1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Joon P, Mandelia A, Dhiraaj S, Singh TK, Shamshery C, Mishra P. Physiological and Anesthetic Considerations of Safe and Optimal Pneumoperitoneal Pressures for Laparoscopic Surgeries in Children. J Indian Assoc Pediatr Surg 2024; 29:13-18. [PMID: 38405258 PMCID: PMC10883174 DOI: 10.4103/jiaps.jiaps_87_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 07/29/2023] [Accepted: 08/18/2023] [Indexed: 02/27/2024] Open
Abstract
Context In the era of minimally invasive surgeries, pediatric laparoscopic surgeries are now becoming the standard of care. Aim In this study, we aim to determine the safe and optimal pneumoperitoneal pressures (PPs) for laparoscopic surgery in children aged 1-5 years, along with the technical ease for the surgeon. Settings and Design Prospective, randomized, single-blinded study was conducted at SGPGI Lucknow. Materials and Methods Children aged 1-5 years were randomized into Group I (n = 24): PP = 6-8 mmHg and Group II: (PP) = 9-10 mmHg. Hemodynamic, ventilatory, and blood gas changes were measured before CO2 insufflation (T0), 20 min after insufflation (T1), before desufflation (T2), and 10 min after desufflation (T3). Surgeon's technical ease of surgery, postoperative pain, the requirement of rescue analgesia, time to resume feeding, and complications were recorded and analyzed. Statistical Analysis Used Paired t-test, Mann-Whitney test, and Wilcoxon signed-rank test were used for nonparametric/parametric data. Chi-square/Fisher's test was used for nominal data. Results Partial pressure of CO2 (PaCO2) was significantly higher in Group II at T1, T2, and T3, requiring frequent changes in ventilatory settings. Postoperative pain scores were higher in Group II at 1, 6, and 12 h, requiring rescue analgesia. Surgeon's scores and hemodynamics were similar in both groups. Conclusions Higher PP in Group II caused significant changes in PaCO2, end-tidal CO2, and postoperative pain requiring rescue analgesia, but blood gas changes were clinically insignificant and there were no significant changes in hemodynamic parameters. Since the surgeon's ease of performing surgery was similar in both groups, we recommend that laparoscopy in children aged 1-5 years can be started with lower PPs of 6-8 mmHg, which can be increased if needed based on the surgeon's comfort and the patient's body habitus.
Collapse
Affiliation(s)
- Preeti Joon
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ankur Mandelia
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Dhiraaj
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Tapas Kumar Singh
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Chetna Shamshery
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhaker Mishra
- Department of Health Informatics and Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
3
|
Alhusseinawi H, Haase R, Rasmussen S, Jensen JB, Kingo PS. Validation of a surgical workspace scale during robot-assisted surgery. Int J Med Robot 2023; 19:e2482. [PMID: 36403108 PMCID: PMC10078223 DOI: 10.1002/rcs.2482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/26/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND A sufficient surgical workspace is crucial to avoid complications. Within classic laparoscopy, many subjective surgical rating scales (SRSs) have previously been used to evaluate the surgical workspace. This study aimed to validate a modified version of the 5-point SRS during robot-assisted radical nephrectomy (RARN). METHODS Thirty-two intra-operative videos of intraperitoneal spaces were recorded from eight patients who underwent RARN. To attain the visualisation of different types of workspaces, we recorded 20 s panoramic videos of different pneumoperitoneum, namely 3, 5, 7 and 12 mmHg. The videos were randomised and presented two times to eight experienced robotic surgeons to evaluate the workspace using our modified 5-point SRS. Both inter-and intra-rater reliabilities were tested. RESULTS The results of the validation study showed moderate inter-rater and good to excellent intra-rater reliability. CONCLUSION This is a valid tool that can be confidently used by future researchers in the field of robot-assisted surgery.
Collapse
Affiliation(s)
- Hayder Alhusseinawi
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Rikke Haase
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark
| | - Sten Rasmussen
- Department of Urology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jørgen B Jensen
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pernille S Kingo
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
4
|
Mandelia A, Haldar R, Siddiqui Y, Mishra A. Optimising working space for laparoscopic pyeloplasty in infants: Preliminary observations with the SGPGI Protocol. J Minim Access Surg 2022; 18:105-110. [PMID: 35017400 PMCID: PMC8830566 DOI: 10.4103/jmas.jmas_202_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AIMS This study aimed to test the efficacy of SGPGI protocol to minimise bowel distension and optimise working space for laparoscopic pyeloplasty in infants. METHODOLOGY All infants who underwent laparoscopic pyeloplasty for unilateral pelvi-ureteric junction obstruction (PUJO) between January 2017 and March 2020 were included in the study. The patient cohort was divided into two groups: Group A and B. Group A included patients who underwent routine pre-operative preparation. Group B included patients wherein the SGPGI protocol was used. The key features of the protocol were fasting for 8 h, enemas, inserting a nasogastric tube in the pre-operative period and decompressing the colon on the operation table. Demographic features, pre-operative, intraoperative and post-operative parameters were compared between the two groups. RESULTS A total of 26 infants with unilateral PUJO underwent laparoscopic pyeloplasty during the study period. Group A included 12 patients and Group B included 14 patients. Both the groups were similar in age, weight and sex distribution. The median surgeon's rating score for suturing conditions was 2 for Group A and 5 for Group B patients (P > 0.05). The operating time was significantly longer in Group A (196 ± 21 min) as compared to Group B (114 ± 18 min) (P < 0.05). In Group A, intra-abdominal pressure (IAP) varied between 9 and 14 mmHg (median 12 mmHg), while in Group B, IAP varied between 6 and 9 mmHg (median 8 mmHg) (P < 0.05). In Group A, in 2/12 cases (16.7%), conversion to an open procedure was necessary because of inadequate working space owing to gross intestinal distension. Two patients in Group A also had intraoperative injuries to adjacent structures due to poor working space. CONCLUSIONS Optimal working space is critical to the performance of advanced laparoscopic surgery like pyeloplasty in infants. SGPGI protocol significantly improves working space, which permits a faster and safer surgery with a lower intra-abdominal working pressure. This protocol is simple, safe and easy to replicate at most centres in our country.
Collapse
Affiliation(s)
- Ankur Mandelia
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Yousuf Siddiqui
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashwani Mishra
- Department of Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
5
|
Loh PS, Yeong CH, Masohood NS, Sulaiman N, Zaki RA, Fabell K, Abdullah BJJ. Comparison of deep and moderate neuromuscular blockade in microwave ablation of liver tumours: a randomized-controlled clinical trial. Sci Rep 2021; 11:2299. [PMID: 33504909 PMCID: PMC7840903 DOI: 10.1038/s41598-021-81913-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/07/2021] [Indexed: 01/18/2023] Open
Abstract
Microwave ablation (MWA) is gaining popularity for the treatment of small primary hepatocellular carcinoma and metastatic lesions especially if patients are not candidates for surgical resection. Deep neuromuscular blockade (DMB) is perceived to improve surgical working conditions compared to moderate neuromuscular blockade (MMB) but no studies have examined the same benefits in MWA of liver tumours. This study aimed to compare the clinical outcomes of DMB and MMB in MWA of liver tumours in terms of liver excursion, performance scores by the interventional radiologists and patients, requirements of additional muscle relaxants and complications. 50 patients were recruited and 45 patients (22 in MMB group, 23 in DMB group) completed the study. The mean liver excursion for the MMB group (1.42 ± 1.83 mm) was significantly higher than the DMB group (0.26 ± 0.38 mm) (p = 0.001). The mean Leiden-Surgical Rating Scale (L-SRS) rated by the two interventional radiologists were 4.5 ± 0.59 and 3.6 ± 0.85 for the DMB and MMB groups, respectively (p = 0.01). There was also statistically significant difference on patient satisfaction scores (0–10: Extremely Dissatisfied–Extremely Satisfied) between DMB (8.74 ± 1.1) and MMB (7.86 ± 1.25) groups (p = 0.01). 5 patients from MMB group and none from DMB group required bolus relaxant during the MWA procedure. Adverse events were also noted to be more severe in the MMB group. In conclusion, DMB significantly reduced liver excursion and movement leading to improved accuracy, safety and success in ablating liver tumour.
Collapse
Affiliation(s)
- Pui San Loh
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Chai Hong Yeong
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, 47500, Subang Jaya, Selangor, Malaysia.
| | - Naeema S Masohood
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Norshazriman Sulaiman
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Rafdzah Ahmad Zaki
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Kamil Fabell
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Basri Johan Jeet Abdullah
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| |
Collapse
|
6
|
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).
Collapse
|
7
|
Deep neuromuscular blockade improves surgical conditions during gastric bypass surgery for morbid obesity. Eur J Anaesthesiol 2019; 36:486-493. [DOI: 10.1097/eja.0000000000000996] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
|
10
|
Deep neuromuscular blockade and surgical conditions during laparoscopic ventral hernia repair. Eur J Anaesthesiol 2018; 35:876-882. [DOI: 10.1097/eja.0000000000000833] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
11
|
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.
Collapse
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
| |
Collapse
|