Hindawi

Anesthesiology Research and Practice

Volume 2019, Article ID 7585043, 6 pages
https://doi.org/10.1155/2019/7585043

Research Article
Effect of Spinal Anesthesia versus General Anesthesia on Blood
Glucose Concentration in Patients Undergoing Elective Cesarean
Section Surgery: A Prospective Comparative Study

Khaled El-Radaideh ,1 Ala’’a Alhowary ,1 Mohammad Alsawalmeh,1

Ahmed Abokmael,1 Haitham Odat ,2 and Amer Sindiani 3
1
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Jordan University of Science and Technology,
P.O. Box 953, Irbid 21110, Jordan
2
Department of Special Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 953,
Irbid 21110, Jordan
3
Department of Obstetrics & Gynecology, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 953,
Irbid 21110, Jordan

Correspondence should be addressed to Khaled El-Radaideh; elradk61@yahoo.com

Received 16 July 2019; Accepted 3 September 2019; Published 1 October 2019

Academic Editor: Enrico Camporesi

Copyright © 2019 Khaled El-Radaideh et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. This prospective study compared the blood glucose concentration with spinal anesthesia or general anesthesia in
patients undergoing elective cesarean section surgery. Methods. In total, 58 pregnant women who underwent elective cesarean
section surgery were included in this prospective comparative study. Group S (n � 35) included patients who chose spinal
anesthesia, and group G (n � 23) included patients who chose general anesthesia. The patients were allocated to the groups upon
patients’ preference. For the group G, the blood glucose concentration (BGC) was obtained 5 minutes before induction, T1, and
5 minutes after induction T2. For the group S, the BGC was obtained immediately before the injection of the local anesthetic agent
T1 and 5 minutes after the complete block T2. For both groups, BGC was measured 5 minutes before the end of surgery T3 and
30 minutes after the end of surgery T4. For BGC measurements, we used a blood glucose monitoring system with a lancet device to
prick the finger. Results. There was no statistically significant difference in the mean blood glucose concentration between the
groups S and G in T1 (78.3 ± 18.2 vs. 74.3 ± 14.7, p > 0.05) and T2 (79.2 ± 18.3 vs. 84.9 ± 23.7, p > 0.05). The mean BGC was
statistically significantly higher in group G in comparison to group S in the times 5 minutes before (80.2 ± 18.1 vs. 108.4 ± 16.7,
p < 0.05) and 30 minutes after the end of surgery (80.9 ± 17.7 vs. 121.1 ± 17.4, p < 0.05). Conclusion. There is a much lower increase
in blood glucose concentration under spinal anesthesia than under general anesthesia. It is reasonable to suggest that the blood
sugar concentration must be intraoperatively monitored in patients undergoing general anesthesia.

1. Introduction and immunological changes triggered by neuronal activa-

tion of the hypothalamic-pituitary-adrenal axis [6, 7]. The
Spinal anesthesia has become the preferred anesthetic overall metabolic effect of the stress response to surgery
technique when providing anesthesia for patients un- includes an increase in secretion of catabolic hormones, such
dergoing elective cesarean section as the risk of maternal and as cortisol and catecholamine, and a decrease in secretion of
fetal complications associated with spinal anesthesia is less anabolic hormones, such as insulin and testosterone. The
than with general anesthesia [1–5]. increase in levels of catabolic hormones in plasma stimulates
Every surgical procedure is associated with a stress re- glucose production, and there is a relative lack of insulin
sponse which comprises a number of endocrine, metabolic, together with impaired tissue insulin sensitivity and glucose
2 Anesthesiology Research and Practice

utilization, which is called insulin resistance. Consequently, was administered through a simple face mask with a flow
blood glucose concentrations will increase, even in the of 4 liters per minute.
absence of preexisting diabetes [6–9]. For group G, after breathing oxygen for 3 minutes via a
The hyperglycemic response to surgical stresses in the face mask, anesthesia was induced with 2–2.5 mg/kg pro-
perioperative period may harm patients since it is an in- pofol and 0.6 mg/kg rocuronium to facilitate tracheal in-
dependent risk factor associated with adverse outcomes such tubation and with rapid sequence intubation using a regular
as impaired wound healing and an increased risk of wound 6.5 mm ID endotracheal tube. After delivery of the baby and
infection [7, 9, 10]. The risk related to hyperglycemia is seen cutting the umbilical cord, 3 μg/kg fentanyl was given. Before
in patients both with and without a history of diabetes [11]. delivery of the baby, anesthesia was maintained with 0.7%
Notably, even short-term hyperglycemia compromises im- isoflurane in 50% oxygen and 50% nitrous oxide, and after
mune function and increases the risk of infection [9, 12, 13]. delivery and cutting the umbilical cord, anesthesia was
In surgical patients, the stress response is activated by maintained with a propofol infusion at a rate of 150 μg/kg/
afferent neural activity from the site of trauma. These af- min and the inhaled anesthetic agents were discontinued.
ferent neurons travel along sensory nerve roots through the ETCO2 was maintained between 30 mmHg and 40 mmHg
dorsal root of the spinal cord up the spinal cord to the throughout the surgery. At the end of surgery, anesthetic
medulla to activate the hypothalamus. Neuraxial anesthesia maintenance was discontinued, and reversal of the neuro-
such as epidural or spinal anesthesia blocks afferent neural muscular blockade consisting of 2.5 mg of neostigmine and
impulses; consequently, the stress response to surgery in- 1 mg of atropine was given intravenously (IV). The extu-
cluding hyperglycemia is inhibited [6, 7, 14, 15]. bation of the trachea was performed when the patient was
In the present study, we tested the hypothesis that spinal breathing spontaneously with a good tidal volume, fully
anesthesia would result in a less-pronounced stress-induced awake, and could sustain head elevation for more than
hyperglycemia than general anesthesia during cesarean 5 seconds.
sections in nondiabetic patients. Upon arrival at the operating theater, both groups re-
ceived 750 mg of cefuroxime IV, 8 mg of dexamethasone IV,
2. Materials and Methods 50 mg of ranitidine IV, and 10 mg of metoclopramide IV
before starting anesthesia. After delivery of the baby, both
After obtaining formal approval from the institutional ethics groups received 10 IU oxytocin IV bolus and 20 IU oxytocin
committee (approval no. 3492017), a prospective compar- infusion over 1 hour. Both groups were given 2000–3000 ml
ative study included 58 pregnant women scheduled for the crystalloids IV; half of the amount was 0.9% normal saline,
elective cesarean section at King Abdullah University and the other half was Ringer’s lactate solution.
Hospital. Written informed consents for participation in the For the group G, the blood glucose concentration (BGC)
study were obtained from all patients. was obtained 5 minutes before induction (T1) and 5 minutes
The criteria for inclusion in this study were female after induction (T2). For the group S, the BGC was obtained
patients who were scheduled for elective cesarean section, immediately before the injection of the local anesthetic agent
American Society of Anesthesiologists (ASA) physical status (T1) and 5 minutes after the complete block (T2). For both
of I–II, above 18 years of age, and fasting time preoperatively groups, the blood glucose concentration was measured
between 8 and 12 hours. Patients with diabetes mellitus type 5 minutes before the end of surgery, T3, and 30 minutes after
1, diabetes mellitus type 2, gestational diabetes, chronic the end of surgery in the postanesthesia care unit, T4, using a
advanced renal disease, heart failure, ischemic heart disease, blood glucose monitoring kit with a lancet device (Joycoo
eclampsia, preeclampsia, and psychiatric disorders were BG-102; Joycoo, Amman, Jordan). After disinfecting with
excluded. All patients with failed spinal anesthesia and those alcohol, swap the tips of the fingers of the nondominant
who had converted to general anesthesia from spinal an- hand pricked with a lancet tip to measure the blood glucose
esthesia were excluded. concentration.
On arrival at the operating theater, two intravenous
access sites were prepared. For all participants in the study,
standard monitoring of blood pressure, three-lead electro- 2.1. Statistical Analysis. A sample size of 20 patients per
cardiogram, and pulse oximetry oxygen saturation were group was required to achieve a power of 0.80 and alpha of
conducted and continuously monitored during the intra- 0.05 based on a hypothetical 25% increase in glucose con-
operative period in the operating theater and during the centration either at the end of surgery or after surgery. Mean
postoperative period in the postanesthesia care unit. age, weight, and fasting time were compared in group S and
The patients were electively allocated to two groups (S group G using the t-test. To test for statistically significant
and G). Group S included patients who chose spinal an- differences between the four blood glucose readings and
esthesia, and group G included patients who chose general their interaction with the type of anesthesia, repeated
anesthesia. measures of analysis of variance were conducted and the
For group S, spinal anesthesia was administered under results of such analyses are reported in Tables 1 and 2.
aseptic conditions, at the level of L3-L4 or L4-L5 of the Statistical analyses were performed using SPSS for Windows
spinal column. Spinal anesthesia was performed with version 18.0 (SPSS Inc., Chicago, IL, USA). All values were
2.3 ml of 0.5% heavy bupivacaine and 0.4 ml of 0.005% expressed as mean ± SD unless otherwise specified, and p
fentanyl using 25- or 27-gauge spinal needles; 100% O2 values <0.05 were considered to be statistically significant.
Anesthesiology Research and Practice 3

Table 1: Multivariate testsa on glucose-check data and type of anesthesia for patients included in the study.
Hypothesis
Effect Error
Value F df Significance
df
Glucose-check Wilks’ lambda 0.168 88.838b 3.000 54.000 0.000
Glucose level ∗ type b
Wilks’ lambda 0.204 70.440 3.000 54.000 0.000
of anesthesia
a b
Design: intercept + type of anesthesia. Within-subjects design: glucose-check. Exact statistic.

Table 2: Tests of within-subjects effects for patients included in the study.

Measure: readings
Type III sum Mean
Source df F Significance
of squares square
Glucose-check Sphericity assumed 21192.823 3 7064.274 131.448 0.000
Glucose level ∗ type
Sphericity assumed 17143.099 3 5714.366 106.329 0.000
of anesthesia
Error (glucose-check) Sphericity assumed 9028.673 168 53.742

3. Results There has been a great deal of interest in the potential

beneficial effects of preservation of glucose homeostasis
The two groups were statistically equivalent with regard to and early avoidance of stress-induced hyperglycemia in
age, weight, and fasting duration, as indicated in Table 3, surgical patients by modification of the stress response.
which shows the means, standard deviations, and t-test Acute hyperglycemia, a typical feature of the metabolic
statistic for the difference between the mean values. Table 4 response to surgery, has been demonstrated to significantly
shows the means and standard deviations for the four compromise immune function and contributes to poor
glucose-check readings for the two groups. The mean values clinical outcome [9, 12, 13, 16]. The degree of this response
for the general anesthesia group increased more rapidly than was shown to be proportional to the severity and length of
those in the spinal anesthesia group. the surgical injury [17], and the magnitude of insulin re-
According to Tables 1 and 2, there was a statistically sistance increased during surgery according to the degree of
significant difference (at α � 0.01) in glucose-check readings surgical injury [11]. Turinaet al. [12] showed that short-term
with regard to time of readings and its interaction with type hyperglycemia is associated with increased risk of infection
of anesthesia (general anesthesia and spinal anesthesia). and mortality in critically ill patients related to a significant
The results in Table 4 were plotted as a graph in Figure 1. decrease in monocyte HLA-DR expression due to hyper-
This shows the difference between the glucose-check read- glycemia and hyperinsulinemia.
ings according to glucose-check timing in both spinal an- Treating hyperglycemia results in an increased risk of
esthesia and general anesthesia and shows the difference in hypoglycemia and the risks associated with hypoglycemia,
the effect of type of anesthesia (general anesthesia and spinal and thus avoidance of stress-induced hyperglycemia is
anesthesia) on blood glucose concentration. According to preferable for treating dysglycemia [15]. It has long been
Figure 1, there is a significant proportional increase in mean recognized that the type of anesthetic technique has an
blood glucose concentrations with glucose-check timing influence on hyperglycemic response to surgery [18]. During
(5 minutes before induction, 5 minutes after induction, surgery, stress-induced hyperglycemia is more pronounced
5 minutes before the end of surgery, and 30 minutes after the with inhalation anesthesia. In animals, earlier studies
end of surgery), and this increase is significantly much revealed that inhalational anesthetics such as enflurane and
greater in general anesthesia than it is in spinal anesthesia. halothane impaired glucose tolerance in dogs and that was
related to inhibition of insulin secretion and decreased tissue
4. Discussion insulin sensitivity [9]. Other studies on isoflurane in-
halational anesthetic demonstrated an increase in the plasma
This study compared the effects of spinal and general an- glucose concentration during anesthesia even without sur-
esthesia on changes in blood glucose concentrations during gical stress related to impairment of glucose tolerance and
cesarean section in nondiabetic patients. Although mean stimulation of whole body glucose production [9, 13, 19].
blood glucose concentrations showed a significant pro- Furthermore, the hyperglycemic stress response in patients
portional increase during surgery in both groups, this effect undergoing major abdominal surgery under isoflurane
was much more significant with general anesthesia than with general anesthesia could be related to an increase in en-
spinal anesthesia. These results indicate that spinal anes- dogenous glucose production accompanied by a decrease in
thesia is more effective than general anesthesia in attenu- glucose utilization [9, 20] Tanaka et al. [21]showed that there
ating the hyperglycemic response to surgery during cesarean was glucose intolerance and impairment of insulin secretion
section. and glucose utilization during sevoflurane and isoflurane
4 Anesthesiology Research and Practice

Table 3: Age, weight, and fasting time of patients included in the study (n � 58).
Group G, mean ± SD (n � 23) Group S, mean ± SD (n � 35) t P value
Age (years) 28.2 ± 4.2 28.9 ± 5.6 –0.470 0.640
Weight (kg) 69.4 ± 8.3 70.4 ± 12.5 –0.330 0.742
Fasting time (hours) 9.2 ± 1.4 9.7 ± 1.2 –1.584 0.119
Data are given as mean ± SD and the significance of the difference in age, weight, and fasting time between group G (general anesthesia) and group S (spinal
anesthesia).

Table 4: Descriptive statistics for the mean blood glucose concentrations for spinal anesthesia and general anesthesia at different
measurement times.
Type of anesthesia Mean Std. deviation N
General anesthesia 74.3 14.7 23
5 min before induction Spinal anesthesia 78.3 18.2 35
Total 76.7 16.9 58
General anesthesia 84.9 23.7 23
5 min after induction Spinal anesthesia 79.2 18.3 35
Total 81.4 20.6 58
General anesthesia 108.4 16.7 23
5 min before the end of surgery Spinal anesthesia 80.2 18.1 35
Total 91.4 22.3 58
General anesthesia 121.1 17.4 23
30 min after the end of surgery Spinal anesthesia 80.9 17.7 35
Total 96.8 26.4 58

Regarding neuraxial anesthesia such as epidural or spinal

130 Type of anesthesia block with local anesthetics, this blocks both afferent input
General anesthesia from the operative site to the central nervous system and the
P < 0.001 hypothalamic-pituitary axis and efferent autonomic neuronal
120
pathways to the liver and adrenal medulla. Consequently, the
Blood glucose level means (mg/dl)

adrenocortical and glycemic responses to surgery are greatly

110 P < 0.001 inhibited [7, 16]. A study by Kehlet [23] showed that epidural
blockade attenuated the hyperglycemic response during
surgery, most likely mediated through its inhibitory action on
100 the hypothalamic-pituitary-adrenal axis. Some studies look-
ing at glucose tolerance tests during pelvic procedures showed
90
that epidural block improved tissue glucose uptake [24, 25]. In
P = 0.3 contrast, other studies revealed that epidural block attenuated
the hyperglycemic response during surgery by inhibiting
80 P = 0.38 hepatic glucose release rather than improving tissue glucose
Spinal anesthesia
utilization [26, 27]. In another study, Lattermannet al. [16]
concluded that epidural blockade attenuated the hypergly-
70
cemic response to abdominal surgery through modification of
5 minutes 5 minutes 5 minutes 30 minutes glucose production without affecting glucose utilization.
before after before after However, it is still unclear whether the inhibitory effect of the
induction induction the end the end epidural block on the hyperglycemic response during surgery
Glucose-check timing was a consequence of the improvement in tissue glucose
Figure 1: Relationship between glucose-check timing, type of uptake, a decrease in glucose production, or a combination of
anesthesia, and mean blood glucose concentrations for patients in both. In any case, it has been well recognized that epidural
the study. blockade with a local anesthetic inhibits or even prevents the
endocrine and metabolic responses to surgery including
anesthesia in a dose-independent manner. According to the hyperglycemia [16]. An earlier study by Enquist et al. [28]
results of a study by Cok et al. [22], although isoflurane and showed that epidural blockade, established before the start of
propofol, both combined with remifentanil, provided a surgery, prevented the increase in plasma glucose and cortisol
clinically comparable insulin and cortisol response to sur- levels in response to surgery in patients undergoing hyster-
gery in craniotomy operations, propofol attenuated the ectomy. A more recent study by Hadimioglu et al. [6]
increase in plasma blood glucose. This suggested that pro- demonstrated that combined general and epidural anesthesia,
pofol may be preferred over isoflurane when tight control of when compared with general anesthesia alone, reduced in-
blood glucose is a goal. flammatory activation and insulin resistance responses to the
Anesthesiology Research and Practice 5

stress of the renal transplantation procedure and that in- with the ethical standards of the institutional committee and
hibition of stress responses had a beneficial effect on length of with the Helsinki Declaration of 2013.
stay in hospital postoperatively. To summarize those pre-
viously mentioned studies, epidural anesthesia attenuates the Consent
hyperglycemic response during surgery. Our study looked at
spinal anesthesia, a different neuraxial technique, and con- Written informed consent was obtained from all the par-
firmed the results of those earlier studies as spinal anesthesia ticipants prior to publication.
resulted in effects comparable to epidural anesthesia with
attenuation of the hyperglycemic response to surgery. Disclosure
As we mentioned previously, spinal anesthesia is the
most common technique used to provide anesthesia for No animals were used in this research. This research did not
patients undergoing elective cesarean section due to the receive any specific grant from funding agencies in the
lower risk of maternal and fetal complications associated public, commercial, or not-for-profit sectors.
with spinal anesthesia than general anesthesia. The results of
our study add more weight to the use of spinal anesthesia in Conflicts of Interest
the obstetric population since spinal anesthesia facilitates The authors declare that there are no conflicts of interest.
glycemic control in the perioperative period. This might be
beneficial in reducing the incidence of previously mentioned Acknowledgments
complications associated with hyperglycemia and other
maternal and fetal complications. Therefore, these added The authors would like to thank all patients who agreed to
benefits of spinal anesthesia over general anesthesia should participate in this research and also all the physician and
be conveyed to patients during patient counseling about nursing staff in the operating rooms at King Abdullah
cesarean sections. University Hospital, who supported this research. The au-
One study limitation is that our study design did not thors wish to thank Professor Y. Sawalmeh for his support
allow measurement of the level of stress hormones. and advice on statistical analyses.
Furthermore, we only measured blood glucose concen-
trations up to 30 minutes after the end of surgery; References
therefore, the long-term trends are not known. However,
our study was not designed to address the long-term [1] F. Reynolds, “General anesthesia is unacceptable for elective
effects of spinal anesthesia on hyperglycemic response to cesarean section,” International Journal of Obstetric Anes-
surgery or to study the effects of spinal anesthesia on other thesia, vol. 19, no. 2, pp. 212–217, 2010.
parameters of stress response to surgery. Another limi- [2] C. A. Wong, “General anesthesia is unacceptable for elective
cesarean section,” International Journal of Obstetric Anes-
tation of our study is that it only included nondiabetic
thesia, vol. 19, no. 2, pp. 209–212, 2010.
pregnant women who were candidates for elective ce- [3] B. A. Bucklin, J. L. Hawkins, J. R. Anderson, and F. A. Ullrich,
sarean section surgery. The results may be different in “Obstetric anesthesia workforce survey,” Anesthesiology,
diabetic patients, in male patients, or in patients un- vol. 103, no. 3, pp. 645–653, 2005.
dergoing other types of surgery, and so further studies are [4] M. Heesen, A. Stewart, and R. Fernando, “Vasopressors for
required to examine the effects of spinal anesthesia on the treatment of maternal hypotension following spinal an-
blood glucose concentrations among these groups. aesthesia for elective caesarean section: past, present and
In conclusion, according to this study, there was a future,” Anaesthesia, vol. 70, no. 3, pp. 252–257, 2015.
significant proportional increase in mean blood glucose [5] A. T. Heng Sia, K. H. Tan, B. L. Sng, Y. Lim, E. S. Y. Chan, and
concentrations from glucose-check timing with both general F. J. Siddiqui, “Hyperbaric versus plain bupivacaine for spinal
anesthesia for cesarean delivery,” Anesthesia and Analgesia,
anesthesia and spinal anesthesia. The effect of general an-
vol. 120, no. 1, pp. 132–140, 2015.
esthesia on blood glucose concentrations was significantly [6] N. Hadimioglu, H. Ulugol, H. Akbas, N. Coskunfirat, Z. Ertug,
greater than the effect of spinal anesthesia, which indicates and A. Dinckan, “Combination of epidural anesthesia and
that the hormonal stress response is much greater in general general anesthesia attenuates stress response to renal trans-
anesthesia than in spinal anesthesia. plantation surgery,” Transplantation Proceedings, vol. 44,
no. 10, pp. 2949–2954, 2012.
Data Availability [7] J. P. Desborough, “The stress response to trauma and surgery,”
British Journal of Anaesthesia, vol. 85, no. 1, pp. 109–117,
The data used to support the findings of this study have been 2000.
deposited in the Figshare repository (DOI: https://doi.org/ [8] S. Demirbilek, S. Ganidağli, N. Aksoy, C. Becerik, and
10.6084/m9.figshare.845654?noredirect). Z. Baysal, “The effects of remifentanil and alfentanil-based
total intravenous anesthesia (TIVA) on the endocrine re-
sponse to abdominal hysterectomy,” Journal of Clinical An-
Ethical Approval esthesia, vol. 16, no. 5, pp. 358–363, 2004.
[9] W. Geisser, M. Schreiber, H. Hofbauer et al., “Sevoflurane
A formal approval from the institutional ethics committee versus isoflurane—anaesthesia for lower abdominal surgery.
(approval no. 3492017) was obtained for this study. All Effects on perioperative glucose metabolism,” Acta Anaes-
human research procedures followed were in accordance thesiologica Scandinavica, vol. 47, no. 2, pp. 174–180, 2003.
6 Anesthesiology Research and Practice

[10] G. Y. Gandhi, G. A. Nuttall, M. D. Abel et al., “Intraoperative general and extradural anaesthesia,” British Journal of An-
hyperglycemia and perioperative outcomes in cardiac surgery aesthesia, vol. 50, no. 5, pp. 495–499, 1978.
patients,” Mayo Clinic Proceedings, vol. 80, no. 7, pp. 862–866, [25] C. H. Jensen, P. Berthelsen, C. Kühl, and H. Kehlet, “Effect of
2005. epidural analgesia on glucose tolerance during surgery,” Acta
[11] R. E. Anderson, J. Ehrenberg, G. Barr et al., “Effects of thoracic Anaesthesiologica Scandinavica, vol. 24, no. 6, pp. 472–474, 1980.
epidural analgesia on glucose homeostasis after cardiac sur- [26] J. Lund, H. Stjernström, L. Jorfeldt, and L. Wiklund, “Effect of
gery in patients with and without diabetes mellitus,” European extradural analgesia on glucose metabolism and gluconeo-
Journal of Anaesthesiology, vol. 22, no. 7, pp. 524–529, 2005. genesis,” British Journal of Anaesthesia, vol. 58, no. 8,
[12] M. Turina, F. N. Miller, C. F. Tucker, and H. C. Polk, “Short- pp. 851–857, 1986.
term hyperglycemia in surgical patients and a study of related [27] J. H. Shaw, L. Galler, I. M. Holdaway, and C. M. Holdaway,
cellular mechanisms,” Annals of Surgery, vol. 243, no. 6, “The effect of extradural blockage upon glucose and urea
pp. 845–853, 2006. kinetics in surgical patients,” Surgery, Gynecology and Ob-
[13] S. Behdad, A. Mortazavizadeh, V. Ayatollahi, Z. Khadiv, and stetrics, vol. 165, pp. 260–266, 1987.
S. Khalilzadeh, “The effects of propofol and isoflurane on [28] A. Enquist, M. R. Brandt, A. Fernandes, and H. Kehlet, “The
blood glucose during abdominal hysterectomy in diabetic blocking effect of epidural analgesia on the adrenocortical and
patients,” Diabetes and Metabolism Journal, vol. 38, no. 4, hyperglycaemic responses to surgery,” Acta Anaesthesiologica
Scandinavica, vol. 21, no. 4, pp. 330–335, 1977.
pp. 311–316, 2014.
[14] F. Amiri, A. Ghomeishi, S. M. Aslani, S. Nesioonpour, and
S. Adarvishi, “Comparison of surgical stress responses during
spinal and general anesthesia in curettage surgery,”Anesthesiol-
ogy and Pain Medicine, vol. 4, no. 3, Article ID e20554, 2014.
[15] A. Gottschalk, B. Rink, R. Smektala, A. Piontek, B. Ellger, and
A. Gottschalk, “Spinal anesthesia protects against peri-
operative hyperglycemia in patients undergoing hip arthro-
plasty,” Journal of Clinical Anesthesia, vol. 26, no. 6,
pp. 455–460, 2014.
[16] R. Lattermann, F. Carli, L. Wykes, and T. Schricker, “Epidural
blockade modifies perioperative glucose production without
affecting protein catabolism,” Anesthesiology, vol. 97, no. 2,
pp. 374–381, 2002.
[17] T. A. Raju, M. C. Torjman, and M. E. Goldberg, “Perioperative
blood glucose monitoring in the general surgical population,”
Journal of Diabetes Science and Technology, vol. 3, no. 6,
pp. 1282–1287, 2009.
[18] T. Schricker, R. Lattermann, M. Schreiber, W. Geisser,
M. Georgieff, and P. Radermacher, “The hyperglycaemic
response to surgery: pathophysiology, clinical implications
and modification by the anaesthetic technique,” Clinical In-
tensive Care, vol. 9, no. 3, pp. 118–128, 1998.
[19] F. F. Horber, S. Krayer, J. Miles, P. Cryer, K. Rehder, and
M. W. Haymond, “Isoflurane and whole body leucine, glu-
cose, and fatty acid metabolism in dogs,” Anesthesiology,
vol. 73, no. 1, pp. 82–92, 1990.
[20] R. Lattermann, T. Schricker, U. Wachter, M. Georgieff, and
A. Goertz, “Understanding the mechanisms by which iso-
flurane modifies the hyperglycemic response to surgery,”
Anesthesia and Analgesia, vol. 93, pp. 121–127, 2001.
[21] T. Tanaka, H. Nabatame, and Y. Tanifuji, “Insulin secretion
and glucose utilization are impaired under general anesthesia
with sevoflurane as well as isoflurane in a concentration-
independent manner,” Journal of Anesthesia, vol. 19, no. 4,
pp. 277–281, 2005.
[22] O. Y. Cok, Z. Ozkose, H. Pasaoglu, and S. Yardim, “Glucose
response during craniotomy: propofol-remifentanil versus
isoflurane-remifentanil,” Minerva Anestesiologica, vol. 77,
pp. 1141–1148, 2011.
[23] H. Kehlet, “Modification of responses to surgery by neural
blockade,” in Neural blockade in clinical anesthesia and
management of pain, M. J. Cousins and P. O. Bridenbaugh,
Eds., pp. 129–175, Lippincott-Raven Publishers, Philadelphia,
USA, 1988.
[24] A. Houghton, J. B. Hickey, S. A. Ross, and J. Dupre, “Glucose
tolerance during anaesthesia and surgery. Comparison of
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