Laparoscopic surgery and muscle relaxants: is deep block helpful?

The arousal effect of sugammadex reversal of neuromuscular blockade differs with anesthetic depth in propofol-remifentanil anesthesia: a randomized controlled trial

Sugammadex reverses neuromuscular blockade by encapsulating steroidal neuromuscular blockers; therefore, it does not pharmacologically affect sedation levels. However, some clinicians avoid using it because of sudden unwanted acting out or patient arousal. Previous studies suggested sugammadex-induced awakening, but frontal muscle contraction after sugammadex administration compromised reliability of results obtained from EEG-based anesthesia depth monitoring tools like bispectral index (BIS). We hypothesized that sugammadex would affect patients' arousal depending on their baseline levels of sedation. We evaluated arousal signs after sugammadex administration with BIS between 25 - 35 and 45 - 55 under steady-state propofol-remifentanil anesthesia at the end of a surgery (n = 33 in each group). After sugammadex administration, twelve patients with a BIS of 45 - 55 showed clinical signs of awakening but none with a BIS of 25 - 35 (36.4% vs. 0%, P = 0.001). The distribution of the modified observer's assessment of alertness/sedation scale scores was also significantly different between the two groups (P < 0.001). Changes in the BIS were significantly greater in the BIS 45 - 55 than in the 25 - 35 group (median difference, 7; 95% CI 2 - 19, P = 0.002). Arousal after sugammadex was affected by patient sedation levels, and clinical signs of awakening appeared only in those with BIS 45 - 55. Unwanted arousal of the patient should be considered when using sugammadex under shallow anesthesia.Clinical trial registry number: Clinical Trial Registry of Korea ( https://cris.nih.go.kr ; Principal investigator: Jieae Kim; Registration number: KCT0006248; Date of first registration: 11/06/2021).

Evaluation of a Protocol for the Management of Maintenance and Reversal of Rocuronium Block Using Neostigmine or Sugammadex

BACKGROUND

Postoperative residual neuromuscular blockade (PRNB) is defined as an adductor pollicis train-of-four ratio (TOFR) <0.9. It is a common postoperative complication when nondepolarizing muscle relaxants are either not reversed or reversed with neostigmine. PRNB has been reported in 25% to 58% of patients who receive intermediate-acting nondepolarizing muscle relaxants, and it is associated with increased morbidity and decreased patient satisfaction. We conducted a prospective descriptive cohort study during the implementation of a practice guideline that included the selective use of sugammadex or neostigmine. The primary study aim of this pragmatic study was to estimate the incidence of PRNB at arrival to the postanesthesia care unit (PACU) when the practice guideline is followed.

METHODS

We enrolled patients undergoing orthopedic or abdominal surgery requiring neuromuscular blockade. Rocuronium administration was guided by surgical requirements and based on ideal body weight, with dose reductions for women and/or age >55 years. Only qualitative monitoring was available to the anesthesia providers, and selection of sugammadex or neostigmine was guided by tactile assessments of the response to train-of-four (TOF) stimulation by a peripheral nerve stimulator. Neostigmine was administered if no fade was detected in the TOF response at the thumb. Deeper blocks were reversed with sugammadex. The prespecified primary and secondary end points were the incidence of PRNB at arrival to the PACU, defined as a normalized TOFR (nTOFR) < 0.9, and severe PRNB, defined as nTOFR <0.7 on arrival to the PACU. Anesthesia providers were blinded to all quantitative measurements made by research staff.

RESULTS

Analysis included 163 patients, and 145 underwent orthopedic and 18 abdominal surgeries. Of the 163 patients, 92 (56%) were reversed with neostigmine and 71 (44%) with sugammadex. The overall incidence of PRNB at PACU arrival was 5 of 163 or 3% (95% confidence interval [CI], 1-7). The incidence of severe PRNB in PACU was 1% (95% CI, 0-4). Three of the 5 subjects with PRNB had TOFR <0.4 at time of reversal but were given neostigmine since anesthesia providers detected no fade by qualitative assessment.

CONCLUSIONS

The use of a protocol that specifies rocuronium dosing and selective use of sugammadex versus neostigmine based on qualitative assessment of TOF count and fade allowed us to achieve an incidence of PRNB of 3% (95% CI, 1-7) at PACU arrival. Quantitative monitoring may be needed to further reduce this incidence.

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.

The effects of moderate neuromuscular blockade combined with transverse abdominal plane block on surgical space conditions during laparoscopic colorectal surgery: a randomized clinical study

Background

Deep neuromuscular blockade may be beneficial on surgical space conditions during laparoscopic surgery. The effects of moderate neuromuscular blockade combined with transverse abdominal plane block (TAPB) on surgical space conditions during laparoscopic surgery have not been described. This work investigated whether the above combination is associated with similar surgical space conditions to those of deep neuromuscular blockade.

Methods

Eighty patients undergoing elective laparoscopic surgery for colorectal cancer were randomly divided into two groups. The intervention group was treated with moderate neuromuscular blockade (train-of-four (TOF) count between 1 and 3) combined with TAPB (M group), while the control group was treated with deep neuromuscular blockade (D group), with a TOF count of 0 and a post-tetanic count (PTC) ≥1. Both groups received the same anesthesia management. The distance between the sacral promontory and the umbilical skin during the operation was compared between the two groups. The surgeon scored the surgical space conditions according to a five-point ordinal scale. Patients’ pain scores were evaluated 8 h after the operation.

Results

The distance from the sacral promontory to the umbilical skin after pneumoperitoneum was similar between the D group and M group (16.03 ± 2.17 cm versus 16.37 ± 2.78 cm; P = 0.544). The 95% confidence intervals of the difference in the distance from the sacral promontory to the umbilical skin between the two groups were − 1.45–0.77 cm. According to the preset non-inferior standard of 1.5 cm, (− 1.45, ∞) completely fell within (− 1.50, ∞), and the non-inferior effect test was qualified. No significant difference was found in the surgical rating score between the two groups. The dosage of rocuronium in the group D was significantly higher than that in the group M (P < 0.01). The M group had significantly lower pain scores than the D group 8 h after the operation (P < 0.05).

Conclusions

Moderate neuromuscular blockade combined with TAPB applied to laparoscopic colorectal cancer surgery can provide surgical space conditions similar to those of deep neuromuscular blockade. In addition, it reduces the use of muscle relaxants, relieves postoperative pain within 4 h after operation, and shorten the extubation time and stay in PACU when neostigmine was used as muscle relaxant antagonist.

Trial registration

chictr.org.cn (ChiCTR2000034621), registered on July 12, 2020.

Does deep neuromuscular blockade provide improved outcomes in low pressure laparoscopic colorectal surgery? A single blinded randomized pilot study

BACKGROUND

Low intra-abdominal pressure during laparoscopic colorectal surgery may improve outcomes and reduce hospital stay, in addition to Enhanced Recovery After Surgery (ERAS) protocols. There is concern that low pressure reduces laparoscopic vision and may increase surgical complications. Deep neuromuscular blockade may abrogate any reduction in vision of low-pressure pneumoperitoneum. However, antagonism of deep neuromuscular blockade at completion of surgery necessitates the use of sugammadex, which is prohibitively expensive, if there are no surgical benefits and warrants further study.

METHODS

A single institution, single blinded randomized controlled pilot study was performed comparing deep to moderate neuromuscular blockade in major laparoscopic colorectal surgery.

RESULTS

Thirty-eight patients were randomized to deep or moderate neuromuscular blockade. There were no statistically significant differences between groups, when comparing key patient demographics, or surgeon satisfaction with view, which required increased pressure or further relaxation demands. The deep blockade group had increased QoR15 scores and a decrease in pain, C-Reactive Protein (CRP) measurements and operating times, although were non-significant. The moderate group had slightly higher incidents of Medical Emergency Team (MET) calls and more severe complications, although were non-significant.

CONCLUSIONS

Low intra-abdominal pressure in laparoscopic colorectal surgery is feasible and allows adequate surgical visualization, regardless of the degree of neuromuscular blockade. Potential benefits of deep neuromuscular blockade may include improved pain and quality of recovery and a possible reduction of complications; however a larger cohort is required to confirm this. Future ERAS protocols may consider deep neuromuscular blockade with low intra-abdominal pressure to further benefit patients.

Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations: A 2021 Update

Background

This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol.

Methods

A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations.

Results

The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries.

Conclusion

A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

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.

Comparison of airway management without neuromuscular blockers in laparoscopic gynecological surgery

New generation supraglottic airway devices are suitable for airway management in many laparoscopic surgeries. In this study, we evaluated and compared the ventilation parameters of the laryngeal mask airway-supreme (LM-S) and endotracheal tube (ETT) when a neuromuscular blocker (NMB) agent was not used during laparoscopic gynecological surgery. The second outcome was based on the evaluation of the surgical view because it may affect the surgical procedure.This was a randomized study that enrolled 100 patients between 18 and 65 years old with an ASA I-II classification. Patients were divided into 2 groups: Group ETT and Group LM-S. Standard anesthesia and ventilation protocols were administered to patients in each group. Ventilation parameters [airway peak pressure (Ppeak), mean airway pressure (Pmean), total volume, and oropharyngeal leak pressure] were recorded before, after, and during peritoneal insufflation and before desufflation, as well as after the removal of the airway device. Perioperative surgical view quality and the adequacy of the pneumoperitoneum were also recorded.The data of 100 patients were included in the statistical analysis. The Ppeak values in Group ETT were significantly higher in the second minute after airway device insertion. The Ppeak and Pmean values in Group ETT were significantly higher before desufflation and after removal of the airway device. No significant differences were found between the groups in terms of adequacy of the pneumoperitoneum or quality of the surgical view.The results of this study showed that gynecological laparoscopies can be performed without using a NMB. Satisfactory conditions for ventilation and surgery can be achieved while sparing the use of muscle relaxants in both groups despite the Trendelenburg position and the pneumoperitoneum of the patients, which are typical for laparoscopic gynecological surgery. The results are of clinical significance because they show that the use of a muscle relaxant is unnecessary when supraglottic airways are used for these surgical procedures.

Paravertebral block using levobupivacaine or dexmedetomidine-levobupivacaine for analgesia after cholecystectomy: a randomized double-blind trial

Background

Thoracic paravertebral block (TPVB) has emerged as an effective and feasible mode of providing analgesia in laparoscopic cholecystectomy. Though a variety of local anaesthetic combinations are used for providing TPVB, literature is sparse on use of dexmedetomidine in TPVB. We aimed to compare levobupivacaine and levobupivacaine-dexmedetomidine combination in ultrasound guided TPVB in patients undergoing laparoscopic cholecystectomy.

Methodology

70 ASA I/II patients, aged 18–60 years, scheduled to undergo laparoscopic cholecystectomy under general anaesthesia were enrolled and divided into two groups. Before anaesthesia induction, group A patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml normal saline while group B patients received unilateral right sided ultrasound guided TPVB with 15 ml 0.25% levobupivacaine plus 2 ml solution containing dexmedetomidine 1 μg.kg^-1. Patients were monitored for pain using Numeric Rating Scale (NRS) at rest, on movement, coughing and comfort scores post surgery. Total analgesic consumption in first 48 hour postoperative period, time to first request analgesic and pain scores were recorded.

Results

Total amount of rescue analgesia (injection tramadol plus injection tramadol intravenous equivalent dose) consumed during 48 hours postoperatively in group A was 146.55 mg while in group B was 111.30 mg (p = 0.026). Mean time for demanding rescue analgesia was 273 minutes in group A while in group B was 340 minutes (p = 0.00).

Conclusion

TPVB using dexmedetomidine 1 μg.kg^-1 added to levobupivacaine 0.25% in patients undergoing laparoscopic cholecystectomy significantly reduced total analgesic consumption in first 48 hours and provided longer duration of analgesia postoperatively compared to levobupivacaine 0.25% alone.

Half-dose sugammadex with neostigmine versus full-dose sugammadex for reversal of rocuronium in laparoscopic bariatric surgery

Background

Sugammadex reverses rocuronium more effective than neostigmine during deeper neuromuscular blockade levels. Relying upon the high cost of sugammadex we hypothesized that combined neostigmine with half-dose sugammadex (1.2 mg/kg) would be as effective as the full dose (2.4 mg/kg IBW) in reversing rocuronium-induced deep neuromuscular block in obese patients. A multimodal approach would be an effective cost saving strategy, while preserving the advantages of this novel agent.

Patient and methods

A prospective randomized study done on 50 morbid obese patients undergoing elective laparoscopic sleeve gastrectomy operation. Patients were allocated into two groups each of 25. Group NS received sugammadex 1.2 mg/kg and neostigmine 50 μg/kg with atropine 20 μg/kg. Group S received sugammadex 2.4 mg/kg and 10 mL of normal saline.

Primary outcome

Interval between administration of reversal and reaching TOF of 90%.

Secondary outcomes

Total dose of rocuronium (mg), duration between last dose rocuronium and reverse, number of patients reached TOF of 90% within 5 min, duration between IV reversal and extubation, and the number of patients with residual neuromuscular blockade.

Results

Number of patients who reached TOF 90% within 5 min, the interval between reversal and 90% TOF, the interval between reversal and extubation were comparable between the study groups.

Conclusion

As regards neuromuscular blocker reversal in obese patients, the neostigmine 50 μg/kg plus sugammadex half dose (1.2 mg/kg) is as effective as full-dose sugammadex (2.4 mg/kg) alone.

Trial registration

Institutional Research Board: (IRB code number): MS/17.12.195 on 16 January 2018.

Does Deep Neuromuscular Blockade Improve Operating Conditions during Minimally Invasive Anterolateral Total Hip Replacements?: A Randomized Controlled Trial

Background

Neuromuscular blockade (NMB) is thought to improve operative conditions during certain procedures. Published descriptions of minimally invasive hip replacement techniques specify the need for “excellent relaxation”, however, the optimal degree of NMB required for such cases has not been studied. We performed a randomized, single-blind study comparing the effect of moderate and deep neuromuscular blockade on surgical conditions and operating time during minimally invasive anterolateral hip replacement. Vecuronium was administered to maintain moderate NMB (train-of-four count of 1-2) or deep NMB (train-of-four count of 0, post-tetanic count of 1-2).

Methods

In this study, 116 patients were randomized to receive moderate or deep neuromuscular blockade; depth of blockade was monitored using acceleromyography. The primary outcome was the number of requests from the surgeon for additional blockade intraoperatively. Secondary outcomes included operative times and assessment of the operative conditions by the surgeon utilizing the Leiden-Surgical Rating Scale.

Results

Cases with additional requests for blockade did not differ between the deep and moderate NMB groups (11/58, 19.0% vs 8/58, 13.8%); relative risk, 1.22 (95% CI [confidence interval], 0.70-2.15), p=0.62. Neither time from incision to prosthesis reduction (33.8±1.2 min vs. 32.6 ±1.2 min; difference in geometric mean, 0.96 [95% CI, 0.90-1.04] minutes, p=0.33), nor the surgeon’s assessment of operative conditions (p=0.88), differed between the deep or moderate NMB groups, respectively. 

Conclusions

Deep NMB did not produce significantly improved operative conditions compared with moderate NMB. Routine use of deep NMB during minimally invasive anterolateral hip arthroplasty is not supported by this study.

Effect of intraoperative neuromuscular blockade on postoperative sore throat and hoarseness in patients undergoing spinal surgery: a prospective observational study

Intraoperative neuromuscular blockade affects the resting tension between the vocal cords. We assessed the effect of neuromuscular blockade on postoperative sore throat and hoarseness following tracheal intubation in patients undergoing lumbar spinal surgery in the prone position. Altogether, 99 patients were included; 50 patients did not receive neuromuscular blockade, and 49 patients received moderate neuromuscular blockade during the maintenance of anesthesia. Neuromuscular blockade was performed depending on the use of intraoperative neurophysiological monitoring. The number of intubation attempts, time to achieve tracheal intubation, and duration of intubation were recorded accordingly. The incidence and severity of postoperative sore throat and hoarseness was assessed at 1, 6, and 24 h after surgery. The overall cumulative incidence of postoperative sore throat (60% vs. 59%, respectively; P = 1.000) and postoperative hoarseness (68% vs. 61%, respectively; P = 0.532) did not differ between the no neuromuscular blockade and moderate neuromuscular blockade. The incidence and severity of postoperative sore throat and hoarseness was also not different between the moderate and no neuromuscular blockade at each time point after surgery. Nevertheless, the incidences of postoperative sore throat and hoarseness were quite high. Further studies investigating strategies to alleviate them are warranted accordingly.

Effect of pneumoperitoneum pressure and the depth of neuromuscular block on renal function in patients with diabetes undergoing laparoscopic pelvic surgery: study protocol for a double-blinded 2 × 2 factorial randomized controlled trial

Background

Patients with diabetes mellitus are at a high risk of developing postoperative acute kidney injury. For patients receiving laparoscopic surgery, standard-pressure pneumoperitoneum (SPP) currently applied in clinical practice also undermines renal perfusion. Several studies have shown that low-pressure pneumoperitoneum (LPP) might reduce pressure-related ischemic renal injury. However, LPP may compromise the view of the surgical field. Previous studies have indicated that deep neuromuscular blockade (NMB) can ameliorate this issue. However, the conclusion is still uncertain. The hypothesis of this study is that the joint use of LPP and deep NMB can reduce perioperative renal injury in diabetic patients undergoing laparoscopic pelvic surgery without impeding the view of the surgical field.

Methods

This is a double-blinded, randomized controlled trial using a 2 × 2 factorial trial design. A total of 648 diabetes patients scheduled for major laparoscopic pelvic surgeries at Peking Union Medical College Hospital will be randomized into the following four groups: SPP (12–15 mmHg) + deep-NMB (post-tetanic count of 1–2) group, LPP (7–10 mmHg) + deep-NMB group, SPP + moderate-NMB (train-of-four of 1–2) group, and LPP + moderate-NMB group. The primary outcome is serum cystatin C level measured before insufflation, after deflation, 24 h postoperatively, and 72 h postoperatively. The secondary outcomes are serum creatinine level, intraoperative urine output, erythrocytes in urinary sediment, renal tissue oxygen saturation, Leiden’s surgical condition rating scale, surgery duration, and occurrence of bucking or body movement.

Discussion

This study will provide evidence for the effect of LPP on renal function protection in patients with diabetes undergoing laparoscopic pelvic surgery. The trial can also help us to understand whether deep NMB can improve surgical conditions.

Trial registration

ClinicalTrials.gov: NCT04259112. Prospectively registered on 5 February 2020.

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.

The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials

Background

Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy.

Methods

An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials.

Results

The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]: − 0.70; 95% credible interval [CrI]: − 1.26, − 0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD: − 0.14 days; 95% CrI − 0.30, − 0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery.

Conclusions

Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients’ post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07527-2) contains supplementary material, which is available to authorized users.

Impact of Sugammadex Versus Neostigmine/Glycopyrrolate on Perioperative Efficiency

Purpose

Neuromuscular blockade in the operating room necessitates the utilization of reversal agents to accelerate postoperative recovery and sustain operating room patient throughput. Cholinesterase inhibitors represent the historical standard of care for neuromuscular blockade reversal within anesthesia practice. Sugammadex, a synthetic gamma-cyclodextrin, was introduced to the market with evidence of more rapid and predictable reversal of neuromuscular blockade compared to alternative agents. Higher medication acquisition costs have limited more extensive use of sugammadex compared to that of neostigmine/glycopyrrolate. The purpose of this study was to examine the impact of sugammadex versus neostigmine/glycopyrrolate on perioperative efficiency to validate medication acquisition cost value.

Methods

A retrospective investigation was performed of patients with a surgical procedure at Houston Methodist Hospital from July 31, 2017 through August 1, 2018. The primary endpoint was time from reversal medication administration to operating room exit. Patient-specific doses were assessed to calculate average medication acquisition costs. The economic benefits of sugammadex were measured through review of average operating room and postanesthesia care unit costs per minute.

Results

There were a total of 640 surgical cases at Houston Methodist Hospital eligible for inclusion into the research study. The time from medication administration to operating room exit was significantly faster for sugammadex compared to neostigmine/glycopyrrolate (P<0.001) upon univariate analysis. However, when measured with linear regression, the difference in operating room exit time between sugammadex and neostigmine/glycopyrrolate was no longer statistically significant (P=0.122). Medication acquisition cost review highlighted a difference of $178.20, favoring use of neostigmine/glycopyrrolate.

Conclusion

The utilization of sugammadex does not correlate to consequential time saved in the operating room or extrapolation to workflow capacity for increased surgical case volume. Consideration of the medication acquisition cost promotes more restrictive use of sugammadex to indications with clinical relevance.

Low intra-abdominal pressure and deep neuromuscular blockade laparoscopic surgery and surgical space conditions: A meta-analysis

BACKGROUND

Low intra-abdominal pressure (IAP) and deep neuromuscular blockade (NMB) are frequently used in laparoscopic abdominal surgery to improve surgical space conditions and decrease postoperative pain. The evidence supporting operations using low IAP and deep NMB is open to debate.

METHODS

The feasibility of the routine use of low IAP +deep NMB during laparoscopic surgery was examined. A meta-analysis is conducted with randomized controlled trials (RCTs) to compare the influence of low IAP + deep NMB vs. low IAP + moderate NMB, standard IAP +deep NMB, and standard IAP + moderate NMB during laparoscopic procedures on surgical space conditions, the duration of surgery and postoperative pain. RCTs were identified using the Cochrane, Embase, PubMed, and Web of Science databases from initiation to June 2019. Our search identified 9 eligible studies on the use of low IAP + deep NMB and surgical space conditions.

RESULTS

Low IAP + deep NMB during laparoscopic surgery did not improve the surgical space conditions when compared with the use of moderate NMB, with a mean difference (MD) of -0.09 (95% confidence interval (CI): -0.55-0.37). Subgroup analyses showed improved surgical space conditions with the use of low IAP + deep NMB compared with low IAP + moderate NMB, (MD = 0.63 [95% CI:0.06-1.19]), and slightly worse conditions compared with the use of standard IAP + deep NMB and standard IAP + moderate NMB, with MDs of -1.13(95% CI:-1.47 to 0.79) and -0.87(95% CI:-1.30 to 0.43), respectively. The duration of surgery did not improve with low IAP + deep NMB, (MD = 1.72 [95% CI: -1.69 to 5.14]), and no significant reduction in early postoperative pain was found in the deep-NMB group (MD = -0.14 [95% CI: -0.51 to 0.23]).

CONCLUSION

Low IAP +deep NMB is not significantly more effective than other IAP +NMB combinations for optimizing surgical space conditions, duration of surgery, or postoperative pain in this meta-analysis. Whether the use of low IAP + deep NMB results in fewer intraoperative complications, enhanced quality of recovery or both after laparoscopic surgery should be studied in the future.

[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.

Consensus Statement on Perioperative Use of Neuromuscular Monitoring

A panel of clinician scientists with expertise in neuromuscular blockade (NMB) monitoring was convened with a charge to prepare a consensus statement on indications for and proper use of such monitors. The aims of this article are to: (a) provide the rationale and scientific basis for the use of quantitative NMB monitoring; (b) offer a set of recommendations for quantitative NMB monitoring standards; (c) specify educational goals; and (d) propose training recommendations to ensure proper neuromuscular monitoring and management. The panel believes that whenever a neuromuscular blocker is administered, neuromuscular function must be monitored by observing the evoked muscular response to peripheral nerve stimulation. Ideally, this should be done at the hand muscles (not the facial muscles) with a quantitative (objective) monitor. Objective monitoring (documentation of train-of-four ratio ≥0.90) is the only method of assuring that satisfactory recovery of neuromuscular function has taken place. The panel also recommends that subjective evaluation of the responses to train-of-four stimulation (when using a peripheral nerve stimulator) or clinical tests of recovery from NMB (such as the 5-second head lift) should be abandoned in favor of objective monitoring. During an interim period for establishing these recommendations, if only a peripheral nerve stimulator is available, its use should be mandatory in any patient receiving a neuromuscular blocking drug. The panel acknowledges that publishing this statement per se will not result in its spontaneous acceptance, adherence to its recommendations, or change in routine practice. Implementation of objective monitoring will likely require professional societies and anesthesia department leadership to champion its use to change anesthesia practitioner behavior.

The effect of neuromuscular reversal agent on postoperative pain after laparoscopic gastric cancer surgery: Comparison between the neostigmine and sugammadex

Use of sugammadex for neuromuscular block reversal is associated with fewer postoperative complications than neostigmine; however, the effects on postoperative pain outcomes are largely unknown. In this retrospective study, we investigated the relationship between neuromuscular reversal agents and postoperative pain-related outcomes following laparoscopic gastric cancer surgery.We reviewed the electronic health records of patients who underwent laparoscopic gastric cancer surgery between January 2010 and June 2017. Patients were divided into a sugammadex group and a neostigmine group, according to the neuromuscular block reversal agent used. We compared the pain outcomes in the first 3 days postoperatively (POD 0-3), length of hospital stay, and postoperative complications (Clavien-Dindo grade ≥II).During the study period, 3056 patients received sugammadex (n = 901) or neostigmine (n = 2155) for neuromuscular reversal. After propensity score matching, 1478 patients (739 in each group) were included in regression analysis. In linear regression analysis, intravenous morphine equivalent consumption (mg) during POD 0 to 3 was higher in the sugammadex group than in the neostigmine group [coefficient 103.41, 95% confidence interval (CI): 77.45-129.37; P <.001]. However, hospital stay was shorter (coefficient: -0.60, 95% CI -1.12 to -0.08; P = .025) and postoperative complication rate was lower (odds ratio: 0.20, 95% CI 0.07-0.58; P = .003) in the sugammadex group.In this retrospective study, patients undergoing laparoscopic gastric cancer surgery who received sugammadex for neuromuscular block reversal exhibited greater postoperative analgesic requirements than those who received neostigmine but had a shorter hospital stay and a lower postoperative complication rate. A randomized and blinded study should be conducted in the future to confirm the findings of the present study.

An individualised versus a conventional pneumoperitoneum pressure strategy during colorectal laparoscopic surgery: rationale and study protocol for a multicentre randomised clinical study

Background

A recent study shows that a multifaceted strategy using an individualised intra-abdominal pressure titration strategy during colorectal laparoscopic surgery results in an acceptable workspace at low intra-abdominal pressure in most patients. The multifaceted strategy, focused on lower to individualised intra-abdominal pressures, includes prestretching the abdominal wall during initial insufflation, deep neuromuscular blockade, low tidal volume ventilation settings and a modified lithotomy position. The study presented here tests the hypothesis that this strategy improves outcomes of patients scheduled for colorectal laparoscopic surgery.

Methods

The Individualized Pneumoperitoneum Pressure in Colorectal Laparoscopic Surgery versus Standard Therapy (IPPCollapse-II) study is a multicentre, two-arm, parallel-group, single-blinded randomised 1:1 clinical study that runs in four academic hospitals in Spain. Patients scheduled for colorectal laparoscopic surgery with American Society of Anesthesiologists classification I to III who are aged > 18 years and are without cognitive deficits are randomised to an individualised pneumoperitoneum pressure strategy (the intervention group) or to a conventional pneumoperitoneum pressure strategy (the control group). The primary outcome is recovery assessed with the Post-operative Quality of Recovery Scale (PQRS) at postoperative day 1. Secondary outcomes include PQRS score in the post anaesthesia care unit and at postoperative day 3, postoperative complications until postoperative day 28, hospital length of stay and process-related outcomes.

Discussion

The IPPCollapse-II study will be the first randomised clinical study that assesses the impact of an individualised pneumoperitoneum pressure strategy focused on working with the lowest intra-abdominal pressure during colorectal laparoscopic surgery on relevant patient-centred outcomes. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance for optimising the care and safety of laparoscopic abdominal surgery. Selection of patient-reported outcomes as the primary outcome of this study facilitates the translation into clinical practice. Access to source data will be made available through anonymised datasets upon request and after agreement of the Steering Committee of the IPPCollapse-II study.

Trial registration

ClinicalTrials.gov, NCT02773173. Registered on 16 May 2016. EudraCT, 2016-001693-15. Registered on 8 August 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3255-1) contains supplementary material, which is available to authorized users.

Effects of deep vs moderate neuromuscular block on the quality of recovery after robotic gastrectomy

BACKGROUND

It remains unclear whether deep neuromuscular blockade results in better postoperative recovery than does moderate neuromuscular blockade. Therefore, in this study, we aimed to compare the effects of deep neuromuscular blockade and moderate neuromuscular blockade on the quality of postoperative recovery in patients undergoing robotic gastrectomy.

METHODS

In this prospective, double-blind, single-center randomized controlled superiority trial with two parallel groups, 56 adult patients (19-80 years) scheduled for elective robotic gastrectomy were randomly assigned to a moderate neuromuscular blockade group or a deep neuromuscular blockade group in a 1:1 ratio. In the deep and moderate neuromuscular blockade groups, the infusion rate for rocuronium was adjusted to maintain a post-tetanic count of 1-2 or a train-of-four count of 1-2, respectively. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day 1. Secondary outcomes included the QoR-40 score on postoperative day 2, intraoperative hemodynamic data, intraoperative respiratory data, visual analog scale score for pain, postoperative incidences of nausea and vomiting, postoperative rescue analgesic use, and postoperative rescue antiemetic use.

RESULTS

The postoperative QoR-40 score was similar between the two groups on postoperative days 1 and 2. Moreover, the two groups showed no differences in intraoperative hemodynamic and respiratory data or postoperative pain, nausea and vomiting, and rescue medication use.

CONCLUSION

Our findings suggest that the quality of recovery after robotic gastrectomy is similar for deep and moderate neuromuscular blockade. Therefore, deep neuromuscular blockade during robotic gastrectomy may be unnecessary, at least in patients with normal body mass index.

A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study

BACKGROUND

While guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery.

METHODS

Multicenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO₂ gas needed to perform the surgical procedure.

RESULTS

Ninety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8 mmHg. In 17 patients, IAP was raised up to 12 mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO₂ volume at which surgery was performed was 3.2 L.

CONCLUSION

A multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure. ClinicalTrials.gov (Trial Identifier: NCT03000465).

Comparison of deep or moderate neuromuscular blockade for thoracoscopic lobectomy: a randomized controlled trial

Background

Laparoscopic surgery typically requires deep neuromuscular blockade (NMB), but whether deep or moderate NMB is superior for thoracoscopic surgery remains controversial.

Methods

Patients scheduled for thoracoscopic lobectomy under intravenous anesthesia were randomly assigned to receive moderate [train of four (TOF) 1–2] or deep NMB [TOF 0, post-tetanic count (PTC) 1–5]. Depth of anesthesia was controlled at a Narcotrend rating of 30 ± 5 in both groups. The primary outcome was the need to use an additional muscle relaxant (cisatracurium) during surgery. Secondary outcomes included surgeon satisfaction, recovery time of each stage after drug withdrawal [time from withdrawal until TOF recovery to 20% (antagonists administration), 25, 75, 90, 100%], blood gas data, VAS pain grade after extubation, the time it takes for patients to begin walking after surgery, postoperative complications and hospitalization time. Results were analyzed on an intention-to-treat basis.

Results

Thirty patients were enrolled per arm, and all but one patient in each arm was included in the final analysis. Among patients undergoing moderate NMB, surgeons applied additional cisatracurium in 8 patients because of body movement and 5 because of coughing (13/29, 44.8%). Additional cisatracurium was not applied to any of the patients undergoing deep NMB (p < 0.001). Surgeons reported significantly higher satisfaction for patients undergoing deep NMB (p < 0.001, Wilcoxon rank sum test). The mean difference between the two groups in the time from withdrawal until TOF recovery of 25% or 90% was 10 min (p < 0.001). The two groups were similar in other recovery data, blood gas analysis, VAS pain grade, days for beginning to walk and mean hospitalization time.

Conclusions

Deep NMB can reduce the use of additional muscle relaxant and increase surgeon satisfaction during thoracoscopic lobectomy.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-IOR-15007117, 22 September 2015.

Ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy: comparison of efficacy of bupivacaine and levobupivacaine on postoperative pain control

Background and objective

The use of transversus abdominis plane block with different local anesthetics is considered as a part of multimodal analgesia regimen in laparoscopic cholecystectomy patients. However no studies have been published comparing bupivacaine and levobupivacaine for transversus abdominis plane block. We aimed to compare bupivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

Methods

Fifty patients (ASA I/II), undergoing laparoscopic cholecystectomy were randomly allocated into two groups. Following anesthesia induction, ultrasound-guided bilateral transversus abdominis plane block was performed with 30 mL of bupivacaine 0.25% in Group B (n = 25) and 30 mL of levobupivacaine 0.25% in Group L (n = 25) for each side. The level of pain was evaluated using 10 cm visual analog scale (VAS) at rest and during coughing 1, 5, 15, 30 min and 1, 2, 4, 6, 12 and 24 h after the operation. When visual analogue scale > 3, the patients received IV tenoxicam 20 mg. If visual analogue scale remained >3, they received IV. tramadol 1 mg.kg⁻¹. In case of inadequate analgesia, a rescue analgesic was given. The analgesic requirement, time to first analgesic requirement was recorded.

Results

Visual analogue scale levels showed no difference except first and fifth minutes postoperatively where VAS was higher in Group L (p < 0.05). Analgesic requirement was similar in both groups. Time to first analgesic requirement was shorter in Group L (4.35 ± 6.92 min vs. 34.91 ± 86.26 min, p = 0.013).

Conclusions

Bupivacaine and levobupivacaine showed similar efficacy at TAP block in patients undergoing laparoscopic cholecystectomy.

Investigation of intraoperative dosing patterns of neuromuscular blocking agents

There is a growing body of literature documenting the use of deep neuromuscular block (NMB) during surgery. Traditional definitions of depth of NMB rely on train-of-four assessment, which can be less reliable in retrospective studies. The goal of our study was to investigate the real-world practice pattern of dosing of neuromuscular blocking agents (NMBA), utilizing the amount of NMBA used during the course of a case, adjusted for patient weight and case duration, as a surrogate measure of depth of NMB. We also aimed to identify case factors associated with larger NMBA doses. In this retrospective observational analysis of our anesthesia information management system, we analyzed all general endotracheal anesthesia cases from 2012 to 2015 in which an intermediate-acting NMBA was used. Cases using a long-acting NMBA or only succinylcholine were excluded. The expected duration of the case was calculated based on the cumulative dose of NMB used, normalized to the patient's ideal body weight and the ED95 of the drug. If the expected duration of the case was greater than the actual case duration documented in the case record, it was classified as higher dosing (HD). If the expected duration was equal to or less than the actual duration, it was considered predicted dosing (PD). Categorical comparisons between HD and PD groups were made for various patient, procedural, and provider factors. 72,684 cases were included in the final analysis, of which 46,358, or 64% of cases, used HD. Cases with patients who were morbidly obese, younger than 65 years, and who were lower ASA Physical Status classification (I or II) used more HD as opposed to PD. Cases that were non-open, used total intravenous anesthesia, emergent cases, or used non-rapid sequence anesthesia induction had higher rates of HD than their matched counterparts. All results were statistically significant. HD was more common in cases that documented train-of-four and used the reversal agent neostigmine. Approximately two-thirds of general endotracheal anesthesia cases using an intermediate-acting NMBA used HD. Cases with higher rates of HD may be those that are traditionally technically complex or emergent, would benefit from greater paralysis, or do not use adjunctive medications for muscle relaxation. Age greater than 65 years was shown to have lower rates of HD, likely due to provider awareness of age-related changes in pharmacokinetics and pharmacodynamics. Intraoperative monitoring and NMB antagonism with neostigmine were used more frequently with HD.

Neuromuscular blockade of atracurium in permissive hypercapnic versus normocapnic swine undergoing laparoscopy

Neuromuscular blocking agents (NMBAs) are commonly used in experimental laparoscopy in swine undergoing carbon dioxide pneumoperitoneum. Hypercapnia may be present and may prolong NMBAs’ pharmacologic activity. The aim of this study is to evaluate the effect of permissive hypercapnia on the neuromuscular blockade of atracurium in swine. Six Large White swine weighing 30.5 ± 1.6 kg were sedated with intramuscular ketamine and medetomidine, after which anaesthesia was induced with propofol and maintained with sevoflurane. Atracurium 0.4 mg/kg was administered intravenously and the neuromuscular block monitored by acceleromyography during normocapnic and hypercapnic conditions (PaCO₂ range 35–45 mmHg and 60–70 mmHg, respectively). Onset time and time to reach a train of four ratio (TOFR) of 0.7 and 0.9 were recorded. Cardiorespiratory parameters, electrolytes and acid-base status were measured under both conditions. Onset time was similar between the two conditions. Time to reach a TOFR of 0.7 and 0.9 (duration of the neuromuscular block) was longer in hypercapnic compared to normocapnic animals being 1325 ± 300 vs 855 ±111 (p = 0.002) and 1823 ± 434 vs 1218 ± 210 seconds (p = 0.005), respectively. Three hypercapnic swine had a TOF count of 2 and 1 instead of a count of 4 with fade. Permissive hypercapnia was associated with a decrease in pH from 7.444 ± 0.039 to 7.257 ± 0.025 (p < 0.001). No differences were observed for heart rate, end-tidal concentration of sevoflurane, body temperature and arterial haemoglobin saturation. Nonetheless, hypercapnic swine had a statistically significant increase in mean arterial pressure (p = 0.020) and plasma potassium concentration (p = 0.003). The values of PaCO₂ achieved during hypercapnia were well tolerated in swine undergoing CO₂ pneumoperitoneum for laparoscopy. Permissive hypercapnia increased the duration of the atracurium effect and caused an increase in the intensity of the neuromuscular block in few swine.

[Ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy: comparison of efficacy of bupivacaine and levobupivacaine on postoperative pain control]

BACKGROUND AND OBJECTIVE

The use of transversus abdominis plane block with different local anesthetics is considered as a part of multimodal analgesia regimen in laparoscopic cholecystectomy patients. However no studies have been published comparing bupivacaine and levobupivacaine for transversus abdominis plane block. We aimed to compare bupivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy.

METHODS

Fifty patients (ASA I/II), undergoing laparoscopic cholecystectomy were randomly allocated into two groups. Following anesthesia induction, ultrasound-guided bilateral transversus abdominis plane block was performed with 30mL of bupivacaine 0.25% in Group B (n=25) and 30mL of levobupivacaine 0.25% in Group L (n=25) for each side. The level of pain was evaluated using 10cm visual analog scale (VAS) at rest and during coughing 1, 5, 15, 30min and 1, 2, 4, 6, 12 and 24h after the operation. When visual analogue scale>3, the patients received IV tenoxicam 20mg. If visual analogue scale remained >3, they received IV. tramadol 1mg.kg^-1. In case of inadequate analgesia, a rescue analgesic was given. The analgesic requirement, time to first analgesic requirement was recorded.

RESULTS

Visual analogue scale levels showed no difference except first and fifth minutes postoperatively where VAS was higher in Group L (p<0.05). Analgesic requirement was similar in both groups. Time to first analgesic requirement was shorter in Group L (4.35±6.92min vs. 34.91±86.26min, p=0.013).

CONCLUSIONS

Bupivacaine and levobupivacaine showed similar efficacy at TAP block in patients undergoing laparoscopic cholecystectomy.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Sugammadex: Appropriate Use in the Context of Budgetary Constraints

Purpose of Review

The purpose of this review is to assess how sugammadex impacts postoperative residual curarization using appropriate doses based on neuromuscular transmission monitoring and whether the advantages of sugammadex versus neostigmine outweigh its higher cost.

Recent Findings

An accurate assessment of neuromuscular blockade with monitoring is necessary before selecting neostigmine versus sugammadex for reversal at the end of surgery to overcome incomplete neuromuscular recovery. The main advantages of sugammadex over neostigmine are its predictability and its ability to extend the range of blockade reversal. The cost of sugammadex is greater when higher doses of sugammadex are required for antagonism of deep block. Sugammadex probably has the potential to be cost-effective compared with neostigmine if its time savings are put to productive use in clinical practice. However, to date, the economic benefits of the drug are unknown.

Summary

With sugammadex, almost any degree of neuromuscular block can be antagonized within 2–3 min; neostigmine is the only reversal agent effective against benzylisoquinolines and can ideally be used for reversal of lower levels of residual paralysis. The performance of the more expensive sugammadex on improving patient outcomes may depend on several elements of clinical strategy.

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.

What is the proper ventilation strategy during laparoscopic surgery?

The main stream of intraabdominal surgery has changed from laparotomy to laparoscopy, but anesthetic care for laparoscopic surgery is challenging for clinicians, because pneumoperitoneum might aggravate respiratory mechanics and arterial oxygenation. The authors reviewed the literature regarding ventilation strategies that reduce deleterious pulmonary physiologic changes during pneumoperitoneum for laparoscopic surgery under general anesthesia and make appropriate recommendations.