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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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Liu S, He B, Deng L, Li Q, Wang X. Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2023; 18:e0282790. [PMID: 36893114 PMCID: PMC9997990 DOI: 10.1371/journal.pone.0282790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/17/2023] [Indexed: 03/10/2023] Open
Abstract
Deep neuromuscular blockade provides better surgical workspace conditions in laparoscopic surgery, but it is still not clear whether it improves perioperative outcomes, not to mention its role in other types of surgeries. We performed this systematic review and meta-analysis of randomized controlled trials to investigate whether deep neuromuscular blockade versus other more superficial levels of neuromuscular blockade provides improved perioperative outcomes in adult patients in all types of surgeries. Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to June 25, 2022. Forty studies (3271 participants) were included. Deep neuromuscular blockade was associated with an increased rate of acceptable surgical condition (relative risk [RR]: 1.19, 95% confidence interval [CI]: [1.11, 1.27]), increased surgical condition score (MD: 0.52, 95% CI: [0.37, 0.67]), decreased rate of intraoperative movement (RR: 0.19, 95% CI: [0.10, 0.33]), fewer additional measures to improve the surgical condition (RR: 0.63, 95% CI: [0.43, 0.94]), and decreased pain score at 24 h (MD: -0.42, 95% CI: [-0.74, -0.10]). There was no significant difference in the intraoperative blood loss (MD: -22.80, 95% CI: [-48.83, 3.24]), duration of surgery (MD: -0.05, 95% CI: [-2.05, 1.95]), pain score at 48 h (MD: -0.49, 95% CI: [-1.03, 0.05]), or length of stay (MD: -0.05, 95% CI: [-0.19, 0.08]). These indicate that deep neuromuscular blockade improves surgical conditions and prevents intraoperative movement, and there is no sufficient evidence that deep neuromuscular blockade is associated with intraoperative blood loss, duration of surgery, complications, postoperative pain, and length of stay. More high-quality randomized controlled trials are needed, and more attention should be given to complications and the physiological mechanism behind deep neuromuscular blockade and postoperative outcomes.
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Affiliation(s)
- Siyuan Liu
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Bin He
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Lei Deng
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Qiyan Li
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
| | - Xiong Wang
- Department of Anesthesiology, Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, People’s Republic of China
- * E-mail:
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Reijnders-Boerboom GTJA, van Helden EV, Minnee RC, Albers KI, Bruintjes MHD, Dahan A, Martini CH, d'Ancona FCH, Scheffer GJ, Keijzer C, Warlé MC. Deep neuromuscular block reduces the incidence of intra-operative complications during laparoscopic donor nephrectomy: a pooled analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:56. [PMID: 34879862 PMCID: PMC8656013 DOI: 10.1186/s13741-021-00224-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022] Open
Abstract
Study objective To assess whether different intensities of intra-abdominal pressure and deep neuromuscular blockade influence the risk of intra-operative surgical complications during laparoscopic donor nephrectomy. Design A pooled analysis of ten previously performed prospective randomized controlled trials. Setting Laparoscopic donor nephrectomy performed in four academic hospitals in the Netherlands: Radboudumc, Leiden UMC, Erasmus MC Rotterdam, and Amsterdam UMC. Patients Five hundred fifty-six patients undergoing a transperitoneal, fully laparoscopic donor nephrectomy enrolled in ten prospective, randomized controlled trials conducted in the Netherlands from 2001 to 2017. Interventions Moderate (tetanic count of four > 1) versus deep (post-tetanic count 1–5) neuromuscular blockade and standard (≥10 mmHg) versus low (<10 mmHg) intra-abdominal pressure. Measurements The primary endpoint is the number of intra-operative surgical complications defined as any deviation from the ideal intra-operative course occurring between skin incision and closure with five severity grades, according to ClassIntra. Multiple logistic regression analyses were used to identify predictors of intra- and postoperative complications. Main results In 53/556 (9.5%) patients, an intra-operative complication with ClassIntra grade ≥ 2 occurred. Multiple logistic regression analyses showed standard intra-abdominal pressure (OR 0.318, 95% CI 0.118–0.862; p = 0.024) as a predictor of less intra-operative complications and moderate neuromuscular blockade (OR 3.518, 95% CI 1.244–9.948; p = 0.018) as a predictor of more intra-operative complications. Postoperative complications occurred in 31/556 (6.8%), without significant predictors in multiple logistic regression analyses. Conclusions Our data indicate that the use of deep neuromuscular blockade could increase safety during laparoscopic donor nephrectomy. Future randomized clinical trials should be performed to confirm this and to pursue whether it also applies to other types of laparoscopic surgery. Trial registration Clinicaltrials.gov LEOPARD-2 (NCT02146417), LEOPARD-3 trial (NCT02602964), and RELAX-1 study (NCT02838134), Klop et al. (NTR 3096), Dols et al. 2014 (NTR1433).
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Affiliation(s)
- Gabby T J A Reijnders-Boerboom
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands. .,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.
| | - Esmee V van Helden
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Robert C Minnee
- Department of Surgery, Erasmus Medical Centre, Doctor Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Kim I Albers
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands.,Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Moira H D Bruintjes
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Albert Dahan
- Department of Anaesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Chris H Martini
- Department of Anaesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
| | - Frank C H d'Ancona
- Department of Urology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Christiaan Keijzer
- Department of Anaesthesiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, The Netherlands
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Honing M, Reijnders-Boerboom G, Dell-Kuster S, van Velzen M, Martini C, Valenza F, Proto P, Cambronero OD, Broens S, Panhuizen I, Roozekrans M, Fuchs-Buder T, Boon M, Dahan A, Warlé M. The impact of deep versus standard neuromuscular block on intraoperative safety during laparoscopic surgery: an international multicenter randomized controlled double-blind strategy trial - EURO-RELAX TRIAL. Trials 2021; 22:744. [PMID: 34702332 PMCID: PMC8546748 DOI: 10.1186/s13063-021-05638-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 09/15/2021] [Indexed: 11/30/2022] Open
Abstract
Background Muscle relaxants are routinely used during anesthesia to facilitate endotracheal intubation and to optimize surgical conditions. However, controversy remains about the required depth of neuromuscular block (NMB) needed for optimal surgical working conditions and how this relates to other outcomes. For instance, a deep neuromuscular block yields superior surgical working conditions compared to a standard NMB in laparoscopic surgery, however, a robust association to other (safety) outcomes has not yet been established. Methods Trial design: an international multicenter randomized controlled double-blind strategy trial. Trial population: 922 patients planned for elective, laparoscopic or robotic, abdominal surgery. Intervention: Patients will be randomized to a deep NMB (post-tetanic count 1–2 twitches) or standard care (single-dose muscle relaxant administration at induction and repeated only if warranted by surgical team). Main trial endpoints: Primary endpoint is the difference in incidence of intraoperative adverse events during laparoscopic surgery graded according to ClassIntra® classification (i.e., ClassIntra® grade ≥ 2) between both groups. Secondary endpoints include the surgical working conditions, 30-day postoperative complications, and patients’ quality of recovery. Discussion This trial was designed to analyze the effect of deep neuromuscular block compared to standard neuromuscular block on intra- and postoperative adverse events in patients undergoing laparoscopic surgery. Trial registration ClinicalTrials.gov NCT04124757(EURO-RELAX); registration URL: https://clinicaltrials.gov/ct2/show/NCT04124757, registered on October 11th, 2019.
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Affiliation(s)
- Maarten Honing
- Leiden University Medical Center, Leiden, The Netherlands. .,Netherlands Cancer Institute, Amsterdam, The Netherlands.
| | - Gabby Reijnders-Boerboom
- Radboud University Medical Center, Nijmegen, The Netherlands.,Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | | | | | - Chris Martini
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - Paolo Proto
- Istituto Nazionale Dei Tumori, Milano, Italy
| | | | - Suzanne Broens
- Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Ivo Panhuizen
- Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | | | | | - Martijn Boon
- Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel Warlé
- Radboud University Medical Center, Nijmegen, The Netherlands
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Richebé P, Bousette N, Fortier LP. A narrative review on the potential benefits and limitations of deep neuromuscular blockade. Anaesth Crit Care Pain Med 2021; 40:100915. [PMID: 34174460 DOI: 10.1016/j.accpm.2021.100915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neuromuscular blockade was shown to improve surgical conditions. However, the risk of residual neuromuscular blockade upon extubation prevents anaesthesiologists from maintaining complete paralysis. For this reason, deep NMB is still underused in anaesthesia. This review focused on answering six questions revolving around the use of deep NMB versus moderate NMB. METHODS This was a non-exhaustive narrative review based on 6 selected relevant questions: does deep NMB 1) improve surgical conditions? 2) reduce surgical complications? 3) facilitate a reduction in intraoperative pneumoperitoneum pressure (PnP)? 4) does a reduction in intraoperative PnP impact clinical outcomes? 5) does the combination of deep NMB and lower PnP improve respiratory parameters? 6) improve OR efficiency or readmission rates? RESULTS This review highlights some of the key studies that have demonstrated potential benefits of deep NMB, but it also included reports showing no benefit, highlighting that the evidence is not unequivocal. Deep NMB does in fact improve surgical conditions, but whether this improvement translates into improved clinical outcomes is far from concluded. Indeed, there is an increased risk or residual curarisation, especially if patients are not monitored and reversed appropriately. The most important benefit of deep NMB may be the prevention of unacceptable surgical working conditions. The other potential major benefits are the reduction in PnP and reduction in pain. Deep NMB must be used with appropriate monitoring. CONCLUSION Deep NMB was associated with an improvement in surgical conditions, reduction in PnP, pain, and complications; but further research is needed to definitively prove this relationship.
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Affiliation(s)
- Philippe Richebé
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada.
| | - Nicolas Bousette
- Merck Canada Inc., 16750 Trans Canada Hwy, Kirkland, QC, H9H 4M7, Canada
| | - Louis-Philippe Fortier
- Department of Anaesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal (CEMTL), University of Montréal, Montréal, QC, Canada
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Deep neuromuscular block does not improve surgical conditions in patients receiving sevoflurane anaesthesia for laparoscopic renal surgery. Br J Anaesth 2020; 126:377-385. [PMID: 33092803 PMCID: PMC7572301 DOI: 10.1016/j.bja.2020.09.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/18/2020] [Accepted: 09/18/2020] [Indexed: 02/07/2023] Open
Abstract
Background Deep neuromuscular block is associated with improved working conditions during laparoscopic surgery when propofol is used as a general anaesthetic. However, whether deep neuromuscular block yields similar beneficial effects when anaesthesia is maintained using volatile inhalation anaesthesia has not been systematically investigated. Volatile anaesthetics, as opposed to intravenous agents, potentiate muscle relaxation, which potentially reduces the need for deep neuromuscular block to obtain optimal surgical conditions. We examined whether deep neuromuscular block improves surgical conditions over moderate neuromuscular block during sevoflurane anaesthesia. Methods In this single-centre, prospective, randomised, double-blind study, 98 patients scheduled for elective renal surgery were randomised to receive deep (post-tetanic count 1–2 twitches) or a moderate neuromuscular block (train-of-four 1–2 twitches). Anaesthesia was maintained with sevoflurane and titrated to bispectral index values between 40 and 50. Pneumoperitoneum pressure was maintained at 12 mm Hg. The primary outcome was the difference in surgical conditions, scored at 15 min intervals by one of eight blinded surgeons using a 5-point Leiden-Surgical Rating Scale (L-SRS) that scores the quality of the surgical field from extremely poor1 to optimal5. Results Deep neuromuscular block did not improve surgical conditions compared with moderate neuromuscular block: mean (standard deviation) L-SRS 4.8 (0.3) vs 4.8 (0.4), respectively (P=0.94). Secondary outcomes, including unplanned postoperative readmissions and prolonged hospital admission, were not significantly different. Conclusions During sevoflurane anaesthesia, deep neuromuscular block did not improve surgical conditions over moderate neuromuscular block in normal-pressure laparoscopic renal surgery. Clinical trial registration NL7844 (www.trialregister.nl).
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Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
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Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
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Albers KI, Polat F, Panhuizen IF, Snoeck MMJ, Scheffer GJ, de Boer HD, Warlé MC. The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): study protocol for a randomized controlled study. Trials 2020; 21:541. [PMID: 32552782 PMCID: PMC7301516 DOI: 10.1186/s13063-020-04496-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 06/10/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND There is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery. Deep neuromuscular blockade allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. While there is considerable evidence to support superior surgical conditions during deep neuromuscular blockade, there is only a limited amount of studies investigating patient outcomes. Moreover, results are not always consistent between studies and vary between different types of laparoscopic surgery. This study will investigate the effect of low-pressure pneumoperitoneum facilitated by deep NMB on quality of recovery after laparoscopic colorectal surgery. METHODS The RECOVER study is a multicenter double-blinded randomized controlled trial consisting of 204 patients who will be randomized in a 1:1 fashion to group A, low-pressure pneumoperitoneum (8 mmHg) facilitated by deep neuromuscular blockade (post tetanic count of 1-2), or group B, normal-pressure pneumoperitoneum (12 mmHg) with moderate neuromuscular blockade (train-of-four response of 1-2). The primary outcome is quality of recovery on postoperative day 1, quantified by the Quality of Recovery-40 questionnaire. DISCUSSION Few studies have investigated the effect of lower insufflation pressures facilitated by deep neuromuscular blockade on patient outcomes after laparoscopic colorectal procedures. This study will identify whether low pressure pneumoperitoneum and deep neuromuscular blockade will enhance recovery after colorectal laparoscopic surgery and, moreover, if this could be a valuable addition to the Enhanced Recovery After Surgery guidelines. TRIAL REGISTRATION EudraCT 2018-001485-42. Registered on April 9, 2018. Clinicaltrials.govNCT03608436. Registered on July 30, 2018.
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Affiliation(s)
- Kim I. Albers
- Department of Surgery and Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Ivo F. Panhuizen
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Marc M. J. Snoeck
- Department of Anesthesiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Hans D. de Boer
- Department of Anesthesiology, Martini General Hospital, Van Swietenplein 1, 9728 NT Groningen, The Netherlands
| | - Michiel C. Warlé
- Department of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Raval AD, Deshpande S, Rabar S, Koufopoulou M, Neupane B, Iheanacho I, Bash LD, Horrow J, Fuchs-Buder T. Does deep neuromuscular blockade during laparoscopy procedures change patient, surgical, and healthcare resource outcomes? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0231452. [PMID: 32298304 PMCID: PMC7161978 DOI: 10.1371/journal.pone.0231452] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/24/2020] [Indexed: 01/02/2023] Open
Abstract
Background Deep neuromuscular blockade may facilitate the use of reduced insufflation pressure without compromising the surgical field of vision. The current evidence, which suggests improved surgical conditions compared with other levels of block during laparoscopic surgery, features significant heterogeneity. We examined surgical patient- and healthcare resource use-related outcomes of deep neuromuscular blockade compared with moderate neuromuscular blockade in adults undergoing laparoscopic surgery. Methods We conducted a systematic literature review according to the quality standards recommended by the Cochrane Handbook for Systematic Reviews. Randomized controlled trials comparing outcomes of deep neuromuscular blockade and moderate neuromuscular blockade among adults undergoing laparoscopic surgeries were included. A random-effects model was used to conduct pair-wise meta-analyses. Results The systematic literature review included 15 studies—only 13 were analyzable in the meta-analysis and none were judged to be at high risk of bias. Compared with moderate neuromuscular blockade, deep neuromuscular blockade was associated with improved surgical field of vision and higher vision quality scores. Also, deep neuromuscular blockade was associated with a reduction in the post-operative pain scores in the post-anesthesia care unit compared with moderate neuromuscular blockade, and there was no need for an increase in intra-abdominal pressure during the surgical procedures. There were minor savings on resource utilization, but no differences were seen in recovery in the post-anesthesia care unit or overall length of hospital stay with deep neuromuscular blockade. Conclusions Deep neuromuscular blockade may aid the patient and physician surgical experience by improving certain patient outcomes, such as post-operative pain and improved surgical ratings, compared with moderate neuromuscular blockade. Heterogeneity in the pooled estimates suggests the need for better designed randomized controlled trials.
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Affiliation(s)
- Amit D. Raval
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Sohan Deshpande
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Silvia Rabar
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Maria Koufopoulou
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Binod Neupane
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Ike Iheanacho
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Lori D. Bash
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Jay Horrow
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Thomas Fuchs-Buder
- Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy, Vandoeuvre-les-Nancy, France
- * E-mail: ,
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10
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Laosuwan P, Songarj P, Lapisatepun W, Boonsri S, Rodanant O, Wasinwong W, Sriraj W, Watcharotayangul J, Wongyingsinn M. Deep neuromuscular blockade for endolaryngeal procedures: A multicenter randomized study. Laryngoscope 2019; 130:437-441. [DOI: 10.1002/lary.27956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/03/2019] [Accepted: 03/13/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Prok Laosuwan
- Department of AnesthesiologyKing Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Thai Red Cross Society Bangkok Thailand
| | - Phuriphong Songarj
- Department of AnesthesiologyFaculty of Medicine, Siriraj Hospital, Mahidol University Bangkok Thailand
| | - Worawut Lapisatepun
- Department of AnesthesiologyFaculty of Medicine, Chiang Mai University Chiang Mai Thailand
| | - Settapong Boonsri
- Department of AnesthesiologyFaculty of Medicine, Chiang Mai University Chiang Mai Thailand
| | - Oraluxna Rodanant
- Department of AnesthesiologyKing Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Thai Red Cross Society Bangkok Thailand
| | - Wirat Wasinwong
- Department of AnesthesiologyFaculty of Medicine, Prince of Songkla University Songkhla Thailand
| | - Wimonrat Sriraj
- Department of Anesthesiology, Faculty of MedicineKhon Kaen University Khon Kaen Thailand
| | - Jittiya Watcharotayangul
- Department of AnesthesiologyFaculty of Medicine, Ramathibodi Hospital, Mahidol University Bangkok Thailand
| | - Mingkwan Wongyingsinn
- Department of AnesthesiologyFaculty of Medicine, Siriraj Hospital, Mahidol University Bangkok Thailand
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11
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Retrospective analysis of 30-day unplanned readmission after major abdominal surgery with reversal by sugammadex or neostigmine. Br J Anaesth 2019; 122:370-378. [DOI: 10.1016/j.bja.2018.11.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/30/2018] [Accepted: 11/13/2018] [Indexed: 12/17/2022] Open
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