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Arumugaswamy PR, Chumber S, Rathore YS, Maitra S, Bhattacharjee HK, Bansal VK, Aggarwal S, Dhar A, Asuri K, Kataria K, Ranjan P. Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial. Surg Endosc 2024; 38:449-459. [PMID: 38012441 DOI: 10.1007/s00464-023-10558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/22/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
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Affiliation(s)
- Prasanna Ramana Arumugaswamy
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Yashwant Singh Rathore
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| | - Souvik Maitra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Hemanga Kumar Bhattacharjee
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Sandeep Aggarwal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Anita Dhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Krishna Asuri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Kamal Kataria
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Piyush Ranjan
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
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Zhang YW, Li Y, Huang WB, Wang J, Qian XE, Yang Y, Huang CS. Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer: An academic perspective. World J Gastrointest Surg 2023; 15:1405-1415. [PMID: 37555115 PMCID: PMC10405126 DOI: 10.4240/wjgs.v15.i7.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 06/02/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Few studies have examined the specific efficacy of deep neuromuscular blockade (NMB) combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy (LRG) in the elderly. AIM To investigate the application effect of deep neuromuscular blockade (NMB) combined with reduced pneumoperitoneum pressure in LRG for gastric cancer (GC) in elderly patients and its influence on inflammation. METHODS Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed. Among them, 45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group, while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group. The two groups were compared in the changes of the Leiden-surgical rating scale score, serum tumor necrosis fact-α (TNF-α) and interleukin 6 (IL-6) before and after therapy. The visual analogue scale (VAS) was adopted for evaluating the shoulder pain of patients at 8 h, 24 h and 48 h after the operation. The driving pressure of the two groups at different time points was also compared. Additionally, the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room, TOF% = 90% time and post-anesthetic recovery room (PACU) stay time were all recorded, and adverse PACU-associated respiratory events were also recorded. The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared. RESULTS No significant difference was found between the two groups at the time of skin incision, 60 minutes since the operation and abdominal closure after surgery (P > 0.05). The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery (P < 0.05). Additionally, the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum (P < 0.05). Additionally, the two groups were similar in terms of the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room and TOF% = 90% time (P > 0.05), and the observation group showed significantly lower TNF-α and IL-6 Levels than the control group at 24 h after therapy (P < 0.05). Moreover, the incidence of adverse events was not significantly different between the two groups (P > 0.05), and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group (P < 0.05). CONCLUSION Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction, without hindering the surgical vision and increasing adverse PACU-associated respiratory events, and can thus shorten the hospitalization time and treatment cost for patient.
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Affiliation(s)
- Yi-Wei Zhang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yong Li
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Wan-Bo Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Jue Wang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Xing-Er Qian
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Yu Yang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
| | - Chang-Shun Huang
- Department of Anesthesiology, Ningbo First Hospital, Ningbo 315016, Zhejiang Province, China
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Krijtenburg P, Bruintjes MHD, Fütterer JJ, van de Steeg G, d'Ancona F, Scheffer GJ, Keijzer C, Warlé MC. MRI measurement of the effects of moderate and deep neuromuscular blockade on the abdominal working space during laparoscopic surgery, a clinical study. BMC Anesthesiol 2023; 23:238. [PMID: 37452279 PMCID: PMC10347813 DOI: 10.1186/s12871-023-02201-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Conflicting data exist regarding the effects of deep neuromuscular blockade (NMB) on abdominal dimensions during laparoscopic procedures. We performed a clinical study to establish the influence of moderate and deep neuromuscular blockade (NMB) on the abdominal working space, measured by Magnetic Resonance Imaging (MRI), during laparoscopic donor nephrectomy with standard pressure (12 mmHg) pneumoperitoneum under sevoflurane anaesthesia. METHODS Ten patients were intraoperatively scanned three times in the lateral decubitus position, with pneumoperitoneum maintained by a mobile insufflator. The first scan without NMB (T1) was followed by scans with moderate (T2) and deep NMB (T3). The skin-sacral promontory (S-SP) distance was measured, and 3D pneumoperitoneum volumes were reconstructed. RESULTS The mean difference in the S-SP distance was -0.32 cm between T2 and T3 (95% CI -1.06 - 0.42 cm; p = 0.344) and + 2.1 cm between T1 and T2 (95% CI 0.81 - 3.39 cm; p = 0.006). The mean differences in pneumoperitoneum volume were 166 mL between T2 and T3 (95% CI, 5 - 327 mL; p = 0.044) and 108 mL between T1 and T2 (95% CI, -273 - 488 mL; p = 0.525). The pneumoperitoneum volume showed high inter-individual variability and no increase in three patients with a high volume at T1. CONCLUSIONS During laparoscopic surgery in the lateral decubitus position with standard pressure under sevoflurane anaesthesia, deep NMB did not increase the S-SP distance compared to moderate NMB. Moderate NMB increased the S-SP distance by a mean of 2.1 cm (15.2%) compared with no NMB. The mean pneumoperitoneum volume increased slightly from moderate to deep NMB, with high inter-individual variability. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT03287388.
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Affiliation(s)
- Piet Krijtenburg
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands.
| | | | - Jurgen J Fütterer
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | | | - Frank d'Ancona
- Department of Urology, Radboudumc, Nijmegen, the Netherlands
| | - Gert Jan Scheffer
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Christiaan Keijzer
- Department of Anaesthesiology, Radboudumc, Route 717, Geert Grooteplein Zuid 10, Nijmegen, 6525 GA, The Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboudumc, 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Neuromuscular blockade (TOF count = 0) can improve tracheal intubation and microlaryngeal surgery. It is also frequently used in many surgical fields including both nonlaparoscopic and laparoscopic surgery to improve surgical conditions and to prevent sudden muscle contractions. Currently there is a controversy regarding the need and the clinical benefits of deep neuromuscular blockade for different surgical procedures. Deep neuromuscular relaxation improves laparoscopic surgical space conditions only marginally when using low intra-abdominal pressure. There is no outcome-relevant advantage of low compared to higher intra-abdominal pressures, but worsen the surgical conditions. Postoperative, residual curarisation can be avoided by algorithm-based pharmacological reversing and quantitative neuromuscular monitoring.
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Affiliation(s)
- C Unterbuchner
- Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauß-Allee 11, 93051, Regensburg, Deutschland.
| | - M Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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Rosenberg J, Herring WJ, Blobner M, Mulier JP, Rahe-Meyer N, Woo T, Li MK, Grobara P, Assaid CA, Fennema H, Szegedi A. Deep Neuromuscular Blockade Improves Laparoscopic Surgical Conditions: A Randomized, Controlled Study. Adv Ther 2017; 34:925-36. [PMID: 28251555 DOI: 10.1007/s12325-017-0495-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Sustained deep neuromuscular blockade (NMB) during laparoscopic surgery may facilitate optimal surgical conditions. This exploratory study assessed whether deep NMB improves surgical conditions and, in doing so, allows use of lower insufflation pressures during laparoscopic cholecystectomy. We further assessed whether use of low insufflation pressure improves patient pain scores after surgery. METHODS This randomized, controlled, blinded study (NCT01728584) compared use of deep (1-2 post-tetanic-counts) or moderate (train-of-four ratio 10%) NMB, and lower (8 mmHg) or higher (12 mmHg; 'standard') insufflation pressure in a 2 × 2 factorial design. Primary endpoint was surgeon's overall satisfaction with surgical conditions, rated at end of surgery using an 11-point numerical scale. Post-operative pain scores were also evaluated. Data were analyzed using analysis of covariance. RESULTS Of 127 randomized patients, 120 had evaluable data for the primary endpoint. Surgeon's score of overall satisfaction with surgical conditions was significantly higher with deep versus moderate NMB indicated by a least-square mean difference of 1.1 points (95% confidence interval 0.1-2.0; P = 0.026). Furthermore, strong evidence of an effect was observed for standard versus low pressure: least-square mean difference of 3.0 points (95% confidence interval 2.1-4.0; P < 0.001). No significant difference was observed in average pain scores within 24 h post-surgery for low versus standard pressure [0.17 (95% confidence interval -0.67 to +0.33); P = 0.494]. CONCLUSIONS Although associated with significantly improved surgical conditions, deep NMB alone was insufficient to promote use of low insufflation pressure during laparoscopic cholecystectomy. Furthermore, low insufflation pressure did not result in reduced pain, compared with standard pressure. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01728584. FUNDING Merck Sharp and Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA.
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