THORACIC EPIDURAL ANESTHESIA/ANALGESIA PREVENTS BNP LEVEL INCREASING AFTER MAJOR ABDOMINAL SURGERY
Keywords:
cardiac risk, B-type natriuretic peptide, thoracic epidural anaesthesia and analgesiaAbstract
Background. B-type natriuretic peptide (BNP) was shown to be a marker of myocardial ischemia and elevated BNP and NT-proBNP levels identify patients undergoing major noncardiac surgery at high risk of cardiac complications. With this study, we aimed to determine the factors associated with increase in BNP level during surgery. Methods. Thirty two consecutive patients, American Society of Anesthesiologists status II or III, scored as 2 or 3 on the Revised Cardiac Risk Index, scheduled to undergo major abdominal surgery were included in the study. Hemodynamic responses and pain scores were recorded throughout the procedure and on the first postoperative day. Blood samples were drawn before the procedure, 1 hr after incision, at the end of surgery and in the morning of the first postoperative day and analysed for BNP, troponin I, glucose, fibrinogen and C-reactive protein level. Results. Comparing the patients with increase in BNP level at the end of the surgery and those without significant differences were found in type of anesthesia (general anesthesia, 100% vs. 41.6%; combined (epidural + general) anesthesia, 0% vs. 58.3%; p=0,004), in mean heart rate (HR) during surgery (86.97 [79.71– 90.18] vs. 65.35 [60.28–71.18]; р=0.002), in the percentage of time during surgery HR remained at more than 90 beats/min (34.7% [20.4–47.9] vs. 0% [0–0]; p=0.0001), in glucose level 1 hr after incision (6.4 [5.7–7.6] vs. 4.5 [4.0–5.4]; р=0.005). Significant differences between patients with increase in BNP level in the morning of the first postoperative day and those without were found in type of analgesia (intravenous patient-controlled analgesia with morphine, 100% vs. 33.3%; epidural analgesia, 0% vs. 66.6%; p<0.001), in mean postoperative MAP (118.33 [112.72–119.33] vs. 93,33 [88,38–110.0]; р<0.001), mean postoperative pain scores at rest (33.5 [29.0–38.0] vs. 16.66 [14.0–24.0]; р<0.001) and during coughing (57.87 [50.75–65.0] vs. 29.33 [26.33–43.00]; р<0.001). Conclusions. Increase in BNP level during abdominal surgery was associated with tachycardia and hyperglycaemia. In the postoperative period hypertension and high pain scores predicted BNP level elevation. Thoracic epidural anaesthesia and analgesia abolish increase in BNP level during abdominal surgical procedures and on the first postoperative day.
References
Hypoxia induces B-type natriuretic peptide release in cell lines derived from human cardiomyocytes / G. Casals, J. Ros, A. Sionis [et al.] // Am J Physiol Heart Circ Physiol. – 2009. – Vol. 297. – P. H550–H555.
Acute myocardial hypoxia increases BNP gene expression / J. P. Goetze, A. Gore, C. H. Moller [et al.] // FASEB J. – 2004. – Vol. 18. – P. 1928–1930.
The Breathing Not Properly Multinational Study Investigators: Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure / A. S. Maisel, P. R. Krishnaswamy, R. M. Nowak [et al.] // N Engl J Med. – 2002. – Vol. 347. – P. 161–167.
Weber M. Role of b-type natriuretic peptide (BNP) and NT-proBNP in clinical routine / M. Weber, C. Hamm // Heart. – 2006. – Vol. 92. – P. 843–849.
Daniels L. B. Natriuretic peptides / L. B. Daniels, A. S. Maisel // J Am Coll Cardiol. – 2007. – Vol. 50. – P. 2357–2368.
B-type natriuretic peptide predicts sudden death in patients with chronic heart failure /R. Berger, M. Huelsman, K. Strecker [et al.] // Circulation. – 2002. – Vol. 105. – P. 2392–2397.
N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease / C. Kragelund, B. Gronning, L. Kober [et al.] // N Engl J Med. – 2005. – Vol. 352. – P. 666–675.
B-type natriuretic peptide and ischemia in patients with stable coronary disease: Data from the Heart and Soul study / K. Bibbins-Domingo, M. Ansari, N. B. Schiller [et al.] // Circulation. – 2003. – Vol. 108. – P. 2987–2992.
The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes / J. A. De Lemos, D. A. Morrow, J. H. Bentley [et al.] // N Engl J Med. – 2001. – Vol. 345. – P. 1014–1021.
A-type and B-type natriuretic peptides in cardiac surgical procedures / E. Berendes, C. Schmidt, H. Van Aken [et al.] // Anesth Analg. – 2004. – Vol. 98. – P. 11–19.
Simultaneous measurement of cardiac troponin I, B-type natriuretic peptide, and C-reactive protein for the prediction of long-term cardiac outcome after cardiac surgery / J. L. Fellahi, J. L. Hanouz, Y. Le Manach [et al.] // Anesthesiology. – 2009. – Vol. 111. – P. 250–257.
Preoperative B-type natriuretic peptide is as independent predictor of ventricular dysfunction and mortality after primary coronary artery bypass grafting / A. A. Fox, S. K. Shernan, C. D. Collard [et al.] // J Thorac Cardiovasc Surg. – 2008. – Vol. 136. – P. 452–461.
Prognostic value of brain natriuretic peptide in noncardiac surgery: A meta-analysis / A. D. S. Ryding, S. Kumar, A. M. Worthington, D. Burgess // Anesthesiology. – 2009. – Vol. 111. – P. 311–319.
Dernellis J. M. Assessment of cardiac risk before noncardiac surgery: Brain natriuretic peptide in 1590 patients / J. M. Dernellis, M. P. Panaretou // Heart. – 2006. – Vol. 92. – P. 1645–1650.
Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non-cardiac surgery / B. H. Cuthbertson, A. R. Amiri1, B. L. Croal [et al.] // Br J Anaesth. – 2007. – Vol. 99. – P. 170–176.
Preoperative plasma N-terminal pro-brain natriuretic peptide concentration and perioperative cardiovascular risk in elderly patients / K. H. Yun, M. H. Jeong, S. K. Oh [et al.] // Circ J. – 2008. – Vol. 72 (2). – P. 195–199.
Comparison of the utility of preoperative versus postoperative B-type natriuretic peptide for predicting hospital length of stay and mortality after primary coronary artery bypass grafting / A. A. Fox, J. D. Muehlschlegel, S. C. Body [et al.] // Anesthesiology. – 2010. – Vol. 112. – P. 842–851.
Increased peak postoperative B-type natriuretic peptide predicts decreased longer-term physical function after primary coronary artery bypass graft surgery / A. A. Fox, E. R. Marcantonio, C. D. Collard [et al.] // Anesthesiology. – 2011. – Vol. 114. – P. 807–816.
N-terminal pro-brain natriuretic peptide identifies patients at high risk for adverse cardiac outcome aftervascular surgery / E. Mahla, A. Baumann, P. Rehak [et al.] // Anesthesiology. – 2007. – Vol. 106. – P. 1088–1095.
Beattie W. S. Epidural analgesia reduces postoperative myocardial infarction: A metaanalysis / W. S. Beattie, N. H. Badner, P. Choi // Anesth Analg. – 2001. – Vol. 93. – P. 853–858.
Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: A meta-analysis / D. M. Popping, N. Elia, E. Marret [et al.] // Arch Surg. – 2008. – Vol. 143 (10). – P. 990–999.
Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA) / D. Poldermans, J. J. Bax, E. Boersma [et al.] // European Heart Journal. – 2009. – Vol. 30. – P. 2769–2812.
Continuous intra- and postoperative thoracic epidural analgesia attenuates brain natriuretic peptide release after major abdominal surgery / S. Suttner, K. Lang, S. N. Piper [et al.] // Anesth Analg. – 2005. – Vol. 101. – P. 896–903.
Does tight heart rate control improve beta-blocker efficacy? An updated analysis of the noncardiac surgical randomized trials / W. S. Beattie, D. N. Wijeysundera, K. Karkouti [et al.] // Anesth Analg. – 2008. – Vol. 106. – P. 1039–1048.
