Nusa TUNA, Metin TUNA, Demet KOCA, Şebnem ATICI, Anış ARIBOĞAN, Geylan IŞIK

İntrakraniyal cerrahide kullanılan anestezi yöntemlerinin immün-enflamatuar yanıt üzerine etkileri

Bu çalışmada intrakraniyal cerrahi uygulanan olgularda, propofol-fentanil ile intravenöz anestezi (İVA) ve izofluran veya sevofluran ile fentanilden oluşan dengeli anestezi tekniklerinin organizmanın immun-enflamatuar yanıtı üzerine etkilerinin araştırılması amaçlandı. Etik kurul onayı alındıktan sonra, intrakraniyal cerrahi uygulanacak ASA-I grubu 30 olgu çalışma kapsamına alındı. Anestezi indüksiyonu tüm olgularda; intravenöz fentanil (1.5 µg.kg-1) ve propofol (2.5-3 mg kg-1) ile sağlandı. Endotrakeal entübasyonun ardından 3 eşit gruba ayrılan olgularda anestezi; I. Grupta (n=10) 4-5 mgkg-1dk-1 propofol ve 3 µg kg-1 dk-1 fentanil ile IVA şeklinde, H. grupta (n=10) 0.5-1 MAC değerinde izofluran ve 45 dk'da bir 0.1 mg fentanil ile, III. grupta (n=10) 0.5-1 MAC değerinde sevofluran ve 45 dk'da bir 0.1 mg fentanil ile sürdürüldü. Anestezi indüksiyonundan 10 dakika önce (I. dönem), anestezi indüksiyonundan 1 saat sonra (II. dönem), postoperatif 3. saatte (III. dönem) ve postoperatif 3. günde (IV. dönem) serum TNF-α, IL-1-α, IL-6 ve IL-8 değerleri saptandı. TNF-α, IL-1-α, IL-6 ve IL-8 düzeylerinde saptanan değişiklikler; ne gruplar arasında ne de dönemler arasında anlamlı bir farklılık göstermedi. Sonuç olarak; intrakraniyal girişimlerde IVA ve izofluran/sevofluran-fentanil ile dengeli anestezi tekniklerinin organizmanın immun-enflamatuar yanıtını önemli derecede etkilemedikleri, immün etkilenim ve postoperatif enfeksiyon riski düşünüldüğünde her üç yöntemin de birbirlerine üstünlük göstermediği kanısına varıldı.

Anahtar Kelimeler:

Fentanil, Sitokinler, İzofluran, Propofol, Enflamasyon, Kraniyotomi, Anestezikler, Anestezi, ven içi, Cerrahi işlemler, operatif

The effects of neurosurgical anesthetic methods on immune response

The aim of this study was to assess the different effects of intravenous anaesthesia (IVA) with propofol and balanced anesthesia with isoflurane/sevoflurahe-fentanyl on the immune inflammatory response of neurosurgical patients. Following approval of the ethics committee 30 ASA I patients scheduled to undergo intracranial surgery were included in the study. Anesthesia was induced with iv fentanyl (1.5 µkg-1) and propofol (3 mg kg-1) in all patients. After endotracheal intubation, patients were divided into three equal groups. In Group I anesthesia was maintained by iv anaesthesia (4-5 mg kg-1 min-1 propofol and 3µg kg-1 min-1 fentanyl infusion), in Group II by MAC 0.5-1 isoflurane and 0.1 mg fentanyl in every 45 min and in Group III by MAC 0.5-1 sevoflurane and 0.1 mg fentanyl in every 45 min. Plasma TNF-α, IL-1α, IL-6 and IL-8 were determined 10 minutes before induction (I), 1 hour after induction (II), at the 3rd postoperative hour (III) and 3rd postoperative day (IV). No significant difference was found in the levels of TNF-α, IL-1-α, IL-6 and IL-8 among and within the groups throughout the study. We concluded that IVA and balanced anesthesia with isoflurane/sevoflurane-fentanyl did not affect immune-inflammatory response significantly. One method is not superior to another in the basis of immune effect and all three methods may be used safely in case of taking infection risk into consideration.

Keywords:

Fentanyl, Cytokines, Isoflurane, Propofol, Inflammation, Craniotomy, Anesthetics, Anesthesia, Intravenous, Surgical Procedures, Operative,

___

1. Blomstedt GC. Infections in neurosurgery: A retrospective study of 1143 patients and 1517 operations. Acta Neurochir (Wien) 1985: 78: 81-90.
2. Polk HC Jr. Consensus summary on infection. J Trauma 1979; 19:894-6.
3. Asadullah K. Woiciechowsky C, Döcke W. Immunodepression following neurosurgical procedures. Crit Care Med 1995 ; 23: 1976-82.
4. Schmand J, Ayala A, Chaudry I. Effects of trauma, duration of hypotension, and resuscitation regimen on cellular immunity after hemorrhagic shock. Crit Care Med 1994 ; 22: 1076-81.
5. Barth J, Petermann W, Entzian P, et al. Modulation of oxygen-free radicals from human leukocytes during halotane- and en-flurane-induced general anaesthesia. Acta Anaesthesiol Scand 1987; 31: 740-3.
6. Cullen BF, van Belle G. Lymphocyte transformation and changes in leukocyte count: Effects of anesthesia and operation. Anesthesiology 1975: 43: 563-9.
7. Duncan PG, Cullen BF, Calverly R, et al. Failure of enflurane and halotane anesthesia to inhibit lymphocyte transformation in volunteers. Anesthesiology 1976; 45: 661-5.
8. Eskola J, Salo M, Viljanen MK, et al. Impaired B lymphocyte function during open heart surgery; Effects of anaesthesia and surgery. Br J Anaesth 1984; 56: 333-7.
9. Koenig A, Koenig UD, Heicappel R, et al. Differences in lymphocyte mitogenic stimulation pattern depending on anaesthesia and operative trauma: I. Halothane-nitrous oxide anesthesia. Eur J Anaesthesiol 1987; 4: 17-24.
10. Stevenson GW, Hall SC, Rudnick S, et al. The effect of anesthetic agents on the human immun response. Anesthesiology 1990: 72; 542-52.
11. Brodsky JB. Toxicity of Nitrous Oxide. In: Eger E, (ed.) Nitrous 0xide/N20, New York, Elsevier Sciense Publishing Company Inc 1985; 259-262.
12. Hisatomi K, Isomura T. Kawara T, et al. Changes in lymphocyte subsets, mitogen responsiveness, and interleukin-2 production after cardiac operations. J Thorae Cardiovasc Surg 1989;98:580-91.
13. Salo M. Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand 1992: 36: 201-20.
14. Bauer M, Rensing H, Ziegenfuss T. Anesthesia and perioperative immune function. Anaesthesist 1998;47:538-56.
15. Stanley TH, Hill GE, Portas MR. et al. Neutrophil chemotaxis during and after general anesthesia and operation. Anesth Analg 1976;55:668-73.
16. Hole A, Unsgaard G. The effect of epidural and general anaesthesia on lymphocyte functions during and after major orthopaedic surgery. Acta Anaesthesiol Scand 1983; 27:135-41.
17. Hoch RC, Rodriguez R, Manning T, et al. Effects of accidental trauma on cvtokine and endotoxin production. Crit Care Med 1993;21:839-45.
18. Shapiro L, Gelfand JA. Cytokines and sepsis, pathophysiology and therapy. New Horizons 1993; 1: 13-22.
19. Blalock JE. The syntax of immune-neuroendocrine communication. Immunol Today 1994;15:504-11.
20. Crozier TA, Muller JE. Effect of anaesthesia on the cytocine responses to abdominal surgery. Br J Anaesth. 1994 ; 72: 280-5.
21. Prittigangas CO, Salo M. The influence of anaesthetic technique upon the immune response to hysterectomy. A comparison of propofol infusion and isoflurane. Anaesthesia 1995 ; 50: 1056-61.
22. Brand JM, Kirchner H, Poppe C, Schmucker P. Cytokine release and changes in mononuclear cells in peripheral blood under the influence of general anaesthesia. Anaesthesist 1998; 47: 379-86.