The effects of combined epidural and general anesthesia on the autonomic nervous system and bioavailability of nitric oxide in patients undergoing laparoscopic pelvic surgery.
BACKGROUND
Pneumoperitoneum during laparoscopic surgery is known to affect visceral blood flow and result in oxidative stress. Whether epidural anesthesia will effectively reduce visceral ischemia and oxidative stress by blocking the sympathetic nervous system (SNS) during laparoscopic surgery has not been proven.


METHODS
Forty-five patients who were to undergo robot-assisted laparoscopic prostatectomy were randomly assigned to the combined general-epidural anesthesia group (group GE, n = 22) or to the general anesthesia group (group G, n = 23). Blood pressure, heart rate, and the balance between sympathetic and parasympathetic nervous system activity as measured by heart rate variability were recorded at 10 min after induction of anesthesia (T1), 60 (T2) and 120 (T3) min after intra-abdominal CO(2) insufflation, and 10 min after returning the patient to the supine position following CO(2) exsufflation (T4). Arterial blood gas analysis and blood sampling for measurements of nitrite (NO(2-)) and malondialdehyde (MDA) were performed at all time points.


RESULTS
Intraoperative mean blood pressure was significantly lower in group GE compared with group G. The low-frequency to high-frequency ratio was significantly increased after induction of pneumoperitoneum in group G but was unchanged in group GE. Plasma levels of nitrite decreased after pneumoperitoneum induction in group G while there was no change in group GE. A significant increase in MDA levels was seen in group G after pneumoperitoneum induction and were higher than group GE at T3 and T4. The 24-h urine output was higher in group GE than in group G on POD 1. The 24-h CrCl was higher in group GE on POD 1 but was not different between groups on POD 2.


CONCLUSIONS
Combined epidural and general anesthesia effectively blocks SNS stimulation during laparoscopic surgery and reduces NO inactivation and oxidative stress.
Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. skshin@yuhs.ac
Seokyung
S
Shin
Sun Joon
SJ
Bai
Koon Ho
KH
Rha
Yun
Y
So
Young Jun
YJ
Oh
D000368:Aged; D000767:Anesthesia, Epidural; D000768:Anesthesia, General; D019162:Anesthetics, Combined / Q000493:pharmacokinetics / Q000494:pharmacology*; D001341:Autonomic Nervous System / Q000187:drug effects*; D001682:Biological Availability; D001794:Blood Pressure / Q000187:drug effects; D006339:Heart Rate / Q000187:drug effects*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008315:Malondialdehyde / Q000378:metabolism; D009569:Nitric Oxide / Q000493:pharmacokinetics*; D009573:Nitrites / Q000378:metabolism; D018384:Oxidative Stress / Q000187:drug effects*; D011028:Pneumoperitoneum, Artificial; D011468:Prostatectomy / Q000379:methods; D012371:Robotics / Q000379:methods; D013564:Sympathetic Nervous System / Q000187:drug effects*
D019162:Anesthetics, Combined; D009573:Nitrites; D009569:Nitric Oxide; D008315:Malondialdehyde