Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique

Abstract

The influence of epidural neural blockade on postoperative insulin resistance was studied using the euglycaemic insulin clamp technique. Eighteen patients undergoing elective upper abdominal surgery of moderate severity were allocated to two groups: group G patients underwent operation under general anaesthesia, and postoperative pain was relieved by systemic administration of analgesia; and group E patients received epidural analgesia during surgery and epidural morphine postoperatively. In each patient the euglycaemic insulin clamp test was performed twice: several days before surgery and on postoperative day 1. Peroperative catecholamine and cortisol responses were also measured to investigate possible endocrine mechanisms of the insulin resistance. Glucose disposal (M) decreased in both groups on postoperative day 1 at plasma insulin concentrations ranging from 1.2 to 10.0 milliunits ml-1, resulting in the downward shift of dose-response curves. However, this downward shift was significantly smaller in group E than in group G patients. Urinary adrenaline excretion increased markedly on the day of operation in group G, but was significantly inhibited in group E. Urinary noradrenaline excretion increased mainly on postoperative day 1 in group G, but was significantly inhibited in group E. Plasma cortisol response was lower in group E than in group G during and shortly after operation, and was significantly inhibited in group E on postoperative day 1. These results indicate that insulin resistance after elective abdominal surgery is due to a postreceptor deficit in glucose utilization, as indicated by the downward shift of the dose-response curves. This disturbance in glucose metabolism was reduced by epidural analgesia, the results being associated with inhibited catecholamine and cortisol responses.

Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

“…Using low-dose concentrations of local anaesthetic combined with a short-acting opiate appears to offer the best combination of analgesia while minimising the risk of motor block and hypotension due to sympathetic blockade. Several meta-analyses have shown improved outcomes with TEA compared with opioid-based analgesia, including pain, complications, PONV and insulin resistance [81][82][83][84][85]. Hypotension induced by sympathetic block should be treated with vasopressors provided the patient is not hypovolaemic.…”

Physiologic considerations of Enhanced Recovery After Surgery (ERAS) programs: implications of the stress response

“…Neural blockade (epidural or spinal) with local anesthetics initiated before surgery and continued after surgery has shown to decrease the level of intra and postoperative insulin resistance. 31 This is probably related to the attenuation of hormonal response (cortisol and epinephrine) and, to a lesser degree, inflammatory response. No impact on insulin resistance has been shown by systemic opioids, while available data are lacking on the use of nonsteroidal anti-inflammatory drugs (NSAIDs), betablockers, alpha-2 agonists, or intravenous lidocaine.…”

“…31,34,54 The addition of nutritional supplementation while receiving postoperative neuraxial analgesia promotes protein synthesis and improves postoperative protein balance. 55 Maintaining a patient's normothermic state during surgery has been shown to attenuate the perioperative release of catecholamines 56 and decrease loss of body nitrogen.…”

Perioperative catabolism

“…It has been linked primarily to the invasiveness of surgery. 24,25 Other factors may also contribute, such as the duration of trauma, 26 bed rest and immobilization, 27 type of anesthesia and analgesia, 28,29 nutrition and preoperative fasting, 30,31 blood loss, 25 physical status, and post-surgery rehabilitation. 32 …”