Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

Bart Torensma, Chris H Martini, Martijn Boon, Erik Olofsen, Bas In 't Veld, Ronald S L Liem, Mireille T T Knook, Dingeman J Swank, Albert Dahan, Bart Torensma, Chris H Martini, Martijn Boon, Erik Olofsen, Bas In 't Veld, Ronald S L Liem, Mireille T T Knook, Dingeman J Swank, Albert Dahan

Abstract

Background: It remains unknown whether the administration of a deep neuromuscular block (NMB) during bariatric surgery improves surgical conditions and patient outcome. The authors studied the effect of deep versus moderate NMB in laparoscopic bariatric surgery on surgical conditions and postoperative pain.

Methods and results: One hundred patients scheduled to undergo elective bariatric surgery were randomized to a deep NMB (post-tetanic-count 2-3) or a moderate NMB (train-of-four 1-2). The quality of the surgical field was scored using the Leiden-Surgical Rating Scale (L-SRS), a 5-point scale ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Three surgeons scored the L-SRS at 10-min intervals during surgery; postoperative pain scores were obtained in the postanesthesia-care-unit (PACU) and on the ward. Mean (95% confidence interval) L-SRS scores in moderate NMB 4.2 (4.0-4.4) versus 4.8 (4.7-4.9) in deep NMB (p < 0.001). Moderate NMB resulted in 17% of scores at L-SRS scores of 1-3, while deep NMB resulted in 100% scores at the high end of the L-SRS (4-5). Deep NMB led to improved pain scores in the PACU (4.6 (4.2-4.9) versus 3.9 (3.6-4.4), p = 0.03) and reduced shoulder pain on the ward (1.8 (1.5-2.1) versus 1.3 (1.1-1.5), p = 0.03). A composite score of pain and opioid use in the PACU favoured deep NMB (p = 0.001).

Conclusions: In bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to moderate NMB, deep NMB produced stable and improved surgical conditions with less postoperative pain.

Conflict of interest statement

I have read the journal's policy and the authors of this manuscript have the following competing interests: Albert Dahan, Chris Martini and Martijn Boon received speaker fees and/or consultancy fees from MSD Nederland.

Figures

Fig 1. Consort flow diagram.
Fig 1. Consort flow diagram.
Fig 2. Influence of deep relaxation on…
Fig 2. Influence of deep relaxation on surgical conditions.
Leiden-surgical rating scale (L-SRS) values of patients during a deep neuromuscular block (target PTC 2–3; orange, n = 50) and during a moderate neuromuscular block (target TOF 1–2; blue, n = 50). Values are mean (95% confidence interval) with confidence intervals derived from bootstrap analyses. * Mann-Whitney-U test p < 0.01 versus moderate block.
Fig 3. Distribution of L-SRS scores.
Fig 3. Distribution of L-SRS scores.
A. Distribution of the individual Leiden-surgical rating scale (L-SRS) scores across the 5 possible categories (see Table 1). B. Percentage of L-SRS values of 5 over time in single, moderate and deep blocks. Orange depicts deep NMB, blue moderate NMB and grey single NMB.

References

    1. Martini CH, Boon M, Bevers RF, Aarts LP, Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014; 112: 498–505. 10.1093/bja/aet377
    1. Kopman AF, Naguib M. Letter to the editor (in response). Anesth Analg 2016; 122: 289–290.
    1. Kopman AF, Naguib M. Laparoscopic surgery and muscle relaxants: is deep block helpful? Anesth Analg 2015; 120: 51–58. 10.1213/ANE.0000000000000471
    1. Boon M, Martini C, Hellinga M, Bevers R, Aarts L, Dahan A. Influence of variations in arterial PCO2 on evaluation of surgical conditions during laparoscopic surgery. Br J Anaesth 2016; 117: 59–65. 10.1093/bja/aew114
    1. Loupec T, Frasca D, Rousseau N, Faure JP, Mimoz O, Debaene B. Appropriate dosing of sugammadex to reverse deep rocuronium-induced neuromuscular block in morbidly obese patients. Anaesthesia 2016; 71: 265–72. 10.1111/anae.13344
    1. Silverman DG, O’Connor TZ, Brull SJ. Integration of pain score and morphine consumption in analgesic clinical studies. J Pain 2013; 14: 767–77. 10.1016/j.jpain.2013.04.004
    1. Romundstad L, Breivik H, Roald H, Skolleborg K, Haugen T, Narum J, et al. Methylprednisolone reduces pain, emesis, and fatigue after breast augmentation surgery: a single-dose, randomized, parallel-group study with methylprednisolone 125 mg, parecoxib 40 mg, and placebo. Anesth Analg 2006; 102: 418–25. 10.1213/01.ane.0000194358.46119.e1
    1. Abrishami A, Ho J, Wong J, Yin L, Chung F. Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade. Cochrane Database Syst Rev 2009; CD007632.
    1. Welliver M, McDonough J, Kalynych N, Redfern R. Discovery, development, and clinical application of sugammadex sodium, a selective relaxant binding agent. Drug Des Devel Ther 2009; 2: 49–59.
    1. Madsen MV, Staehr-Rye AK, Claudius C, Gätke MR. Is deep neuromuscular blockade beneficial in laparoscopic surgery? Yes, probably. Acta Anaesthesiol Scand 2016; 60: 710–716. 10.1111/aas.12698
    1. Kopman AF, Naguib M. Is deep neuromuscular block beneficial in laparoscopic surgery? No, probably not. Acta Anaesthesiol Scand 2016; 60: 717–722. 10.1111/aas.12699
    1. Madsen MV, Staehr-Rye AK, Gätke MR, Claudius C. Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review. Acta Anaesthesiol Scand 2015; 59: 1–16.
    1. Castro DS, Leão P, Borges S, Gomes L, Pacheco M, Figuiredo P. Sugammadex reduces postoperative pain after laparoscopic bariatric surgery: a randomized trial. Surg Laparoscop Endosc Percutan Tech 2014; 24: 420–423.
    1. Gurusamy KS, Vaughan J, Davidson BR. Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database Syst Rev 2014; 3: CD006930.
    1. Hua J, Gong J, Yao L, Zhou B, Song Z. Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: a systematic review and meta-analysis. Am J Surg 2014; 208: 143–150. 10.1016/j.amjsurg.2013.09.027
    1. Özdemir-van Brunschot DMD, van Laarhoven KCJM, Scheffer GJ, Pouwels S, Wever KE, Warlé MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc 2015; 30: 2049–2065. 10.1007/s00464-015-4454-9
    1. Karlsson A, Wendel K, Polits S, Gislason H, Hendenbro JL. Preoperative nutrition and postoperative discomfort in an ERAS setting: a randomized stidy in gastric bypass surgery. Obes Surg 2016; 26: 743–748. 10.1007/s11695-015-1848-7
    1. Dubois PE, Putz L, Jamart J, Marotta ML, Gourdin M, Donnez O. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy; a randomised controlled trials. Eur J Anaesthesiol 2014; 31: 430–436. 10.1097/EJA.0000000000000094
    1. Staehr-Rye AK, Rasmussen LS, Rosenberg J, Juul P, Lindekaer AL, Riber C, et al. Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study. Anesth Analg 2014; 119: 1084–1092. 10.1213/ANE.0000000000000316
    1. Blobner M, Frick CG, Stäuble RB, Feussner H, Schaller SJ, Unterbuchner C, et al. Neuromuscular blockade improves surgical conditions (NISCO). Surg Endosc 2015; 29: 627–636. 10.1007/s00464-014-3711-7
    1. Yoo YC, Kim NY, Shin S, Choi YD, Hong JH, Kim CY, et al. The intraocular pressure under deep versus moderate neuromuscular blockade during low-pressure robot assisted laparoscopic radical prostatectomy in a randomized trial. PLoS ONE 2015; 10: e0135412 10.1371/journal.pone.0135412
    1. Kim HJ, Lee K, Park WK, Lee BR, Joo HM, Koh YW, et al. Deep neuromuscular block improves the surgical conditions of laryngeal microscopy. Br J Anaesth 2015; 115: 867–872. 10.1093/bja/aev368

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