Deep neuromuscular blockade for endolaryngeal procedures: A multicenter randomized study

Abstract

Objectives/Hypothesis The aim of the present study was to compare the surgical condition between deep neuromuscular blockade (NMB) and moderate NMB. Study Design Multicenter, randomized, parallel intervention trial. Methods One hundred two patients underwent microscopic endolaryngeal surgery at four university hospitals. The patients were randomized into moderate NMB (train‐of‐four 1‐2) (M group) or deep NMB (post‐tetanic count 1‐2) (D group) with moderate or high doses of rocuronium, respectively. Surgical rating conditions (SRCs) were evaluated during the surgery. Sugammadex was given to the M group at 2 mg/kg and the D group at 4 mg/kg. Perioperative clinical signs and conditions were recorded until discharge from the postanesthesia care unit. Results Clinically acceptable SRC was observed in 49 patients (100%) in the D group and 43 patients (89.6%) in the M group (P = .027). The frequency of notable vocal fold movement in the M group was significantly higher than the D group (70.8% vs. 32.7%). The patients in the M group required more additional doses of rocuronium (47.9%) than the D group (20.4%) to maintain full relaxation (P = .005). The median time (interquartile range) from administration of sugammadex to train‐of‐four ratio 0.9 in the D group was shorter than the M group (120 [109–180 minutes] vs. 180 minutes [120–240 minutes], P = .034). Conclusions Deep NMB with high doses of rocuronium combined with 4 mg/kg of sugammadex for reversal during endolaryngeal surgery provided better SRC and anesthetic conditions than moderate NMB of rocuronium with 2 mg/kg of sugammadex. Level of Evidence 1b Laryngoscope, 130:437–441, 2020

Deep Neuromuscular Block for Endolaryngeal Surgery: A Systematic Review and Meta‐Analysis

“…Intraoperative complications were reported in three studies, 38,40,41 two reported intraoperative cord movement, and three reported intraoperative coughing. A total of 201 patients were enrolled, 103 in the deep NMB group and 98 in the no‐deep NMB group.…”

“…The data extracted by the two investigators were identical. Four RCT studies with 242 participants were included in the meta‐analysis 38–41 …”

“…All included studies described the method of random sequence generation and the blinding method, and only two described allocation concealment 39,40 . All included studies were confirmed as having a low risk of incomplete outcome data, reporting, and other biases.…”

“…(2) 6‐ or 7‐point Likert scale (satisfied = 6‐point; extremely satisfied = 7‐point) 39 . (3) Excellent surgical conditions (8, 9) or good surgical conditions (6, 7) according to surgical endolaryngeal rating condition (SRC) 40 . Secondary outcome was the incidence of perioperative complications, including intraoperative and postoperative complications.…”

“…Minimizing the risk of PORC of deep NMB by sugammadex could facilitate the clinical application of deep NMB 26,34–37 . However, only small sample size studies have evaluated the efficiency of deep NMB on surgical conditions during endolaryngeal surgery 38–41 . Whether deep NMB could provide better surgical conditions without increasing PORC remains uncertain.…”