Background: Surgical stress is aggravated by anesthesia especially opioid-based anesthesia. Epidural anesthesia (EA) was previously found to modulate the immune response. Bupivacaine (BUP) may suffice as anesthetic but adjuvant might increase this and possibly may modulate the stress response
Objectives: Evaluation of the effects of dexmedetomidine (DEX), fentanyl (FEN), or tramadol (TRM) as adjuvants to BUP-EA on anesthetic outcomes and serum levels of interleukin (IL)-6, IL-1β and Tumor necrosis factor-α (TNF-α) during varicose vein surgery.
Patients and methods: 120 patients received single-shoot BUP 0.5% EA alone or with 25, 50 and 100 µg of DEX, FEN and TRM, respectively. Blood samples were obtained at start (T1) and end of surgery (T2) and 24-h postoperative (PO) (T3) for ELISA estimations of cytokines' levels.  Study outcomes include the effect of adjuvants on anesthetic outcome and serum cytokines.
Results: Adjuvants significantly fastened complete sensory block especially BUP/DEX and BUP/FEN with significant difference with BUP/DEX. Duration till Bromage-3 was significantly shorter and duration till Bromage-2 and 0 grades were significantly longer with DEX. Both DEX and FEN provided hemodynamic stability. Adjuvants provided significantly better PO analgesia especially DEX. Serum cytokines' levels were increased in all T2 and T3 samples than T1 levels, but levels were the lowest with DEX. Serum TNF-α and IL-6 levels were negatively affected by epidural adjuvants especially DEX.
Conclusion: EA ameliorates the surgery-induced inflammatory response and adjuvants might augment this effect. Epidural BUP/DEX anesthesia significantly suppressed, while BUP/FEN augments the serum cytokines' levels.