Maintaining Optimal Surgical Conditions With Low Insufflation Pressures is Possible With Deep Neuromuscular Blockade During Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind, Parallel-Group Clinical Trial

Myoung Hwa Kim, Ki Young Lee, Kang-Young Lee, Byung-Soh Min, Young Chul Yoo, Myoung Hwa Kim, Ki Young Lee, Kang-Young Lee, Byung-Soh Min, Young Chul Yoo

Abstract

Carbon dioxide (CO2) absorption and increased intra-abdominal pressure can adversely affect perioperative physiology and postoperative recovery. Deep muscle relaxation is known to improve the surgical conditions during laparoscopic surgery. We aimed to compare the effects of deep and moderate neuromuscular block in laparoscopic colorectal surgery, including intra-abdominal pressure. In this prospective, double-blind, parallel-group trial, 72 adult patients undergoing laparoscopic colorectal surgery were randomized using an online randomization generator to achieve either moderate (1-2 train-of-four response, n = 36) or deep (1-2 post-tetanic count, n = 36) neuromuscular block by receiving a continuous infusion of rocuronium. Adjusted intra-abdominal pressure, which was titrated by a surgeon with maintaining the operative field during pneumoperitoneum, was recorded at 5-minute intervals. Perioperative hemodynamic parameters and postoperative outcomes were assessed. Six patients from the deep and 5 from the moderate neuromuscular block group were excluded, leaving 61 for analysis. The average adjusted IAP was lower in the deep compared to the moderate neuromuscular block group (9.3 vs 12 mm Hg, P < 0.001). The postoperative pain scores (P < 0.001) and incidence of postoperative shoulder tip pain were lower, whereas gas passing time (P = 0.002) and sips of water time (P = 0.005) were shorter in the deep neuromuscular block than in the moderate neuromuscular block group. Deep neuromuscular blocking showed several benefits compared to conventional moderate neuromuscular block, including a greater intra-abdominal pressure lowering effect, whereas surgical conditions are maintained, less severe postoperative pain and faster bowel function recovery.

Conflict of interest statement

The authors have no funding and conflicts of interest to disclose.

References

    1. Neudecker J, Sauerland S, Neugebauer E, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 2002; 16:1121–1143.
    1. Nguyen NT, Anderson JT, Budd M, et al. Effects of pneumoperitoneum on intraoperative pulmonary mechanics and gas exchange during laparoscopic gastric bypass. Surg Endosc 2004; 18:64–71.
    1. Hua J, Gong J, Yao L, et al. Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: a systematic review and meta-analysis. Am J Surg 2014; 208:143–150.
    1. Joshipura VP, Haribhakti SP, Patel NR, et al. A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech 2009; 19:234–240.
    1. Sandhu T, Yamada S, Ariyakachon V, et al. Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial. Surg Endosc 2009; 23:1044–1047.
    1. Madsen MV, Gatke MR, Springborg HH, et al. Optimising abdominal space with deep neuromuscular blockade in gynaecologic laparoscopy—a randomised, blinded crossover study. Acta Anaesthesiol Scand 2015; 59:441–447.
    1. Dubois PE, Putz L, Jamart J, et al. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial. Eur J Anaesthesiol 2014; 31:430–436.
    1. Martini CH, Boon M, Bevers RF, et al. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014; 112:498–505.
    1. Jones RK, Caldwell JE, Brull SJ, et al. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology 2008; 109:816–824.
    1. Geldner G, Niskanen M, Laurila P, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia 2012; 67:991–998.
    1. Welliver M, McDonough J, Kalynych N, et al. Discovery development and clinical application of sugammadex sodium, a selective relaxant binding agent. Drug Des Devel Ther 2009; 2:49–59.
    1. Staehr-Rye AK, Rasmussen LS, Rosenberg J, 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.
    1. Fuchs-Buder T, Claudius C, Skovgaard LT, et al. Good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents II: the Stockholm revision. Acta Anaesthesiol Scand 2007; 51:789–808.
    1. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7:89–91.
    1. Rist M, Rauh R, Klingel R, et al. Hemodynamic effects of pneumoperitoneum in lithotomy position. Zentralbl Chir 2001; 126:75–79.
    1. Ozdemir-van Brunschot DM, van Laarhoven KC, Scheffer GJ, et al. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc 2015; [Epub ahead of print].
    1. Ordemann J, Jacobi CA, Schwenk W, et al. Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections. Surg Endosc 2001; 15:600–608.
    1. Khan SA, Khokhar HA, Nasr AR, et al. Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis. Surg Endosc 2013; 27:2581–2591.
    1. Bisgaard T, Klarskov B, Kristiansen VB, et al. Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study. Anesth Analg 1999; 89:1017–1024.
    1. Ure BM, Troidl H, Spangenberger W, et al. Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events. Surg Endosc 1994; 8:90–96.
    1. Joris J, Thiry E, Paris P, et al. Pain after laparoscopic cholecystectomy: characteristics and effect of intraperitoneal bupivacaine. Anesth Analg 1995; 81:379–384.
    1. Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg 2000; 87:1480–1493.
    1. Schwarte LA, Scheeren TW, Lorenz C, et al. Moderate increase in intraabdominal pressure attenuates gastric mucosal oxygen saturation in patients undergoing laparoscopy. Anesthesiology 2004; 100:1081–1087.
    1. Schindler E, Muller M, Kelm C. Cerebral carbon dioxide embolism during laparoscopic cholecystectomy. Anesth Analg 1995; 81:643–645.
    1. Hubner M, Blanc C, Roulin D, et al. Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 2015; 261:648–653.
    1. Koivusalo AM, Kellokumpu I, Ristkari S, et al. Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method. Anesth Analg 1997; 85:886–891.
    1. Van Wijk RM, Watts RW, Ledowski T, et al. Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy: a prospective observational study. Acta Anaesthesiol Scand 2015; 59:434–440.
    1. Bloechle C, Emmermann A, Strate T, et al. Laparoscopic vs open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs. Surg Endosc 1998; 12:212–218.
    1. Umar A, Mehta KS, Mehta N. Evaluation of hemodynamic changes using different intra-abdominal pressures for laparoscopic cholecystectomy. Indian J Surg 2013; 75:284–289.

Source: PubMed

Sponsorer og samarbeidspartnere

Medisinsk tilstand

Legemiddelintervensjoner

3
Abonnere