Apakah Epidural Preemtif Menghambat Stres Pembedahan dengan Sempurna? - Ahmad, Muh. Rumli; Bisri, Tatang (Majalah Kedokteran Bandung, 2013)
Analgesia preemtif adalah pemberian regimen analgesik sebelum onset stimulus noksius. Kerusakan jaringan akibat pembedahan menimbulkan rangsang noksius, melalui dua jalur input noksius ke susunan saraf pusat (SSP), melalui jalur neural dan jalur sirkulasi. Penelitian uji klinik tersamar ganda mengikutsertakan 48 pasien yang menjalani pembedahan orthopedi tungkai bawah. Dibagi 2 kelompok: kelompok I (n=24) diberikan bupivakain 0,25% 10 mL dan kelompok II (n=24) diberikan NaCl 0,9% melalui epidural sebagai kontrol sebelum dilakukan induksi. Kedua kelompok diberikan anestesi umum. Selama pembedahan pada kelompok I diberikan 5 mL bupivakain 0,25% selang 90 menit, sedangkan pada kelompok kontrol diberikan 5 mL NaCl 0,9% dengan selang waktu yang sama. Pascabedah kedua kelompok diberikan bupivakain 0,25% secara kontinu 4 mL/jam sampai 24 jam pascabedah. Pengukuran kadar sitokin: tumor necrosis factor- α (TNF-α), interleukin-1β (IL-1β), IL-6 dan IL-10 dilakukan sebelum induksi anestesi, pascabedah dini, jam ke-4, 8, dan 24 pascabedah. Kelompok I memperlihatkan dinamika kadar proinflamasi lebih rendah dibandingkan dengan kelompok II namun secara statisik tidak bermakna (p>0,05). Sebaliknya, kadar sitokin antiinflamasi lebih tinggi pada kelompok epidural, namun tidak berbeda bermakna (p>0,05). Intensitas nyeri pada 4 jam, 8 jam, 24 jam pascabedah secara nyata lebih rendah pada kelompok I (p<0,05). Respons hemodinamik juga ditemukan lebih rendah pada kelompok I walaupun tidak berbeda nyata ( p>0,05) kecuali pada pascabedah dini namun tidak secara sempurna. Simpulan, pemberian analgetik epidural preemtif menghasilkan analgesia disertai hemodinamik yang stabil dibandingkan tanpa epidural preemtif, namun epidural premtif tidak dapat menekan produksi sitokin proinflamasi dan antiinflamasi. [MKB. 2013;45(3):147–54]Kata kunci: Epidural preemtif, hemodinamik, intensitas nyeri, sitokin Does Preemptive Epidural Analgesia Completely Blok Surgical Stress Responses?Preemptive analgesia is initiating an analgesic regimen before the onset of the noxious stimulus. Damages to the tissue caused by surgical trauma generate noxious response conveyed to the central nervous system (CNS) by two pathways, neural pathway and circulatory pathway. This study is a double- blinded clinical trial that included 48 patients undergoing lower extremity orthopedic surgery. The subjects were divided into two groups: group I (n=24) received 10 mL bupivacaine 0.25% from epidural route, and group II (n=24) received 10 mL NaCl 0.9% from epidural route as the control group before induction of anesthesia. Both groups were anesthetized under general anesthesia. Group I received 5 mL bupivacaine 0,5% every 90 minutes and group II received 5 mL NaCl 0,9 with similar time intraoperatively. Post-operatively, both groups received continuous bupivacaine 0,25% 4 mL/ hour until 24 hours after surgery. Measurements of cytokine levels: tumor necrosis factor-α (TNF-α), interleukin- 1β (IL-1β), IL-6 and IL-10 were done before induction of anesthesia, in the early post-operative period, at 4, 8, and 24 hours after surgery. Group I showed lower level proinflammatory cytokines level compared with group II but the difference was not statistically significant (p>0.05). The level of anti-inflammatory cytokine was higher in group I, but the difference was not statistically significant (p>0.05). Pain intensity at 4 hours, 8 hours, 24 jam hours post operative was lower significantly (p<0.05) Hemodynamic responses was lower in group I but not significant (p>0.05) excepst at early postoperative period (p<0.05). Generally, preemptive epidural analgesia was able to suppress the cytokine responses, but not completely. In conclusion, preemptive epidural analgesia is associated with better analgesia and better hemodynamic stability compared without preemptive epidural, but unable to suppress the production of proinflammatory and anti-inflammatory cytokines. [MKB. 2013;45(3):147–54]Key words: Cytokines, hemodynamic, pain intensity, preemptive epidural DOI: http://dx.doi.org/10.15395/mkb.v45n3.144