• Comparison of different methods of postoperative analgesia in children with peritonitis complicated with intra-abdominal hypertension
en To content Full text of article

Comparison of different methods of postoperative analgesia in children with peritonitis complicated with intra-abdominal hypertension

Paediatric surgery.Ukraine.2020.1(66):41-50; doi 10.15574/PS.2020.66.41
Perova-Sharonova V.
Danylo Halytskyy Lviv National Medical University, Ukraine
Communal Noncommercial Enterprise of Lviv Regional Concil Lviv Regional Children's Clinical Hospital «OHMATDYT», Ukraine

For citation: Perova-Sharonova V. (2020). Comparison of different methods of postoperative analgesia in children with peritonitis complicated with intra-abdominal hypertension. Paediatric surgery.Ukraine.2020.1(66):41-50; doi 10.15574/PS.2020.66.41
Article received: Oct 12, 2019. Accepted for publication: Feb 17, 2020.

Appendicular peritonitis is the most common cause of complicated intra-abdominal infection in children that leads to risk of development intra-abdominal hypertension (IAH). Post-operative pain in patients with peritonitis and IAH is associated not only with surgical trauma, but may also have somato-visceral origin. Analgesia is recommended in patients with IAH treatment to improve abdominal wall compliance. Optimal method of analgesia for patients with peritonitis and IAH has not been find out.
Objective. To investigate effect of different analgesia methods on postoperative pain intensity in children with IAH after appendicular peritonitis surgery.
Materials and methods. Seventy-three children who underwent appendicular peritonitis surgery were randomized into three groups depending on the postoperative analgesia method: «Opioids» (n=25, intravenous morphine infusion), «Lidocaine» (n=22, intravenous infusion) and «EA» (n=26, epidural anesthesia). Postoperatively, evaluation of pain intensity with NRS or FLACC scale, and intra-abdominal pressure level (IAP) measurement were performed in all children. Depending on the IAP level, children were retrospectively divided into subgroups: «No IAH» (IAT˂10 mmHg) and «IAH» (IAT>10 mmHg).
Results. IAP was statistically significantly higher in children with IAH in «Opioids» group compared to «Lidocaine» (Р<0.05) and «EDA» (Р<0.05) groups. Postoperative pain intensity at rest and during movement were statistically significantly higher in «Opioids» group compared to «Lidocaine» (Р<0.01 and Р<0.001) and «EA» (Р<0.01 and Р<0.001) groups in children with IAH and without IAH. There was no statistically significant difference in the postoperative pain intensity at rest (Р>0.05) and during movements (Р>0.05) and in the morphine daily dose (Р>0.05) in children without IAH and with IAH between the «Lidocaine» and «EA» groups. Postoperative pain intensity during movements (P=0.026) and morphine daily dose (P=0.032) were statistically significantly higher in subgroup «IAH» compared to subgroup «Without IAH» in «Opioids» group. Correlation between IAP and postoperative pain intensity at rest and during movements was strong in the «Opioids» (rs=0.63; P˂0.05 and rs=0.76; P˂0.05) and «Lidocaine «(rs=0.59; P˂0.05 and rs=0.71; P˂0.05) groups and moderate during movement only in «EA» group (rs=0.43; R˂0.05) in children with IAH.
Conclusions. Pain intensity is directly proportional to intra-abdominal pressure level in children. Epidural anesthesia is optimal analgesic technique for patients with peritonitis and IAH that does not cause additional intra-abdominal pressure increase and provides sufficient somato-visceral analgesia. Intravenous lidocaine infusion can be used as alternative to epidural anesthesia.
The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institution. The informed consent of the patient was obtained for conducting the studies.
No conflict of interest was declared by the author.
Key words: intra-abdominal hypertension, pain, intravenous lidocaine infusion, epidural anesthesia.

REFERENCES

1. Barletta JF, Asgeirsson T, Senagore AJ. (2011). Influence of intravenous opioid dose on postoperative ileus. Ann Pharmacother. 45(7-8): 916-23. https://doi.org/10.1345/aph.1Q041; PMid:21730280

2. Boric K, Dosenovic S, Jelicic Kadic A, Batinic M et al. (2017). Interventions for postoperative pain in children: An overview of systemati of systematic reviews. Paediatr Anaesth. 27(9): 893-904. doi: 10.1111/pan.13203

3. Borys M, Zyzak K, Hanych A, Domagała M et al. (2018). Survey of postoperative pain control in different types of hospitals: a multicenter observational study. BMC Anesthesiol. 18(1): 83. https://doi.org/10.1186/s12871-018-0551-3; PMid:30021520 PMCid:PMC6052639

4. Both CP, Thomas J, Buhler PK, Schmitz A et al. (2018). Factors associated with intravenous lidocaine in pediatric patients undergoing laparoscopic appendectomy – a retrospective, single-centre experience. BMC Anesthesiol. 18(1): 88. https://doi.org/10.1186/s12871-018-0545-1; PMid:30021507 PMCid:PMC6052565

5. Dunn LK, Durieux ME. (2017). Perioperative Use of Intravenous Lidocaine. Review. Anesthesiology. 126(4): 729-737. https://doi.org/10.1097/ALN.0000000000001527; PMid:28114177

6. Gebhart GF, Bielefeldt K. (2016). Physiology of Visceral Pain. Review. Compr Physiol. 6(4): 1609-1633. https://doi.org/10.1002/cphy.c150049; PMid:27783853

7. Hakobyan RV, Mkhoyan GG. (2008). Epidural analgesia decreases intraabdominal pressure in postoperative patients with primary intra-abdominal hypertension. Acta Clin Belg. 63(2): 86-92. https://doi.org/10.1179/acb.2008.63.2.005; PMid:18575048

8. Harvey KP, Adair JD, Isho M, Robinson R. (2009). Can intravenous lidocaine decrease postsurgical ileus and shorten hospital stay in elective bowel surgery? A pilot study and literature review. Am J Surg. 198(2): 231-6. https://doi.org/10.1016/j.amjsurg.2008.10.015; PMid:19285304

9. Iwata H, Tsuchiya S, Nakamura T, Yano S. (2007). Morphine leads to contraction of the ileal circular muscle via inhibition of the nitrergic pathway in mice. Eur J Pharmacol. 574(1): 66-70. https://doi.org/10.1016/j.ejphar.2007.06.029; PMid:17632101

10. Kaneko M, Saito Y, Kirihara Y, Collins JG, Kosaka Y. (1994). Synergistic antinociceptive interaction after epidural coadministration of morphine and lidocaine in rats. Anesthesiology. 80(1): 137-50. https://doi.org/10.1097/00000542-199401000-00021; PMid:8291703

11. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R et al. (2013). Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 39(7): 1190-1206. https://doi.org/10.1007/s00134-013-2906-z; PMid:23673399 PMCid:PMC3680657

12. Kolkman JJ, Mensink PB. (2003). Non-occlusive mesenteric ischaemia: a common disorder in gastroenterology and intensive care. Review. Best Pract Res Clin Gastroenterol. 17(3): 457-73. https://doi.org/10.1016/S1521-6918(03)00021-0

13. Kurabe M, Furue H, Kohno T. (2016). Intravenous administration of lidocaine directly acts on spinal dorsal horn and produces analgesic effect: An in vivo patch-clamp analysis. Sci Rep. 6: 26253. https://doi.org/10.1038/srep26253; PMid:27188335 PMCid:PMC4870564

14. Lauder GR. (2017). A Review of Intravenous Lidocaine Infusion Therapy for Paediatric Acute and Chronic Pain Management. In C Maldonado (Ed.), Pain relief. From analgesics to alternative therapies. InTech. Chapter 9. https://doi.org/10.5772/66771

15. Lian B, Vera-Portocarrero L, King T, Ossipov MH, Porreca F. (2010). Opioid-induced latent sensitization in a model of noninflammatory viscerosomatic hypersensitivity. Brain Res. 1358: 64-70. https://doi.org/10.1016/j.brainres.2010.08.032; PMid:20727859 PMCid:PMC4028661

16. Montravers P, Blot S, Dimopoulos G, Eckmann C et al. (2016). Therapeutic management of peritonitis: a comprehensive guide for intensivists. Intensive Care Med. 42(8): 1234-47. https://doi.org/10.1007/s00134-016-4307-6; PMid:26984317

17. Morimoto K, Nishimura R, Matsunaga S, Mochizuki M, Sasaki N. (2001). Epidural analgesia with a combination of bupivacaine and buprenorphine in rats. J Vet Med A Physiol Pathol Clin Med. 48(5): 303-12. https://doi.org/10.1046/j.1439-0442.2001.00360.x; PMid:11475905

18. Ness TJ. (2000). Intravenous lidocaine inhibits visceral nociceptive reflexes and spinal neurons in the rat. Anesthesiology. 92: 1685-91. https://doi.org/10.1097/00000542-200006000-00028; PMid:10839920

19. Onoglu R, Narin C, Kiyici A, Sarkilar G et al. (2016). The Potential Effect of Epidural Anesthesia on Mesenteric Injury after Supraceliac Aortic Clamping in a Rabbit Model. Ann Vasc Surg. 34: 227-33. https://doi.org/10.1016/j.avsg.2015.11.013; PMid:26902941

20. Page AJ, O’Donnell TA, Blackshaw LA. (2008). Opioid modulation of ferret vagal afferent mechanosensitivity. Am J Physiol Gastrointest Liver Physiol. 294(4): G963-70. https://doi.org/10.1152/ajpgi.00562.2007; PMid:18258789

21. Rawal N. (2012). Epidural technique for postoperative pain: gold standard no more? Review. Reg Anesth Pain Med. 37(3): 310-7. https://doi.org/10.1097/AAP.0b013e31825735c6; PMid:22531384

22. Russell P, von Ungern-Sternberg BS, Schug SA. (2013). Perioperative analgesia in pediatric surgery. Review. Curr Opin Anaesthesiol. 26(4): 420-7. https://doi.org/10.1097/ACO.0b013e3283625cc8; PMid:23756911

23. Salicath JH, Yeoh EC, Bennett MH. (2018). Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev. 8: CD010434. https://doi.org/10.1002/14651858.CD010434

24. Sangesland A, Storen C, Vaegter HB. (2017). Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review. Scand J Pain. 15: 44-52. https://doi.org/10.1016/j.sjpain.2016.12.002; PMid:28850344

25. Sweetser S. (2019). Abdominal Wall Pain: A Common Clinical Problem. Review. Mayo Clin Proc. 94(2): 347-355. https://doi.org/10.1016/j.mayocp.2018.04.031; PMid:30711130

26. Thabet FC, Ejike JC. (2017). Intra-abdominal hypertension and abdominal compartment syndrome in pediatrics. A review. J Crit Care. 41: 275-282. https://doi.org/10.1016/j.jcrc.2017.06.004; PMid:28614762

27. Thomas S, Kriplani D, Crane C, Dehom SO et al. (2017). Outcomes in pediatric patients with abdominal compartment syndrome following urgent exploratory laparotomy. J Pediatr Surg. 52(7): 1144-1147. https://doi.org/10.1016/j.jpedsurg.2016.09.071; PMid:27810147

28. Thompson JM, Neugebauer V. (2017). Amygdala Plasticity and Pain. Review. Pain Res Manag. 2017: 8296501. https://doi.org/10.1155/2017/8296501; PMid:29302197 PMCid:PMC5742506

29. Van Noord BA, Roffey P, Thangathurai D. (2013). Abdominal compartment syndrome following opioid-induced postoperative ileus. J Clin Anesth. 25(2): 146-9. https://doi.org/10.1016/j.jclinane.2012.07.004; PMid:23333788

30. Warren DT, Liu SS. (2008). Neuraxial Anesthesia. In DE Longnecker et al (Eds.) Anesthesiology. New York: McGraw-Hill Medical.

31. Weibel S, Jelting Y, Pace NL, Helf A et al. (2018). Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Review. Cochrane Database Syst Rev. 6:CD009642. https://doi.org/10.1002/14651858.CD009642

32. Weiss R, Popping DM. (2018). Is epidural analgesia still a viable option for enhanced recovery after abdominal surgery. Review. Curr Opin Anaesthesiol. 31(5): 622-629. https://doi.org/10.1097/ACO.0000000000000640; PMid:29994937

33. Yam MF, Loh YC, Tan CS, Khadijah Adam S et al. (2018). General Pathways of Pain Sensation and the Major Neurotransmitters Involved in Pain Regulation. Review. Int J Mol Sci. 19(8). pii: E2164. https://doi.org/10.3390/ijms19082164; PMid:30042373 PMCid:PMC6121522

34. Yousef Y, Youssef F, Dinh T, Pandya K et al. (2018). Risk stratification in pediatric perforated appendicitis: Prospective correlation with outcomes and resource utilization. J Pediatr Surg. 53(2): 250-255. https://doi.org/10.1016/j.jpedsurg.2017.11.023; PMid:29223673