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EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON CARBOHYDRATE AND FAT METABOLISM IN MAN
Brit. J. Anaesth. (1970), 42, 723
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON CARBOHYDRATE AND FAT METABOLISM IN MAN BY
T. OYAMA AND A. MATSUKI SUMMARY
The present study was undertaken to investigate the effects of spinal anaesthesia and surgery on carbohydrate and fat metabolism, by measuring their influences on plasma human growth hormone, insulin, free fatty adds and blood glucose levels. Human growth hormone (HGH) of the anterior pituitary gland is known to be related not only to growth but also to the metabolism of glucose, fat and protein. Large rises in plasma HGH concentration have recently been reported during surgical stress (Glick et al., 1965; Ketterer, Powell and Unger, 1966; Schalch, 1967; Charters, Odell and Thompson, 1969; Oyama and Takiguchi, 1970). Furthermore, participation of HGH in the metabolic responses to acute stress has been suggested by Schalch (1967).
TABLE I
Patients studied and operations performed in the quatacame group.
DuraPerformed Case Age Sex
1 2
34 27
F
3 4
28 27 16 19 23 46 20 32 28 26
M M M M F F F F F F
5 6 7 8 9 10 11 12
F
operation
Operation time (hr min)
40 Tubal sterilization Removal of abdominal lipoma 40 Appendkcctomy 1 10 Hemiorrhaphy 20 Appeadicectomy 45 Appendicectomy 35 Cervical suture 20 Haemorrhoidectomy 30 Appendicectomy 40 Isthomorrhaphy 25 Caesarean section 55 Simple hysterectomy 1 00
tion of analgesia 1 40 1 1 1 2 2 1 1 1 1 1 1
20 30 50 20 00 50 30 30 10 30 50
MATERIAL AND METHOD
Thirty patients, ranging in age from 16 to 62 years were the subjects of the study. All patients underwent elective operations (tables I, II) except for six subjects who underwent neither spinal anaesthesia nor surgery and served as controls. No patient was included who had hepatic, renal, endocrine or cardiovascular disease. Normal saline 500 ml was infused during the entire procedure and blood was transfused to replace the loss if this exceeded 500 ml due to surgery. No patients received premedication. Spinal anaesthesia was performed between 1 and 3 pjn.
Spinal puncture was made at the level of L3-4 or L4-5 with a No. 20-21 needle, the patient being in the right lateral position. The new local anaesthetic quatacaine* was used in twelve patients. A 3 per cent solution was used, 200 mg being diluted in 6.7 ml of 10 per cent glucose. The specific gravity is 1.040 ±0.003. In addition lignocaine (3 per cent solution, sp.gr. 1.030 ±0.003) was employed for twelve patients. No adrenaline was added to these agents. The duration of analgesia and type of surgery are
TSUTOMU
* Tanacaine (Tanabe Pharmaceutical Company)=2methyl-2-n-propyiaminopropion-O-toluide hydrochloride. It is similar to lignocaine in potency and duration of action.
OYAMA,
MX>.; AKITOMO
MATSUKI, MJ>.;
Department of Anaesthesia, Hirosaki University School of Medicine, Hirosaki, Aomori-Ken, Japan.
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The effects of spinal anaesthesia and surgery on carbohydrate and fat metabolism were studied in thirty patients by determining plasma concentrations of human growth hormone (HGH), insulin, blood glucose and free fatty acids (FFA). Hyperbaric spinal anaesthesia with lignocaine or quatacaiae alone and subsequent surgery did not influence the plasma HGH, insulin or FFA levels. Mean blood glucose levels were elevated significantly during spinal anaesthesia and surgery, but remained within the normal range.
724
BRITISH JOURNAL OF ANAESTHESIA TABLE II
Determinations of plasma growth hormone (HGH) were made according to the method of Schalch and Parker (1964). The analysis of plasma Dura- insulin was made after the method of Morgan Opera- tion and Lazarow (1963). These double antibody tion of time anal- methods were based on the principle of radio(hr min) gesia immunoassay utlizing 125 I. Duplicate determina45 1 50 tions were made on all specimens and the mean 40 1 50 values were taken. The recovery rate for HGH 45 2 20 and insulin was 98 per cent and 94 per cent res55 1 20 30 2 00 pectively by our method, which indicates reliable 25 1 00 analysis. The blood glucose was measured by the 00 2 00 15 1 30 method of Somogyi (1952), and plasma FFA was 55 2 40 determined by colorimetric method of Duncombe 45 1 00 (1963).
Patients studied and operations performed in the lignocaine group.
M F F F M M F M F F M F
40
1 00
20
1 40
shown in tables I and II. The average dose of quatacaine was 75 mg (2.5 ml), the average duration of analgesia was 105, SEM 5.1 min, and the average level of analgesia was T9. The mean operating time was 40 ±4.3 min in the case of lignocaine the mean dose was 38 mg (2.6 ml), the average duration of analgesia was 100 ±8.9 min and the mean upper level of analgesia was T9. The average operating time was 44 ±5.5 min. There was no significant difference between these parameters in both groups. The level of analgesia was checked by pinprick. The analgesia time was taken as a time between the start of spinal injection and the disappearance of analgesia over the right L5 region, which was checked every 10 min Blood was sampled at the following times: (1) in the afternoon 10 min before starting spinal anaesthesia; (2) 10 min after establishing spinal anaesthesia but before surgery; (3) 15 min after the stan of surgery; and (4) 3i hours after the start of spinal anaesthesia. On each occasion 5 ml of venous blood was collected in a heparinized syringe, rapidly transferred to a tube, then centrifuged within 30 min of collection. One ml of each plasma sample was stored at - 2 0 ° C and thawed within one month just prior to radioimmunoassay for growth hormone and insulin. One ml of plasma was stored at 4°C for analysis of FFA [=free fatty acid = nonesterified fatty acids (NEFA)], and 0.2 ml of blood was used to measure blood glucose.
RESULTS
Plasma growth hormone. The mean growth hormone (HGH) levels in plasma in the six control patients are shown in table HI and figure 1. The mean value was 1.87 ng/ml at 1 pjn., and varied insignificantly from 2.70 ng/ml at 1.20 pjn. to 3.1 ng/ml at 6 p.m. The average HGH level in plasma in the
c "5 to
—.
-
E
I!1
30 20
8
36 26 26 31 55 61 27 62 23 34 24 20
50
150
*< 100 13.00pm
13.20pm
13.40pm
18.00pm
1 Plasma levels of HGH, insulin, FFA and blood glucose in the control group. FIG.
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1 2 3 4 5 6 7 8 9 10 11 12
Performed operation Removal of testicle Tubal sterilization Caesarean section Tubal sterilization Removal of testicle T.U.R. Caesarean section Herniorrhaphy Appendicectomy Tubal sterilization Appendicectomy Removal of vaginal polyp
Blood Sugar (mg/1 00ml)
Case Age Sex
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM T A B U III
Plasma levels of HGH, insulin, glucose and FFA in the control group. Case No. HGH (ng/ml)
Insulin
M SE P Glucose (mg/ 100 ml)
M SE P FFA (m.equiv/1.)
M SE P %
1.20 p.m.
1.3 2.3 1.3 2.3 1.0 3.0
4.3 2.3 2.0 2.3 1.3 4.0
1.87 0.29
2.70 0.44 0.131
1.40 pjn. 18.0 1.7 1.0 1.3 2.0 3.3 4.55 2.47 0.385
6.00 pjn. 4.0 2.0 3.7 2.0 4.0 3.0
3.11 0.35 0.11
16.7 21.7 21.7 16.7 71.7 21.7
15.0 23.3 26.7 20.0 63.3 38.3
15.0 18.3 10.0 3.3 48.3 38.3
18.3 20.0 16.7 30.0 41.7 16.7
28.4 7.96
31.1 6.56 0.455
22.2 6.48 0.317
23.9 3.74 0.477
87.0 92.0 75.0 74.0 80.0 99.0
69.0 65.0 97.0 83.0 82.0 85.0
66.0 68.0 91.0 79.0 62.0 85.0
58.0 62.0 90.0 65.0 69.0 66.0
84.5 3.7
80.2 4.23 0.590
75.2 4 32 0.215
683 4.19 0.08
0.378 0.203 0.243 0.162 0.269 0.217
0.473 0.276 0.149 0.081 0.252 0.217
0.359 0.243 0.095 0.068 0.241 0.113
0.245 0.028
0.241 0.050 0.904 98.4
100
start of spinal anaesthesia respectively. The values did not differ significantly from pre-spinal control levels. Plasma insulin. The mean plasma insulin level in the control group (table IE and fig. 1) varied insignificantly from 28.4 to 23.9 /xU/ml. The plasma insulin level in the quatacaine and lignocaine groups did not change significantly during spinal anaesthesia or operation (table V and figs. 2 and 3).
11
n- * a. _i £ 3
20
»
10
=
0.541 0.230 0.176 0.095 0.209 0.390
0.186 0273 0.042 0.060 0.572 0.090 111.4 75.9
quatacaine group is shown in table IV and figure 2. The control pre-spinal value was 4.6 ng/ml. It was 5.8 ng/ml 10 min after the start of spinal anaesthesia, 4.0 ng/ml 15 min after the start of operation, and 5.2 ng/ml 3i hours after the start of spinal anaesthesia. Plasma HGH levels in the lignocaine group are shown in table IV and figure 3. The prespinal control level was 4.0 ng/ml. Ten minutes after the start of spinal anaesthesia it was 4.5 ng/ml and 3.2 ng/ml and 4.7 ng/ml 15 min after the start of operation and 3J hours after the
Pre-SAB
SAB 10' Ope 15' Time In minutes
SAB 210'
FIG. 2 Plasma levels of HGH, insulin, FFA and blood glucose in the quatacaine group during spinal anaesthesia.
Blood glucose. The mean blood glucose level in the control group decreased insignificantly from 84.5 to 68.3 mg/100 ml. The mean levels in both quatacaine and lignocaine groups were significantly raised (by 8.4 and 2.7 mg/100 ml) during spinal anaesthesia alone and during operation (by 14.5 and 9.9 mg/100 ml) (table VI and figs. 2 and 3).
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M SE P
1.00 pjn.
725
BRITISH JOURNAL OF ANAESTHESIA
726 TABLE
IV
Plasma levels of HGH (.ng/ml) during spinal anaesthesia (SAB) and surgery (Op). Group Quatacaine
1 2 3 4 5 6 7 8 9 10 11 12
PreSAB 2.0 3.7
SAB 10 min 1.0 2.0
2.3 9.3 3.7 4.0 6.0 6.7
18.7 2.3 8.3 9.3 9.7 0.7 2.0 3.3 9.0 3.7
2.7 4.0 4.7 3,8
12.3
M SE P
4.6 0.9
5.8 1.5
4.0 0.7
5.2 1.9
0.342
0.325
0.856
1 2 3 4 5 6 7 8 9 10 11 12
6.7 4.7 2.7 2.7 1.0 3.0 2.0 2.3 3.7 3.0
5.0 2.0 2.3 2.0 4.7 1.7 8.3 10 1.7 1.7 5.3 2.3
2.0 3.0 2.3 2.0 2.3 1.7 3.0
M SE P
14.0 2.3 4.0 1.0
2.0 3.0 2.0 2.0 1.7
2.0 1.3 1.7 2.7 11.0 2.7 4.5 1.7 0.735
•
0.5 3.7 1.0 9.3 6.0 1.0 2.0 1.0
9.0 2.0 8.0 1.3 9.3 1.7 3.0 3.3 9.0 4.7
21.7
(0
SAB Op 15 min 210 min 23.0 0.5
0.5
1.3 2.0
18.3 2.7 1.7
15.0 2.3
3.2 0.6
4.7 1.6
0.432
0.650
Blood FFA. The mean values in the control group did not change significantly. In both the quatacaine and lignocaine groups there were slight increases after 10 minutes of spinal anaesthesia alone (table VII and figs. 2 and 3), but gradual declines during and after operation. These changes were not significantly different from control pre-spinal levels. DISCUSSION
The present study did not demonstrate any significant influence of spinal anaesthesia alone on plasma HGH level in either the quatacaine or the lignocaine group. The short duration of study (10 min) of spinal anaesthesia alone might in pan account for this finding. Under the influence of spinal anaesthesia also, the plasma HGH levels did not rise significantly during operation or postoperatively. This is in contrast to the effect of
20 10
w>
f-
1
IT"
8
E100
3
O
—
o
_ _ i > 50 120 100 80 Pr«-SAB
SAB 10'
Ope 1 5'
SAB 210'
Time In minutes FIG. 3 Plasma levels of HGH, insulin, FFA and blood glucose in the lignocaine group during spinal anaesthesia.
surgical stress under general anaesthesia which usually elevates blood HGH levels markedly (Glick et al., 1965; Ketterer, Powell and Unger, 1966; Ross et aL, 1966; Schalch, 1967; Charters, Odell and Thompson, 1969; Oyama and Takiguchi, 1970). Spinal anaesthesia appears to depress the elevation of blood HGH caused by surgical stress. There are few reports on the effect of spinal anaesthesia on plasma HGH and insulin levels. Charters, Odell and Thompson (1969) reported a case of nailing for fractured femur. The plasma HGH level increased from a control value of 2.7 to 6.2 and 36.0 ng/ml 30 minutes and 1 hour respectively after the start of operation, but they did not separate the effect of spinal anaesthesia alone. Glick and associates (1965) observed an increase of HGH in four patients during operation under spinal anaesthesia, but again did not study the effect of spinal anaesthesia alone. Growth hormone is an anabolic hormone which increases uptake and synthesis of amino acids. It also has diabetogenic and anti-insulin effects
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Lignocaine
Case No.
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM
727
TABLE V
TABLE VI
Plasma levels of insulin (jiU/mJ) during spinal anaesthesia {SAB) and surgery (Op).
Blood levels of glucose (mg/100 ml) during spinal anaesthesia (SAB) and surgery (Op).
Group Quatacaine
PreSAB
lOmin
1 2 3 4 5 6 7 8 9 in 11 12 M SE P
21.5 23.3 7.2 13 7 2.3 13.7 22.3 13.8 50 14 5.9 3.9
24.1 20.3 10.0 11 1 11.7 10.9 18.2 20.0 3.9 15 6.1 4.4
25.0 20.1 2.5 18 5.0 12.4 21.8 20.0 8.3 28 4.8 17.6
11.2 2.2
11.9 2.0 0 568
11.8 2.4 0.716
1 2 3 4 5 6 7 3
8.3 18.3 83 20 0 100 3.3 5.0 50
11.5 5.0 16 7 23.3 11 7 8.3 10.0 33 13.3 6.7 6.7
8.3 13.0 28 3 23.0 67 10.0 8.3 33
9
10 11 12
M SE P
83
6.7 67 11.7 9.3 1.4
SAB
8.3
10.4 1.5 0.511
Op
SAB
15 min 210 min
4.0
8.3 7.0 11.9 11.0 2.1 0.396
21.1 18.5 9.5 19 13.3 13.3 18.9 23.9 7.0 13 2.3 7.3 11.6 2.2 0.829 11.5 13.0 11 7 11.7 10 0 5.0 13.3 36 11.7 4.0 4.0 10.8 9.2 1.1 0.935
which enhance the mobilization of fatty acids from adipose tissue and increases FFA in blood. Growth hormone is also considered to be one of the "stress hormones". Plasma insulin levels were not changed during spinal anaesthesia, surgery or the postoperative period. Similar observations were made during operation under general anaesthesia (Glick et al., 1965; Charters, Odell and Thompson, 1969). Although in the present study blood glucose levels increased significantly during spinal anaesthesia alone and during surgery, they were within the normal range (80-100 mg/100 ml). This is in contrast to the marked hyperglycaemic influence of surgical stress under general anaesthesia (Bunker, 1963). Annamundiodo, Keating and Patrick (1958) observed that during spinal anaeschesia with hyperbaric cinchocaine the blood glucose level or muscle glycogen content did not
Group Quatacaine
Lignocaine
Case
Pre-
SAB
No.
SAB
10 min 90.0 68.0 87.0 70.0 84.0 72.0 68.0 74.0 150.0 71.0 105.0 86.0
1 75.0 2 70.0 3 78.0 4 66.0 5 83.0 6 66.0 7 64.0 8 62.0 9* 161.0 10 61.0 11 95.0 12 62.0
Op
SAB
15 min 210 min 104.0 71.0 75.0 88.0 76.0 79.0 69.0 71.0 105.0 75.0 95.0 64.0 67.0 76.0 67.0 122.0 73.0 89.0 94.0 114.0 85.0 111.0 111.0
M SE P
71.1 3.1
79.5 3.4 0.003
1 2 3 4 5 6 7 8
87.0 71.0 59.0 87.0 82.0 66.0 67.0 61.0 79.0 78.0 68.0 61.0 72.2 2.8
89.0 92.0 145.0 74.0 74.0 119.0 59.0 80.0 73.0 104.0 93.0 83.0 90.0 90.0 104.0 68.0 68.0 69.0 73.0 69.0 70.0 70.0 64.0 96.0 86.0 80.0 78.0 113.0 78.0 83.0 70.0 70.0 65.0 65.0 68.0 82.1 74.9 89.8 4.2 3.1 7.0 0.032 0.005 0.002
9
10 11 12
M SE P
85.6 4.9 0.016
84.0 4.8 0.037
significantly alter. Kleinerman, Sancetta and Hackel (1958) reported similar findings during spinal anaesthesia with hyperbaric procaine. The blood glucose level is regulated by liver function, insulin, HGH, glucocorticoids, adrenaline and glucagon. The present study demonstrates that spinal anaesthesia did not alter significantly the blood insulin and HGH levels. It is also well known that spinal anaesthesia does not increase blood cortisol (Hammond et al., 1958) or adrenaline levels (Hamelberg et al., 1960). Therefore, an unchanged blood glucose level appears to be consistent with expectation. Psychological stress associated with spinal anaesthesia in non-premedicated patients might account for the observed slight but significant elevation in blood glucose in the present study; thus, Allison, Tomlin and Chamberlain (1969) have recently observed significant elevations of
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Lignocaine
Case No.
728
BRITISH JOURNAL OF ANAESTHESIA TABLE VII
Plasma levels of FFA (m.equiv/l.) during spinal anaesthesia (SAB) and surgery (Op). Group Quatacaine
M SE P
PreSAB SAB lOmin 1.122 1.573 0.651 0.610 0.963 1.122 1.759 1.904 1.000 1.075 0.817 0355 0.963 1.122 0.683 0.780 0.217 0.361 1.220 1.488 0.389 0.614 — 1.550 0.889 1.046 0.120 0.141 0.432 0.300 0.400 0.275 0.659 1.581 1.395 1.274 1.006 0.076 0.080 0.454 0.590 0.991 1.148 0.969 1.50O 0.765 1.000 0.828 1.012 0.959 1.297 0.623 0.635 0.757 0.120
0.893 0.118 0.064
Op SAB 15min 210 mia 1.000 0.598 0.976 1.664 0.806 0.796 0.976 0.707 0.217 1.122 0.470 1.372 0.890 0.107 0.988 0.418 0.424 0.977 0.858 0.050 0.490 0.723 1.698 0.663 0.542 1.068 0.622
0.122 0.890 1.000 1.108 0.387 0.699 1.002 0.764 1.108 0.504 0325 0.699 0.717 0.090 0.281 0320 0.264 0.698 0.365 0.460 0.480 0.686 0.684 1.082 0.072 0.905 0.608
0.711 0.114 0.641
0.552 0.078 0.13O
blood glucose caused by pre-operative emotional stress. The major portion of plasma lipids includes triglyceride (neutral fat), phospholipid and cholesterol in approximately equal quantities. In addition, a much smaller fraction of unesterified fatty adds (FFA) accounts for less than 5 per cent of the total fatty acid present in plasma. This FFA is known to be metabolically the most active of the plasma lipids. Fat is released from adipose tissue in the form of FFA and carried in the unesterified state in the plasma as an albumin-FFA complex at concentrations varying between 0.1 and 2 /x.equiv/ml plasma. The rate of removal of FFA from the blood is extremely rapid and is sufficient to account for the whole of the caloric expenditure in fasting humans (Harper, 1969). FFA concentration in plasma is controlled by the FFA production in adipose tissue and the
REFERENCES
Allison, S. P., Tomlin, P. F., and Chamberlain, M. F. (1969). Some effects of anaesthesia and surgery on carbohydrate and fat embolism. Brit. J. Anaesth., 41, 588. Annamunthodo, H., Keating, V. J., and Patrick, S. J. (1958). Liver glycogen alterations in anaesthesia and surgery. Anaesthesia, 13, 429. Bunker, J. P. (1963). Neuroendocrine and other effects on carbohydrate metabolism during anesthesia. Anesthesiology, 24, 515. Charters, A. C , Odell, W. O., and Thompson, J. C (1969). Anterior pituitary function during surgical stress and convalescence: radioimmunoassay measurement of blood TSH, LH, FSH and growth hormone. J. dm. Endocr., 29, 63. Duncombe, W. G. (1963). The colorimetric microdetermination of long-chain fatty acids. Biochem. J., 8S, 7. Glick, S. M., Roth, J., Yalow, R. S., and Berson, S. A. (1965). The regulation of growth hormone secretion. Recent Progr. Hormone Res., 21, 241. Greene, N. M. (1969). Physiology of Spinal Anesthesia, p. 179. Baltimore: Williams & Wilkins. Hamelberg, W., Sprowe, J. H., Mahaffey, J. E., and Richardson, J. A. (1960). Catecholamine levels during light and deep anesthesia. Anesthesiology, 21, 297. Hammond, W. G., Vandam, L. D., Davis, J. M , Carter, R. D., Ball, M R., and Moore, F. D . (1958). Studies in surgical endocrinology. IV: Anesthetic agents as stimuli to change in corticosteroids and metabolism. Ann. Surg., 148, 199. Harper, H. A. (1969). Review of Physiological Chemistry, pp. 278, 299. New York: Lange. Ketterer, H., Powell, D., and Unger, R, H. (1966). Growth hormone response to surgical stress. Clin. Res., 14, 65. Kleinerman, J., Sancetta, S. M , and Hackel, D. B. (1958). Effects of high spinal anesthesia on cerebral circulation and metabolism in man. J. din. Invest., 37, 285. Morgan, C R-, and Lazarow, A. (1963). Immunoassay of insulin: two antibody system. Diabetes, 12, 115.
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on March 16, 2015
lignocaine
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 M SE P 1 2 3 4 5 6 7 8 9 10 11 12
uptake of FFA by tissues from blood. HGH promotes the production of FFA from triglyceride, thereby increasing die plasma FFA level. Insulin has the opposite effect on plasma FFA. Hyperglycaemia decreases the plasma FFA level and hypoglycaemia has the opposite effect. The present study shows no appreciable influence of spinal anaesthesia or surgery on plasma FFA levels. Since the above-mentioned influencing factors did not change during the procedure, it appears appropriate that little variation in plasma FFA concentration occurred in our study. Our data suggest that spinal anaesthesia and operation under spinal anaesthesia does not cause a temporary diabetic state and that this technique is suitable for use in diabetic patients.
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM
LES EFFETS DE LA RACHI-ANESTHESIE ET DE LA CHIRURGIE SUR LE METABOLISME DES HYDRATES DE CARBONE ET DES GRAISSES CHEZ LHOMME SOMMAIRE
Les effets de la rachi-enesthesie et de la chirurgie sur le me'tabolisme des hydrates de carbone et des graisses ont ivt Studies chez trente patients, en determinant les tauz plasmatiques de l'hormone de croissance humaine
(HGH), insuline, glucose sanguin et acides gras libres (FFA). L'anesthe'sie spinale hyperbare a la lignocaine ou quatacaine seule, suivie de l'intcrvention chirurgicale n'influenca pas les taux plasmatiques de HGH, insuline ou FFA. Les taux moyens de glucose sanguin fluent significativement sieves durant la rachi-anestheste et la chirurgie, mais resterent dans les limites de la normale. AUSWIRKUNGEN VON SPINAL-ANAESTHESIE UND onRURGISCHEN EINGRIFFEN AUF DEN KOHLEHYDRAT- UND FETTSTOFFWECHSEL DES MENSCHEN ZUSAMMENFASSUNG
Die Auswirkungen der Spinal-Anaesthesie und Chirurgischer Eingriffe auf den Kohlehydrat- und Fettstoffwechsel wurden an dreiflig Patienten untersuchL Man bistimmte die Plasmakonzentration des menschlichen Wachstumhonnons (HGH) Insulin, Blutzucker und freie Fettsauren (FFA). Hyperbarische SpinalAnaesthesie mit Lignocain oder Quatacain und daran anschlieflend der chirurgische Eingriff hatten keinen Einflufi auf die Spiegel von menschlichem Wachstumhonnon. Insulin oder freien Fettsauren. Die mittleren Blutzuckerspiegel wanrend Spinal-Anaesthesie und chirurgischem Eingriflf waren deutlich erhoht, bewegten sich jedoch im Normbereich.
FACULTY OF ANAESTHETISTS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND SYMPOSIUM ON "THE METABOLIC EFFECTS OF ANAESTHESIA" September 18 and 19, 1970 "Aerobic and Anaerobic Mechanisms" Dr I. C. Geddes, University of Liverpool "Anaesthesia and Cell Division" Professor J. F. Nunn, MRC Clinical Research Centre, Harrow "Anaesthesia and Carbohydrate Transport across Cell Membranes" Professor N. Greene, Yale University, Connecticut "Effect of Temperature Changes on the Cell Membrane" Dr P. J. Goodford, Wellcome Research Laboratories. Beckenham "Use of Tracer Techniques in the Study of Anaesthetic Metabolism" "Biotransformation of Halothane" Professor E. N. Cohen, Stanford University Medical Center, California "Chronic Toxidty of Inhalational Anaesthetics" Dr M. Chenoweth, Dow Chemical Company, Midland, Michigan
Toxkity of Nitrous Oxide" Dr G. D. Parbrook, University of Glasgow "Malignant Hyperpyrexia" Dr J. E. S. Relton and Dr B. Britt, University of Toronto, Canada "Anaesthesia and Cerebral Metabolism" Professor D. G. McDowall, University of Leeds "Metabolic Responses to Surgery" Professor I. D. A. Johnston, University of Newcastle upon Tyne "Anaesthesia and Body Fluid Compartments" Dr M. D. Vickers, Dudley Road Hospital, Birmingham "Circulatory Response to Metabolic Demands" Dr C Prys-Roberts, Raddiffe Infirmary, Oxford "Metabolism of Drugs by the Liver" Dr L. Strunin, The London Hospital "Metabolism of the Barbiturates" Professor L. C Mark, Columbia University, NewYork
Registration fee: £7. Refreshments will be available at £1 per head per day. Application forms and further details for this Symposium are obtainable from The Secretary, Faculty of Anaesthetists, Royal College of Surgeons of England, Lincoln's Inn Fields, London W.C.2.
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on March 16, 2015
Oyama, T., and Takiguchi, M. (1970). Effects of neuroleptic anaesthesia on carbohydrate and fat metabolism in man. Brit. J. Anaesth. (awaiting publication). Ross, H., Johnstone, I. D. A., Welbon, T. A., and Wright, A. D. (1966). Effect of abdominal operation on glucose tolerance and serum levels of insulin, GH, and hydrocortisone. Lancet, 2, 563. Schakh, D. S. (1967). The influence of physical stress and exercise on GH and insulin secretion in man. J. Lab. din. M*d., 69, 256. Parker, M. L. (1964). A sensitive double antibody immunoassay for human growth hormone in plasma. Nature, 203, 1141. Somogyi, M. (1952). Notes on sugar determination. J. biol. Chem., 195. 19.
729
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON CARBOHYDRATE AND FAT METABOLISM IN MAN BY
T. OYAMA AND A. MATSUKI SUMMARY
The present study was undertaken to investigate the effects of spinal anaesthesia and surgery on carbohydrate and fat metabolism, by measuring their influences on plasma human growth hormone, insulin, free fatty adds and blood glucose levels. Human growth hormone (HGH) of the anterior pituitary gland is known to be related not only to growth but also to the metabolism of glucose, fat and protein. Large rises in plasma HGH concentration have recently been reported during surgical stress (Glick et al., 1965; Ketterer, Powell and Unger, 1966; Schalch, 1967; Charters, Odell and Thompson, 1969; Oyama and Takiguchi, 1970). Furthermore, participation of HGH in the metabolic responses to acute stress has been suggested by Schalch (1967).
TABLE I
Patients studied and operations performed in the quatacame group.
DuraPerformed Case Age Sex
1 2
34 27
F
3 4
28 27 16 19 23 46 20 32 28 26
M M M M F F F F F F
5 6 7 8 9 10 11 12
F
operation
Operation time (hr min)
40 Tubal sterilization Removal of abdominal lipoma 40 Appendkcctomy 1 10 Hemiorrhaphy 20 Appeadicectomy 45 Appendicectomy 35 Cervical suture 20 Haemorrhoidectomy 30 Appendicectomy 40 Isthomorrhaphy 25 Caesarean section 55 Simple hysterectomy 1 00
tion of analgesia 1 40 1 1 1 2 2 1 1 1 1 1 1
20 30 50 20 00 50 30 30 10 30 50
MATERIAL AND METHOD
Thirty patients, ranging in age from 16 to 62 years were the subjects of the study. All patients underwent elective operations (tables I, II) except for six subjects who underwent neither spinal anaesthesia nor surgery and served as controls. No patient was included who had hepatic, renal, endocrine or cardiovascular disease. Normal saline 500 ml was infused during the entire procedure and blood was transfused to replace the loss if this exceeded 500 ml due to surgery. No patients received premedication. Spinal anaesthesia was performed between 1 and 3 pjn.
Spinal puncture was made at the level of L3-4 or L4-5 with a No. 20-21 needle, the patient being in the right lateral position. The new local anaesthetic quatacaine* was used in twelve patients. A 3 per cent solution was used, 200 mg being diluted in 6.7 ml of 10 per cent glucose. The specific gravity is 1.040 ±0.003. In addition lignocaine (3 per cent solution, sp.gr. 1.030 ±0.003) was employed for twelve patients. No adrenaline was added to these agents. The duration of analgesia and type of surgery are
TSUTOMU
* Tanacaine (Tanabe Pharmaceutical Company)=2methyl-2-n-propyiaminopropion-O-toluide hydrochloride. It is similar to lignocaine in potency and duration of action.
OYAMA,
MX>.; AKITOMO
MATSUKI, MJ>.;
Department of Anaesthesia, Hirosaki University School of Medicine, Hirosaki, Aomori-Ken, Japan.
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The effects of spinal anaesthesia and surgery on carbohydrate and fat metabolism were studied in thirty patients by determining plasma concentrations of human growth hormone (HGH), insulin, blood glucose and free fatty acids (FFA). Hyperbaric spinal anaesthesia with lignocaine or quatacaiae alone and subsequent surgery did not influence the plasma HGH, insulin or FFA levels. Mean blood glucose levels were elevated significantly during spinal anaesthesia and surgery, but remained within the normal range.
724
BRITISH JOURNAL OF ANAESTHESIA TABLE II
Determinations of plasma growth hormone (HGH) were made according to the method of Schalch and Parker (1964). The analysis of plasma Dura- insulin was made after the method of Morgan Opera- tion and Lazarow (1963). These double antibody tion of time anal- methods were based on the principle of radio(hr min) gesia immunoassay utlizing 125 I. Duplicate determina45 1 50 tions were made on all specimens and the mean 40 1 50 values were taken. The recovery rate for HGH 45 2 20 and insulin was 98 per cent and 94 per cent res55 1 20 30 2 00 pectively by our method, which indicates reliable 25 1 00 analysis. The blood glucose was measured by the 00 2 00 15 1 30 method of Somogyi (1952), and plasma FFA was 55 2 40 determined by colorimetric method of Duncombe 45 1 00 (1963).
Patients studied and operations performed in the lignocaine group.
M F F F M M F M F F M F
40
1 00
20
1 40
shown in tables I and II. The average dose of quatacaine was 75 mg (2.5 ml), the average duration of analgesia was 105, SEM 5.1 min, and the average level of analgesia was T9. The mean operating time was 40 ±4.3 min in the case of lignocaine the mean dose was 38 mg (2.6 ml), the average duration of analgesia was 100 ±8.9 min and the mean upper level of analgesia was T9. The average operating time was 44 ±5.5 min. There was no significant difference between these parameters in both groups. The level of analgesia was checked by pinprick. The analgesia time was taken as a time between the start of spinal injection and the disappearance of analgesia over the right L5 region, which was checked every 10 min Blood was sampled at the following times: (1) in the afternoon 10 min before starting spinal anaesthesia; (2) 10 min after establishing spinal anaesthesia but before surgery; (3) 15 min after the stan of surgery; and (4) 3i hours after the start of spinal anaesthesia. On each occasion 5 ml of venous blood was collected in a heparinized syringe, rapidly transferred to a tube, then centrifuged within 30 min of collection. One ml of each plasma sample was stored at - 2 0 ° C and thawed within one month just prior to radioimmunoassay for growth hormone and insulin. One ml of plasma was stored at 4°C for analysis of FFA [=free fatty acid = nonesterified fatty acids (NEFA)], and 0.2 ml of blood was used to measure blood glucose.
RESULTS
Plasma growth hormone. The mean growth hormone (HGH) levels in plasma in the six control patients are shown in table HI and figure 1. The mean value was 1.87 ng/ml at 1 pjn., and varied insignificantly from 2.70 ng/ml at 1.20 pjn. to 3.1 ng/ml at 6 p.m. The average HGH level in plasma in the
c "5 to
—.
-
E
I!1
30 20
8
36 26 26 31 55 61 27 62 23 34 24 20
50
150
*< 100 13.00pm
13.20pm
13.40pm
18.00pm
1 Plasma levels of HGH, insulin, FFA and blood glucose in the control group. FIG.
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1 2 3 4 5 6 7 8 9 10 11 12
Performed operation Removal of testicle Tubal sterilization Caesarean section Tubal sterilization Removal of testicle T.U.R. Caesarean section Herniorrhaphy Appendicectomy Tubal sterilization Appendicectomy Removal of vaginal polyp
Blood Sugar (mg/1 00ml)
Case Age Sex
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM T A B U III
Plasma levels of HGH, insulin, glucose and FFA in the control group. Case No. HGH (ng/ml)
Insulin
M SE P Glucose (mg/ 100 ml)
M SE P FFA (m.equiv/1.)
M SE P %
1.20 p.m.
1.3 2.3 1.3 2.3 1.0 3.0
4.3 2.3 2.0 2.3 1.3 4.0
1.87 0.29
2.70 0.44 0.131
1.40 pjn. 18.0 1.7 1.0 1.3 2.0 3.3 4.55 2.47 0.385
6.00 pjn. 4.0 2.0 3.7 2.0 4.0 3.0
3.11 0.35 0.11
16.7 21.7 21.7 16.7 71.7 21.7
15.0 23.3 26.7 20.0 63.3 38.3
15.0 18.3 10.0 3.3 48.3 38.3
18.3 20.0 16.7 30.0 41.7 16.7
28.4 7.96
31.1 6.56 0.455
22.2 6.48 0.317
23.9 3.74 0.477
87.0 92.0 75.0 74.0 80.0 99.0
69.0 65.0 97.0 83.0 82.0 85.0
66.0 68.0 91.0 79.0 62.0 85.0
58.0 62.0 90.0 65.0 69.0 66.0
84.5 3.7
80.2 4.23 0.590
75.2 4 32 0.215
683 4.19 0.08
0.378 0.203 0.243 0.162 0.269 0.217
0.473 0.276 0.149 0.081 0.252 0.217
0.359 0.243 0.095 0.068 0.241 0.113
0.245 0.028
0.241 0.050 0.904 98.4
100
start of spinal anaesthesia respectively. The values did not differ significantly from pre-spinal control levels. Plasma insulin. The mean plasma insulin level in the control group (table IE and fig. 1) varied insignificantly from 28.4 to 23.9 /xU/ml. The plasma insulin level in the quatacaine and lignocaine groups did not change significantly during spinal anaesthesia or operation (table V and figs. 2 and 3).
11
n- * a. _i £ 3
20
»
10
=
0.541 0.230 0.176 0.095 0.209 0.390
0.186 0273 0.042 0.060 0.572 0.090 111.4 75.9
quatacaine group is shown in table IV and figure 2. The control pre-spinal value was 4.6 ng/ml. It was 5.8 ng/ml 10 min after the start of spinal anaesthesia, 4.0 ng/ml 15 min after the start of operation, and 5.2 ng/ml 3i hours after the start of spinal anaesthesia. Plasma HGH levels in the lignocaine group are shown in table IV and figure 3. The prespinal control level was 4.0 ng/ml. Ten minutes after the start of spinal anaesthesia it was 4.5 ng/ml and 3.2 ng/ml and 4.7 ng/ml 15 min after the start of operation and 3J hours after the
Pre-SAB
SAB 10' Ope 15' Time In minutes
SAB 210'
FIG. 2 Plasma levels of HGH, insulin, FFA and blood glucose in the quatacaine group during spinal anaesthesia.
Blood glucose. The mean blood glucose level in the control group decreased insignificantly from 84.5 to 68.3 mg/100 ml. The mean levels in both quatacaine and lignocaine groups were significantly raised (by 8.4 and 2.7 mg/100 ml) during spinal anaesthesia alone and during operation (by 14.5 and 9.9 mg/100 ml) (table VI and figs. 2 and 3).
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M SE P
1.00 pjn.
725
BRITISH JOURNAL OF ANAESTHESIA
726 TABLE
IV
Plasma levels of HGH (.ng/ml) during spinal anaesthesia (SAB) and surgery (Op). Group Quatacaine
1 2 3 4 5 6 7 8 9 10 11 12
PreSAB 2.0 3.7
SAB 10 min 1.0 2.0
2.3 9.3 3.7 4.0 6.0 6.7
18.7 2.3 8.3 9.3 9.7 0.7 2.0 3.3 9.0 3.7
2.7 4.0 4.7 3,8
12.3
M SE P
4.6 0.9
5.8 1.5
4.0 0.7
5.2 1.9
0.342
0.325
0.856
1 2 3 4 5 6 7 8 9 10 11 12
6.7 4.7 2.7 2.7 1.0 3.0 2.0 2.3 3.7 3.0
5.0 2.0 2.3 2.0 4.7 1.7 8.3 10 1.7 1.7 5.3 2.3
2.0 3.0 2.3 2.0 2.3 1.7 3.0
M SE P
14.0 2.3 4.0 1.0
2.0 3.0 2.0 2.0 1.7
2.0 1.3 1.7 2.7 11.0 2.7 4.5 1.7 0.735
•
0.5 3.7 1.0 9.3 6.0 1.0 2.0 1.0
9.0 2.0 8.0 1.3 9.3 1.7 3.0 3.3 9.0 4.7
21.7
(0
SAB Op 15 min 210 min 23.0 0.5
0.5
1.3 2.0
18.3 2.7 1.7
15.0 2.3
3.2 0.6
4.7 1.6
0.432
0.650
Blood FFA. The mean values in the control group did not change significantly. In both the quatacaine and lignocaine groups there were slight increases after 10 minutes of spinal anaesthesia alone (table VII and figs. 2 and 3), but gradual declines during and after operation. These changes were not significantly different from control pre-spinal levels. DISCUSSION
The present study did not demonstrate any significant influence of spinal anaesthesia alone on plasma HGH level in either the quatacaine or the lignocaine group. The short duration of study (10 min) of spinal anaesthesia alone might in pan account for this finding. Under the influence of spinal anaesthesia also, the plasma HGH levels did not rise significantly during operation or postoperatively. This is in contrast to the effect of
20 10
w>
f-
1
IT"
8
E100
3
O
—
o
_ _ i > 50 120 100 80 Pr«-SAB
SAB 10'
Ope 1 5'
SAB 210'
Time In minutes FIG. 3 Plasma levels of HGH, insulin, FFA and blood glucose in the lignocaine group during spinal anaesthesia.
surgical stress under general anaesthesia which usually elevates blood HGH levels markedly (Glick et al., 1965; Ketterer, Powell and Unger, 1966; Ross et aL, 1966; Schalch, 1967; Charters, Odell and Thompson, 1969; Oyama and Takiguchi, 1970). Spinal anaesthesia appears to depress the elevation of blood HGH caused by surgical stress. There are few reports on the effect of spinal anaesthesia on plasma HGH and insulin levels. Charters, Odell and Thompson (1969) reported a case of nailing for fractured femur. The plasma HGH level increased from a control value of 2.7 to 6.2 and 36.0 ng/ml 30 minutes and 1 hour respectively after the start of operation, but they did not separate the effect of spinal anaesthesia alone. Glick and associates (1965) observed an increase of HGH in four patients during operation under spinal anaesthesia, but again did not study the effect of spinal anaesthesia alone. Growth hormone is an anabolic hormone which increases uptake and synthesis of amino acids. It also has diabetogenic and anti-insulin effects
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Lignocaine
Case No.
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM
727
TABLE V
TABLE VI
Plasma levels of insulin (jiU/mJ) during spinal anaesthesia {SAB) and surgery (Op).
Blood levels of glucose (mg/100 ml) during spinal anaesthesia (SAB) and surgery (Op).
Group Quatacaine
PreSAB
lOmin
1 2 3 4 5 6 7 8 9 in 11 12 M SE P
21.5 23.3 7.2 13 7 2.3 13.7 22.3 13.8 50 14 5.9 3.9
24.1 20.3 10.0 11 1 11.7 10.9 18.2 20.0 3.9 15 6.1 4.4
25.0 20.1 2.5 18 5.0 12.4 21.8 20.0 8.3 28 4.8 17.6
11.2 2.2
11.9 2.0 0 568
11.8 2.4 0.716
1 2 3 4 5 6 7 3
8.3 18.3 83 20 0 100 3.3 5.0 50
11.5 5.0 16 7 23.3 11 7 8.3 10.0 33 13.3 6.7 6.7
8.3 13.0 28 3 23.0 67 10.0 8.3 33
9
10 11 12
M SE P
83
6.7 67 11.7 9.3 1.4
SAB
8.3
10.4 1.5 0.511
Op
SAB
15 min 210 min
4.0
8.3 7.0 11.9 11.0 2.1 0.396
21.1 18.5 9.5 19 13.3 13.3 18.9 23.9 7.0 13 2.3 7.3 11.6 2.2 0.829 11.5 13.0 11 7 11.7 10 0 5.0 13.3 36 11.7 4.0 4.0 10.8 9.2 1.1 0.935
which enhance the mobilization of fatty acids from adipose tissue and increases FFA in blood. Growth hormone is also considered to be one of the "stress hormones". Plasma insulin levels were not changed during spinal anaesthesia, surgery or the postoperative period. Similar observations were made during operation under general anaesthesia (Glick et al., 1965; Charters, Odell and Thompson, 1969). Although in the present study blood glucose levels increased significantly during spinal anaesthesia alone and during surgery, they were within the normal range (80-100 mg/100 ml). This is in contrast to the marked hyperglycaemic influence of surgical stress under general anaesthesia (Bunker, 1963). Annamundiodo, Keating and Patrick (1958) observed that during spinal anaeschesia with hyperbaric cinchocaine the blood glucose level or muscle glycogen content did not
Group Quatacaine
Lignocaine
Case
Pre-
SAB
No.
SAB
10 min 90.0 68.0 87.0 70.0 84.0 72.0 68.0 74.0 150.0 71.0 105.0 86.0
1 75.0 2 70.0 3 78.0 4 66.0 5 83.0 6 66.0 7 64.0 8 62.0 9* 161.0 10 61.0 11 95.0 12 62.0
Op
SAB
15 min 210 min 104.0 71.0 75.0 88.0 76.0 79.0 69.0 71.0 105.0 75.0 95.0 64.0 67.0 76.0 67.0 122.0 73.0 89.0 94.0 114.0 85.0 111.0 111.0
M SE P
71.1 3.1
79.5 3.4 0.003
1 2 3 4 5 6 7 8
87.0 71.0 59.0 87.0 82.0 66.0 67.0 61.0 79.0 78.0 68.0 61.0 72.2 2.8
89.0 92.0 145.0 74.0 74.0 119.0 59.0 80.0 73.0 104.0 93.0 83.0 90.0 90.0 104.0 68.0 68.0 69.0 73.0 69.0 70.0 70.0 64.0 96.0 86.0 80.0 78.0 113.0 78.0 83.0 70.0 70.0 65.0 65.0 68.0 82.1 74.9 89.8 4.2 3.1 7.0 0.032 0.005 0.002
9
10 11 12
M SE P
85.6 4.9 0.016
84.0 4.8 0.037
significantly alter. Kleinerman, Sancetta and Hackel (1958) reported similar findings during spinal anaesthesia with hyperbaric procaine. The blood glucose level is regulated by liver function, insulin, HGH, glucocorticoids, adrenaline and glucagon. The present study demonstrates that spinal anaesthesia did not alter significantly the blood insulin and HGH levels. It is also well known that spinal anaesthesia does not increase blood cortisol (Hammond et al., 1958) or adrenaline levels (Hamelberg et al., 1960). Therefore, an unchanged blood glucose level appears to be consistent with expectation. Psychological stress associated with spinal anaesthesia in non-premedicated patients might account for the observed slight but significant elevation in blood glucose in the present study; thus, Allison, Tomlin and Chamberlain (1969) have recently observed significant elevations of
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Lignocaine
Case No.
728
BRITISH JOURNAL OF ANAESTHESIA TABLE VII
Plasma levels of FFA (m.equiv/l.) during spinal anaesthesia (SAB) and surgery (Op). Group Quatacaine
M SE P
PreSAB SAB lOmin 1.122 1.573 0.651 0.610 0.963 1.122 1.759 1.904 1.000 1.075 0.817 0355 0.963 1.122 0.683 0.780 0.217 0.361 1.220 1.488 0.389 0.614 — 1.550 0.889 1.046 0.120 0.141 0.432 0.300 0.400 0.275 0.659 1.581 1.395 1.274 1.006 0.076 0.080 0.454 0.590 0.991 1.148 0.969 1.50O 0.765 1.000 0.828 1.012 0.959 1.297 0.623 0.635 0.757 0.120
0.893 0.118 0.064
Op SAB 15min 210 mia 1.000 0.598 0.976 1.664 0.806 0.796 0.976 0.707 0.217 1.122 0.470 1.372 0.890 0.107 0.988 0.418 0.424 0.977 0.858 0.050 0.490 0.723 1.698 0.663 0.542 1.068 0.622
0.122 0.890 1.000 1.108 0.387 0.699 1.002 0.764 1.108 0.504 0325 0.699 0.717 0.090 0.281 0320 0.264 0.698 0.365 0.460 0.480 0.686 0.684 1.082 0.072 0.905 0.608
0.711 0.114 0.641
0.552 0.078 0.13O
blood glucose caused by pre-operative emotional stress. The major portion of plasma lipids includes triglyceride (neutral fat), phospholipid and cholesterol in approximately equal quantities. In addition, a much smaller fraction of unesterified fatty adds (FFA) accounts for less than 5 per cent of the total fatty acid present in plasma. This FFA is known to be metabolically the most active of the plasma lipids. Fat is released from adipose tissue in the form of FFA and carried in the unesterified state in the plasma as an albumin-FFA complex at concentrations varying between 0.1 and 2 /x.equiv/ml plasma. The rate of removal of FFA from the blood is extremely rapid and is sufficient to account for the whole of the caloric expenditure in fasting humans (Harper, 1969). FFA concentration in plasma is controlled by the FFA production in adipose tissue and the
REFERENCES
Allison, S. P., Tomlin, P. F., and Chamberlain, M. F. (1969). Some effects of anaesthesia and surgery on carbohydrate and fat embolism. Brit. J. Anaesth., 41, 588. Annamunthodo, H., Keating, V. J., and Patrick, S. J. (1958). Liver glycogen alterations in anaesthesia and surgery. Anaesthesia, 13, 429. Bunker, J. P. (1963). Neuroendocrine and other effects on carbohydrate metabolism during anesthesia. Anesthesiology, 24, 515. Charters, A. C , Odell, W. O., and Thompson, J. C (1969). Anterior pituitary function during surgical stress and convalescence: radioimmunoassay measurement of blood TSH, LH, FSH and growth hormone. J. dm. Endocr., 29, 63. Duncombe, W. G. (1963). The colorimetric microdetermination of long-chain fatty acids. Biochem. J., 8S, 7. Glick, S. M., Roth, J., Yalow, R. S., and Berson, S. A. (1965). The regulation of growth hormone secretion. Recent Progr. Hormone Res., 21, 241. Greene, N. M. (1969). Physiology of Spinal Anesthesia, p. 179. Baltimore: Williams & Wilkins. Hamelberg, W., Sprowe, J. H., Mahaffey, J. E., and Richardson, J. A. (1960). Catecholamine levels during light and deep anesthesia. Anesthesiology, 21, 297. Hammond, W. G., Vandam, L. D., Davis, J. M , Carter, R. D., Ball, M R., and Moore, F. D . (1958). Studies in surgical endocrinology. IV: Anesthetic agents as stimuli to change in corticosteroids and metabolism. Ann. Surg., 148, 199. Harper, H. A. (1969). Review of Physiological Chemistry, pp. 278, 299. New York: Lange. Ketterer, H., Powell, D., and Unger, R, H. (1966). Growth hormone response to surgical stress. Clin. Res., 14, 65. Kleinerman, J., Sancetta, S. M , and Hackel, D. B. (1958). Effects of high spinal anesthesia on cerebral circulation and metabolism in man. J. din. Invest., 37, 285. Morgan, C R-, and Lazarow, A. (1963). Immunoassay of insulin: two antibody system. Diabetes, 12, 115.
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on March 16, 2015
lignocaine
Case No. 1 2 3 4 5 6 7 8 9 10 11 12 M SE P 1 2 3 4 5 6 7 8 9 10 11 12
uptake of FFA by tissues from blood. HGH promotes the production of FFA from triglyceride, thereby increasing die plasma FFA level. Insulin has the opposite effect on plasma FFA. Hyperglycaemia decreases the plasma FFA level and hypoglycaemia has the opposite effect. The present study shows no appreciable influence of spinal anaesthesia or surgery on plasma FFA levels. Since the above-mentioned influencing factors did not change during the procedure, it appears appropriate that little variation in plasma FFA concentration occurred in our study. Our data suggest that spinal anaesthesia and operation under spinal anaesthesia does not cause a temporary diabetic state and that this technique is suitable for use in diabetic patients.
EFFECTS OF SPINAL ANAESTHESIA AND SURGERY ON METABOLISM
LES EFFETS DE LA RACHI-ANESTHESIE ET DE LA CHIRURGIE SUR LE METABOLISME DES HYDRATES DE CARBONE ET DES GRAISSES CHEZ LHOMME SOMMAIRE
Les effets de la rachi-enesthesie et de la chirurgie sur le me'tabolisme des hydrates de carbone et des graisses ont ivt Studies chez trente patients, en determinant les tauz plasmatiques de l'hormone de croissance humaine
(HGH), insuline, glucose sanguin et acides gras libres (FFA). L'anesthe'sie spinale hyperbare a la lignocaine ou quatacaine seule, suivie de l'intcrvention chirurgicale n'influenca pas les taux plasmatiques de HGH, insuline ou FFA. Les taux moyens de glucose sanguin fluent significativement sieves durant la rachi-anestheste et la chirurgie, mais resterent dans les limites de la normale. AUSWIRKUNGEN VON SPINAL-ANAESTHESIE UND onRURGISCHEN EINGRIFFEN AUF DEN KOHLEHYDRAT- UND FETTSTOFFWECHSEL DES MENSCHEN ZUSAMMENFASSUNG
Die Auswirkungen der Spinal-Anaesthesie und Chirurgischer Eingriffe auf den Kohlehydrat- und Fettstoffwechsel wurden an dreiflig Patienten untersuchL Man bistimmte die Plasmakonzentration des menschlichen Wachstumhonnons (HGH) Insulin, Blutzucker und freie Fettsauren (FFA). Hyperbarische SpinalAnaesthesie mit Lignocain oder Quatacain und daran anschlieflend der chirurgische Eingriff hatten keinen Einflufi auf die Spiegel von menschlichem Wachstumhonnon. Insulin oder freien Fettsauren. Die mittleren Blutzuckerspiegel wanrend Spinal-Anaesthesie und chirurgischem Eingriflf waren deutlich erhoht, bewegten sich jedoch im Normbereich.
FACULTY OF ANAESTHETISTS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND SYMPOSIUM ON "THE METABOLIC EFFECTS OF ANAESTHESIA" September 18 and 19, 1970 "Aerobic and Anaerobic Mechanisms" Dr I. C. Geddes, University of Liverpool "Anaesthesia and Cell Division" Professor J. F. Nunn, MRC Clinical Research Centre, Harrow "Anaesthesia and Carbohydrate Transport across Cell Membranes" Professor N. Greene, Yale University, Connecticut "Effect of Temperature Changes on the Cell Membrane" Dr P. J. Goodford, Wellcome Research Laboratories. Beckenham "Use of Tracer Techniques in the Study of Anaesthetic Metabolism" "Biotransformation of Halothane" Professor E. N. Cohen, Stanford University Medical Center, California "Chronic Toxidty of Inhalational Anaesthetics" Dr M. Chenoweth, Dow Chemical Company, Midland, Michigan
Toxkity of Nitrous Oxide" Dr G. D. Parbrook, University of Glasgow "Malignant Hyperpyrexia" Dr J. E. S. Relton and Dr B. Britt, University of Toronto, Canada "Anaesthesia and Cerebral Metabolism" Professor D. G. McDowall, University of Leeds "Metabolic Responses to Surgery" Professor I. D. A. Johnston, University of Newcastle upon Tyne "Anaesthesia and Body Fluid Compartments" Dr M. D. Vickers, Dudley Road Hospital, Birmingham "Circulatory Response to Metabolic Demands" Dr C Prys-Roberts, Raddiffe Infirmary, Oxford "Metabolism of Drugs by the Liver" Dr L. Strunin, The London Hospital "Metabolism of the Barbiturates" Professor L. C Mark, Columbia University, NewYork
Registration fee: £7. Refreshments will be available at £1 per head per day. Application forms and further details for this Symposium are obtainable from The Secretary, Faculty of Anaesthetists, Royal College of Surgeons of England, Lincoln's Inn Fields, London W.C.2.
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Oyama, T., and Takiguchi, M. (1970). Effects of neuroleptic anaesthesia on carbohydrate and fat metabolism in man. Brit. J. Anaesth. (awaiting publication). Ross, H., Johnstone, I. D. A., Welbon, T. A., and Wright, A. D. (1966). Effect of abdominal operation on glucose tolerance and serum levels of insulin, GH, and hydrocortisone. Lancet, 2, 563. Schakh, D. S. (1967). The influence of physical stress and exercise on GH and insulin secretion in man. J. Lab. din. M*d., 69, 256. Parker, M. L. (1964). A sensitive double antibody immunoassay for human growth hormone in plasma. Nature, 203, 1141. Somogyi, M. (1952). Notes on sugar determination. J. biol. Chem., 195. 19.
729