Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis

Abstract

Neuromuscular block (NMB) is frequently used in abdominal surgery to improve surgical conditions by relaxation of the abdominal wall and prevention of sudden muscle contractions. The evidence supporting routine use of deep NMB is still under debate. We aimed to provide evidence for the superiority of routine use of deep NMB during laparoscopic surgery. We performed a systematic review and meta-analysis of studies comparing the influence of deep vs moderate NMB during laparoscopic procedures on surgical space conditions and clinical outcomes. Trials were identified from Medline, Embase, and Central databases from inception to December 2016. We included randomized trials, crossover studies, and cohort studies. Our search yielded 12 studies on the effect of deep NMB on the surgical space conditions. Deep NMB during laparoscopic surgeries improves the surgical space conditions when compared with moderate NMB, with a mean difference of 0.65 (95% confidence interval (CI): 0.47-0.83) on a scale of 1-5, and it facilitates the use of low-pressure pneumoperitoneum. Furthermore, deep NMB reduces postoperative pain scores in the postanaesthesia care unit, with a mean difference of - 0.52 (95% CI: -0.71 to - 0.32). Deep NMB improves surgical space conditions during laparoscopic surgery and reduces postoperative pain scores in the postanaesthesia care unit. Whether this leads to fewer intraoperative complications, an improved quality of recovery, or both after laparoscopic surgery should be pursued in future studies. The review methodology was specified in advance and registered at Prospero on July 27, 2016, registration number CRD42016042144.

Effects of depth of neuromuscular block on surgical conditions during laparoscopic colorectal surgery: a randomised controlled trial

“…Based on our clinical experience and previous studies, maintaining deep intra‐operative neuromuscular blockade that is reversed by sugammadex at the end of surgery, makes practitioners more comfortable and satisfied, which itself could be related to patient outcome . However, empirically demonstrating these intuitively beneficial effects is a separate matter.…”

“…Since the introduction of sugammadex, studies evaluating the utility of intra‐operative deep neuromuscular blockade have been ongoing, and controversy still exists over its clinical usefulness . The main focus of the studies are laparoscopic surgeries, for which deep neuromuscular blockade appears to improve surgical conditions . The improved surgical conditions and effectiveness have also been shown in laryngeal microsurgery and in surgery involving morbidly obese patients .…”

Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

“…56 However, a meta-analysis and systematic review of 12 studies has recently substantiated the benefits of deep neuromuscular block, which improves surgical conditions, although not substantially, and facilitates use of a low-pressure peritoneum, which is probably the reason for lower pain scores postoperatively. 57 Larger doses of sugammadex up to 16 mg kg À1 can reverse block immediately after administration of rocuronium. 10 This approach could be advantageous in a 'cannot intubate, cannot ventilate' scenario, but it has impracticalities.…”

Neuromuscular Block and Blocking Agents in 2018

“…This might be beneficial in situations, where deep neuromuscular blockade is required like in precision procedures, where unexspected movements might be deleterious (robot-guided procedures, neurosurgery, vocal cord and eye laser surgery) or in interventions where maximal muscle relaxation might improve operating conditions, like in laparscopic surgery (68). Meta-analysis identified fewer composite adverse events in using sugammadex compared to neostigmine (risk ratio [RR]: 0.6), with a number needed to treat (NNT) of 8 in order to prevent adverse events as follows (55,67): Bradycardia (RR: 0.16; NNT: 14), postoperative nausea and vomiting (RR: 0.52; NNT: 16), risk of overall signs of PORC (headlift-test, general muscle weakness, amblyopia, oxygen desaturation, POPCs) (RR: 0.40; NNT: 13) (55).…”