The Intraocular Pressure under Deep versus Moderate Neuromuscular Blockade during Low-Pressure Robot Assisted Laparoscopic Radical Prostatectomy in a Randomized Trial

Young-Chul Yoo, Na Young Kim, Seokyung Shin, Young Deuk Choi, Jung Hwa Hong, Chan Yun Kim, HeeJoon Park, Sun-Joon Bai, Young-Chul Yoo, Na Young Kim, Seokyung Shin, Young Deuk Choi, Jung Hwa Hong, Chan Yun Kim, HeeJoon Park, Sun-Joon Bai

Abstract

Background: This study aimed to determine whether continuous deep neuromuscular blockade (NMB) improves the surgical conditions and facilitates robotic-assisted laparoscopic radical prostatectomy (RALRP) under low intra-abdominal pressure (IAP) to attenuate the increase in intraocular pressure (IOP) during CO2 pneumoperitoneum in the steep Trendelenburg (ST) position.

Methods: Sixty-seven patients undergoing RALRP were randomly assigned to a moderate NMB group (Group M), including patients who received atracurium infusion until the end of the ST position, maintaining a train of four count of 1-2; and the deep NMB group (Group D), including patients who received rocuronium infusion, maintaining a post-tetanic count of 1-2. IOP was measured in all patients at nine separate time points. All RALRPs were performed by one surgeon, who rated the overall and worst surgical conditions at the end of the ST position.

Results: The highest IOP value was observed at T4 (60 min after the ST position) in both Group M (23.3 ± 2.7 mmHg) and Group D (19.8 ± 2.1 mmHg). RALRP was accomplished at an IAP of 8 mmHg in 88% Group D patients and 25% Group M patients. The overall surgical condition grade was 4.0 (3.0-5.0) in Group D and 3.0 (2.0-5.0) in Group M (P < 0.001).

Conclusion: The current study demonstrated that continuous deep NMB may improve surgical conditions and facilitate RALRP at a low IAP, resulting in significant attenuation of the increase on IOP. Moreover, low-pressure pneumoperitoneum, facilitated by deep NMB still provided acceptable surgical conditions.

Trial registration: ClinicalTrials.gov NCT02109133.

Conflict of interest statement

Competing Interests: The authors of this manuscript have read the journal's policy and have the following competing interests: This study was supported by the grants of the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. (http://engagezone.merck.com/misp.html). There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1. CONSORT Flow Diagram.
Fig 1. CONSORT Flow Diagram.
Group M, moderate NMB group; Group D, deep NMB group.
Fig 2. Study protocol.
Fig 2. Study protocol.
NMB, neuromuscular block; Group M, moderate NMB group; Group D, deep NMB group; TOF, train of four; PTC, post-tetanic count; ST, steep Trendelenburg.
Fig 3. Distribution of intra-abdominal pressure (IAP)…
Fig 3. Distribution of intra-abdominal pressure (IAP) during RALRP (A) and the mean intraocular pressure (IOP) (B).
Group M, moderate neuromuscular blockade group; Group D, deep neuromuscular blockade group; RALRP, robotic-assisted laparoscopic radical prostatectomy. * P

Fig 4. Mean blood pressure (MBP) (A),…

Fig 4. Mean blood pressure (MBP) (A), end-tidal CO 2 (ETCO 2 ) (B), peak…

Fig 4. Mean blood pressure (MBP) (A), end-tidal CO2 (ETCO2) (B), peak inspiratory pressure (PIP) (C), and intra-abdominal pressure (IAP) (D) in Group M and Group D.
Group M, moderate neuromuscular blockade group; Group D, deep neuromuscular blockade group. * P
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This study was supported by the grants of the Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. (http://engagezone.merck.com/misp.html). No additional funding sources were received for this study. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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Fig 4. Mean blood pressure (MBP) (A),…
Fig 4. Mean blood pressure (MBP) (A), end-tidal CO2 (ETCO2) (B), peak inspiratory pressure (PIP) (C), and intra-abdominal pressure (IAP) (D) in Group M and Group D.
Group M, moderate neuromuscular blockade group; Group D, deep neuromuscular blockade group. * P

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