Percutaneous nephrolithotomy is an alternative to open surgery in the treatment of kidney stones . Continuous irrigation of the kidneys during this procedure may cause excessive water absorption and increase hydrostatic pressure. In response to changes in intravascular volume, metabolic, endocrine and haemodynamic changes may occur [2-4]. In addition, surgical trauma and anaesthesia may also alter autonomic and neuroendocrine functions. The response to surgical stress is documented and characterized by increased release of neuroendocrine hormones. The effect of anaesthetic agents on this response has not been studied during percutaneous nephrolithotomy.
Propofol and sevoflurane are anaesthetic agents known to have a minimal effect on renal function, haemodynamic variables and endocrine responses [5,6]. Moreover, the pharmacokinetics of propofol are not changed in renal insufficiency [7,8]. Sevoflurane does not activate the sympathetic nervous system. It has a weak dysrhythmogenic effect even in patients with high serum concentrations of endogenous or exogenous catecholamines . Sevoflurane does not decrease the urine concentrating ability of kidneys in volunteers . It does not have any effect on postoperative renal function even if used for 9-10 h at 0.8-2% and when serum fluoride concentration is >50 μmol L−1. Serum creatinine concentration does not change in patients with chronic renal failure after the administration of sevoflurane at doses of 0.8-6.5 MAC h−1. The aim of this study was to investigate and compare the effects of sevoflurane and total intravenous anaesthesia (TIVA) using propofol and alfentanil on neuroendocrine and haemodynamic changes during percutaneous nephrolithotomy.
The study was performed at Cukurova University Research Hospital, Adana, Turkey. It was approved by the Hospital Ethics Committee and informed consent was obtained from patients. Forty-two patients (ASA I-II) selected for percutaneous nephrolithotomy were included. Those receiving medication for hypertension, diabetes mellitus or atherosclerotic heart disease were excluded.
Patients were randomly divided into two groups. Thiopental (5 mg kg−1) as a hypnotic agent was used for induction, and sevoflurane 2% for the maintenance of anaesthesia in Group S (sevoflurane group). Group TIVA received propofol (2 mg kg−1) for induction and alfentanil (20 μg kg−1 h−1) plus propofol (4 mg kg−1 h−1) for the maintenance of anaesthesia. Additionally, patients in each group inhaled N2O 66% in an oxygen mixture via a rebreathing system during anaesthesia. Vecuronium (0.1 mg kg−1 for tracheal intubation; thereafter 2 mg as needed) was used as a neuromuscular blocking agent for both groups. Lidocaine 1% was used to reduce pain due to propofol injection.
Radial artery cannulation was performed to permit systolic and diastolic arterial pressures and heart rate to be recorded preoperatively and during the procedure at 5, 10, 15 and 60 min. Haematocrit, serum sodium and potassium concentrations were measured preoperatively and during the procedure at the 15th min and at 1 h. All the above variables were measured again 24 h after operation. Arterial blood-gas status, plasma renin, aldosterone and adrenocorticotrophic hormone concentrations were measured before intubation and at the 15th and 60th min of irrigation. Intravenous fluid volumes delivered during the operation and irrigation fluid volume were recorded.
Arterial blood-gases were measured by an autoanalyser (AVL, Compact 2, Australia). Plasma renin (DSL-25100, normal range 5.2-33.4 pg mL−1), aldosterone (DSL-8600, 29.4-161.5 pg mL−1) and adrenocorticotrophic hormone (ACTH) (DSL-2300, <25-68.6 pg mL−1) concentrations were measured by radioimmunoassay.
Percutaneous access to the renal collecting system was established under the guidance of monoplane fluoroscopy using a 19-G percutaneous needle. The tract was then dilated by Amplatz semirigid dilators. Irrigation with 0.9% saline solution, fragmentation and extraction of stones were done using a rigid nephroscope.
Statistical analysis was performed with using SPSS® for Windows 9.0 (SPSS, Inc., Chicago, IL, USA). Patients' characteristics data were compared using the χ2-test. The duration of the procedure and amount of irrigation volume were compared using the t-test. Wilcoxon signed rank sum and Friedman tests were used for intragroup and the U-test for intergroup comparisons. The 95% confidence interval (CI) was calculated; P < 0.05 was considered as statistically significant.
The age of the patients ranged from 15 to 65 yr (mean 40.1 ± 12.2 yr). Fifteen of the patients (35.7%) were females, 27 were males (64.3%). Their mean age, gender, ASA classification, duration of operation and the volume of irrigation fluid were not different between the two groups (Table 1).
Although the mean heart rate was not different before induction and 24 h after the operation, it was significantly lower during the operation in group TIVA (P < 0.01) (Fig 1). The mean systolic and diastolic arterial pressures were not different between the sevoflurane and TIVA groups before, during or after the operation (P > 0.05).
Haematocrit measured after operation was significantly lower (Group S 35.1 ± 5.4%, Group TIVA 35.7 ± 4.1%) compared with preoperative concentrations (41.6 ± 4.8 and 40.7 ± 5.0%, respectively) in both groups (P < 0.05). However, no significant difference in any measurement was found between the two groups (P > 0.05).
Serum sodium concentrations were significantly lower in every consecutive stage of measurement in each group during the operation (P < 0.01). Serum sodium concentration continued to decrease at 24 h after operation, but the difference from the baseline was significant only in Group S (136.2 ± 3.2; 145.1 ± 3.3 mmol L−1, P < 0.01) (Fig. 2). Although mean potassium concentration decreased during operation in both groups, it was not different between groups (P > 0.05).
Blood pH, PaO2, PaCO2 and SaO2 remained constant during operation in both groups and no significant differences were present between the groups (P > 0.05). Although the mean base excess and plasma HCO−3 values before irrigation were significantly higher compared with the values obtained at the 15th and 60th min of irrigation in both groups (P < 0.05 intragroup comparison compared with baseline), there were no significant differences between the two groups at the same time point (Table 2).
Renin, aldosterone and ACTH concentrations were significantly higher at the 15th min of irrigation in Group S compared with Group TIVA (P < 0.01, <0.05 and <0.05, respectively). Serum aldosterone concentrations continued to be significantly higher in Group S at the 60th min of irrigation (P <0.01) (Table 3).
Percutaneous nephrolithotomy is widely used in the treatment of kidney stones. It is a relatively less-invasive endoscopic intervention compared with open surgery . Although it appears to be a safer method, irrigation of the kidneys and drugs used for anaesthesia may cause some biochemical, haemodynamic and hormonal disturbances .
Propofol may cause bradycardia. Deutschman and colleagues tried to explain the cause of bradycardia. They proposed that the sympathetic system was strongly suppressed by propofol while the same suppressive effect was very weak for the parasympathetic system . Lindgren and colleagues noted bradycardia in their propofol group and found that serum norepinephrine concentrations were not increased . Sevoflurane has minimal effect on heart rate compared with other inhalation anaesthetics. Ozkan and colleagues reported a lower heart rate in patients receiving TIVA (propofol and alfentanil) compared with patients receiving sevoflurane . In our study, a lower heart rate compared with baseline was noted during operation in both groups but the mean heart rate remained above 60 beats min−1.
Hug and colleagues reported a 15-35% decrease in arterial pressure in the first 15 min of anaesthesia using propofol; thereafter it remained slightly lower compared with baseline . In some studies, arterial pressure was reported to be stable when sevoflurane was used as an anaesthetic agent . In our study, systolic and diastolic arterial pressures were not different during and after operation in either sevoflurane or TIVA groups.
A decrease in haematocrit concentration is frequently reported during or after percutaneous nephrolithotomy . This complication is usually due to haemorrhage from small cortical renal vessels and sometimes due to water absorption. A significant decrease in haematocrit concentration was found in our patients 24 h after the procedure, which may indicate haemorrhage in addition to water absorption. Although isotonic sodium chloride was used for irrigation of the kidneys, a decrease in serum sodium concentration was observed in both groups. This may be explained by excessive water absorption. Monitoring serum sodium concentration is required during percutaneous nephrolithotomy, especially in prolonged procedures.
Metabolic acidosis is considered one of the complications of percutaneous nephrolithotomy . Although the pH remained constant, base excess and plasma bicarbonate concentrations decreased in our patients in both of groups. This may be explained by excessive loss of bicarbonate due to continuous irrigation of the kidneys.
The relationship between anaesthetic agents and hormones has been investigated in many studies. Renin, aldosterone and ACTH were among the most studied hormones because of their immediate effects on haemodynamic variables during operation [20,21]. Halothane and isoflurane have been reported to increase serum concentrations of renin and angiotensin significantly . Aldosterone was also slightly increased in the same study, but arterial pressure was not increased . Increased concentrations of these hormones were explained as compensation against hypotension caused by the inhalation anaesthetic agents.
Reports on the effects of sevoflurane or TIVA (propofol plus alfentanil) on renin, aldosterone and ACTH could not be found in the literature. In our study, these hormones were increased in both groups, but the increase was significantly higher in the sevoflurane group compared with the TIVA group.
In conclusion, serum sodium and bicarbonate concentrations were decreased during percutaneous nephrolithotomy, which were attributed to the invasive procedure itself but not to the anaesthetic agents. These complications should be taken into consideration and patients should be monitored for these changes. Haemodynamics and renal function were not significantly affected by either sevoflurane or TIVA. However, the increases in renin and aldosterone concentrations were significantly higher in the sevoflurane group compared with the TIVA group. Although these changes did not cause any significant clinical deterioration in our patients, they should be taken into consideration in selected patients with cardiovascular and endocrine diseases.
This work was presented at the 8th European Society of Anaesthesiologists Annual Meeting, Vienna, Austria, 2000. The authors thank Dr Larry Perin for proofreading the manuscript.
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