Deep versus moderate neuromuscular blockade during total hip arthroplasty to improve postoperative quality of recovery and immune function: protocol for a randomised controlled study

INTRODUCTION

There is accumulating evidence that deep neuromuscular blockade (NMB) improves intraoperative surgical conditions during laparoscopic surgery. Studies investigating the effects of deep NMB in open surgery are scarce. In theory, by limiting surgical damage through deeper muscle relaxation, postoperative inflammation and concomitant immune suppression can be reduced. Therefore, this study will investigate the effects of deep NMB during total hip arthroplasty, which demands a relatively large exposure of the hip joint through and in between muscles.

METHODS AND ANALYSIS

This study is a monocentre blinded randomised controlled trial in 100 patients undergoing total hip arthroplasty under general anaesthesia. Patients will be randomised in a 1:1 fashion to an intervention group of intraoperative deep NMB (a post-tetanic count of 1-2) or a control group receiving moderate NMB (a train-of-four count of 1-2). NMB will be achieved by continuous or bolus administration of rocuronium, respectively. The primary endpoint is the quality of recovery at postoperative day 1 measured by the Quality of Recovery-40 Questionnaire, analysed by Analysis of Variance. The secondary endpoint is postoperative innate immune function, measured by ex vivo production capacity of tumour necrosis factor and interleukin-1β on endotoxin stimulation of whole blood.

ETHICS AND DISSEMINATION

Ethical approval for this study was granted by the Medical Ethics Committee 'METC Oost-Nederland' (reference number 2022-15754). Informed consent will be obtained prior to study participation. Study results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov Registry (NCT05562999) and EudraCT Registry (2022-002451-19).

Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care

Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research ( n  = 24 000) to the finally relevant clinical studies ( n  = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg -1 or rocuronium 0.9 to 1.2 mg kg -1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C).

Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials

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.

Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial

BACKGROUND

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.

STUDY DESIGN

We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m -2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5-1.0 and 0.1-0.5 mg kg -1 h -1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon's surgical rating score (SRS) and interrupted events.

RESULTS

Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.

CONCLUSION

Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.

Comparison of Deep and Moderate Neuromuscular Blockade on Intestinal Mucosal Barrier in Laparoscopic Gastrectomy: A Prospective, Randomized, Double-Blind Clinical Trial

Deep neuromuscular blockade (NMB) improves the surgical conditions and is benefit for the postoperative recovery after laparoscopic surgery. However, the mechanisms of deep NMB in promoting the recovery of intestinal function have not been completely investigated. The objective of our study was to determine the impact of the deep NMB and moderate NMB strategy on the intestinal barrier function after laparoscopic gastrectomy. We collected patients undergoing elective laparoscopic gastrectomy. Patients were randomized to deep NMB (post-tetanic count 1–2) vs. moderate NMB (train-of-four count 1–2) during the surgery. Primary outcomes were time to flatus, serum diamine oxidase (DAO) and D-lactate, and gut microbiota. Other outcomes were surgical condition scores, postoperative visual analog pain scores, and length of hospital stay. Ninety patients in deep NMB group and sixty patients in moderate NMB group completed the study. Main results showed that the time to flatus was decreased in deep NMB group (74 ± 32 h) than that in moderate NMB group (93 ± 52 h, P = 0.006). The level of serum D-lactate was statistically increased in the moderate NMB group than that in the deep NMB group (1,209 ± 224 vs. 1,164 ± 185 ng/ml, p < 0.001). But no significant differences could be detected in the level of DAO between the groups. Additionally, the 16s rRNA analysis indicated that gut microbiota were similar in Alpha diversity but distinct in Beta diversity. Furthermore, the beneficial bacteria, such as genus Lactobacillus and Bifidobacterium, were more abundant in the deep NMB group, while the potentially harmful bacteria were more abundant in the moderate NMB group. Our findings suggested that the intestinal mucosal barrier and gut microbiota were better preserved in deep NMB, which greatly improved the postoperative recovery of intestinal function after laparoscopic gastrectomy.

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

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. 

Sugammadex in Colorectal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Traditionally, reversal of neuromuscular blocking agents following the completion of surgery was achieved with cholinesterase inhibitors. Recently, sugammadex has been increasingly relied upon. Sugammadex is a γ-cyclodextrin molecule that rapidly reverses steroidal neuromuscular blocking drugs. Its use following colorectal surgery has become more common, and while the rapidity of reversal is undoubtedly improved, whether sugammadex impacts clinical postoperative outcomes is unknown. This systematic review and meta-analysis aims to compare postoperative outcomes in patients receiving sugammadex to those receiving a control during colorectal surgery.

METHODS

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared sugammadex with a control (e.g., neostigmine, pyridostigmine, placebo) in patients undergoing colorectal surgery in terms of total hospital length of stay and frequency of postoperative adverse respiratory events. Pairwise meta-analyses using inverse variance random effects was performed.

RESULTS

From 269 citations, five studies with 535 patients receiving sugammadex (45.8% female; mean age: 64.4) and 569 patients receiving a control (45.0% female; mean age: 64.3) were included. There was no significant difference in length of stay between the two groups (MD -0.01, 95% CI -0.27 to 0.25, P = 0.95). The risk of adverse respiratory events postoperatively was similar between the two groups (RR 1.33, 95% CI 0.81-2.19, P = 0.25).

CONCLUSION

There are no current data to suggest an improvement in postoperative outcomes with the use of sugammadex in patients undergoing colorectal surgery. This study is limited by the number of included studies. Further prospective studies comparing sugammadex and a control in colorectal surgery is required.

A narrative review on the potential benefits and limitations of deep neuromuscular blockade

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.

Deep neuromuscular block does not improve surgical conditions in patients receiving sevoflurane anaesthesia for laparoscopic renal surgery

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).

Onset time and duration of action of rocuronium 0.6 mg/kg in patients above 80 years of age: A comparison with young adults

BACKGROUND

The number of elderly is increasing, and a large proportion of these people will require surgery and anaesthesia. However, little data exist regarding rocuronium in patients above 80 years of age. The aim of this study was to determine the onset time and duration of action for rocuronium 0.6 mg/kg in patients above 80 years compared with young adults.

METHODS

This prospective observational study included 16 young (18-40 years) and 16 elderly (>80 years) patients scheduled for total intravenous anaesthesia. Neuromuscular block following rocuronium 0.6 mg/kg was monitored with acceleromyography using train-of-four (TOF) stimulation. The primary outcome was onset time (from administration of rocuronium until TOF count = 0). Secondary outcomes were duration of action (from administration to TOF ratio >0.9) and intubating conditions according to Intubation Difficulty Score.

RESULTS

Elderly patients, median age of 84 years, had significantly prolonged onset time compared to younger patients; median 135 seconds (135-158) vs 90 seconds (90-105), respectively, a mean difference of 82 seconds (40-124) and Wilcoxon Mann-Whitney odds (WMW) of 19.48 (7.48-X). Duration of action in elderly patients was significantly longer, with a median time of 81 minute (71-97) vs 53 minute (42-73), respectively, a mean difference of 31 minute (14-48), and WMW odds of 6.35 (2.59-X). There was no significant difference in intubating conditions.

CONCLUSIONS

Patients above 80 years had significantly prolonged onset time and duration of action after rocuronium 0.6 mg/kg compared with patients aged 18-40 years.

Efficacy of profound versus moderate neuromuscular blockade in enhancing postoperative recovery after laparoscopic donor nephrectomy: A randomised controlled trial

BACKGROUND

Profound neuromuscular blockade (NMB) during anaesthesia has been shown to reduce postoperative pain scores, when compared with a moderate block. We hypothesised that profound NMB during laparoscopic donor nephrectomy (LDN) could also improve the early quality of recovery after surgery.

OBJECTIVES

To compare the effectiveness of profound versus moderate NMB during LDN in enhancing postoperative recovery.

DESIGN

A phase IV, double-blinded, randomised controlled trial.

SETTING

Multicentre trial, from November 2016 to December 2017.

PATIENTS

A total of 101 living kidney donors scheduled for LDN were enrolled, and 96 patients were included in the analyses.

INTERVENTIONS

Patients were randomised to receive profound (posttetanic count 1 to 3) or moderate (train-of-four count 1 to 3) neuromuscular block.

MAIN OUTCOME MEASURES

The primary outcome was the early quality of recovery at postoperative day 1, measured by the Quality of Recovery-40 Questionnaire. Secondary outcomes were adverse events, postoperative pain, analgesic consumption and length-of-stay.

RESULTS

The intention-to-treat analysis did not show a difference with regard to the quality of recovery, pain scores, analgesic consumption and length-of-stay. Less intra-operative adverse events occurred in patients allocated to profound NMB (1/48 versus 6/48). Five patients allocated to a profound NMB received a moderate block and in two patients neuromuscular monitoring failed. The as-treated analysis revealed that pain scores were significantly lower at 6, 24 and 48 h after surgery. Moreover, the quality of recovery was significantly better at postoperative day 2 in patients receiving a profound versus moderate block (179.5 ± 13.6 versus 172.3 ± 19.2).

CONCLUSION

Secondary analysis indicates that an adequately maintained profound neuromuscular block improves postoperative pain scores and quality of recovery. As the intention-to-treat analysis did not reveal a difference regarding the primary endpoint, future studies should pursue whether a thoroughly maintained profound NMB during laparoscopy improves relevant patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02838134.

Depth of Neuromuscular Block Is Not Associated with Abdominal Wall Distention or Surgical Conditions during Gynecologic Laparoscopic Operations. A Prospective Trial

The influence of the degree of a neuromuscular block (NMB) on surgical operating conditions during laparoscopic surgery is debated controversially. The extent of abdominal distension during the time course of the NMB was assessed as a new measurement tool. In 60 patients scheduled for gynecologic laparoscopic surgery, the increase of the abdominal wall length induced by the capnoperitoneum was measured at 5 degrees of the NMB: intense NMB—post-tetanic count (PTC) = 0; deep NMB—train-of-four count (TOF) = 0 and PTC = 1–5; medium NMB—PTC > 5 and TOF = 0–1; shallow NMB—TOF > 1; full recovery—train-of-four ratio TOFR > 90%. Simultaneously, the quality of operating conditions was assessed with a standardized rating scale (SRS) reaching from 1 (extremely poor conditions) to 5 (excellent conditions). Fifty patients could be included in the analysis. The abdominal wall length increased by 10–13 mm induced by the capnoperitoneum. SRS was higher during intense NMB (4.7 ± 0.5) vs. full recovery (4.5 ± 0.5) (mean ± SD; p = 0.025). Generally, an intense NMB did not increase abdominal wall length induced by capnoperitoneum. Additionally, its influence on the quality of surgical operating conditions seems to be of minor clinical relevance.

SUGAMMADEX versus neostigmine after ROCURONIUM continuous infusion in patients undergoing liver transplantation

BACKGROUND

Rapid neuromuscular block reversal at the end of major abdominal surgery is recommended to avoid any postoperative residual block. To date, no study has evaluated sugammadex performance after rocuronium administration in patients undergoing liver transplantation. This is a randomized controlled trial with the primary objective of assessing the neuromuscular transmission recovery time obtained with sugammadex versus neostigmine after rocuronium induced neuromuscular blockade in patients undergoing orthotopic liver transplantation.

METHODS

The TOF-Watch SX®, calibrated and linked to a portable computer equipped with TOF-Watch SX Monitor Software®, was used to monitor and record intraoperative neuromuscular block maintained with a continuous infusion of rocuronium. Anaesthetic management was standardized as per our institution's internal protocol. At the end of surgery, neuromuscular moderate block reversal was obtained by administration of 2 mg/kg of sugammadex or 50 mcg/kg of neostigmine (plus 10 mcg/kg of atropine).

RESULTS

Data from 41 patients undergoing liver transplantation were analysed. In this population, recovery from neuromuscular block was faster following sugammadex administration than neostigmine administration, with mean times±SD of 9.4 ± 4.6 min and 34.6 ± 24.9 min, respectively (p < 0.0001).

CONCLUSION

Sugammadex is able to reverse neuromuscular block maintained by rocuronium continuous infusion in patients undergoing liver transplantation. The mean reversal time obtained with sugammadex was significantly faster than that for neostigmine. It is important to note that the sugammadex recovery time in this population was found to be considerably longer than in other surgical settings, and should be considered in clinical practice.

TRIAL REGISTRATION

ClinicalTrials.govNCT02697929 (registered 3rd March 2016).

[Deep neuromuscular blockade : Benefits and risks]

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.

Thirty-Day Postoperative Outcomes Following Sugammadex Use in Colorectal Surgery Patients; Retrospective Study

Purpose: Sugammadex rapidly reverses muscle relaxation compared to acetylcholinesterase inhibitors. The long-term outcomes of sugammadex, however, are not well known. We compared 30-day postoperative outcomes following sugammadex and acetylcholinesterase inhibitor use in colorectal surgery patients. Patients and methods: Colorectal surgical patients older than 21 were included in this retrospective study, and were dichotomized according to use of reversal agents, sugammadex (group S), and acetylcholinesterase inhibitor (group A). We assessed 30-day postoperative outcomes, including total length of hospital stay, length of postoperative hospital stay, readmission rate, and delayed discharge rate. Additional parameters included postanesthetic care unit stay time, time to first successful oral intake, unforeseen intensive care unit (ICU) admission rate, postoperative pulmonary complications, and mortality. Results: Among a total of 585 patients, 157 patients remained in each group after propensity score matching. Total length of hospital stay, length of postoperative hospital stay, and readmission rates did not differ between the two groups, while the incidence of delayed discharge was significantly lower in group S (23 (15%) vs. 40 (25%), p = 0.017). Other outcomes did not differ between the two groups. Conclusion: We found no difference in 30-day postoperative outcomes following sugammadex and acetylcholinesterase inhibitor use. The only difference between these treatments was the associated incidence of delayed discharge, which was lower in group S.

Recent advances in neuromuscular block during anesthesia

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.