Recovery and immune function after low pressure pneumoperitoneum during robot-assisted radical prostatectomy: a randomised controlled trial

OBJECTIVE

To compare the effectiveness of low intra-abdominal pressure (IAP) facilitated by deep neuromuscular block (NMB) to standard practice in improving the quality of recovery, preserving immune function, and enhancing parietal perfusion during robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

In this blinded, randomised controlled trial, 96 patients were randomised to the experimental group with low IAP (8 mmHg) facilitated by deep NMB (post-tetanic count 1-2) or the control group with standard IAP (14 mmHg) and moderate NMB (train-of-four 1-2). Recovery was measured using the 40-item Quality of Recovery questionnaire and 36-item Short-Form Health survey. Immune function was evaluated by plasma damage-associated molecular patterns, cytokines, and ex vivo lipopolysaccharide-stimulated cytokine production. Parietal peritoneum perfusion was measured by analysing the recordings of indocyanine-green injection.

RESULTS

Quality of recovery was not superior in the experimental group (n = 46) compared to the control group (n = 50). All clinical outcomes, including pain scores, postoperative nausea and vomiting, and hospital stay were similar. There were no significant differences in postoperative plasma concentrations of damage-associated molecular patterns, cytokines, and ex vivo cytokine production capacity. The use of low IAP resulted in better parietal peritoneum perfusion.

CONCLUSION

Despite better perfusion of the parietal peritoneum, low IAP facilitated by deep NMB did not improve the quality of recovery or preserve immune function compared to standard practice in patients undergoing RARP.

A Practical Dosing Algorithm for Deep Neuromuscular Blockade During Total Intravenous Anesthesia: ROCURITHM

BACKGROUND

The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a post tetanic count of 1-2) and how to implement it has not been reached. The ESAIC does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia.

METHODS

Data from three trials investigating deep NMB during laparoscopic surgery with TIVA (n=424) was pooled to analyze the required rocuronium dose, when to start continuous infusion and how to adjust. The resulting algorithm was validated (n=32) and compared to the success rate in ongoing studies where the algorithm was not used (n=180).

RESULTS

The mean rocuronium dose based on actual bodyweight for PTC 1-2 was 1.0 ± 0.27 mg.kg -1.h -1 in the trials where mean duration of surgery was ±2 hours (116 minutes). An induction dose of 0.6 mg.kg -1 lead to a PTC of 1-5 in a quarter of patients after a mean of 11 minutes. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a ±15-minute wait after PTC 0 for return of PTC to ≥1. Using the proposed algorithm, a mean 76% of all 5-minute measurements throughout surgery were on target PTC 1-2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0-20 patients (42% on target, P≤.001, Cohen's d=1.4 [95% CI 0.9, 1.8]) to 81-100 patients (61% on target, P≤.05, Cohen's d=0.7 [95% CI 0.1, 1.2]).

CONCLUSIONS

We propose a dosing algorithm for deep NMB with rocuronium in patients receiving TIVA.

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

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.

[Ultrasound-guided anterior approach to sciatic nerve block]

Ultrasound guidance has made it possible to carry out an anterior approach to sciatic nerve block. This technique can be performed as fast and as successfully as the posterior or subgluteal approach. A major advantage of this technique is that the patient can remain comfortable in a neutral supine position.

Erratum to Predictors of Death in Trauma Patients who are Alive on Arrival at Hospital

OBJECTIVE

To determine which factors predict death occurring in trauma patients who are alive on arrival at hospital Design Prospective cohort study Method Data were collected from 507 trauma patients with multiple injuries, with a Hospital Trauma Index-Injury Severity Score of 16 or more, who were initially delivered by the Emergency Medical Services to the Emergency Department of the University Medical Centre Utrecht (UMCU) during the period 1999-2000.

RESULTS

Univariate analysis showed that every year of age increase resulted in a 2% greater risk of death. If the patient had been intubated at the scene of the accident, this risk was increased 4.3-fold. Every point of increase in the Triage Revised Trauma Score (T-RTS) reduced the risk of death by 30%. A similar (but inverse) tendency was found for the HTI-ISS score, with every point of increase resulting in a 5% greater risk of death. There was a clear relationship between the base excess (BE) and hemoglobin (Hb) levels and the risk of death, the latter being increased by 8% for each mmol/l drop in BE, and reduced by 22% for each mmol/l increase in Hb. The risk of death occurring was 2.6 times higher in cases with isolated neurotrauma. These associations hardly changed in the multivariate analysis; only the relation with having been intubated at the scene disappeared.

CONCLUSION

The risk of severely injured accident patients dying after arriving in hospital is mainly determined by the T-RTS, age, presence of isolated neurological damage, BE and Hb level. Skull/brain damage and hemorrhage appear to be the most important causes of death in the first 24 h after the accident. The time interval between the accident and arrival at the hospital does not appear to affect the risk of death.

[Background and consequences of injuries missed when diagnosing severely injured accident victims in prehospital care in patients transported by ambulance to the University Medical Centre in Utrecht, 1999-2000]

OBJECTIVE

To determine the background and consequences of failing to diagnose injuries in prehospital care.

DESIGN

Prospective cohort study.

METHOD

Data were collected from 507 trauma patients with multiple injuries, and a Hospital trauma index-injury severity score of 16 or higher, who were delivered by the emergency ambulance service to the emergency department of the University Medical Centre Utrecht, the Netherlands, in 1999-2000.

RESULTS

The percentage of missed injuries varied from 9-55. For every additional year of age the risk of missing thoracic injuries was 2% higher. The risk of missing head injuries was 84% lower in people with a Triage revised trauma score (T-RTS) < 11. Initially missing an injury had no consequences for duration of stay in the ICU except in those patients with injuries to the lower extremities. A difference in quality of life was only reported for patients in whom injuries ofthe ribs, shoulder or clavicle had been missed. For every year of age, there was a 2% greater risk of dying within 1.5 years. A T-RTS < 11 resulted in a 5.6-fold greater risk of death. Failing to diagnose an injury did not in itself increase the risk of death.

CONCLUSION

Frequently missing an injury prior to hospitalization did not result in a poorer chance of survival or lesser quality of life. The risk of dying was mainly related to a higher age and a poorer general condition at the scene of the accident. According to these findings there is no reason to adapt the current policy with regard to initial care and transport of trauma patients.