Donatelli Francesco, Vavassori Angelo, Bonfanti Simona, Parrella Piervirgilio, Lorini Luca, Fumagalli Roberto, Carli Franco
Department of Cardiovascular Medicine, Ospedali Riuniti di Bergamo, Largo Barozzi n. 3, Bergamo, Italy.
Anesth Analg. 2007 Jun;104(6):1587-93, table of contents. doi: 10.1213/01.ane.0000261506.48816.5c.
Insulin resistance (IR) is a feature of the endocrine stress response to surgery. It is not known whether a preoperative state of IR would affect the postoperative endocrine response. We sought to characterize the preoperative state of IR in a group of patients undergoing elective hip and knee arthroplasty, and to determine to what extent perioperative epidural analgesia modifies the postoperative state of IR in those who are and are not insulin-resistant before surgery.
Sixty patients undergoing either hip or knee arthroplasty were screened by using the homeostatic model assessment (HOMA) in two populations: insulin-resistant patients and noninsulin-resistant patients, whereas HOMA is fasting insulin (microU/mL) x fasting glucose (mmol/L)/22.5. The patients belonging to each population were then randomly assigned to receive either intraoperative epidural blockade followed by postoperative epidural analgesia (epidural group) or general anesthesia followed by patient-controlled analgesia (control group). Analgesia was assessed with visual analog scale up to 48 h after surgery and HOMA was repeated at the end of surgery and 48 h after surgery to determine the postoperative state of IR.
Epidural anesthesia and analgesia significantly influenced the postoperative HOMA score (smaller proportion of IR) in the postoperative period only in those patients who were insulin-resistant before surgery (P < 0.01). In contrast, noninsulin-resistant patients had a similar postoperative proportion of IR between the epidural and control groups (P > 0.05). At rest and during movement, visual analog scale scores were not different between groups at the end of surgery and in the first and second days after surgery.
Epidural anesthesia and analgesia compared to general anesthesia followed by patient-controlled analgesia decreased the incidence of IR soon after surgery and 48 h after surgery only in patients who were insulin-resistant before surgery.
胰岛素抵抗（IR）是手术内分泌应激反应的一个特征。术前IR状态是否会影响术后内分泌反应尚不清楚。我们试图描述一组接受择期髋关节和膝关节置换术患者的术前IR状态，并确定围手术期硬膜外镇痛在术前有和没有胰岛素抵抗的患者中对术后IR状态的改善程度。
采用稳态模型评估（HOMA）对60例接受髋关节或膝关节置换术的患者进行筛查，分为两个群体：胰岛素抵抗患者和非胰岛素抵抗患者，HOMA计算方法为空腹胰岛素（微单位/毫升）×空腹血糖（毫摩尔/升）/22.5。然后将每个群体的患者随机分配接受术中硬膜外阻滞并术后硬膜外镇痛（硬膜外组）或全身麻醉并术后自控镇痛（对照组）。术后48小时内用视觉模拟量表评估镇痛效果，并在手术结束时和术后48小时重复测量HOMA以确定术后IR状态。
仅在术前有胰岛素抵抗的患者中，硬膜外麻醉和镇痛在术后显著影响术后HOMA评分（IR比例较小）（P<0.01）。相比之下，非胰岛素抵抗患者在硬膜外组和对照组之间的术后IR比例相似（P>0.05）。在手术结束时以及术后第一天和第二天，两组在静息和活动时的视觉模拟量表评分没有差异。
与全身麻醉并术后自控镇痛相比，硬膜外麻醉和镇痛仅在术前有胰岛素抵抗的患者中降低了术后即刻和术后48小时的IR发生率。
