Effect of neuromuscular block on surgical conditions during short-duration paediatric laparoscopic surgery involving a supraglottic airway

Intrathecal Morphine and Ropivacaine for Quality of Recovery After Laparoscopic Colorectal Surgery: A Randomized Controlled Trial

Purpose

Intrathecal morphine is increasingly used for pain management in laparoscopic colorectal surgery. While ropivacaine shows advantages of reduced cardiotoxicity and faster motor recovery compared to bupivacaine, the impact of intrathecal morphine-ropivacaine combination on postoperative recovery quality remains unclear. This study aimed to evaluate this combination's effect on recovery outcomes after laparoscopic colorectal surgery.

Patients and Methods

In this randomized, double-blind, placebo-controlled trial, 78 patients undergoing laparoscopic colorectal surgery received either preservative-free intrathecal morphine 250 μg with ropivacaine 15 mg (Intrathecal group) or a sham subcutaneous saline injection (Control group). The primary outcome was the Quality of Recovery-15 (QoR-15) score 24 hours after surgery. Secondary outcomes included pain scores, opioid consumption, and adverse effects.

Results

The intrathecal group showed significantly higher QoR-15 scores 24 hours postoperatively compared to the control group (median [IQR]: 121 [109-128] vs 111 [102-116], p < 0.001), with improvements in pain management (p < 0.001), physical comfort (p = 0.001), and physical independence (p = 0.002). The intrathecal group had lower pain scores at rest (area under the curve 0-48 h: 66 [59-90] vs 107 [89-126], p < 0.001) and during coughing (152 [137-172] vs 191 [166-213], p < 0.001), particularly from 0.5 to 24 hours. They also required less postoperative morphine (0-48 h: 10 [6-20] vs 26 [22-36] mg, p < 0.001). While hypotension (43.6% vs 17.9%, p = 0.014) and pruritus (35.9% vs 2.6%, p < 0.001) were more frequent in the intrathecal group, but no respiratory depression occurred in either group.

Conclusion

Intrathecal morphine-ropivacaine administration improves 24-hour postoperative recovery quality and provides superior pain relief after laparoscopic colorectal surgery, despite increased but manageable side effects. Further research should focus on dose optimization and comparative studies of different intrathecal local anesthetic combinations.

Trial Registration

The Chinese Clinical Trial Registry, ChiCTR2100052337.

Innovative (and Safe) Techniques With Supraglottic Airways

ABSTRACT

Supraglottic airways have been utilized as an alternative to facemask ventilation and endotracheal intubation and thus have been essential to airway management since their introduction in the late 1980s. This chapter describes basic considerations in their use and an update on current clinical practice, with an emphasis on safe management. The devices have evolved to meet today's clinical airway challenges, and they provide benefits for patients and practitioners.

Application of placing the anterior end of endotracheal tube at the glottis in laryngeal mask airway positive ventilation during general anesthesia: A prospective, randomized, controlled trial

BACKGROUND

Glottic contraction and closure causes ventilation obstruction and laryngeal mask airway (LMA) leakage during positive pressure ventilation using LMA. This study aimed to assess the effect of placing the anterior end of the endotracheal tube (ET) at the glottis through the LMA ventilation conduit on treating LMA leakage following glottic contraction and closure.

METHODS

In this prospective, randomized, controlled trial, patients with non-minor surgery using LMA ventilation were randomly allocated to the i-gel group (group L) and the i-gel combined with ET group (group LE). The tip of ET was placed 2 cm under glottis guided by fiberoptic bronchoscope through i-gel ventilation conduit in group LE. The perioperative incidence of i-gel leakage, the changes of systolic blood pressure (SBP) and heart rate (HR) following artificial airway insertion, and adverse events were recorded.

RESULTS

Perioperative i-gel leakage was observed in 7 of 48 patients (14.6%) in group L and 1 of 49 patients (2.0%) in group LE. There was significant difference in the incidence of leakage between the 2 groups (P = .031). SBP and HR after ET insertion in group LE increased significantly compared to those in group L (P < .05/5). The values of both SBP and HR after ET insertion did not exceed the basic values in group LE (P > .05/4). There were no significant differences in the incidence and severity of postoperative sore pain and hoarseness, cough during i-gel and ET removal between the 2 groups (P > .05).

CONCLUSION

Placing the anterior end of ET at the glottis reduced LMA air leakage related to glottic contraction and closure in non-minor surgery. The ET placing had low stress response and did not significantly increase postoperative complications.

Comparison of Deep and Moderate Neuromuscular Blockade for Major Laparoscopic Surgery in Children: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Neuromuscular blocking agents are routinely used in laparoscopic surgery to optimize operative conditions. We compared the effect of a deep and moderate neuromuscular blockade (NMB) on surgical conditions and postoperative outcomes in children undergoing major laparoscopic surgery.

METHODS

Sixty children aged 2-14 years scheduled to undergo major laparoscopic surgery were randomly allocated to deep (post-tetanic count 1-2 twitches) or moderate (train-of-four 1-2 twitches) NMB groups. The anesthesia was maintained with propofol and remifentanil, and the NMB was maintained with a rocuronium continuous infusion. At the end of the operation, the NMB were antagonized with sugammadex. The intra-abdominal pressure, airway pressure, Leiden Surgical Rating Scale, intraoperative hemodynamics, drug usages, duration of surgery, postoperative recovery time, pain, and complications were compared between the groups.

RESULTS

The maximum and mean intra-abdominal pressure, the peak inspiratory pressure, and mean airway pressure were significantly lower in the deep NMB group than in the moderate NMB group (p < 0.001). The Leiden Surgical Rating Scale and the dosage of rocuronium were significantly higher in the deep NMB group than the moderate NMB group (p < 0.001). The intraoperative hemodynamics, duration of surgery, post-operative recovery time, pain, and the incidence rate of complications were not significantly different between the groups (p > 0.05).

CONCLUSIONS

A deep NMB provided better operative conditions and similar recovery profiles compared with a moderate NMB as reversed with sugammadex in children undergoing major laparoscopic surgery.

CLINICAL TRIAL REGISTRATION

Chinese Clinical Trial Registry, No. ChiCTR2100053821.

Effect of neuromuscular block on surgical conditions during laparoscopic surgery in neonates and small infants: A randomised controlled trial

BACKGROUND

Neuromuscular block (NMB) is routinely used in paediatric and adult anaesthesia to facilitate endotracheal intubation and optimise surgical conditions. However, there are limited data regarding NMB and optimising the conditions for laparoscopic surgery in neonates and small infants.

OBJECTIVE

The goal of this study was to determine the effect of NMB on the conditions for laparoscopic surgery in neonates and small infants.

DESIGN

A randomised controlled trial.

SETTING

Single-centre Children's Hospital, conducted from November 2021 to December 2022.

PATIENTS

One hundred and two ASA I-II neonates and small infants aged up to 60 weeks postmenstrual age who were scheduled to undergo an elective laparoscopic Ladd's procedure were included in the study.

INTERVENTIONS

Patients were randomised into three groups: no NMB group, shallow NMB group and moderate NMB group. Each group was given different doses of rocuronium to achieve the target depth of NMB.

MAIN OUTCOME MEASURES

The primary outcome was the quality of the surgical conditions evaluated with the Leiden-Surgical Rating Scale (L-SRS) by a blinded surgeon. Secondary outcomes included tracheal intubating conditions and adverse events.

RESULTS

The percentage of L-SRS scores of 4 or 5 was similar among the three groups at all the assessment times ( P  > 0.05 for each time interval). The distribution of L-SRS scores was also similar among the three groups. There were no significant differences in operating condition scores between the groups at any time interval ( P  > 0.05 for each time interval). The incidence of adverse events during anaesthesia induction was significantly higher in the no NMB group (51.4%) than in the other two groups (13.6% and 14.7%) (adjusted P  = 0.012 and adjusted P  = 0.003). In particular, clinically unacceptable intubation conditions occurred in 12 patients (34.3%) in the no NMB group, significantly more than in the shallow NMB group (6.1%, adjusted P  = 0.012) and moderate NMB group (2.9%, adjusted P  = 0.003). There was no statistically significant difference in the incidence of adverse events in the PACU among the three groups ( P  = 0.103).

CONCLUSIONS

The depth of NMB was not associated with superior surgical conditions during laparoscopic surgery, but it was associated with a reduction in adverse events during induction and maintenance of anaesthesia in neonates and small infants.

TRIAL REGISTRATION

Registered at www.chictr.org.cn (ChiCTR2100052296).

Effect of epidural block on surgical conditions during pediatric subumbilical laparoscopic surgery involving a supraglottic airway: a randomized clinical trial

Background

Few studies have examined the effect of epidural block on surgical conditions during pediatric subumbilical laparoscopic surgery involving a supraglottic airway (SGA). This study investigated the surgical condition scores for such procedures in cases where neuromuscular block, epidural block, or neither was used.

Methods

A total of 150 patients aged 3-12 years undergoing laparoscopic orchiopexy with a ProSeal SGA device were randomly allocated to one of three groups: the control group (did not receive neuromuscular block and epidural block), the NMB group [received a neuromuscular block (train-of-four 1-2 twitches) using rocuronium], or the EDB group (received an epidural block using ropivacaine). The primary outcome was the quality of surgical conditions evaluated with the Leiden-Surgical Rating Scale by the blinded surgeon. The secondary outcome measures included intraoperative hemodynamic data (including mean arterial pressure and heart rate), the SGA device removal time, the PACU discharge time, the pain score in the PACU and intraoperative adverse events (including bradycardia, hypotension, peak airway pressure > 20 cmH2O, and poor or extremely poor surgical conditions occurred during the operation). Statistical analysis was performed with one-way analysis of variance, the Kruskal-Wallis test, the chi-square test or Fisher's exact test. Bonferroni corrections for multiple comparisons were made for primary and secondary outcomes.

Results

Surgical condition scores were significantly higher in the NMB and EDB groups than in the control group (median difference: 0.8; 95% confidence interval [CI], 0.5-1.0; p < 0.0001; and median difference: 0.7; 95% CI, 0.5-0.8; p < 0.0001, respectively). Blood pressure and heart rate were significantly lower in the EDB group than in the other two groups (p < 0.0001 and p = 0.004). Patients in the EDB group had significantly lower pain scores during PACU than those in the other two groups (p < 0.0001). The sufentanil dose was lower in the EDB group than in the other two groups (p = 0.001).

Conclusion

Epidural block can improve surgical conditions during pediatric subumbilical laparoscopic surgery involving a SGA to a degree comparable to that with moderate neuromuscular block.

Second-generation supraglottic airway in laparoscopic donor nephrectomy

Supraglottic airway (SGA) may have advantages over endotracheal tube (ETT) regarding laryngospasm, coughing, sore throat, and hemodynamic changes; however, studies on the use of SGA in laparoscopic donor nephrectomy (LDN) are lacking. Here, we aimed to confirm the safety and feasibility of second-generation SGA in LDN and compare them with those of ETT. Enrolled adult donors (aged > 18 years) who underwent LDN between August 2018 and November 2021 were divided into two groups-ETT vs. SGA. Airway pressure, lung compliance, desaturation, and hypercapnia were recorded during surgery. After propensity score matching for baseline characteristics and surgical duration, 82 and 152 donors were included in the ETT and SGA groups, respectively, and their outcomes were compared. The peak airway pressure was lower in the SGA group than in the ETT group 5 min after pneumoperitoneum. Dynamic lung compliance was higher in the SGA group than in the ETT group during surgery. There were no cases of intraoperative desaturation, hypercapnia, or postoperative aspiration pneumonitis. The use of second-generation SGA, a safe alternative to ETT for LDN, resulted in reduced airway resistance and increased lung compliance, which suggests its benefits for airway management in kidney donors.

Comparison of 3 Rates for the Continuous Infusion of Mivacurium During Ambulatory Vitreoretinal Surgery Under General Anesthesia: A Prospective, Randomized, Controlled Clinical Trial

Purpose

Mivacurium, the shortest-acting benzylisoquinoline nondepolarizing neuromuscular blocker used in clinical practice, is suitable for short-term ambulatory operations under general anesthesia. We investigated the neuromuscular blockade effect of different maintenance doses of mivacurium during ambulatory vitreoretinal surgery under general anesthesia and tried to determine the appropriate maintenance dose.

Patients and Methods

Ninety-nine patients undergoing general anesthesia for elective ambulatory vitreoretinal surgery were randomly divided into three groups using the random number table method. Patients received three maintenance doses of mivacurium during surgery as follows: 3 μg/(kg·min) in group M1 (n = 33), 6 μg/(kg·min) in group M2 (n = 33), and 9 μg/(kg·min) in group M3 (n = 33). The primary outcome was the time from mivacurium withdrawal to a train-of-four stimulation ratio (TOFr) ≥ 0.9, and the secondary outcomes were the time from mivacurium withdrawal to TOFr ≥ 0.7, extubation time, incidence of TOFr < 0.9 after surgery and neuromuscular block effect.

Results

The time from mivacurium withdrawal to TOFr ≥ 0.9 and to TOFr ≥ 0.7 was significantly longer in group M3 than in groups M1 and M2 (25.6±7.2 min vs 16.4±5.9 min and 18.6±5.3 min, P < 0.001; 22.1±6.3 min vs 13.6 ± 5.8 min and 15.5 ± 4.8 min; P < 0.001, respectively). There was a significant difference in the extubation time, the incidence of TOFr < 0.9 during extubation and upon leaving the operating room between group M3 and group M1 (all P < 0.05), but there was no such significant difference between group M2 and group M1 (all P > 0.05). The intraoperative depth of neuromuscular blockade in the three groups was significantly different, with 69.7% shallow block in group M1, 75.8% moderate block in group M2 and 63.6% deep block in group M3 (P < 0.001). One patient in group M1 experienced slight body movement during the operation.

Conclusion

An intraoperative continuous infusion of 6 μg/(kg·min) mivacurium can not only achieve good postoperative recovery but also provide a satisfactory neuromuscular blockade effect during surgery, and this maintenance dose is suitable for neuromuscular blockade during ambulatory vitreoretinal surgery.