Postoperative Stress Response Research Articles

Role of nutrition support in the enhanced recovery after surgery for gastrointestinal surgery patients

Nutrition support therapy can improve the general condition of the patient and is one of the main factors to ensure the success of the operation. Enhanced recovery after surgery (ERAS) improves the recovery following gastrointestinal surgery by reducing postoperative stress response. The application of nutrition support in ERAS includes nutrition risk assessment before surgery and preoperative nutrition treatment for malnutrition. The time to fasting and clear liquid was shortened to 6 h and 2 h before anesthesia induction. Early postoperative recovery of oral feeding can improve the patient's clinical outcome. The application of ERAS enables the development and improvement of clinical nutrition concepts, and deepens the role of nutrition support therapy, which is conducive to the recovery of patients.

Effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy

AIMTo prospectively evaluate the effect of local wound infiltration with ropivacaine on postoperative pain relief and stress response reduction after open hepatectomy.METHODSA total of 56 patients undergoing open hepatectomy were randomly divided into two groups: a ropivacaine group (wound infiltration with ropivacaine solution) and a control group (infiltration with isotonic saline solution). A visual analog scale (VAS) at rest and on movement was used to measure postoperative pain for the first 48 h after surgery. Mean arterial pressure (MAP), heart rate (HR), time to bowel recovery, length of hospitalization after surgery, cumulative sufentanil consumption, and incidence of nausea and vomiting were compared between the two groups. Surgical stress hormones (epinephrine, norepinephrine, and cortisol) were detected using enzyme-linked immunosorbent assay, and the results were compared.RESULTSVAS scores both at rest and on movement at 24 h and 48 h were similar between the two groups. Significantly lower VAS scores were detected at 0, 6, and 12 h in the ropivacaine group compared with the control group (P < 0.05 for all). MAP was significantly lower at 6, 12, and 24 h (P < 0.05 for all); HR was significantly lower at 0, 6, 12, and 24 h (P < 0.05 for all); time to bowel recovery and length of hospitalization after surgery (P < 0.05 for both) were significantly shortened; and cumulative sufentanil consumption was significantly lower at 6, 12, 24, and 36 h (P < 0.05 for all) in the ropivacaine group than in the control group, although the incidence of nausea and vomiting showed no significant difference between the two groups. The levels of epinephrine, norepinephrine, and cortisol were significantly lower in the ropivacaine group than in the control group at 24 and 48 h (P < 0.01 for all).CONCLUSIONLocal wound infiltration with ropivacaine after open hepatectomy can improve postoperative pain relief, reduce surgical stress response, and accelerate postoperative recovery.

Effects of Preoperative Psychological Interventions on Catecholamine and Cortisol Levels After Surgery in Coronary Artery Bypass Graft Patients: The Randomized Controlled PSY-HEART Trial.

The aim of the study was to examine whether preoperative psychological interventions targeting patients' expectations are capable of influencing the biological stress response after coronary artery bypass graft (CABG) surgery and could thus improve recovery after heart surgery. Randomized controlled trial with assessments 10 days before surgery, after psychological intervention (day of hospital admission, but before surgery), postoperative (6-8 days later), and at follow-up (6 months after surgery). Eligible patients (N = 124) scheduled for elective on-pump CABG or CABG with valve replacement surgery were approached before hospital admission. Standard medical care (SMC) was compared with two additional preoperative psychological interventions: (a) an expectation manipulation intervention to optimize patients' expectations about course and outcomes or (b) supportive therapy, containing the same amount of therapeutic attention, but without specifically focusing on expectations. Postoperative plasma adrenaline, noradrenaline, and cortisol levels were a secondary outcome of our study (primary outcome patients' disability 6 months after surgery and other secondary patient-reported or clinical outcomes were reported elsewhere). Expectation manipulation intervention (3.68 ln pg/mL, 95% confidence interval = 3.38-3.98, p = .015) and supportive therapy (3.70 ln pg/mL, 95% confidence interval = 3.38-4.01, p = .026) led to significantly lower postoperative adrenaline levels compared with SMC (4.26 ln pg/mL, 95% confidence interval = 3.99-4.53) only. There were no treatment effects of the preoperative intervention for noradrenaline (p = .90) or cortisol (p = .30). Higher postoperative adrenaline levels predicted disability 6 months after surgery (r = .258, p = .018). In addition to SMC, preoperative psychological interventions seem to buffer psychobiological stress responses and could thus facilitate recovery from CABG surgery. Patients' postoperative stress responses could be an important factor for explaining trajectories of long-term outcomes. www.clinicaltrials.gov(NCT01407055).

Does preoperative oral carbohydrate treatment reduce the postoperative surgical stress response in lumbar disc surgery?

ObjectivesSurgical trauma produces metabolic and hormonal responses, which are characterized by insulin resistance. Due to extension of the preoperative fasting period, which increases the magnitude of postoperative insulin resistance, preoperative oral carbohydrates (POC) have been developed. Patients and methodsThis prospective, randomized, controlled study was performed on 43 ASA I–II patients undergoing elective microsurgical lumbar discectomy. The intervention group received oral carbohydrate solution 800mL the night before and 400mL 2h prior to operation. The other group fasted for 8h prior to operation. Blood samples were obtained the day before the operation, before induction of anesthesia, after skin incision, 1h, 2h, 6h and 24h following skin incision. Blood glucose, plasma insulin, cortisol and interleukin-6 (IL-6) levels were determined. The primary endpoint was to assess the effect of POC treatment on insulin resistance and surgical stress response following lumbar disc surgery. The secondary endpoint was to assess POC’s effects on postoperative nausea and vomiting. ResultsThe serum insulin levels were higher before induction of anesthesia in the study group and returned to fasted group levels by 2h after skin incision. The plasma IL-6 levels were higher in the intervention group at 6h after the skin incision. There were no differences between the two groups with respect to blood glucose, plasma cortisol levels and the incidence of nausea and vomiting. ConclusionThis study suggests that use of POC treatment does not attenuate development of insulin resistance in patients undergoing lumbar disc surgery.

Clinical application of enhanced recovery after surgery (ERAS) program in hepatectomy for hepatolithiasis

Objective To investigate the clinical value of enhanced recovery after surgery (ERAS) program in the perioperative period of hepatectomy for hepatolithiasis. Methods From December 2014 to May 2016, 81 hepatolithiasis patients who underwent hepatectomy at the Second Affiliated Hospital Of Nanchang University were retrospectively reviewed. Patients in the ERAS group (n=36) received ERAS management and the control group (n=45) received conventional management. The pain score, changes in inflammatory mediators during the perioperative period, postoperative clinical index and postoperative complications were compared between the two groups. Results The postoperative pain score was significantly lower in the ERAS group when compared with the control group (P 0.05). Conclusion The ERAS program when applied in the perioperative management of hepatectomy for hepatolithiasis patients, significantly decreased postoperative pain and stress responses, shortened time to first pass flatus and hospital stay, and promoted postoperative recovery. Key words: Hepatolithiasis; Enhanced recovery after surgery (ERAS); Stress response; Hepatectomy

Effects of different levels of end-expiratory pressure on hemodynamic, respiratory mechanics and systemic stress response during laparoscopic cholecystectomy

ObjectiveGeneral anesthesia causes reduction of functional residual capacity. And this decrease can lead to atelectasis and intrapulmonary shunting in the lung. In this study we want to evaluate the effects of 5 and 10cmH2O PEEP levels on gas exchange, hemodynamic, respiratory mechanics and systemic stress response in laparoscopic cholecystectomy. MethodsAmerican Society of Anesthesiologist I–II physical status 43 patients scheduled for laparoscopic cholecystectomy were randomly selected to receive external PEEP of 5cmH2O (PEEP 5 group) or 10cmH2O PEEP (PEEP 10 group) during pneumoperitoneum. Basal hemodynamic parameters were recorded, and arterial blood gases (ABG) and blood sampling were done for cortisol, insulin and glucose level estimations to assess the systemic stress response before induction of anesthesia. Thirty minutes after the pneumoperitoneum, the respiratory and hemodynamic parameters were recorded again and ABG and sampling for cortisol, insulin, and glucose levels were repeated. Lastly hemodynamic parameters were recorded; ABG analysis and sampling for stress response levels were taken after 60minutes from extubation. ResultsThere were no statistical differences between the two groups about hemodynamic and respiratory parameters except mean airway pressure (Pmean). Pmean, compliance and PaO2; pH values were higher in ‘PEEP 10 group’. Also, PaCO2 values were lower in ‘PEEP 10 group’. No differences were observed between insulin and lactic acid levels in the two groups. But postoperative cortisol level was significantly lower in ‘PEEP 10 group’. ConclusionVentilation with 10cmH2O PEEP increases compliance and oxygenation, does not cause hemodynamic and respiratory complications and reduces the postoperative stress response.

Intraoperative Dexmedetomidine Promotes Postoperative Analgesia and Recovery in Patients after Abdominal Hysterectomy: a Double-Blind, Randomized Clinical Trial.

Surgery-induced acute postoperative pain and stress response can lead to prolonged convalescence. The present study was designed to investigate the effects of intraoperative dexmedetomidine on postoperative analgesia and recovery following abdominal hysterectomy surgeries. Sixty-four patients scheduled for abdominal hysterectomy under general anesthesia were divided into two groups that were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS). During surgery, patients in the PRD group had a lower bispectral index (BIS) value, which indicated a deeper anesthetic state, and a higher sedation score immediately after extubation than patients in the PRS group. During the first 24 hours post-surgery, PRD patients consumed less morphine with patient-controlled analgesia (PCA) and had lower scores on a visual analogue scale (VAS) than their controls from the PRS group. The global 40-item quality of recovery questionnaire and 9-question fatigue severity score both showed higher recovery scores from day 3 after surgery in the PRD group. with the data are considered together, intraoperative administration of dexmedetomidine appeared to promote the analgesic properties of morphine-based PCA and to expedite recovery following surgery in patients undergoing abdominal hysterectomy.

Intraoperative Dexmedetomidine Promotes Postoperative Analgesia and Recovery in Patients after Abdominal Colectomy: A CONSORT-Prospective, Randomized, Controlled Clinical Trial.

Surgery-induced acute postoperative pain and stress response may lead to prolonged convalescence. The present study was designed to investigate the effects of intraoperative dexmedetomidine on postoperative analgesia and recovery after abdominal colectomy surgeries.Sixty-seven patients scheduled for abdominal colectomy under general anesthesia were divided into two groups, which were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS).During surgery, patients in the PRD group had a lower bispectral index value, which indicated a deeper anesthetic state and a higher sedation score right after extubation, than patients in the PRS group. During the first 24 hours after surgery, PRD patients consumed less morphine in patient-controlled analgesia, and had a lower score in visual analog scale, than their controls from the PRS group. The global 40-item quality of recovery questionnaire and 9-question fatigue severity score both showed a higher recovery score from day 3 after surgery in the PRD group.Intraoperative administration of dexmedetomidine seems to promote the analgesic property of morphine-based patient-controlled analgesia, and speed recovery from surgery in patients after abdominal colectomy.

Frequency and Cause of Transient QT Prolongation After Surgery

Patients undergoing surgery are often exposed to QT-inciting factors that may increase the risk for complications. We evaluated the clinical characteristics and outcomes of patients with QTc ≥500 ms within the first 24 hours after surgery as identified by an institution-wide electrocardiogram alert system. From November 2010 to June 2011, 470 patients exhibited an electrocardiographically isolated QTc ≥500 ms. QT prolongation after surgery was the setting for >1 of every 10 QTc alerts (59 patients). We determined the presence of QT prolonging medical conditions, drugs, electrolyte abnormalities, and the surgical patient's clinical outcome. The average preoperative QTc of the 59 patients demonstrating perioperative QT prolongation was 463 ± 56 ms with a postoperative QTc increase of 54 ± 37 ms. Most patients (n = 48, 83%) had ≥1 known QT-inciting factor before surgery. Compared with presurgical findings, there was a significant increase in pro-QTc score after surgery (1.8 ± 1.5 vs 3.5 ± 2.0, p <0.01) indicating a greater burden of perioperative QT-inciting factors. In conclusion, nearly all cases of QT prolongation could be explained by known etiologic or iatrogenic factors suggesting that maladaptive cardiac repolarization is most likely not a transient, postoperative stress response and may be avoided by altering clinical management.

Pharmacologic Factors: Anaesthetic Agents that May Influence Cancer Outcomes: Local Anaesthetics

Molecular pathways linking inflammation and cancer have been demonstrated. Local anaesthetics have been shown to possess anti-inflammatory effects. Recent retrospective studies have shown that the application of regional anaesthesia is associated with a reduced risk of metastasis and improved long-term outcomes. The beneficial effect of regional anaesthesia has been attributed to the reduction of the postoperative stress response. Biomolecular actions like reduction of Src activation and ICAM-1 expression can explain some of these benefits observed in cancer surgery with local or regional anaesthesia techniques.

(155) Can thoracotomy patients be “immune” to developing chronic pain? Examination of the role of immune and inflammatory markers in the post-surgical trajectory

Recent evidence reveals that approximately 60% of patients who undergo thoracotomy for lung cancer report chronic pain lasting up to 5 years. However, little evidence exists regarding what factors may protect or place one at-risk for developing chronic post-thoracotomy pain. As part of a larger prospective, longitudinal project, this study identified patterns of immune changes and inflammatory markers and examined associations with temporal patterns of and risk for transition to post-thoracotomy chronic pain. Patients (n=43) were recruited prior to undergoing thoracotomy for lung cancer. Extensive baseline tests included QST, psychological measures and biological markers (e.g. genetic, pharmacogenetic/PGx, immunological and inflammatory markers). Peri-operative recordings were taken and post-operative assessments were immediate/ICU, multiple times in-hospital day-of-surgery, Days 1-3-5, follow-up at 2-weeks, 6-weeks, and months 3-6. Timed blood draws pre-, peri-, post-operatively were used for inflammatory, immune, PGx, and genetic examinations. Pain ratings were obtained via validated objective (QST) and subjective measures (i.e. VRS, BPI). There was seeming uniformity among post-operative pain patterns, which were higher at 2-6 weeks and decreased in months 2-4. By month 5, approximately 40% of the sample showed steadily increasing pain associated with higher baseline and post-operative stress responses, and increased immune and inflammatory reactivity out to 2-weeks and associations with elevated pain to 6-months. Analyses are ongoing to reveal corresponding genetic and PGx markers that predispose this subset to less analgesic response, higher stress response, and chronic pain (> than 5/10 pain) (p’s<.05), while protecting others from persistent post-thoracotomy pain. These findings suggest that baseline and post-operative immune, inflammatory/stress response might play an important role in acute recovery and in longer-term post-thoracotomy pain. This suggests the importance of considering potential interventions to pre-emptively reduce surgical stress and potentially regulate immune and inflammatory responses to improve acute-phase and long-term recovery and reduce incidence of chronic post-thoracotomy pain.

A Randomized Trial to Identify the Most Effective Dose of Remifentanil During Le Fort I Osteotomy

The Le Fort I osteotomy (L-I) requires extensive dissection and manipulation of tissue, causing hemodynamic instability and an undesirable postoperative stress response. This study aimed to clarify the most effective dose of remifentanil during L-I. This study was designed as a prospective, randomized, controlled double-blinded study. Patients (American Society of Anesthesiologists physical status I to II) undergoing L-I were randomly assigned to receive anesthesia with propofol and remifentanil under 3 remifentanil dose conditions: 0.25μg/kg/minute (group 1), 0.5μg/kg/minute (group 2), and 0.75μg/kg/minute (group 3). All patients underwent L-I with propofol and remifentanil target-controlled anesthesia. The study endpoints were mean arterial pressure (MAP) and heart rate. Data were recorded before L-I (20-minute period before surgery), during L-I (from the beginning of surgery to downfracture), and after L-I (20-minute period after downfracture). Average age, gender, average body mass index, aimed maxillary position, average bispectral index, average surgery time, and average blood loss also were examined. Data were analyzed using the Bartlett test and then 1-way analysis of variance with the Bonferroni multiple comparison test. Data were obtained from 20 patients (9 men, 11 women). The average operating times for groups 1, 2, and 3 were 53.1, 46.7, and 49minutes, respectively. The age range was 18 to 46years (average, 26.05yr). The rate of MAP increase from before to during L-I in group 1 was 10.8% (n= 7). The rate of MAP increase from before to during L-I in group 3 was 2.1% (n= 6). Group 3 showed a significantly lower rate of MAP increase during and after L-I compared with group 1 (P < .05). Remifentanil administration at 0.75μg/kg/minute stabilized hemodynamics during L-I without major side effects. Results indicated that the standard index of remifentanil administration during L-I should be 0.75μg/kg/minute when using oxygen, propofol, and remifentanil for general anesthesia.

Analgesic efficacy of bilateral superficial and deep cervical plexus block in patients with secondary hyperparathyroidism due to chronic renal failure.

PurposeSecondary hyperparathyroidism (SHPT) develops in patients with chronic renal failure. This study aimed to compare analgesic efficacy in SHPT patients who undergo subtotal parathyroidectomy after superficial versus deep cervical plexus block.MethodsSixty chronic renal failure patients with SPHT scheduled for subtotal parathyroidectomy were randomized to receive general anesthesia (group GA), general anesthesia plus bilateral superficial and deep cervical plexus block (group BD), or general anesthesia plus bilateral superficial cervical plexus block (group BS) (n = 20). Bilateral superficial cervical plexus block or combined superficial and deep cervical plexus block with 0.5% ropivacaine was administered. Postoperative pain was assessed using visual analogue scale (VAS).ResultsVAS score at 1 hour, 4 hours, and 8 hours after operation was 3.71 ± 0.60, 2.72 ± 0.54, 2.17 ± 0.75 in BS group; 4.00 ± 0.28, 2.89 ± 0.21, and 2.46 ± 1.01 in BD group, significantly lower than in GA group (6.50 ± 0.50, 5.02 ± 0.54, and 4.86 ± 0.51, respectively). The dosage of tramadol was 109.0 ± 35.2 mg in BS group and 93.0 ± 24.52 mg in BD group, significantly lower than in GA group (300.0 ± 27.13 mg). The incidence of complications in GA group (90%) was significantly higher than in BS group (30%) and BD group (15%). Serum glucose and norepinephrine levels were significantly higher at 1 hour, 4 hours, and 8 hours after operation, but returned to baseline levels at 24 hours after operation.ConclusionSuperficial cervical plexus block or combined superficial and deep cervical plexus block effectively reduces postoperative pain, stress response, and complications in SHPT patients who undergo subtotal parathyroidectomy.

Does Preoperative Carbohydrate Intake Reduces Postoperative Stress Response in Patients Undergoing Valve Replacement Surgeries

Does Preoperative Carbohydrate Intake Reduces Postoperative Stress Response in Patients Undergoing Valve Replacement Surgeries

PP022-MON: Effects of Immunonutrition on Postoperative Complication, Stress Responses, and Cell-Mediated Immunity After Pancreaticoduodenectomy: Results from Two Randomized Controlled Studies

PP022-MON: Effects of Immunonutrition on Postoperative Complication, Stress Responses, and Cell-Mediated Immunity After Pancreaticoduodenectomy: Results from Two Randomized Controlled Studies

Comparative study between LMA-Proseal™ and Air-Q® Blocker for ventilation in adult eye trauma patients

BackgroundThe disposable Air-Q® Blocker Masked Laryngeal Airway (MLA) is a new supraglottic device used for intubation, rescue ventilation, and for esophageal suctioning. Laryngeal Mask Airway-Proseal™ is a well known supraglottic device in clinical practice. The aim of the study was to compare Air-Q® Blocker against LMA-Proseal™ as supraglottic devices for ventilation.MethodsSixty adult healthy patients scheduled for eye trauma surgeries under general anesthesia were randomly allocated into 2 groups; Group A (n = 30), where Air-Q® Blocker is used, Group P (n = 30), where LMA-Proseal™ is used. The success rate and time of their insertion were measured. Laryngeal view grading was assessed by fiberoptic bronchoscope. Ease of gastric tube placement and any post-operative complications (airway edema, sore throat or hoarseness) were also measured. Stress response of device insertion was measured using the vital sign measurements.ResultsSuccess of insertion at 1st attempt was (90%) in Group A and (83.3%) in Group P. Insertion time was 18.37 ± 3.77 s in Group (A), while 23.43 ± 3.54 s in Group P, (p < 0.001). Airway seal pressure was comparable in both groups. Full view of vocal cords amounted to (76.7%) in Group A, and (56.7%) in Group P respectively. 1st Attempt Gastric Tube Insertion was (93.3%) in Group A, and (83.3%) in Group P. comparison of previous data in both groups showed no statistical significant differences between them. The incidence of postoperative complications and post insertion hemodynamic stress response was statistically nonsignificant when compared between the 2 groups.ConclusionThe Air-Q® Blocker demonstrated to be remarkably good as a ventilatory device, with adequate airway seal pressure, and improved facilitation of gastric tube insertion compared to LMA-Proseal™. Minimal pressor response was achieved after insertion with no statistical significance.

Promotion of postoperative recovery with fast track surgery for gastric cancer patients undergoing gastrectomy: a prospective randomized controlled study

To study the safety and feasibility of fast track surgery (FTS) in the promotion of postoperative recovery for gastric cancer patients undergoing gastrectomy. From January to December in 2013, 71 gastric cancer patients were prospectively enrolled and randomized into the FTS group and the control group. Patient in the FTS group received FTS management and those in the control group received routine management. The postoperative recovery and stress were compared between the two groups. FTS was associated with shorter time to bowel function return [(67.8±19.7) h vs. (90.0±20.6) h, P<0.01], shorter hospital stay [(13.5±3.0) d vs. (17.8±7.3) d, P=0.01], lower hospital cost [(23.8±3.7) thousand Yuan vs. (27.8±6.1) thousand Yuan, P<0.05], and less stress response (lower pain score, WBC count, C-reactive protein, all P<0.01). The postoperative complications including ileus, infection, anastomotic leakage were similar (all P>0.05). Fast track surgery decreases postoperative stress response and promotes recovery.

The Effect of L-bupivacaine on BIS Levels in the Maintenance Doses of Propofol and Fentanyl during General Anesthesia in Chinese People

Levorotatory forms of amino-amide class of epidural anesthetics are considered to be better than their dextrorotatory counterparts in the way that they are associated with less toxicity and improved absorption and bioavailability.In this study we compared the effect of 2 enantiomers; namely racemic preparation of bupivacaine with pure formulation of its levorotatory form levobupivacaine on the dosage requirements for general anesthesia propofol in a series of 273 patients admitted to hospital of China for nephrectomy. We also compared the effect of epidural anesthetics on intra- and postoperative plasma levels of epinephrine, glucose and cortisol.Our results indicate that levobupivacaine is associated with lower dose requirements of propofol as compared to bupivacaine (3.45±0.5 vs. 4.44±0.5 mg/kg/h). Levo-bupivacaine also attenuated the postoperative stress response as indicated by significant reduction plasma epinephrine levels.Our results suggest that levobupivacaine might be more effective as epidural anesthetic in combined regimen as compared to bupivacaine.

Evaluation of the Efficacy of Intra-Operative Celiac Plexus Block on Post-Operative Analgesia, Stress Response, Gut Motility and Pulmonary Function in Upper Abdominal Surgery: A Double-Blind Randomized Study

Evaluation of the Efficacy of Intra-Operative Celiac Plexus Block on Post-Operative Analgesia, Stress Response, Gut Motility and Pulmonary Function in Upper Abdominal Surgery: A Double-Blind Randomized Study Celiac plexus block (CPB) is an effective method of providing intra-abdominal visceral analgesia. It also decreases the post-operative surgical stress response, enhance gut motility, and improve pulmonary function. We observed the effects of intra-operative CPB with wound infiltration on post-operative analgesia, surgical stress response, gut motility and pulmonary function following upper abdominal surgery (UAS) in a prospective double blind randomized study.

Comparison of a single injection of morphine versus ketamine or neostigmine into the epidural space on postoperative analgesia and hormonal stress response after spinal anesthesia

Background In patients undergoing lower extremity orthopedic procedures who receive spinal anesthesia, an epidural injection of morphine, ketamine, or neostigmine has an effect on postoperative analgesia duration and hormonal stress response. Patients and methods We carried out a prospective, randomized study comparing the effects of addition of 0.6 mg morphine versus 50 mg ketamine versus 60 μg neostigmine into the epidural space in patients who received spinal anesthesia in terms of postoperative analgesia duration and hormonal stress response. Results There was marked prolongation in the postoperative analgesia (428 ± 257) and attenuation of the hormonal stress response in the morphine group compared with the other groups. Also, neostigmine led to prolongation of postoperative analgesia and attenuation of stress response but less than morphine (363 ± 119). Conclusion The preemptive morphine injection into the epidural space could attenuate hormonal stress response and led to prolongation in the postoperative analgesia period.