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The Metabolic and Hormonal Response to Cataract Surgery: a Comparison Between General and Local Anaesthesia

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The Metabolic and Hormonal Response to Cataract Surgery: a Comparison Between General and Local Anaesthesia THE METABOLIC AND HORMONAL RESPONSE TO CATARACT SURGERY: A COMPARISON BETWEEN GENERAL AND LOCAL ANAESTHESIA JILL PATRICIA BARKER MB BS FRCA Submitted for the degree of Doctor of Medicine University of London Spring 1996 ProQuest Number: 10045829 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest. ProQuest 10045829 Published by ProQuest LLC(2016). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. Microform Edition © ProQuest LLC. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 Abstract This thesis compares the endocrine and metabolic response to cataract extraction in patients receiving either general or local anaesthesia. Under general anaesthesia, plasma cortisol concentrations increase more than two-fold during cataract surgery, with smaller changes in circulating glucose and catecholamine concentrations. Both retrobulbar and peribulbar anaesthesia completely abolish these changes. Retrobulbar blockade also improves cardiovascular stability, as measured by changes in heart rate and mean arterial pressure. When retrobulbar blockade is combined with general anaesthesia, changes in circulating cortisol and glucose concentrations are prevented during surgery, but there is a marked increase in cortisol concentration during the immediate postoperative period. Similar increases in cortisol concentration are seen in non-insulin- dependent diabetic (NIDDM) patients receiving general anaesthesia. The glycaemic response is greater in NIDDM than in non-diabetic patients, and there is a failure of insulin secretion postoperatively in the diabetic patients receiving general anaesthesia. Retrobulbar blockade maintains hormonal and metabolic stability, which is important in these patients, in whom cataracts are a common complication. The results of a postoperative questionnaire on 231 patients following cataract surgery under either general or local anaesthesia show the acceptability of both techniques. There is significantly less nausea and sore throat in the local anaesthetic patients, but more bruising of the eye. There is no difference in the severity of postoperative pain, but local anaesthetic patients drank and ate much earlier following their operations. The results provide evidence of the benefits of local anaesthesia for cataract surgery in the elderly patient. Both peribulbar and retrobulbar blockade prevent the metabolic and hormonal changes seen when surgery is performed under general anaesthesia and provide better cardiovascular stability. The findings are particularly important to the diabetic patient. Acknowledgements I would like to thank Professor George Hall for all his advice during the preparation of this manuscript. I am indebted to him for his constant and invaluable support and encouragement during these studies, without which they may never have been completed. I am grateful to Miss Gilli Vafidis for the original idea of looking at the stress involved in cataract surgery and for allowing us to study her patients. Also to Dr Neville Robinson, who provided much appreciated support and help with the collection of blood samples. I would also like to thank Mrs Sue Sapsed-Byme for assaying the metabolites and Dr Jacky Burrin for the assays of the hormones in the clinical samples. Jacky's help with the presentation of results in the diabetic study was much appreciated. My thanks also go to the nursing staff of Ward C6&7 at Edgware General Hospital, who kindly helped with the postoperative questioimaire. Table of Contents Abstract .................................................................................................................2 Acknowledgements .................................................................................................... 3 Table of Contents .......................................................................................................4 List of Figures ............................................................................................................7 List of Tables .............................................................................................................. 9 Publications arising from this thesis .......................................................................10 Abbreviations used in this thesis ............................................................................12 Chapter One Anaesthesia for cataract surgery .................................................................... 13 History .................................................................................................. 14 A n a to m y ................................................................................................15 Intraocular pressure .............................................................................. 15 Akinesia ................................................................................................17 The oculocardiac reflex .......................................................................18 Local anaesthetic blocks .................................................................... 18 Eye position .......................................................................................... 20 N eed les..................................................................................................20 Pressure reduction.................................................................................21 Local anaesthetic solutions ..................................................................21 Painless local injections .......................................................................22 Role of anaesthetists ............................................................................23 Sedation ............................................................................................... 23 General anaesthesia ..............................................................................24 Day care ............................................................................................... 25 Chapter Two The endocrine and metabolic response to surgery ......................................28 Initiation ............................................................................................... 29 Modification ........................................................................................ 31 Chapter Three Literature review .............................................................................................34 Effect of anaesthesia on the metabolic and hormonal response to surgery .............................................................................. 34 Regional anaesthesia ............................................................... 34 High-dose opioid anaesthesia ................................................37 General anaesthesia ..................................................................38 Intravenous induction agents ...................................................39 Volatile anaesthetic agents ..................................................... 41 Comparison of general and local anaesthesia for cataract surgery ................................................................................... 42 Thesis plan .......................................................................................................46 Chapter Four Methods ............................................................................................................47 Patients studied ...................................................................................47 General anaesthesia ..............................................................................47 Retrobulbar anaesthesia...................................................................... 48 Peribulbar anaesthesia.........................................................................48 M onitoring .............................................................................................48 Blood samples ..................................................................................... 48 G lucose ..................................................................................................49 Lactate ..................................................................................................50 Non-esterified fatty acids ................................................................. 50 Beta-hydroxybutyrate .........................................................................50 C o rtiso l ..................................................................................................50 Catecholamines .................................................................. 51 Insulin .................................................................................................... 51 Growth hormone ...................................................................................51 Variability of assays........................................................................... 51 Statistical analysis................................................................................ 51 Chapter Five The investigation of the effects of general and local anaesthesia on the metabolic and
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