The impact of deep versus standard neuromuscular block on intraoperative safety during laparoscopic surgery: an international multicenter randomized controlled double-blind strategy trial - EURO-RELAX TRIAL

Maarten Honing, Gabby Reijnders-Boerboom, Salome Dell-Kuster, Monique van Velzen, Chris Martini, Franco Valenza, Paolo Proto, Oscar Díaz Cambronero, Suzanne Broens, Ivo Panhuizen, Margot Roozekrans, Thomas Fuchs-Buder, Martijn Boon, Albert Dahan, Michiel Warlé, Maarten Honing, Gabby Reijnders-Boerboom, Salome Dell-Kuster, Monique van Velzen, Chris Martini, Franco Valenza, Paolo Proto, Oscar Díaz Cambronero, Suzanne Broens, Ivo Panhuizen, Margot Roozekrans, Thomas Fuchs-Buder, Martijn Boon, Albert Dahan, Michiel Warlé

Abstract

Background: Muscle relaxants are routinely used during anesthesia to facilitate endotracheal intubation and to optimize surgical conditions. However, controversy remains about the required depth of neuromuscular block (NMB) needed for optimal surgical working conditions and how this relates to other outcomes. For instance, a deep neuromuscular block yields superior surgical working conditions compared to a standard NMB in laparoscopic surgery, however, a robust association to other (safety) outcomes has not yet been established.

Methods: Trial design: an international multicenter randomized controlled double-blind strategy trial. Trial population: 922 patients planned for elective, laparoscopic or robotic, abdominal surgery.

Intervention: Patients will be randomized to a deep NMB (post-tetanic count 1-2 twitches) or standard care (single-dose muscle relaxant administration at induction and repeated only if warranted by surgical team). Main trial endpoints: Primary endpoint is the difference in incidence of intraoperative adverse events during laparoscopic surgery graded according to ClassIntra® classification (i.e., ClassIntra® grade ≥ 2) between both groups. Secondary endpoints include the surgical working conditions, 30-day postoperative complications, and patients' quality of recovery.

Discussion: This trial was designed to analyze the effect of deep neuromuscular block compared to standard neuromuscular block on intra- and postoperative adverse events in patients undergoing laparoscopic surgery.

Trial registration: ClinicalTrials.gov NCT04124757 (EURO-RELAX); registration URL: https://ichgcp.net/clinical-trials-registry/NCT04124757 , registered on October 11th, 2019.

Keywords: ClassIntra® grade; Deep neuromuscular block; Monitoring; Neuromuscular; Surgical working conditions.

Conflict of interest statement

MB, CM, AD, and MW received speaker fees from MSD. The other authors declare no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Study procedures flow diagram. CCI, Comprehensive Complication Index; L-SRS, Leiden Surgical Rating Scale; NMB, neuromuscular block; TOF, train-of-four; QoR-40, Quality of Recovery; SF-36, Short-Form 36

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