Correlation between Epidural Depth and Physical Measurements / 대한마취과학회지

BACKGROUND: This study was performed to accurately discover the correlation between the epidural depth and physical measurements. METHODS: We measured the L2-3, L3-4 epidural depth pre-marked on the needle shaft only when the block was successful. Correction of the depth was made by the angulation of the needle from the perpendicular line (with regard to both the x- and y-axis) to the skin. Height and weight from the medical record was noted and neck, waist, and hip circumferences of each subject was measured. Physical parameters such as waist/neck (waist circumference-to-neck circumference ratio), waist/height (waist circumference-to-height ratio), waist/hip (waist circumference-to-hip circumference ratio), weight/neck (weight- to-neck circumference ratio), weight/height (weight-to-height ratio) and body mass index (BMI) were calculated. Peason's correlation and a regression test between the epidural depth and the physical mea surements were performed. RESULTS: Significant correlation with epidural depth was found in weight, waist, hip, neck, BMI, waist/height, waist/hip, weight/neck, and weight/height. With the regression test, we found weight to be the most important for predicting epidural depth (R square = 0.330, P < 0.05). CONCLUSIONS: Weight has the highest predictive value for lumbar epidural depth.

The Effects of Intravenous Piroxicam on Pruritus and Pain in Patients Receiving Epidural Fentanyl / 대한마취과학회지

BACKGROUND: This study was designed to evaluate the effect of intravenous piroxicam on pruritus and pain in patients undergoing abdominal surgery after epidural fentanyl was administered. METHODS: Ninety nine patients, ASA physical status 1 - 2, were randomly allocated to receive either piroxicam 20 mg (n = 50) or saline 2 ml (n = 49) intravenously before surgical incision. An epidural catheter was inserted in all patients before induction of anesthesia. All patients received 5 mg/kg of thiopental sodium and 1.5 mg/kg of vecuronium. Anesthesia was maintained by 50% O2 in N2O with 2 vol% enflurane. Epidural fentanyl 50 microgram was administered intraoperatively and 9.5 12.5 microgram/ml of fentanyl mixed in 100 ml of 0.15% bupivacaine was infused continuously by the Baxter two day infusor for 50 hours postoperatively. Postoperative pruritus and pain were measured by a numeric rating scale (0 - 10) in the piroxicam group and control group. RESULTS: Pruritus and pain scores at 1, 4, 8 and 24 hours in the piroxicam group were significantly lower than those in the control group (P < 0.05). The incidence of pruritus after epidural fentanyl varied from 2 to 6% in the piroxicam group and from 57 to 67% in the control group. Mean scores of pruritus were 0.6, 0.3, 0.2 and 0.1 in the piroxicam group and 5.1, 3.5, 2.8 and 1.8 in the control group. Mean scores of pain were 1.7, 1.2, 0.9 and 0.6 in the piroxicam group and 3.2, 2.4, 1.9 and 1.1 in the control group. CONCLUSIONS: This study demonstrates that intravenous piroxicam 20 mg significantly reduces the incidence and severity of postoperative pruritus and pain in patients who received perioperative epidural fentanyl.

Epidural Block of Bupivacaine and Mexiletine for Erythromelalgia / 대한마취과학회지

Erythromelalgia is a rare disease characterized by palmar and plantar erythema, burning pain and local increase in temperature. Secondary erythromelalgia most commonly appears secondary to myeloproliferative disorders, essential thrombocytosis and polycythemia vera. The pain associated with erythromelalgia is often severe and recalcitrant. So far no properly performed therapeutic trials have been published. We present a case of erythromelalgia of both hands and feet in a 52 year old man. A twice daily cervical and lumbar epidural block of mepivacaine 0.5% and mexiletine 100 mg given orally resuletd in complete resolution of the syndrome. After 3 months, the symptom recurred mildly.

Comparison of 0.075% Bupivacaine/Fentanyl and 0.125% Ropivacaine/Fentanyl Infusion for Postoperative Epidural Analgesia / 대한마취과학회지

BACKGROUND: The new, long-acting local anesthetic ropivacaine is structurally very similar to bupivacaine, but the motor block is less profound and of shorter duration. The aim of this study was to compare analgesic effectiveness and side effects during postoperative pain control after a Caesarean section with either a bupivacaine/fentanyl or ropivacaine/fentanyl mixture. METHODS: Thirty-nine patients undergoing a Caesarean section were randomized in a double-blinded manner to receive bupivacaine or ropivacaine. Postoperative epidural analgesia was provided using a PCA pump with either bupivacaine/fentanyl 0.075%/3.4 microgram/ml after 10 ml of 0.125% bupivacaine with morphine (n = 18) or ropivacaine/fentanyl 0.125%/3.4 microgram/ml after 10 ml of 0.2% ropivacaine with morphine (n = 21). Verbal rating pain scores (rest and cough), side effects (nausea, vomiting, pruritus, sedation, motor block and hypotention) and time to ambulation were measured for 48 hr after surgery. RESULTS: There were no significant differences between the groups in verbal pain scores, sensory level, motor blockade and other side effects, but time to ambulation was earlier in the ropivacaine group. CONCLUSIONS: 0.125% ropivacaine with 3.4 microgram/ml fentanyl provided similar successful pain relief as 0.075% bupivacaine/fentanyl. However, earlier recovery of ambulation in patients receiving ropivacaine/ fentanyl will improve outcome after surgery.

Subarachnoid and Subdural-Extraarachnoid Pneumocephalus in the Patient with No CSF LeaKage during Epidural Catheterization / 대한마취과학회지

A 43-year-old female patient with a left L5 radiculopathy was referred to our pain clinic for an epidural steroid injection. An epidural puncture was done at the L4-5 intervertebral space with the loss of resistance technique using air. There was no CSF leaKage during the procedure. After 6 ml of air was injected, she complained of a sudden severe headache, nausea, tinnitus, and mild hearing difficulty. The headache was localized at the left temporal and suboccipital area and the nature of it was constant, squeezing, and non-throbbing. Neurological examination was normal except a mild sensory change on the right face and right hemibody. A brain CT disclosed sudural and subarachnoid pneumocephalus. Twenty-four hours after the event, she was discharged without any specific complaints. To avoid pneumocephalus during epidural puncture, saline instead of air is highly recommended. If physicians use air, a small volume should be used and careful evaluation of the patients condition during injection despite no CSF leaKage should be done.

Differential Analgesic and Adverse Effects of 0.125% Bupivacaine vs. Ropivacaine Coadministered Epidurally with Morphine / 대한마취과학회지

BACKGROUND: This study aimed to compare analgesic efficacy and occurance of motor block and other side effects of a 48 hr postoperative continuous epidural infusion of 0.125% bupivacaine or ropivacaine with morphine. METHODS: Forty patients undergoing a Cesarean section were allocated randomly into two groups. Both groups received an epidural injection of 2.0% lidocaine 18 20 ml and 0.5% bupivacaine 2 5 ml with fentanyl 50microgram 20 minutes before surgical incision and received 2 mg of epidural morphine by bolus 40 minutes after surgical incision. For post-operative pain control, a continuous epidural infusion was started using a two day infusor containing 6 mg of morphine in 100 ml of 0.125% bupivacaine (Group 1, n = 20) or 100 ml of 0.125% ropivacaine (Group 2, n = 20). Visual analog scale (VAS) for pain during rest and movement, sensory change and motor blockade were assessed for 48 hrs. after surgery. RESULTS: There were no significant differences in VAS for pain during rest and movement. The incidences of side effect were similar in both groups. CONCLUSIONS: Using 0.125% bupivacaine with morphine via the epidural route provided similar pain relief and side effects as 0.125% ropivacaine with morphine.

Epidural Steroid Injection for Low Back Pain in Patients with Radicular Pain / 대한마취과학회지

BACKGROUND: This study describes the authors' experience with patients who received an epidural steroid injection (ESI) for lumbosciatica with radicular leg pain as predominant symptom. We analyzed the efficacy of ESI according to duration of pain and history of prior lumbar spine surgery. METHODS: One hundred thirty-six patients who had low back pain with radicular symptoms were included. Each patient was given 10 ml of 1% mepivacaine mixed with 40 mg of methylprednisolone every two weeks until at least a 75% improvement or reduction in pain was seen. We recommended no more than 3 injections within 3 months. RESULTS: Three to six months after the first injection the more favorable results were observed in patients with subacute radicular leg pain (less than 3 months' duration)(87.6 - 75%, good-excellent) and chronic leg pain with no prior surgery (greater than 3 months' duration)(84.8 - 71%, good-excellent) than in patients with chronic leg pain with prior surgery (50 - 40.1%, good-excellent). The efficacy of ESI was decreased after 1 year after the first ESI. CONCLUSIONS: ESI was effective in the management of lumbosacral radicular pain regardless of duration of symptoms. However, patient's who had had prior lumbar spine surgery had the least satisfactory results.

Epidural Anesthesia for Cesarean Section in a Parturient with Eisenmenger's Syndrome / 대한마취과학회지

Eisenmenger's syndrome is defined as pulmonary hypertension with right-to-left or bidirectional shunting of blood through an intracardiac or aorto-pulmonary commumication. It can occur with complex congenital cardiac malformations, such as septal defect and patent ductus arteriosus. Parturients with Eisenmenger's syndrome are at high risk for peripartum morbidity and mortality. We experienced a case of parturient for cesarean section with Eisenmenger's syndrome and performed epidural anesthesia with fractionated doses of 2% lidocaine and fentanyl. The sensory block reached to T10 level and blood pressure was maintained with intravenous phenylephrine. After baby out, sudden hypotension with severe bradycardia developed and arterial oxygen saturation dropped. Immediate intubation and resuscitation was done, but cardiac rhythm disturbance, hypoxemia, and acidosis did not corrected. Cardiac standstill developed and stopped resuscitation. The neonate's Apgar score was 7 and he was transferred to pediatric ICU.

Epidurographical Spreading Patterns of Successive Small Volume Caudal Epidural Injections in Chronic Low Back Pain / 대한마취과학회지

BACKGROUND: A volumetric caudal epidural steroid injection has been advocated to facilitate the delivery of medications to a lesion site. This study was aimed to examine the actual spreading patterns of this technique, using an epidurogram. METHODS: A total of 32 patients with chronic low back pain with a radiculopathy of various causes (degenerative spondylosis, herniated nucleus pulposus, spondylolisthesis, and spinal stenosis) were included. A volumetric caudal epidural injection of a 10 ml mixture of contrast medium 5 ml, 0.5% bupivacaine 1 ml, triamcinolone 1.5 ml (60 mg) and normal saline 2.5 ml was performed. Immediately after the cessation of the first spread, the subsequent solution of another 10 ml of contrast medium 5 ml, 0.5% bupivacaine 1 ml and normal saline 4 ml was injected. This procedure was repeated serially until the total volume equaled 50 ml. Continuous fluoroscopic imaging was obtained after each injection. RESULTS: Average time taken to complete the study was 37 seconds per every 10 ml. The spreading levels of the mixture were distributed mainly at the mid to lower lumbar area in the majority of the investigated patients. During the subsequent injections, these levels did not increase significantly. CONCLUSIONS: We concluded that the multiple small volume caudal epidural injections retraced their own tract repeatedly. This was thought to be due to the minimal resistance in the cephalad direction, anatomic variations and the Starling effect of epidural space.

The Effect of Epidural Block on Renal Function in Patients Undergoing Total Abdominal Hysterectomy with General Anesthesia / 대한마취과학회지

BACKGROUND: There are many documents about the hemodynamic changes during sympathetic blockade produced by epidural anesthesia, but few reports have addressed the effects of epidural anesthesia on renal blood flow and function. We evaluated the effects of epidural anesthesia on renal function in patients undergoing total abdominal hysterectomy with general anesthesia. METHODS: Thirty patients were randomized to groups I (n = 15) or II (n = 15). The epidural catheter was inserted via 17 gauge Tuohy needle through the L2-L3 intervertebral space of the patients in both groups, only in group II, the patients received 15 ml of 0.125% bupivacaine. All the patients were anesthetized with enflurane, nitrous oxide and oxygen. We measured mean arterial pressure and urine output, creatinine clearence, Na clearence, fractional excretion of Na and free water clearance during operation and compared the data between the two groups. RESULTS: Mean arterial pressure was lower in group II than in group I (P < 0.05), but other data were not different significantly between the two groups. CONCLUSIONS: Renal function was maintained even though epidural anesthesia reduced mean arterial pressure.

Effects of Epidural Co-administration of Morphine and Naloxone on Intestinal Motility after Total Hysterectomy / 대한마취과학회지

BACKGROUND: Epidural morphine is usually associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone have been known to reduce morphine-induced side effects including intestinal hypomotility without reversing analgesia, but the effect of epidural naloxone has not been defined in human study. Therefore we evaluated bowel motility and analgesia when naloxone was administered via epidural route. METHODS: Forty-two patients having epiduro-general analgesia for total hysterectomy were randomly assigned to one of two study groups. As a means of postoperative pain control, all received 1.5 mg of epidural morphine bolusly 1 hour before the end of surgery, and a continuous epidural infusion was started using a two-day infusor containing 2.5 mg of morphine in 0.125% bupivacaine 100 ml with either no naloxone (control group, n = 20) or 5 microgram/kg/day of naloxone (experimental group, n = 22). We measured the time to the postoperative first passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were taken at 2 and 4 hours after the operation, 7 AM, 1 PM, and 7 PM of the 1st postoperative day and 7 AM and 1 PM of the 2nd postoperative day. RESULTS: The experimental group revealed less time to the first postoperative passage of flatus and feces. No significant difference was found in resting and movement VAS between the two groups. CONCLUSIONS: This study suggests that epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing analgesic effects.

Comparison of Spinal and Epidural Anesthesia for Transurethral Resection of Prostate (TURP) / 대한마취과학회지

BACKGROUND: The purpose of this study was to determine whether spinal or epidural anesthesia is more suitable in terms of sensory and motor blockade, cardiovascular stability, intraoperative blood loss, postoperative recovery and patient satisfaction in elderly patients undergoing TURP. METHODS: Fourty patients undergoing TURP were randomly allocated to either a spinal or an epidural anesthesia group. The spinal group (n = 20) received 10 12 mg of 0.5% tetracaine in 10% dextrose, while the epidural group (n = 20) received 20 25 ml of 2% lidocaine at L4-5 intervertebral space. After injection of the agent, changes in sensory and motor blockade, blood pressure and heart rate were measured in the two groups. We compared serum Hb, serum Na, foley removal, hospital stay, side effects, analgesic use, and patient satisfaction between the two groups. RESULTS: The two techniques were similar with regard to the level of blood pressure, heart rate, Hb and Na changes, foley removal and hospital stay. At 15 and 30 minutes after spinal and epidural anesthesia, the results for sensory blockade were T8 +/- 2.2 S5, T9 +/- 1.2 S5 (spinal) and T10 +/- 1.5 S3, T8 +/- 2.1 - S4 +/- 1.0 (epidural), and motor blockade was complete in the spinal group but incomplete in the epidural group. Patient satisfaction was better in the epidural group than in the spinal group, but analgesic use was more frequent in the spinal group than in the epidural group. CONCLUSIONS: Both spinal and epidural anesthesia are suitable for TURP. Spinal anesthesia was technically easier and produces a complete and more reliable block of the sacral segment, but was also an unnecessarily profound motor block of the lower extremity. Epidural anesthesia is less pronounced and gives a shorter duration of motor blockade with good patient satisfaction.

Retrial of Anesthetic Management for a Patient with Malignant Hyperthermia during Previous General Anesthesia / 대한마취과학회지

Malignant hyperthermia is a subclinical myopathy, usually triggered by anesthetics and associated with a mortality rate of up to 70%, when left untreated. But with early diagnosis using capnography and with the advent of dantrolene, the mortality rate could be reduced to less than 5%, which implies the significance of early diagnosis and proper treatment. Owing to the reduced mortality rate, anesthesiologists get more chances to encounter patients with a previous history of malignant hyperthermia and knowledge to provide proper anesthetic management become essential. We present a case in which malignant hyperthermia was detected in a 67 year old female patient with gastric cancer and a thyroid mass during the first operation and successfully treated with promptly initiated supportive measures based on capnography finding without dantrolene which was not available at the time and the same patient rescheduled for subsequent gastrectomy in which we chose non-triggering agents in adjunct to epidural anesthesia without provoking malignant hyperthermia.

Adequate Dosage of Butorphanol Combined with Epidural Morphine for Cancer Pain Patients / 대한마취과학회지

BACKGROUND: Continuous epidural morphine administration (CEM) is a common method to treat the pain of terminal cancer patients, but this could produce many side effects/ such as pruritus, nausea, vomiting, constipation and urinary retention. The purpose of this study was to determine the optimal epidural butorphanol dosage to prevent side effects of CEM in terminal cancer patients. METHODS: Thirty terminal cancer patients were randomly assigned to one of three groups. After insertion of epidural catheter, morphine 2 mg and butorphanol 1 mg were injected epidurally for a loading dose and a 2 Day Infusor (2 ml/hr)(Home Pump(R) , I-Flow, Lake Forest, USA) containing morphine 8 mg with butorphanol 2 mg (B2 group, n = 10), 4 mg (B4 group, n = 10) or 6 mg (B6 group, n = 10) mixed with 5% D/W (total 100 ml) was connected. Severity of pain, nausea and vomiting, and pruritus were evaluated using VAS score at 1, 6, 12, 24, 36 and 48 hr after epidural infusion. RESULTS: Severity of pain, nausea and vomiting, and pruritus were significantly decreased in the B6 group as comparable to the other two groups (p < 0.05). CONCLUSIONS: The addition of butorphanol 3 mg to morphine 4 mg in CEM in terminal cancer patients reduced nausea, vomiting and pruritus and improved the pain control effect.

The Effects of Needle Type, Gauge, Insertion Depth and the Use of Introducer Needle on Spinal or Epidural Needle Deflection / 대한마취과학회지

BACKGROUND: This study was performed to discover how much needle deflection occurs during spinal or epidural block and how it can be reduced. METHODS: A styrofoam block was used to simulate the paraspinal area of the back. A line was drawn perpendicular to the edge. Using the line as a guide, the needles were advanced through the block. Quincke-type needles of 22 and 25 gauge, pencil-type needles of 22 and 25 gauge or Tuohy needles of 17 and 18 gauge were used. Using a block of 6 cm thick, spinal needle was advanced through the introducer with their apertures facing to the same or opposite direction. The deflection from the perpendicular line was measured in mm intervals. RESULTS: Small-gauged and beveled spinal needles had more deflection depending on the block thickness (P < 0.05). However, the deflection of epidural needles was not consistent. When the bevel of the introducer and spinal needle was facing the same direction, the use of an introducer needle decreased the deflection in 22 and 25 G Quicke, and 25 G Whitacre needles (P < 0.05). When facing each other, the deflection was reduced in all the spinal needles (P < 0.05), and reduced more in the 25 G Quicke needles (P < 0.05). CONCLUSIONS: Considering the estimated depth of the spinal canal, needle type, bevel direction, its gauge and the use of an introducer needle, we can take advantage of the deflection phenomenon to reduce post-dural puncture headache and to increase the success rate of a spinal or epidural block.

Comparison of General Anesthesia and Thoracic Epidural Anesthesia for Breast Mass Excision Surgery / 대한마취과학회지

BACKGROUND: The purpose of this study is to compare the effectiveness of thoracic epidural anesthesia (TEA) and general anesthesia (GA) in terms of side effects, postoperative pain control and the cost of anesthesia for breast mass excision surgery. METHODS: Forty-three patients rated as ASA physical status class 1 or 2 who underwent breast mass excision surgery were included in the study. In the TEA group (n = 20), 2% lidocaine (3 ml) and 0.5% bupivacaine (3 ml) were administered via the epidural route. Blood pressure and heart rate were measured before and at 3, 6, 9, 12, 15, 18 21, 24, 27 and 30 minutes after epidural injection. In the GA group (n = 23) patients were maintained by general anesthesia with enflurane and 50% nitrous oxide in oxygen. After the operation, patients were given NSAID-diclofenac sodium as they wanted. Analgesic requirement, satisfaction score, and anesthesia-related side effects were recorded 1 day after surgery. Satisfaction scores of the surgeons and patients were recorded as excellent (4 point), good (3 point), fair (2 point), and unacceptable (1 point). RESULTS: Overall satisfaction scores and side effects were not significantly different between the TEA group and the GA group. Anesthesia cost (80,883.2 +/- 3956.9 vs 32,284.8 +/- 1209.4 won) were significantly lower in the TEA group than in the GA group. CONCLUSIONS: There were not significant differences in satisfaction scores and postoperative side effests between the TEA and GA groups. TEA provided lower anesthesia cost than GA for breast mass excision surgery.

Extension of Sensory Blockade after Thoracic and Lumbar Epidural Administration of a Test dose of Lidocaine / 대한마취과학회지

BACKGROUND: The distribution of solutions injected into the epidural space has not been well determined. The aim of this study was to compare the difference in extension of sensory blockade between the thoracic and lumbar regions in epidural analgesia. METHODS: Forty-five female patients scheduled for postoperative pain control were enrolled. In group 1 (n = 22), the Tuohy needle was inserted at T6 10 levels and in group 2 (n = 23), it was inserted at T12 L2 levels. The catheter was introduced 3 4 cm into the epidural space and 3 ml of 1.5% lidocaine with epinephrine (1:200,000) was injected. The extension of sensory anesthesia to loss of cold sensation and pinprick test was measured every 5 minute for 15 minutes. RESULTS: Fifteen minutes after epidural injection, the mean sensory block extension in group 1 (7.8 +/- 2.0 dermatomes) was significantly wider than in group 2 (4.7 +/- 2.2 dermatomes) but cranial and caudad spread of sensory blockade in relation to the puncture level was the same in both groups. CONCLUSION: The mean dose of local anesthetic required for analgesia was smaller in the thoracic region than in the lumbar region.

Lumbar Root Compression Secondary to Epidural Air Retension: A case report / 대한마취과학회지

Air can be introduced into the epidural space during the loss of resistance technique used to identify needle entry into the epidural space. Complications resulting from the injection of air into the epidural space include pneumocephalus, spinal cord and nerve root compression, retroperitoneal air collection, subcutaneous emphysema, venous air embolism, and possibly, incomplete analgesia and anesthesia. We experienced a case of a large epidural collection of air following epidural anesthesia attempted one month before. The CT scan revealed epidural air extending from L1-S1 with moderate compression of nerve root at L4-5.

The Effect of Epidural Phenylephrine on Hypotension Induced by Epidural Anesthesia for Cesarean Delivery / 대한마취과학회지

BACKGROUND: Hypotension can occur after high level of epidural anesthesia. Like ephedrine, epidural phenylephrine is known to reduce the incidence of hypotension induced by the epidural administration of lidocaine. The purpose of this study was to determine whether combining epidural phenylephrine can reduce the incidence of hypotension in epidural anesthesia. METHODS: Ninety-two patients undergoing a cesarean section were divided into three groups. Patients assigned to three groups received 20-25 ml of lidocaine containing fentanyl 50 microgram with one of three doses of phenylephrine; 0 microgram (Group 1), 100 microgram (Group 2), or 200 microgram (Group 3), injected via the lumber epidural catheter. The mean blood pressure and heart rate were recorded every 10 min for 1 h after injection and were compared among the groups. Pinprick testing was performed to determine the highest level of sensory block and the time to two-segment regression. Also, the incidence of hypotension and ephedrine required were investigated. RESULTS: The incidence of hypotension was 37%, 28%, and 40% in Group 1-3, respectively. The time to two-segment regression was 94.7 +/- 21.6 in group 1, 100.8 +/- 20.1 min in Group 2, compared to 118.2 +/- 26.3 min in Group 3. CONCLSIONS: We found that epidural phenylephrine significantly prolonged the duration of epidural anesthesia, but it was ineffective for preventing hypotension induced by lidocaine epidural anesthesia.

The Effects of Anesthetic Techniques and Postoperative Pain Control on the Response of the Stress and Immune System in Cesarean Section Patients / 대한마취과학회지

BACKGROUND: Surgical trauma may affect the host immune system. We have examined the time course of circulating interleukin-6 (IL-6) and cortisol in patients undergoing a cesarean section (c/s) to determine if the anesthetic techniques and postoperative pain control have an effect on the response of the stress and immune system. METHODS: Thirty healthy women undergoing c/s were randomly allocated to three groups. Group I (n = 10) was provided with general anesthesia, group II (n = 10) with epidural anesthesia and group III (n = 10) with epidural anesthesia plus continuous epidural analgesia for postoperative pain control. Blood samplings for IL-6 and cortisol were conducted 4 times in all patients: preoperation, 1 h, 3 h and 24 h after skin incision. RESULTS: The mean concentrations of IL-6 were significantly increased in all three groups at 3 h and 24 h after the skin incision, but there were no significant differences among the three groups. The mean concentrations of cortisol were significantly increased in three groups at 1 h and 3 h after the skin incision, but there were no significant differences among the three groups. CONCLSIONS: No significant differences among three groups were seen. Thus, We couldn't determine that anesthetic techniques and postoperative pain control had a significant effect on the response of the stress and immune system.