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Wei G, Li YX, Chen Y, Diao M, Zhong JW, Pan SD. Comparison of Deep and Moderate Neuromuscular Blockade for Major Laparoscopic Surgery in Children: A Randomized Controlled Trial. Paediatr Drugs 2024; 26:347-353. [PMID: 38512578 DOI: 10.1007/s40272-024-00622-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/23/2024]
Abstract
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.
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Affiliation(s)
- Guo Wei
- Department of Anesthesiology, Capital Institute of Pediatrics, No. 2 Yabao Road, Beijing, 100020, China
| | - Yong-Xin Li
- Department of Anesthesiology, Capital Institute of Pediatrics, No. 2 Yabao Road, Beijing, 100020, China
| | - Ying Chen
- Department of Anesthesiology, Capital Institute of Pediatrics, No. 2 Yabao Road, Beijing, 100020, China
| | - Mei Diao
- Department of General and Neonate Surgery, Capital Institute of Pediatrics, Beijing, China
| | - John Wei Zhong
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center and Children's Health of Texas, Dallas, 75390, TX, USA.
| | - Shou-Dong Pan
- Department of Anesthesiology, Capital Institute of Pediatrics, No. 2 Yabao Road, Beijing, 100020, China.
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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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3
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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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Boon M, Martini CH, Aarts LPHJ, Dahan A. The use of surgical rating scales for the evaluation of surgical working conditions during laparoscopic surgery: a scoping review. Surg Endosc 2019; 33:19-25. [PMID: 30218262 PMCID: PMC6336757 DOI: 10.1007/s00464-018-6424-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 09/05/2018] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Surgical rating scales (SRSs) enable the surgeon to uniformly quantify surgical working conditions. They are increasingly used as a primary outcome in studies evaluating the effect of anaesthesia or surgery-related interventions on the quality of the surgical work field. SRSs are especially used in laparoscopic surgery due to a renewed interest in deep neuromuscular block. There are however no guidelines regarding the uniform use of SRS and the uniform reporting of results. METHODS A systematic search was conducted in the databases of PubMed, Web of Science and Embase for studies that reported the use of an SRS to evaluate surgical conditions in laparoscopic surgery. Only original human research in English language with full text availability through the Leiden university library was considered for this review. The full texts of eligible abstracts were independently reviewed by the first and second author. The quality of SRSs and methodology of rating were systematically reviewed. RESULTS The search yielded 2830 reports, of which 17 were identified using a surgical rating scale (SRS) in laparoscopic surgery. Ten of these reports used a unique SRS, these were systematically appraised for their quality. The overall quality of the SRSs was low: the majority of the scales were poorly described and lacked assessment of inter- and intra-rater reliability. In addition, considerable differences exist in the methodology of rating and the reporting of results. CONCLUSION There is substantial inconsistency in SRS quality, methodology, and results reporting. The uniform use of high-quality surgical rating scales is needed to improve the quality and reproducibility of future research.
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Affiliation(s)
- Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 Leiden, The Netherlands
| | - Christian H. Martini
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 Leiden, The Netherlands
| | - Leon P. H. J. Aarts
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, 2333 Leiden, The Netherlands
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Boon M, Martini C, Yang HK, Sen SS, Bevers R, Warlé M, Aarts L, Niesters M, Dahan A. Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery. PLoS One 2018; 13:e0197036. [PMID: 29791482 PMCID: PMC5965817 DOI: 10.1371/journal.pone.0197036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 04/25/2018] [Indexed: 02/06/2023] Open
Abstract
Recent data shows that a neuromuscular block (NMB) induced by administration of high doses of rocuronium improves surgical conditions in certain procedures. However, there are limited data on the effect such practices on postoperative outcomes. We performed a retrospective analysis to compare unplanned 30-day readmissions in patients that received high-dose versus low-dose rocuronium administration during general anesthesia for laparoscopic retroperitoneal surgery. This retrospective cohort study was performed in the Netherlands in an academic hospital where routine high-dose rocuronium NMB has been practiced since July 2015. Charts of patients receiving anesthesia between January 2014 and December 2016 were searched for surgical cases receiving high-dose rocuronium and matched with respect to procedure, age, sex and ASA classification to patients receiving low-dose rocuronium. The primary post-operative outcome was unplanned 30-day readmission rate. There were 130 patients in each cohort. Patients in the high- and low-dose rocuronium cohorts received 217 ± 49 versus 37 ± 5 mg rocuronium, respectively. In the high-dose rocuronium group neuromuscular activity was consistently monitored; matched patients were unreliably monitored. All patients receiving high-dose rocuronium were reversed with sugammadex, while just 33% of matched patients were reversed with sugammadex and 20% with neostigmine; the remaining patients were not reversed. Unplanned 30-day readmission rate was significantly lower in the high-dose compared to the low-dose rocuronium cohort (3.8% vs. 12.7%; p = 0.03; odds ratio = 0.33, 95% C.I. 0.12–0.95). This small retrospective study demonstrates a lower incidence of unplanned readmissions within 30-days following laparoscopic retroperitoneal surgery with high-dose relaxant anesthesia and sugammadex reversal in comparison to low-dose relaxant anesthesia. Further prospective studies are needed in larger samples to corroborate our findings and additionally assess the pharmacoeconomics of high-dose relaxant anesthesia taking into account the benefits (reduced readmissions) and harm (cost of relaxants and reversal agents) of such practice.
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Affiliation(s)
- Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Chris Martini
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - H. Keri Yang
- Merck & Co., Center for Observational and Real World Evidence, Merck & Co, Inc., Kenilworth, NJ, United States of America
| | - Shuvayu S. Sen
- Merck & Co., Center for Observational and Real World Evidence, Merck & Co, Inc., Kenilworth, NJ, United States of America
| | - Rob Bevers
- Department of Urology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Michiel Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, RC Leiden, The Netherlands
- * E-mail:
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Abstract
Muscle relaxation is a routine part of anesthesia and has important advantages. However, the lingering effects of muscle relaxants in the postoperative period have historically been associated with postoperative adverse events. Neuromuscular reversal, together with neuromuscular monitoring, is a recognized strategy to reduce the rate of postoperative residual relaxation but has only marginally improved outcome in the past few decades. Sugammadex, a novel reversal agent with unique encapsulating properties, has changed the landscape of neuromuscular reversal and opened up new opportunities to improve patient care. By quickly and completely reversing any depth of neuromuscular block, it may reduce the rate of residual relaxation and improve respiratory recovery. In addition, sugammadex has made the use of deep neuromuscular block possible during surgery. Deep neuromuscular block may improve surgical working conditions and allow for a reduction in insufflation pressures during selected laparoscopic procedures. However, whether and how this may impact outcomes is not well established.
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Affiliation(s)
- Martijn Boon
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
| | - Christian Martini
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology , Leiden University Medical Center, Leiden, Netherlands
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Nervil GG, Medici R, Thomsen JLD, Staehr-Rye AK, Asadzadeh S, Rosenberg J, Gätke MR, Madsen MV. Validation of subjective rating scales for assessment of surgical workspace during laparoscopy. Acta Anaesthesiol Scand 2017; 61:1270-1277. [PMID: 28990176 DOI: 10.1111/aas.13001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/09/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recently, studies have focused on how to optimize laparoscopic surgical workspace by changes in intra-abdominal pressure, level of muscle relaxation or body position, typically evaluated by surgeons using subjective rating scales. We aimed to validate two rating scales by having surgeons assess surgical workspace in video sequences recorded during laparoscopic surgery. METHOD Video sequences were obtained from laparoscopic procedures. Eight experienced surgeons assessed the video sequences on a categorical 5-point scale and a numerical 10-point rating scale. Intraclass correlations coefficients (ICC) and 95% confidence intervals (CI) were calculated for intra- and inter-rater reliability. RESULTS The 5-point rating scale had an intra-rater ICC of 0.76 (0.69; 0.83) and an inter-rater ICC of 0.57 (0.45; 0.68), corresponding to excellent and fair reliability, respectively. The 10-point scale had an intra-rater ICC of 0.86 (0.82; 0.89) and an inter-rater ICC of 0.54 (0.39; 0.68), corresponding to excellent and fair as well. All surgeons used the full range of the 5-point scale, but only one surgeon used the full range of the 10-point scale. CONCLUSION In conclusion, both scales showed excellent intra-rater and fair inter-rater reliability for assessing surgical workspace in laparoscopy. The 5-point surgical rating scale had all categories employed by all surgeons.
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Affiliation(s)
- G. G. Nervil
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
| | - R. Medici
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
| | - J. L. D. Thomsen
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
| | - A. K. Staehr-Rye
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
| | - S. Asadzadeh
- Department of Surgery; Herlev and Gentofte Hospital; University of Copenhagen; Copenhagen Denmark
| | - J. Rosenberg
- Department of Surgery; Herlev and Gentofte Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. R. Gätke
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
| | - M. V. Madsen
- Department of Anesthesiology; Herlev and Gentofte Hospital; University of Copenhagen; Herlev Denmark
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Özdemir-van Brunschot DMD, Braat AE, van der Jagt MFP, Scheffer GJ, Martini CH, Langenhuijsen JF, Dam RE, Huurman VA, Lam D, d'Ancona FC, Dahan A, Warlé MC. Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy. Surg Endosc 2017. [PMID: 28643056 PMCID: PMC5770501 DOI: 10.1007/s00464-017-5670-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Evidence indicates that low-pressure pneumoperitoneum (PNP) reduces postoperative pain and analgesic consumption. A lower insufflation pressure may hamper visibility and working space. The aim of the study is to investigate whether deep neuromuscular blockade (NMB) improves surgical conditions during low-pressure PNP. Methods This study was a blinded randomized controlled multicenter trial. 34 kidney donors scheduled for laparoscopic donor nephrectomy randomly received low-pressure PNP (6 mmHg) with either deep (PTC 1–5) or moderate NMB (TOF 0–1). In case of insufficient surgical conditions, the insufflation pressure was increased stepwise. Surgical conditions were rated by the Leiden-Surgical Rating Scale (L-SRS) ranging from 1 (extremely poor) to 5 (optimal). Results Mean surgical conditions were significantly better for patients allocated to a deep NMB (SRS 4.5 versus 4.0; p < 0.01). The final insufflation pressure was 7.7 mmHg in patients with deep NMB as compared to 9.1 mmHg with moderate NMB (p = 0.19). The cumulative opiate consumption during the first 48 h was significantly lower in patients receiving deep NMB, while postoperative pain scores were similar. In four patients allocated to a moderate NMB, a significant intraoperative complication occurred, and in two of these patients a conversion to an open procedure was required. Conclusions Our data show that deep NMB facilitates the use of low-pressure PNP during laparoscopic donor nephrectomy by improving the quality of the surgical field. The relatively high incidence of intraoperative complications indicates that the use of low pressure with moderate NMB may compromise safety during LDN. Clinicaltrials.gov identifier: NCT 02602964.
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Affiliation(s)
- D M D Özdemir-van Brunschot
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - A E Braat
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M F P van der Jagt
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - G J Scheffer
- Department of Anesthesiology, Radboud University Medical Centre, Geert Grooteplein-Zuid10, 6525 GA, Nijmegen, The Netherlands
| | - C H Martini
- Department of Anesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Nijmegen, The Netherlands
| | - J F Langenhuijsen
- Department of Urology, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - R E Dam
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - V A Huurman
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - D Lam
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - F C d'Ancona
- Department of Urology, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - A Dahan
- Department of Anesthesiology, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Nijmegen, The Netherlands
| | - M C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Centre, Geert Grooteplein-Zuid 10, 6525 GA, Nijmegen, The Netherlands.
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Boon M, Martini CH, Aarts LP, Torensma B, Dahan A. Deep Neuromuscular Block and Surgical Conditions During Bariatric Surgery. Anesth Analg 2017; 124:2094-2095. [PMID: 28448393 DOI: 10.1213/ane.0000000000002101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands,
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Torensma B, Martini CH, Boon M, Olofsen E, in ‘t Veld B, Liem RSL, Knook MTT, Swank DJ, Dahan A. Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial. PLoS One 2016; 11:e0167907. [PMID: 27936214 PMCID: PMC5148011 DOI: 10.1371/journal.pone.0167907] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/18/2016] [Indexed: 11/19/2022] Open
Abstract
Background It remains unknown whether the administration of a deep neuromuscular block (NMB) during bariatric surgery improves surgical conditions and patient outcome. The authors studied the effect of deep versus moderate NMB in laparoscopic bariatric surgery on surgical conditions and postoperative pain. Methods and Results One hundred patients scheduled to undergo elective bariatric surgery were randomized to a deep NMB (post-tetanic-count 2–3) or a moderate NMB (train-of-four 1–2). The quality of the surgical field was scored using the Leiden-Surgical Rating Scale (L-SRS), a 5-point scale ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Three surgeons scored the L-SRS at 10-min intervals during surgery; postoperative pain scores were obtained in the postanesthesia-care-unit (PACU) and on the ward. Mean (95% confidence interval) L-SRS scores in moderate NMB 4.2 (4.0–4.4) versus 4.8 (4.7–4.9) in deep NMB (p < 0.001). Moderate NMB resulted in 17% of scores at L-SRS scores of 1–3, while deep NMB resulted in 100% scores at the high end of the L-SRS (4–5). Deep NMB led to improved pain scores in the PACU (4.6 (4.2–4.9) versus 3.9 (3.6–4.4), p = 0.03) and reduced shoulder pain on the ward (1.8 (1.5–2.1) versus 1.3 (1.1–1.5), p = 0.03). A composite score of pain and opioid use in the PACU favoured deep NMB (p = 0.001). Conclusions In bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to moderate NMB, deep NMB produced stable and improved surgical conditions with less postoperative pain.
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Affiliation(s)
- Bart Torensma
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Dutch Obesity Clinic West, The Hague, The Netherlands
- Department of Anesthesiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Chris H. Martini
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas in ‘t Veld
- Department of Anesthesiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Ronald S. L. Liem
- Department of Surgery, Dutch Obesity Clinic West, The Hague, The Netherlands
| | | | - Dingeman J. Swank
- Department of Surgery, Dutch Obesity Clinic West, The Hague, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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