Izbor anestezije i postoperativne analgezije i sistemski odgovor na hirurški stres nakon aloartroplastike kuka
Sažetak
Uvod/ Cilj. Zamena totalne proteze kuka može izazvati značajan sistemski odgovor na hirurški stres, koji uključuje hormonske, metaboličke i zapaljenske promene. Odgovarajući izbor anestezije i postoperativne analgezije bi trebalo da obezbedi slabljenje ovog odgovora i da utiče na smanjenje broja postoperativnih komplikacija. Istraživanja u oblasti sistemskog odgovora na hirurški stres, kod bolesnika kod kojih je primenjen periferni nervni blok nakon ugradnje totalne proteze kuka, nisu brojna. Cilj studije bio je da se ispita da li kontinuirani blok lumbalnog pleksusa može značajno da umanji sistemski odgovor na hirurški stres u poređenju sa drugim vrstama postoperativne analgezije – kontinuiranom epiduralnom analgezijom i intravenskom PKA (pacijent kontrolisanom analgezijom) morfinom. Metode. U prospektivnu studiju bilo je uključeno 60 bolesnika, predviđenih za aloartroplastiku kuka. Bolesnici su bili raspoređeni u četiri grupe u zavisnosti od primenjene vrste anestezije i postoperativne analgezije: grupa CNB (centralni neuroblok - epidural), grupa PNB (periferni neuroblok - blok lumbalnog pleksusa), SAM grupa (spinalna anestezija + PKA morfinom) i OAM (opšta anestezija + PKA morfin). Vrednosti kortizola, tiroidnih hormona (T3, T4) i tiroidni stimulišući hormon (TSH), kao i vrednosti insulina, glukoze i C-reaktivnog proteina (CRP) u serumu merene su kod svih grupa, 4 h, 12 h i 24 h u serumu nakon operacije. Rezultati. Istraživanje je pokazalo da su prosečne vrednosti kortizola u serumu bile značajno niže 4 h postoperativno u grupama gde je intraoperativno primenjena regionalna anestezija (SAM, CNB, PNB), (F = 19.867; p < 0.01). U grupama u kojima je primenjena kontinuirana analgezija preko katetera (CNB, PNB), nivo kortizola u serumu bio je značajno niži 12 h posle operacije; (F = 8.050; p < 0.01). Najveći porast nivoa insulina u serumu detektovan je 4 h postoperativno u grupama CNB i PNB, a najmanji u grupi OAM; (F = 5.811; p < 0.05). Dvanaest sati nakon operacije, najniže vrednosti insulina izmerene su u grupi SAM; (F = 5.052; p < 0.05), dok su nakon 24 h njegove najniže vrednosti bile u grupama SAM i GAM, (F = 6.394; p < 0.05). Nivoi T3, T4 i TSH bili su blago sniženi u odnosu na preoperativne vrednosti, 4 h, 12 h i 24 h nakon operacije. Vrednosti glikemije su se statistički značajno razlikovale među grupama, 4 h posle operacije, a najviše vrednosti su zabeležene u grupi OAM, dok su najniže bile u grupi SAM; (F = 10.084; p < 0.01). Nasuprot tome, 12 h nakon operacije, značajan porast u nivou glukoze u serumu detektovan je u grupi SAM, (F = 7.186; p < 0.01). Vrednosti CRP-a su primetno rasle 12 h i 24 h postoperativno, ali bez statistički značajne razlike između grupa. Zaključak. Primena kontinuiranog bloka lumbalnog pleksusa nakon aloartroplastike kuka značajno smanjuje sistemski odgovor na stres u poređenju sa postoperativnom PKA morfinom i po hormonskom odgovoru može se porediti sa epiduralnom analgezijom. Spinalna anestezija obezbeđuje najveće smanjenje sistemskog odgovora na hirurški stres u ranom postoperativnom periodu u poređenju sa drugim vrstama anestezije.
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