连续股神经阻滞对全膝关节置换术后疼痛、康复和应激反应的影响
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摘要
目的
评价连续股神经阻滞(Continuous Femoral Nerve Block,CFNB)能否降低全膝关节置换术(Total Knee Arthroplasty,TKA)病人的术后疼痛评分,提高病人对康复治疗的配合能力,减轻手术带来的应激反应。
方法
将32例全麻TKA病人随机分成两组,分别接受静脉病人自控镇痛(IVPatient-controlled Analgesia,PCIA)和CFNB作为术后镇痛方式。记录术中血流动力学和芬太尼用量;病人离PACU时、术后4、8、12、24、48小时的静息和活动VAS评分,吗啡的使用量;术后第一天(Postoperative Day 1,POD1)和第二天(POD2)的CPM角度;采集病人入室,切皮,术毕,POD1,POD2的血样检测白细胞计数、乳酸、血糖、C反应蛋白和皮质醇。
结果
试验组术中芬太尼用量明显少于对照组(P＜0.05),术后各个时间点试验组的静息和活动疼痛评分均低于对照组(P＜0.05),试验组的吗啡累计消耗量均显著低于对照组(P＜0.05),试验组的嗜睡、恶心呕吐等副作用的发生率是对照组的一半(P＜0.05),试验组术后第一天和第二天的持续被动运动(ContinuousPassive Motion,CPM)角度均大于对照组(P＜0.05),试验组病人对麻醉和术后镇痛的满意度高于对照组(P＜0.05),两组术中及术后各时间点的血糖、乳酸、CRP、皮质醇、白细胞计数均无显著差异。
结论
在全麻诱导前进行股神经阻滞并留置导管用于术后镇痛可以使术中血流动力学更加平稳,减少术中阿片类药物的用量;显著地降低术后静息和活动疼痛评分,大大降低了术后吗啡消耗量,从而降低了吗啡导致的嗜睡、恶心呕吐等副作用的发生率;使病人更好地耐受术后持续膝关节被动运动,加速了膝关节功能的恢复;提高了病人的满意度。单独连续股神经阻滞对手术引起的应激反应的抑制作用有待于进一步研究。
OBJECTIVE
To assess the influence of continuous femoral nerve block (CFNB) and IV patient-controlled analgesia (PCIA) on postoperative pain scores, knee rehabilitation and stress response after total knee arthroplasty (TKA).
METHODS
The trial was designed as a randomized and controlled study. Before standardized general anesthesia, 32 adult patients scheduled for elective total knee arthroplasty were randomly assigned to CFNB group or PCIA group to receive a different postoperative analgesic technique for 48 hours. Pain was assessed at rest and during continuous passive motion (CPM) using a visual analog scale at PACU and 4, 8,12,24,48 hours postoperatively and morphine consumption was also recorded. The maximal amplitude of knee flexion was measured during CPM in the first postoperative day (POD1) and POD2. As indicators of stress and inflammatory response, changes in the leukocyte count, serum lactic acid, blood glucose, serum C-reactive protein(CRP) and serum cortisol were determined on admission to OR, immediately after skin incision, before extubation, POD1 and POD2, respectively.
RESULTS
Intraoperative consumption of fentanyl was significantly lower in CFNB group than in PCIA group, (137.5±44.4 ug vs. 264.1±67.1 ug, respectively, P<0.05) . The CFNB group showed significantly lower VAS scores both at rest and during CPM compared with PCIA group at all time points (P<0.05) . Morphine consumption was significantly lower in CFNB group than in PCIA group (P<0.05) . The incidence of side effects such as somnolence, nausea and vomiting in CFNB group was half of that of PCIA group. The CPM amplitude of CFNB group was significantly larger compared with PCIA group on both POD1 and POD2 (P<0.05) . Patient satisfaction was higher in CFNB group than in PCIA group, (93.1±7.9 vs. 79.1±11.9, respectively, P<0.05) . No significant differences were observed between the groups in circulating levels of leukocyte count, serum lactic acid, blood glucose, serum C-reactive protein(CRP) and serum cortisol.
CONCLUSIONS
In this study, we determined that, after TKA, CFNB technique provides better pain relief and faster postoperative knee rehabilitation than traditional PCIA. A single CFNB can not attenuate the postoperative stress and inflammatory responses.
评价连续股神经阻滞(Continuous Femoral Nerve Block,CFNB)能否降低全膝关节置换术(Total Knee Arthroplasty,TKA)病人的术后疼痛评分,提高病人对康复治疗的配合能力,减轻手术带来的应激反应。
方法
将32例全麻TKA病人随机分成两组,分别接受静脉病人自控镇痛(IVPatient-controlled Analgesia,PCIA)和CFNB作为术后镇痛方式。记录术中血流动力学和芬太尼用量;病人离PACU时、术后4、8、12、24、48小时的静息和活动VAS评分,吗啡的使用量;术后第一天(Postoperative Day 1,POD1)和第二天(POD2)的CPM角度;采集病人入室,切皮,术毕,POD1,POD2的血样检测白细胞计数、乳酸、血糖、C反应蛋白和皮质醇。
结果
试验组术中芬太尼用量明显少于对照组(P＜0.05),术后各个时间点试验组的静息和活动疼痛评分均低于对照组(P＜0.05),试验组的吗啡累计消耗量均显著低于对照组(P＜0.05),试验组的嗜睡、恶心呕吐等副作用的发生率是对照组的一半(P＜0.05),试验组术后第一天和第二天的持续被动运动(ContinuousPassive Motion,CPM)角度均大于对照组(P＜0.05),试验组病人对麻醉和术后镇痛的满意度高于对照组(P＜0.05),两组术中及术后各时间点的血糖、乳酸、CRP、皮质醇、白细胞计数均无显著差异。
结论
在全麻诱导前进行股神经阻滞并留置导管用于术后镇痛可以使术中血流动力学更加平稳,减少术中阿片类药物的用量;显著地降低术后静息和活动疼痛评分,大大降低了术后吗啡消耗量,从而降低了吗啡导致的嗜睡、恶心呕吐等副作用的发生率;使病人更好地耐受术后持续膝关节被动运动,加速了膝关节功能的恢复;提高了病人的满意度。单独连续股神经阻滞对手术引起的应激反应的抑制作用有待于进一步研究。
OBJECTIVE
To assess the influence of continuous femoral nerve block (CFNB) and IV patient-controlled analgesia (PCIA) on postoperative pain scores, knee rehabilitation and stress response after total knee arthroplasty (TKA).
METHODS
The trial was designed as a randomized and controlled study. Before standardized general anesthesia, 32 adult patients scheduled for elective total knee arthroplasty were randomly assigned to CFNB group or PCIA group to receive a different postoperative analgesic technique for 48 hours. Pain was assessed at rest and during continuous passive motion (CPM) using a visual analog scale at PACU and 4, 8,12,24,48 hours postoperatively and morphine consumption was also recorded. The maximal amplitude of knee flexion was measured during CPM in the first postoperative day (POD1) and POD2. As indicators of stress and inflammatory response, changes in the leukocyte count, serum lactic acid, blood glucose, serum C-reactive protein(CRP) and serum cortisol were determined on admission to OR, immediately after skin incision, before extubation, POD1 and POD2, respectively.
RESULTS
Intraoperative consumption of fentanyl was significantly lower in CFNB group than in PCIA group, (137.5±44.4 ug vs. 264.1±67.1 ug, respectively, P<0.05) . The CFNB group showed significantly lower VAS scores both at rest and during CPM compared with PCIA group at all time points (P<0.05) . Morphine consumption was significantly lower in CFNB group than in PCIA group (P<0.05) . The incidence of side effects such as somnolence, nausea and vomiting in CFNB group was half of that of PCIA group. The CPM amplitude of CFNB group was significantly larger compared with PCIA group on both POD1 and POD2 (P<0.05) . Patient satisfaction was higher in CFNB group than in PCIA group, (93.1±7.9 vs. 79.1±11.9, respectively, P<0.05) . No significant differences were observed between the groups in circulating levels of leukocyte count, serum lactic acid, blood glucose, serum C-reactive protein(CRP) and serum cortisol.
CONCLUSIONS
In this study, we determined that, after TKA, CFNB technique provides better pain relief and faster postoperative knee rehabilitation than traditional PCIA. A single CFNB can not attenuate the postoperative stress and inflammatory responses.
引文
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68. Barrington MJ, Olive DJ, McCutcheon CA, et al. Stimulating catheters for continuous femoral nerve blockade after total knee arthroplasty: a randomized, controlled, double-blinded trial.Anesth Analg 2008; 106:1316-1321.
69. Dauri M, Sidiropoulou T, Fabbi E, et al. Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2007; 32:282-287.
70.Gucev G, Yasui GM, Chang TY, Lee J. Bilateral ultrasound-guided continuous ilioinguinal-iliohypogastric block for pain relief after cesarean delivery. Anesth Analg 2008; 106:1220-1222.
71.Van Geffen GJ, Gielen M. Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. Anesth Analg 2006; 103:328-333.
72. Swenson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg 2006;103:1436-1443.
73. Fredrickson MJ, Ball CM, Dalgleish AJ. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting. Reg Anesth Pain Med 2008; 33:122-128.
74. Gerhard B, Hartmut B, Hugo VA. Postoperative Analgesia After Knee Surgery: A Comparison of Three Different Concentrations of Ropivacaine for Continuous Femoral Nerve Blockade. Anesth Analg 2007;105:256 -62.
75. Shuai Tang, Xi Hong, Yuguang Huang, Hongzhi Ren, Tiehu Ye, Ailun Luo. Sufentanil does not enhance the efficacy of ropivacaine in combined lumbar plexus and sciatic block: A controlled, randomized clinical trial. Acute pain, 2007; 9,59-63.
76. Hadzic A, Vloka JD, Kuroda MM, et al. The practice of peripheral nerve blocks in the United States: a national survey. Reg Anesth Pain Med 1998;23:241 - 6.
77. Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia: results of a prospective survey in France.Anesthesiology 1997;87:479 - 86.
78. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: the SOS regional anesthesia hotline service. Anesthesiology 2002;97:1274 -80.
79. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001;93:1045-9.
80. Kost-Byerly S, Tobin JR, Greenberg RS, et al. Bacterial colonization and infectious rate of continuous epidural catheters in children. Anesth Analg 1998;86:712-6.
81.Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheters in critically ill patients. Intensive Care Med 1988;14:227-231.
82.Cuvillon P, Lalourcey L, Veyrat E, et al. Analgesie postoperatoire continue par catheter poplite' peripherique: innocuite'-efficacite'. Ann Fr Anesth Reanim 1998;17:991.
83. Marana R, Margutti F, Catalano GF, Marana E. Stress response to endoscopic surgery. Curr Opin Obstet Gynecol 2000;12:303- 7.
84. Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G.Systemic stress response after laparoscopic or open cholecyctectomy:a randomized trial. Br J Surg 1997;84:467 - 71.
85. Xin Xu Y, Ayala A, Chaudry IH. Prolonged immunodepression after trauma and hemorrhagic shock. J Trauma 1998;44:335 - 41.
86. Kehlet H. Stress free anesthesia and surgery. Acta Anaesthesiol Scand 1979;23:503- 4.
87. Malatinsky J, Vigas M, Jurcovicova I, Jezova D, Garayova S, Minarikova M. The patterns of endocrine response to surgical stress during different types of anaesthesia and surgery in man.Acta Anaesthesiol Belg 1986;37:23 - 31.
88. Bagry H, de la Cuadra Fontaine JC, Asenjo JF, et al. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.
89. Unase B, Cagatay D, Osman C. Effects of Different Anesthetic Techniques on Serum Leptin, C-reactive Protein, and Cortisol Concentrations in Anorectal Surgery. Croat Med J. 2006;47:862-8.
90. Khalil SN, Hanna E, Farag A. Presurgical caudal block attenuates stress response in children. Middle East J Anesthesiol. 2005 Jun;18(2): 391-400.
91. Leopold, Seth, Casnellie. Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty. Journal of Bone & Joint Surgery - American Volume. 2003;11:85-A(11):2163-2167.
92. Hema B, Juan C, Juan F. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.
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6. Serpell M, Millar F, Thomson M. Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement. Anaesthesia 1991;46:275-7.
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10. Singelyn FJ, Deyaert M, Joris D, et al. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty.Anesth Analg 1998;87:88 -92.
11.Malatinsky J, Vigas M, Jurcovicova I, Jezova D, Garayova S,Minarikova M. The patterns of endocrine response to surgical stress during different types of anaesthesia and surgery in man.Acta Anaesthesiol Belg 1986;37:23 - 31.
12. Bagry H, de la Cuadra Fontaine JC, Asenjo JF, et al. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.
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16. PROSPECT: Procedure-Specific Postoperative Pain Management. http://www.postoppain.org (accessed February 2009).
17.Capdevila X, Barthelet Y, Biboulet P, et al. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.Anesthesiology 1999;91:8 - 15.
18. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesthesiology 2002;96:1297- 1304.
19. Ilfeld BM, Morey TE, Wang RD, Enneking FK. Continuous popliteal sciatic nerve block for postoperative pain control at home: a randomized, doubleblinded, placebo-controlled study.Anesthesiology 2002;97:959 - 965.
20. Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005;100:1822-1833.
21. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology 2008; 108:703 -713.
22. Capdevila X, Dadure C, Bringuier S, et al. Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial.Anesthesiology 2006; 105:566-573.
23. Unase B, Cagatay D, Osman C. Effects of Different Anesthetic Techniques on Serum Leptin, C-reactive Protein, and Cortisol Concentrations in Anorectal Surgery. Croat Med J. 2006;47:862-8.
24. Hema B, Juan C, Juan F. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.
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20. Edwards ND, Wright EM. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement.Anesthesia and Analgesia 1992; 75: 265-7.
21. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM.Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesthesia and Analgesia 1998; 87: 88-92.
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25.Cole PJ, Craske DA, Wheatley RG. Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty. British Journal of Anaesthesia 2000; 85: 233-7.
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28. Tan PH, Chia YY, Lo Y, Liu K, Yang LC, Lee TH. Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery. Canadian Journal of Anaesthesia 2001; 48: 551-6.
29. Jacobson L, Kokri MS, Pridie AK. Intrathecal diamorphine: a dose-response study. Annals of the Royal College of Surgeons of England 1989; 71: 289-92
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32. Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G.Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiologica Scandinavica 1999; 43:1021 - 6.
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37. Axelsson K, Johanzon E, Essving P, Weckstrom J, Ekback G.Postoperative extradural analgesia with morphine and ropivacaine.A double-blind comparison between placebo and ropivacaine 10 mg h or 16 mg h. Acta Anaesthesiologica Scandinavica 2005; 49:1191-9.
38. Weir PS, Fee JP. Double-blind comparison of extradural block with three bupivacaine - ketamine mixtures in knee arthroplasty. British Journal of Anaesthesia 1998; 80: 299-301.
39. Kampe S, Diefenbach C, Kanis B, Auweiler M, Kiencke P, Cranfield K.Epidural combination of ropivacaine with sufentanil for postoperative analgesia after total knee replacement: a pilot study. European Journal of Anaesthesiology 2002; 19: 666-71.
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41.Ritter MA, Koehler M, Keating EM, Faris PM, Meding JB. Intra-articular morphine and or bupivacaine after total knee replacement. Journal of Bone and Joint Surgery - British Volume 1999; 81: 301-3.
42. Tanaka N, Sakahashi H, Sato E, Hirose K, Ishii S. The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis. Journal of Arthroplasty 2001; 16: 306-11.
43. Badner NH, Bourne RB, Rorabeck CH, Doyle JA. Addition of morphine to intra-articular bupivacaine does not improve analgesia following knee joint replacement. Regional Anesthesia 1997; 22:347 - 50
44. Confalonieri N, Manzotti A, Pullen C. Is closed-suction drain necessary in unicompartmental knee replacement? A prospective randomised study Knee 2004; 11: 399-402.
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48.Weinhardt C, Barisic M, Bergmann EG, Heller KD. Early results of subvastus versus medial parapatellar approach in primary total knee arthroplasty. Archives of Orthopaedic and Trauma Surgery 2004;124: 401-3.
49. Barwell J, Anderson G, Hassan A, Rawlings I. The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study. Journal of Bone and Joint Surgery- British Volume 1997; 79: 265-8
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52. Harms M, Engstrom B. Continuous passive motion as an adjunct to treatment in the physiotherapy management of the total knee arthroplasty patient. Physiotherapy 1991; 77: 301-7.
53. Webb JM, Williams D, Ivory JP, Day S, Williamson DM. The use of cold compression dressings after total knee replacement: a randomized controlled trial. Orthopedics 1998; 21: 59-61.
54. Angulo DL, Colwell CW Jr. Use of postoperative TENS and continuous passive motion following total knee replacement. Journal of Orthopaedic and Sports Physical Therapy 1990; 11: 599-604.
55. McDonald DD, Molony SL. Postoperative pain communication skills for older adults. Western Journal of Nursing Research 2004; 26:836-52; Discussion 53-9.
56. PROSPECT: Procedure-Specific Postoperative Pain Management.http://www.postoppain.org (accessed February 2009).
57. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006; 102:248-257.
58. Ilfeld BM, Morey TE, Enneking FK. Continuous infraclavicular brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study.Anesthesiology 2002; 96:1297-1304.
59. Ilfeld BM, Morey TE, Wang RD, Enneking FK. Continuous popliteal sciatic nerve block for postoperative pain control at home: a randomized, doubleblinded, placebo-controlled study.Anesthesiology 2002; 97:959-965.
60. Ilfeld BM, Enneking FK. Continuous peripheral nerve blocks at home: a review. Anesth Analg 2005; 100:1822-1833.
61. Ilfeld BM, Le LT, Meyer RS, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty:a randomized, triple-masked,placebo-controlled study. Anesthesiology 2008; 108:703-713.
62. Capdevila X, Dadure C, Bringuier S, et al. Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial.Anesthesiology 2006; 105:566-573.
63. Birnbaum J, Kip M, Spies CD, et al. The effect of stimulating versus nonstimulating catheters for continuous interscalene plexus blocks in short-term pain management. J Clin Anesth 2007; 19:434-439.
64. Rodr(?)guez J, Taboada M, Carceller J, et al. Stimulating popliteal catheters forpostoperative analgesia after hallux valgus repair.Anesth Analg 2006; 102: 258-262.
65. Casati A, Fanelli G, Koscielniak-Nielsen Z, et al. Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgusrepair as compared with conventional nonstimulating catheters. Anesth Analg 2005; 101:1192-1197.
66. Morin AM, Eberhart LH, Behnke HK, et al. Does femoral nerve catheter placement with stimulating catheters improve effective placement? A randomized, controlled, and observer-blinded trial.Anesth Analg 2005; 100:1503-1510.
67. Hayek SM, Ritchey RM, Sessler D, et al. Continuous femoral nerve analgesia after unilateral total knee arthroplasty: stimulating versus nonstimulating catheters. Anesth Analg 2006; 103:1565-1570.
68. Barrington MJ, Olive DJ, McCutcheon CA, et al. Stimulating catheters for continuous femoral nerve blockade after total knee arthroplasty: a randomized, controlled, double-blinded trial.Anesth Analg 2008; 106:1316-1321.
69. Dauri M, Sidiropoulou T, Fabbi E, et al. Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2007; 32:282-287.
70.Gucev G, Yasui GM, Chang TY, Lee J. Bilateral ultrasound-guided continuous ilioinguinal-iliohypogastric block for pain relief after cesarean delivery. Anesth Analg 2008; 106:1220-1222.
71.Van Geffen GJ, Gielen M. Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study. Anesth Analg 2006; 103:328-333.
72. Swenson JD, Bay N, Loose E, et al. Outpatient management of continuous peripheral nerve catheters placed using ultrasound guidance: an experience in 620 patients. Anesth Analg 2006;103:1436-1443.
73. Fredrickson MJ, Ball CM, Dalgleish AJ. Successful continuous interscalene analgesia for ambulatory shoulder surgery in a private practice setting. Reg Anesth Pain Med 2008; 33:122-128.
74. Gerhard B, Hartmut B, Hugo VA. Postoperative Analgesia After Knee Surgery: A Comparison of Three Different Concentrations of Ropivacaine for Continuous Femoral Nerve Blockade. Anesth Analg 2007;105:256 -62.
75. Shuai Tang, Xi Hong, Yuguang Huang, Hongzhi Ren, Tiehu Ye, Ailun Luo. Sufentanil does not enhance the efficacy of ropivacaine in combined lumbar plexus and sciatic block: A controlled, randomized clinical trial. Acute pain, 2007; 9,59-63.
76. Hadzic A, Vloka JD, Kuroda MM, et al. The practice of peripheral nerve blocks in the United States: a national survey. Reg Anesth Pain Med 1998;23:241 - 6.
77. Auroy Y, Narchi P, Messiah A, et al. Serious complications related to regional anesthesia: results of a prospective survey in France.Anesthesiology 1997;87:479 - 86.
78. Auroy Y, Benhamou D, Bargues L, et al. Major complications of regional anesthesia in France: the SOS regional anesthesia hotline service. Anesthesiology 2002;97:1274 -80.
79. Cuvillon P, Ripart J, Lalourcey L, et al. The continuous femoral nerve block catheter for postoperative analgesia: bacterial colonization, infectious rate and adverse effects. Anesth Analg 2001;93:1045-9.
80. Kost-Byerly S, Tobin JR, Greenberg RS, et al. Bacterial colonization and infectious rate of continuous epidural catheters in children. Anesth Analg 1998;86:712-6.
81.Collignon P, Soni N, Pearson I, et al. Sepsis associated with central vein catheters in critically ill patients. Intensive Care Med 1988;14:227-231.
82.Cuvillon P, Lalourcey L, Veyrat E, et al. Analgesie postoperatoire continue par catheter poplite' peripherique: innocuite'-efficacite'. Ann Fr Anesth Reanim 1998;17:991.
83. Marana R, Margutti F, Catalano GF, Marana E. Stress response to endoscopic surgery. Curr Opin Obstet Gynecol 2000;12:303- 7.
84. Karayiannakis AJ, Makri GG, Mantzioka A, Karousos D, Karatzas G.Systemic stress response after laparoscopic or open cholecyctectomy:a randomized trial. Br J Surg 1997;84:467 - 71.
85. Xin Xu Y, Ayala A, Chaudry IH. Prolonged immunodepression after trauma and hemorrhagic shock. J Trauma 1998;44:335 - 41.
86. Kehlet H. Stress free anesthesia and surgery. Acta Anaesthesiol Scand 1979;23:503- 4.
87. Malatinsky J, Vigas M, Jurcovicova I, Jezova D, Garayova S, Minarikova M. The patterns of endocrine response to surgical stress during different types of anaesthesia and surgery in man.Acta Anaesthesiol Belg 1986;37:23 - 31.
88. Bagry H, de la Cuadra Fontaine JC, Asenjo JF, et al. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.
89. Unase B, Cagatay D, Osman C. Effects of Different Anesthetic Techniques on Serum Leptin, C-reactive Protein, and Cortisol Concentrations in Anorectal Surgery. Croat Med J. 2006;47:862-8.
90. Khalil SN, Hanna E, Farag A. Presurgical caudal block attenuates stress response in children. Middle East J Anesthesiol. 2005 Jun;18(2): 391-400.
91. Leopold, Seth, Casnellie. Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty. Journal of Bone & Joint Surgery - American Volume. 2003;11:85-A(11):2163-2167.
92. Hema B, Juan C, Juan F. Effect of a Continuous Peripheral Nerve Block on the Inflammatory Response in Knee Arthroplasty. Reg Anesth Pain Med 2008;33:17-23.