The Role of the Phrenic Nerves in Stress Response in Upper Abdominal Surgery

Abstract

Previous studies have failed to demonstrate a block of the endocrine response to upper abdominal surgery by thoracic epidural analgesia. To clarify the bases for this failure, we compared the effects of epidural analgesia of different dermatome levels up to C8-T2 or C3-4. The patients who received general anesthesia alone showed significant increases of adrenocorticotropic hormone (ACTH) and arginine vasopressin (AVP) immediately after skin incision. The patients with C8-T2 blocked developed significant increases in these hormones, not after the skin incision, but after the intraabdominal procedure. Of the eight patients with C3-4 block, six developed no such responses throughout the study period. The responses of oxytocin (OXT) and prolactin (PRL) were more susceptible to epidural analgesia and were blocked at the C8-T2 level. Growth hormone (GH) showed no correlation with surgical procedures and epidural block. These findings indicate that the nociceptive neural information during upper abdominal surgery is conveyed by the sensory fibers included in both the thoracic and lumbar spinal nerves that innervate the abdominal wall and the intraabdominal viscera, and by the phrenic nerves that innervate the diaphragm. The rationale for postulating the involvement of the phrenic nerves can be referred to the embryonal descent of the diaphragm from the C3-5 myotomes that serves as the upper wall of the abdominal cavity.

Preincisional intravenous low-dose ketamine and local infiltration with ropivacaine reduces postoperative pain after laparoscopic cholecystectomy

“…The visceroperitoneal organs are innervated multiply by the spinal nerves T5-T12 [13], the vagus nerve [5,6,14], and the phrenic nerve (C3-C5) [8,13] in the upper abdomen. All of these nerves are closely associated with visceroperitoneal nociception.…”

Comparasion of Effect of Epidural and Intravenous Analgesia on Stress Response in Laparoscopic Hiatal Hernia Surgery

“…Segawa ve ark. (11) 'da benzer şekilde frenik sinirin cerrahi stres sonrası gelişen nöral uyarıda önemli rol oynadığını ve baskılanmasının ancak yüksek servikal blokla mümkün olabileceğini belirtmiştir.…”

“…Oluşan hiperinsülinizm ve hiperglisemik yanıtı değişik anestezi metodları ile azaltmak mümkün olmakla beraber özellikle üst batın cerrahisinde bu etki daha azdır. (11,12) Epidural analjezi uygulanan grupta intravenöz gruba oranla 6. saatteki anlamlı yüksek glukoz düzeyleri, bu gruptaki hastaların postoperatif dönemde ortalama arter basınçlarının intravenöz analjezi uygulanan gruba oranla daha düşük saptanarak daha fazla sıvı infüzyonuna gereksinim duymuş olabileceği ve cerrahi serviste uygulanan glukoz içerikli sıvıların bu dönemdeki artıştan sorumlu tutulabileceği düşünülmüştür.…”

Effects of atrial natriuretic peptide at a low dose on water and electrolyte metabolism during general anesthesia

“…Surgical injury activates the renin-angiotensin-aldosterone system, ADH secretion, ACTH-cortisol system; these are involved in renal vasoconstriction, antidiuresis, and fluid and sodium retention [14,15]. Atrial natriuretic peptide increases salt and water excretion mediated by an increase in the glomerular filtration rate, reduction of tubular sodium reabsorption, and inhibition of the tubular actions of angiotensin II, aldosterone, and ADH [1,2].…”

“…Increases in circulating catecholamines, vasopressin, resin, angiotensin II, ACTH, and cortisol occur in patients under surgical stress, promoting renal and peripheral vasoconstriction and salt and water retention [14,15], which may persist for several days. As well, anesthetic agents generally decrease GFR and urine output [16].…”