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Anesth Analg 2007;104:1587-1593
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000261506.48816.5c

REGIONAL ANESTHESIA

Epidural Anesthesia and Analgesia Decrease the Postoperative Incidence of Insulin Resistance in Preoperative Insulin-Resistant Subjects Only

Francesco Donatelli, MD*, Angelo Vavassori, MD*, Simona Bonfanti, MD*, Piervirgilio Parrella, SD*, Luca Lorini, MD*, Roberto Fumagalli, MD{dagger}, and Franco Carli, MD, MPhil{ddagger}

From the *Department of Cardiovascular Medicine, Ospedali Riuniti di Bergamo, Largo Barozzi n. 3, Bergamo, Italy; {dagger}Department of Anesthesia and Intensive Care, Università degli Studi Milano Bicocca Via Cadore 48, Monza, Italy; and {ddagger}Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada.

Address correspondence and reprint requests to Franco Carli, Department of Anesthesia, McGill University Health Centre, Cedar Avenue Room #D10.144, Montreal, Quebec, Canada 1650. Address e-mail to franco.carli{at}mcgill.ca.


   Abstract
Top
 Abstract
Introduction
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND: 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.

METHODS: 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 (µU/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.

RESULTS: 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.

CONCLUSIONS: 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.


   Introduction
Top
 Abstract
 Introduction
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Insulin resistance (IR) is a state in which normoglycemia is maintained with an elevated insulin concentration (1–3). There is a threefold increase in risk for coronary artery disease and stroke in subjects with IR when compared with individuals who have normal glucose tolerance (4–7). A state of IR has been confirmed in several different types of stress, including accidental trauma, sepsis, and burning injury (8–10). However, it is only several years later that studies on IR after surgery have been performed (11,12). These studies found that IR is a feature of the catabolic reactions after major surgery because the postoperative increase in the circulating levels of catabolic hormones increases the production of glucose and weakens its peripheral use (13–15). The greatest degree of IR has been demonstrated, although not consistently, on the second postoperative day after upper abdominal surgery, and normalization seemed to occur after approximately 3 wk (11).

It is not clear which factors predict the degree of change in IR after surgery. A previous study (12) involving patients undergoing elective abdominal surgery reported that factors such as age, body mass index, and duration of surgery had no influence on the relative increase in IR after surgery. Therefore, the change in postoperative IR is a metabolic variable influenced by the degree of the surgical trauma itself, rather than by predisposing or associated factors. In contrast, other studies found that predisposing and associated factors such as a preoperative IR state and type of anesthesia influenced glucose metabolism after surgery (16–18).

The main goal of this study was to characterize the IR state before surgery and to determine whether perioperative epidural anesthesia and analgesia, compared with general anesthesia followed by systemic morphine, influenced the state of IR after arthroplasty surgery. It was hypothesized that patients who received epidural blockade would have a lower postoperative homeostasis assessment model (HOMA) score when compared with those who did not receive epidural blockade. Patients who were insulin-resistant (RP) before surgery would also have a higher postoperative HOMA score when compared with those patients who were noninsulin-resistant (NP) before surgery.


   METHODS
Top
 Abstract
 Introduction
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients
The study was approved by the ethics committee of the Bergamo Ospedali Riuniti and informed consent was obtained from 60 consecutive patients undergoing primary elective hip or knee replacement. Exclusion criteria were history of cirrhosis, renal insufficiency, diabetes, or received any medication known to affect glucose metabolism. None of the participants had developed more than 10% weight loss over the preceding 3 mo or had a hemoglobin <100 g/L.

HOMA
The HOMA is a mathematical model which allows values for insulin sensitivity to be obtained if simultaneous fasting plasma glucose (FG) and fasting insulin (FI)/C-peptide concentrations are known (19). Because insulin secretion is pulsatile, the optimal sample should be the mean of three results at 5-min intervals (0, 5, and 10-min samples) (19). However, many researchers have used single basal samples for epidemiological studies. HOMA modeling is an appropriate method for assessing change in IR with time in individuals (20). Estimates of IR from HOMA correlate well with estimates from the euglycemic clamp which represents the "gold standard" method for measuring IR under a wide variety of circumstances (Rs = 0.88, P < 0.0001 (19), Rs = 0.85, P < 0.0001 (21). Although the coefficient of variation (CV) for HOMA was initially reported as 31% (19) using immunoreactive insulin assays, more recent studies, using specific insulin assays and many more subjects, have demonstrated CVs of between 7.8% (21) and 11.7% (22).

The HOMA score is calculated through the following mathematic formula: HOMAIR = FI x FG/22.5, where FI = fasting serum insulin (µU/mL), FG = fasting plasma glucose (mmol/L), and 22.5 is a constant. According to a previous epidemiological study (23), the mean HOMA score of subjects with a normal status of IR is below 2.1. A subject with a value more than 2.1 is considered insulin resistant.

Design of the Study
All patients who were scheduled for elective hip and knee arthroplasty were seen in the preoperative clinic and a blood sample was taken to measure FG and FI. The HOMA was then calculated and the patients were divided in two populations: RP and NP. In accordance with a previous epidemiological study (23), patients with a preoperative HOMA score less than 2.1 were NP, and patients with a preoperative HOMA score more than 2.1 were defined as RP.

Patients in each population were then randomly assigned to receive either general anesthesia with sevoflurane followed by postoperative patient-controlled analgesia (PCA) with IV morphine (control group) or epidural anesthesia followed by epidural analgesia (epidural group). Blood glucose and serum insulin were measured again at the end of surgery and 48 h after surgery after an overnight fasting when patients received either an IV infusion of NaCl 0.9% or water orally, and HOMA score was calculated. In each population, the proportion of RP patients in the recovery room and 48 h after surgery was compared between groups.

Anesthesia
In the control group, general anesthesia was induced with 5 mg/kg of thiopental and 5 µg/kg of fentanyl. Tracheal intubation was facilitated by 0.6 mg/kg rocuronium, and the lungs were ventilated to normocapnia (35–40 mm Hg) with 30% oxygen enriched with air. General anesthesia was maintained with sevoflurane at end-tidal concentrations as required to keep the heart rate within 20% of preoperative values, and boluses of 1.5 µg/kg of fentanyl were administered every 40 min. The degree of neuromuscular block was monitored using the train-of-four ratio, and supplemental doses of rocuronium were given to achieve complete surgical neuromuscular blockade throughout the surgery. In the epidural group, an epidural catheter was inserted between L2–L3 interspaces before the operation. Neuraxial blockade was established with 0.75% ropivacaine to achieve a bilateral sensory block from T10–S2 and maintained with intermittent boluses of ropivacaine 0.75%. All patients were covered with a warming blanket during surgery to maintain normothermia. IV fluid was given as NaCl 0.9% solution at a rate of 7 mL · kg–1 · h–1. Hemodynamic monitoring included a three-lead electrocardiogram monitor and noninvasive arterial blood pressure measurement.

Postoperative Analgesia
Pain intensity was assessed at rest and moving the operated limb using a visual analog scale (VAS) of 0–10 (where 0 represents no pain and 10 excruciating pain) at the end of surgery and at 7 am the first and second days after surgery. All patients received paracetamol 1 g every 8 h. Analgesia in the control group was provided PCA with IV morphine, with the following settings: bolus dose of 2 mg, lockout interval of 10 min, and maximum dose of 30 mg/h. The epidural group received a continuous epidural infusion with a mixture of 0.2% ropivacaine and 2 µg/mL fentanyl administered at a rate between 4 and 8 mL/h with supplemental top-ups of 7 mL of ropivacaine 0.2% if VAS at rest was over 3.

Sample Size and Statistical Analysis
As no data were available on the proportion of IR after epidural or general anesthesia in NP or RP, we decided to initially study 60 consecutive patients to calculate these proportions and eventually re-sample the data. Then the correct sample size to determine a difference of 20% in the proportion between groups was calculated to obtain a power of at least 80% with a P value of 0.05. After studying the first 60 patients, this number was calculated to be 8 per group for RP, whereas for NP the number to detect the same difference was calculated to be 14 per group. Because after studying the first 60 patients there were 27 RP (14 in the control group and 13 in the epidural group) and 33 NP (16 in the control group and 17 in the epidural group) there was no need to study more patients.

Data are presented as means ± sd. Differences in the proportion of perioperative IR between groups and within groups were analyzed using the {chi}2 method. Differences between groups were analyzed using the Fisher’s exact test, with Monte–Carlo analysis, and t-test for continuous data. Within-group comparison of variables was made by analysis of variance for repeated measures with post hoc analysis by Bonferroni test. A probability of P < 0.05 was considered to be significant.


   RESULTS
Top
 Abstract
 Introduction
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Characteristics of Patients
There were no differences between the two groups regarding age, weight, height, sex, and the ASA classification (Table 1). Normothermia (mean 36.1 ± 0.2°C) was maintained in all patients. Duration of surgery, estimated blood loss, amount of normal saline 0.9% administered, the number of patients receiving autologous and homologous blood transfusion, type of surgery, and insulin state before surgery were also comparable in both groups (Table 1).


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  		Table 1. Characteristics of Patients

 

Arterial Blood Pressure, Heart Rate, Oxygen Saturation, and Hematocrit
Mean arterial blood pressure, heart rate, and oxygen saturation measured before anesthesia, at the end of surgery, and 48 h after surgery were similar in both groups except for heart rate in the epidural anesthesia group which decreased and remained slower than in the control group (P < 0.05; Table 2). The hematocrit decreased in both groups when compared with preoperative values (P < 0.05; Table 2).


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  		Table 2. Arterial Blood Pressure, Heart Rate, Oxygen Saturation, and Hematocrit

 

Level of Sensory Block and Ropivacaine Consumption (Epidural Group)
The level of sensory block, recorded every 20 min after epidural injection, at the end of surgery and at 7 am on the first and second postoperative days after surgery, and intraoperative and postoperative consumption of ropivacaine 0.75% and 0.2% are presented in Table 3.


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  		Table 3. Level of Sensory Block and Ropivacaine Consumption (Epidural Group)

 

General Anesthetic Requirements (Control Group)
The mean end-tidal concentration of sevoflurane (%) measured 60 min after the beginning of surgery, mean intraoperative consumption of fentanyl (µg), and mean postoperative consumption of morphine (mg) during day 0, and postoperative days 1 and 2 are presented in Table 4.


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  		Table 4. General Anesthetic Requirement (Control Group)

 

Pain Score
There was no difference between groups in VAS at rest and during movement at any time (Table 5).


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  		Table 5. VAS

 

Glucose and Insulin Concentrations
The mean concentrations of blood glucose and plasma insulin measured before surgery, at the end of surgery and 48 h after surgery are reported in Table 6.


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  		Table 6. Glucose and Insulin Concentrations

 

The RP control group patients at the end of surgery had a larger concentration of blood glucose when compared with the epidural group and with the NP (epidural and control group) (P < 0.05). The RP patients receiving epidural anesthesia and analgesia had a lower insulin concentration at the end of surgery (P < 0.05) and 48 h after surgery (P < 0.05) compared with before surgery and with the RP control group. The NP patients receiving either epidural anesthesia and analgesia or general anesthesia followed by PCA had a similar insulin concentration throughout the entire study period.

Postoperative Variation in the Proportion of RP
In RP there was a smaller proportion of insulin-resistant patients in the epidural group when compared with the control group, 15.4% ± 10% vs 100% (P = 0.00004) and 54% ± 14% vs 93% ± 7% (P = 0.025), at the end of surgery and 48 h after surgery, respectively. The 95% CI for the difference between the proportions of epidural and control group patients were 0.66, 1.05 at the end of surgery and 0.1, 0.7 at 48 h after surgery. In contrast, in NP the proportion of patients with IR was similar in both epidural and control groups (95% CI for the difference between proportions is –0.17, 0.31 at the end of surgery and –0.30, 0.34 at 48 h after surgery) (Fig. 1 and Table 7).


Figure 150
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  		Figure 1. Proportion of insulin-resistant patients throughout the study period.

 

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  		Table 7. Proportion of Insulin-Resistant Patients and HOMA Throughout the Study Period

 

Variation in HOMA Score
RP receiving epidural anesthesia and analgesia had a lower HOMA score at the end of surgery when compared with the RP control group, 1.5 ± 0.7 vs 4.3 ± 1.2 (P < 0.001) and at 48 h after surgery 2.7 ± 0.9 vs 3.8 ± 1.1 (P < 0.05). In contrast, NP receiving either epidural anesthesia and analgesia or general anesthesia followed by PCA had a comparable HOMA score both at the end of surgery, 1.7 ± 0.8 vs 1.8 ± 0.9 (ns) and at 48 h after surgery, 2.1 ± 1.2 vs 1.9 ± 0.6 (ns) (Table 7).


   DISCUSSION
Top
 Abstract
 Introduction
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this study show that there was a significantly smaller proportion of patients with postoperative IR, measured with HOMA, in the epidural group compared with patients receiving general anesthesia and systemic morphine. This favorable effect of epidural anesthesia and analgesia on the postoperative HOMA score was evident only in those patients who had an insulin-resistant state before surgery. The proportion of RP at the end of surgery and 48 h after surgery in those subjects who were not insulin-resistant before surgery was comparable, and independent of whether they received epidural or systemic morphine. This seemed to be true in both surgical populations, hip and knee arthroplasty, that showed a similar perioperative variation in the HOMA score.

The present investigation implies that intermediary metabolism during surgery and anesthesia could be influenced depending on whether a subject is insulin-resistant or not before surgery. The reason why previous studies (18,24–26) evaluating the effect of anesthesia on protein and glucose metabolism were not able to detect major changes, may be because patients were not stratified between insulin-resistant and nonresistant.

Few studies have attempted to assess whether anesthesia influences postoperative IR. Uchida et al. (27) evaluated the effect of epidural anesthesia on postoperative IR using the hyperinsulinemic euglycemic clamp technique. It was found that, in comparison with systemic analgesia, epidural analgesia attenuated the increase in IR during the first postoperative day. The role of the preoperative IR state was not evaluated. Gouyet et al. (28) evaluated the insulin secretion in response to glucose infusion in children anesthetized with general anesthesia alone or in combination with regional anesthesia. Insulin secretion in response to glucose infusion was higher in the epidural group while blood glucose increased to the same extent in both groups. This implies that patients receiving epidural anesthesia required a higher concentration of insulin to keep the same value of blood glucose of patients receiving only general anesthesia. For this reason, the epidural group had greater IR. Attempting to make a direct comparison between the findings of the present study with those previously cited might be difficult in view of the lack of standardization of anesthesia and lack of stratification of RP versus NP in the latter studies. In addition, the method to assess IR was different in each study.

In a study evaluating IR after open or laparoscopic cholecystectmy, Thorell et al. (29) found that blood loss and the type of surgery were the only independent predictors of the degree of postoperative IR, whereas factors such as age, body mass index, duration of surgery and preoperative insulin sensitivity had no influence on the development of postoperative IR.

The present study was not intended to correlate the findings on postoperative IR with postoperative outcome as the sample of patients studied was small. In addition, it is not yet clear whether patients with preoperative IR can be at risk of developing postoperative complications. Nevertheless, there is a threefold increase in risk for coronary artery disease and stroke in nonsurgical subjects with IR compared with individuals who have normal glucose tolerance (4–7).

Attempts can be made to explain the mechanism for the effectiveness of epidural analgesia in attenuating postoperative IR in those patients who were insulin-resistant before surgery. It has been reported that RP have a highly activated sympathetic nervous system with increased levels of endogenous catecholamines (30), and one could assume that neural blockade, by successfully inhibiting the sympathetic nervous system, would modulate the development of IR. It was observed that the difference between the proportions of RP among groups is more evident at the end of surgery compared with 48 h after surgery. This difference could be explained by the more intense and extended epidural block achieved during the immediate perioperative period as shown by the slower heart rate in the epidural group.

The observed variations in the HOMA score seem to mainly reflect the modifications induced by the type of anesthesia on insulin concentrations rather than on blood glucose. As illustrated in Table 6, the insulin concentration decreased in the epidural anesthesia and analgesia group when compared with the preoperative values and in the control group, but only in RP. In contrast, blood glucose concentrations remained constant throughout the entire study period, with no difference between and within groups.

In the present study, HOMA was chosen to assess IR as it correlates well with estimates from the euglycemic clamp (Rs = 0.88, P < 0.0001, Rs = 0.85, P < 0.0001) (19,21,22). Although the latter is recognized as the gold standard method for assessing insulin sensitivity, it is time-consuming, costly and labor-intensive. HOMA has been applied in a wide variety of clinical studies and has shown good reproducibility and consistency (20,31–36).

One of the limitations of this study is related to the timing of assessment of IR. In fact, the incidence of IR has been measured 48 h after surgery, and although the second postoperative day has been reported to be associated with the greatest degree of IR after abdominal surgery, it is not known whether it can be applied to joint replacement.

In conclusion, epidural anesthesia when compared with general anesthesia decreased the incidence of IR in the immediate postoperative period only in RP undergoing hip or knee replacement. A similar effect was also observed 48 h after surgery. In contrast, in subjects who were noninsulin resistant before surgery, the use of epidural anesthesia and analgesia did not modify the incidence of IR in the perioperative period.


   Footnotes
 
Accepted for publication February 14, 2007.


   REFERENCES
Top
 Abstract
 Introduction
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press