硬膜外镇痛可增强接受结肠手术的2型糖尿病患者术后氨基酸的合成代谢作用。

Epidural analgesia enhances the postoperative anabolic effect of amino acids in diabetes mellitus type 2 patients undergoing colon surgery.

作者信息

Lugli Andrea Kopp, Donatelli Francesco, Schricker Thomas, Wykes Linda, Carli Franco

机构信息

Department of Anesthesia and School of Dietetics and Human Nutrition, McGill University, Montreal, Canada.

出版信息

Anesthesiology. 2008 Jun;108(6):1093-9. doi: 10.1097/ALN.0b013e3181730239.

DOI:10.1097/ALN.0b013e3181730239

PMID:18497611

Abstract

BACKGROUND

It has been suggested that diabetes mellitus type 2 amplifies the endocrine-metabolic stress response to surgery, and patients become more catabolic during the postoperative period. The aim of this study, conducted in patients with diabetes mellitus type 2 scheduled to undergo elective colorectal surgery, was to determine whether the anabolic effects of intravenous amino acids are more pronounced when receiving perioperative epidural analgesia compared with patient-controlled analgesia with intravenous morphine.

METHODS

Twelve patients were randomly assigned to receive either epidural analgesia or patient-controlled analgesia with intravenous morphine for perioperative pain control. Protein and glucose kinetics were measured before surgery and on the second postoperative day using L-[1-C]leucine and [6,6H2]glucose infusion during a fasted and a fed (amino acid infusion) state.

RESULTS

Preoperative parameters for glucose and protein kinetics were comparable in the fasted state for both groups. Postoperative amino acid infusion increased glucose concentration slightly (P = 0.124) and suppressed the endogenous rate of appearance of glucose (P < 0.0001) and glucose clearance (P < 0.0001) regardless of analgesia technique. The rate of appearance of leucine (P = 0.002), leucine oxidation (P < 0.0001), and protein synthesis (P = 0.026) increased, whereas net protein breakdown was decreased (P = 0.002), leading to a positive protein balance (P < 0.0001) in both groups. The increase in protein balance was greater in the epidural group compared with the patient-controlled analgesia group (P = 0.027).

CONCLUSION

Diabetic patients receiving an amino acid infusion after surgery achieved a positive protein balance without hyperglycemia. This anabolic effect was greater in patients receiving epidural analgesia compared with patient-controlled analgesia with intravenous morphine.

摘要

背景

有研究表明，2型糖尿病会增强手术引起的内分泌代谢应激反应，患者在术后会出现更明显的分解代谢。本研究旨在比较择期行结直肠手术的2型糖尿病患者，围手术期接受硬膜外镇痛与静脉注射吗啡自控镇痛时，静脉输注氨基酸的合成代谢作用是否更显著。

方法

12例患者随机分为两组，分别接受硬膜外镇痛或静脉注射吗啡自控镇痛以控制围手术期疼痛。在术前及术后第2天，于禁食和进食（输注氨基酸）状态下，通过输注L-[1-C]亮氨酸和[6,6H2]葡萄糖测定蛋白质和葡萄糖动力学。

结果

两组患者在禁食状态下，术前葡萄糖和蛋白质动力学参数相当。术后输注氨基酸，无论采用何种镇痛技术，均可使血糖浓度略有升高（P = 0.124），并抑制葡萄糖的内源性生成率（P < 0.0001）及葡萄糖清除率（P < 0.0001）。亮氨酸生成率（P = 0.002）、亮氨酸氧化率（P < 0.0001）和蛋白质合成率（P = 0.026）均升高，而蛋白质净分解率降低（P = 0.002）；两组患者均出现正性蛋白质平衡（P < 0.0001）。与静脉注射吗啡自控镇痛组相比，硬膜外镇痛组蛋白质平衡的增加更为显著（P = 0.027）。