Surg Am. 2015; 97(3): 186−93.

Capdevila X, Macaire P, Dadure C, Choquet O, Biboulet P, Ryckwaert Y, et al. Continuous psoas compartment block for postopera-tive analgesia after total hip arthroplasty: new landmarks, tech-nical guidelines, and clinical evaluation. Anesth Analg 2002; 94(6): 1606−13, table of contents.

Miller RD. Miller's anesthesia, 7th ed. Philadelphia, PA: Churchill Livingstone/Elsevier; 2010. p. 2940−3.

Kehlet H. Modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PO, editors. Neural blocked in clinical anesthesia and man-agement of pain. New York: Lippincot-Raven; 1998. p. 129−75.

Rodgers A, Walker N, Schug S, Mckee A, Kehlet H, van Zundert A, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of ran-domised trials. BMJ 2000; 321(7275): 1493.

Donatelli F, Vavassori A, Bonfanti S, Parrella P, Lorini L, Fumagalli R, et al. Epidural anesthesia and analgesia decrease the postop-erative incidence of insulin resistance in preoperative insulin-resistant subjects only. Anesth Analg 2007; 104(6): 1587−93, table of contents.

Ljungqvist O, Soop M, Hedström M. Why metabolism matters in elective orthopedic surgery: A review. Acta Orthop 2007; 78(5): 610−5.

Frisch A, Chandra P, Smiley D, Peng L, Rizzo M, Gatcliffe C, et al. Prevalence and clinical outcome of hyperglycemia in the peri-operative period in noncardiac surgery. Diabetes Care 2010; 33(8): 1783−8.

Jämsen E, Furnes O, Engesæter LB, Konttinen YT, Odgaard A, Stef-ánsdóttir A, et al. Prevention of deep infection in joint replace-ment surgery. Acta Orthop 2010; 81(6): 660−6.

Hahn RG, Ljunggren S. Preoperative insulin resistance reduces complications after hip replacement surgery in non-diabetic patients. BMC Anesthesiol 2013; 13(1): 39.

Barash PG, Cullen BF, Stoelting.R.K. Clinical Anesthesia. 5th ed. Philadelphia, USA: Lippincott Williams and Wilkins; 2009. p. 1280−2.

Schricker T, Lattermann R. Perioperative catabolism. Can J Anaesth 2015; 62(2): 182−93.

Evans CH, Lee J, Ruhlman MK. Optimal glucose management in the perioperative period. Surg Clin North Am 2015; 95(2): 337−54.

Jämsen E, Nevalainen P, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthopaedica 2015; 86(2): 175.

Velickovic I, Yan J, Gross JA. Modifying the neuroendocrine stress response. Seminars in Anaesthesia, Perioperative Medi-cine and Pain 2002; 21: 16−25.

American Diabetes Association, ADA. Diabetes Guidelines Summary Recommendations from NDEI Source. Standards of medical care in diabetes. Diabetes Care 2015; 38(1): 1−93.

Gottschalk A, Rink B, Smektala R, Piontek A, Ellger B, Gottschalk A. Spinal anesthesia protects against perioperative hypergly-cemia in patients undergoing hip arthroplasty. J Clin Anesth 2014; 26(6): 455−60.

Carli F. Physiologic considerations of Enhanced Recovery Af-ter Surgery (ERAS) programs: Implications of the stress re-sponse. Can J Anaesth 2015; 62(2): 110−9.

Larsson S, Thelander U, Friberg S. C-reactive protein (CRP) levels after elective orthopedic surgery. Clin Orthop Relat Res 1992; 275: 237−42.

Bagry H, de la Fontaine CJ, Asenjo JF, Bracco D, Carli F. Effect of a continuous peripheral nerve block on the inflammatory re-sponse in knee arthroplasty. Reg Anesth Pain Med 2008; 33(1): 17−23.

Chloropoulou P, Iatrou C, Vogiatzaki T, Kotsianidis I, Trypsianis G, Tsigalou C, et al. Epidural anesthesia followed by epidural anal-gesia produces less inflammatory response than spinal anesthesia followed by intravenous morphine analgesia in patients with total knee arthroplasty. Med Sci Monit 2013; 19: 73−80.

Original Paper