The Intestinal Barrier Function and Intra-Abdominal Pressure Depend on Postoperative Analgesia Technique in Children...

Peritonitis is one of the risk factors for the development of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The plasma citrulline and intestinal fatty acid-binding protein (I-FABP) are informative markers of intestinal barrier function. The aim of this study was to determine the correlation of the plasma citrulline and I-FABP with intra-abdominal pressure (IAP) and their relation to analgesia techniques in children suffering from appendicular peritonitis.

74 children operated for appendicular peritonitis were randomized into three groups of postoperative analgesia: "Opioids" (n = 25), intravenous morphine of 10 mcg/kg/h; "Lidocaine" (n = 23), intravenous lidocaine with initial bolus of 1.5 mg/kg and then infusion of 1.5 mg/kg/h; and "EA" (n = 26), epidurally 0.25% bupivacaine with initial bolus of 1 mg/kg and then infusion of 0.4 mg/kg/year. Retrospectively patients in each group were divided into the following subgroups: "without IAH" (n = 33), "IAH" (n = 27), and "ACS" (n = 14). We detected citrulline and I-FABP in plasma on day 1 (D1) and day 3 (D3) of hospital stay.

The patients without IAH on D1 presented significantly higher plasma citrulline (23.7 (16.0-31.3) nmol/ml) and lower I-FABP (76.9 (32.6-121.1) pg/ml) levels compared with patients in subgroup "IAH" (9.3 (7.3-11.3) nmol/ml and 226.0 (161.8-290.3) pg/ml, respectively) and subgroup "ACS" (6.9 (5.3-8.6) nmol/ml and 1011.7 (731.9-1291.5) pg/ml, respectively). The IAP had strong inverse correlation (r  = -0.74; p < 0.00001) with citrulline and positive strong correlation (r  = 0.73; p < 0.00001) with I-FABP. The citrulline in patients with IAH during three days postoperatively increased significantly in "Lidocaine" to 72% (p=0.01) and in "EA" to 138% (p=0.02), but it decreased to 13% (p=0.37) in "Opioids" group. In children with ACS, citrulline on D3 was significantly higher than that on D1 and increased in "Lidocaine" to 59% (p=0.05) and in "EA" to 134% (p=0.001), but in "Opioids" it decreased to 30% (p=0.48). The I-FABP in patients with IAH decreased to 12% in "Lidocaine" group (p=0.86) and to 75% in "EA" group (p=0.01), but it increased to 37% (p=0.57) in "Opioids" group. During observation period, I-FABP in patients with ACS decreased significantly in "Lidocaine" to 42% (p=0.05) and in "EA" to 96% (p=0.003), but it increased in "Opioids" to 63% (p=0.22).

The IAP was inversely correlated with plasma citrulline and positively correlated with I-FABP in children with appendicular peritonitis. Epidural analgesia is the most protective for intestinal wall barrier function in patients at risk of IAH and ACS.