Influence of postoperative analgesia on systemic inflammatory response and postoperative cognitive dysfunction after femoral fractures surgery: a randomized controlled trial

Reg Anesth Pain Med. 2019 Jan;44(1):59-68. doi: 10.1136/rapm-2018-000023.

Abstract

Background and objectives: To investigate the possible effect of postoperatively applied analgesics-epidurally applied levobupivacaine or intravenously applied morphine-on systemic inflammatory response and plasma concentration of interleukin (IL)-6 and to determine whether the intensity of inflammatory response is related to postoperative cognitive dysfunction (POCD).

Methods: This is a randomized, prospective, controlled study in an academic hospital. Patients were 65 years and older scheduled for femoral fracture fixation from July 2016 to September 2017. Inflammatory response was assessed by leukocytes, neutrophils, C reactive protein (CRP) and fibrinogen levels in four blood samples (before anesthesia, 24 hours, 72 hours and 120 hours postoperatively) and IL-6 concentration from three blood samples (before anesthesia, 24 hours and 72 hours postoperatively). Cognitive function was assessed using the Mini-Mental State Examination preoperatively, from the first to the fifth postoperative day and on the day of discharge.

Results: The study population included 70 patients, 35 in each group. The incidence of POCD was significantly lower in the levobupivacaine group (9%) than in the morphine group (31%) (p=0.03). CRP was significantly lower in the levobupivacaine group 72 hours (p=0.03) and 120 hours (p=0.04) after surgery. IL-6 values were significantly lower in the levobupivacaine group 72 hours after surgery (p=0.02). The only predictor of POCD in all patients was the level of IL-6 72 hours after surgery (p=0.03).

Conclusions: There is a statistically significant association between use of epidural levobupivacaine and a reduction in some inflammatory markers. Postoperative patient-controlled epidural analgesia reduces the incidence of POCD compared with intravenous morphine analgesia in the studied population.

Trial registration number: NCT02848599.

Keywords: elderly; femoral fractures; pocd; postoperative analgesia; systemic inflammatory response.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Aged, 80 and over
  • Analgesia, Epidural / methods*
  • Analgesia, Epidural / trends
  • Analgesics, Opioid / administration & dosage
  • Analgesics, Opioid / adverse effects
  • Anesthetics, Local / administration & dosage
  • Anesthetics, Local / adverse effects
  • Female
  • Femoral Fractures / drug therapy
  • Femoral Fractures / surgery*
  • Humans
  • Male
  • Pain, Postoperative / chemically induced
  • Pain, Postoperative / diagnosis
  • Pain, Postoperative / prevention & control*
  • Postoperative Cognitive Complications / chemically induced
  • Postoperative Cognitive Complications / diagnosis
  • Postoperative Cognitive Complications / prevention & control*
  • Prospective Studies
  • Systemic Inflammatory Response Syndrome / chemically induced
  • Systemic Inflammatory Response Syndrome / diagnosis
  • Systemic Inflammatory Response Syndrome / prevention & control*

Substances

  • Analgesics, Opioid
  • Anesthetics, Local

Associated data

  • ClinicalTrials.gov/NCT02848599