Does deep neuromuscular block affect pain after laparoscopic surgery?

Abstract

Editor,In a recent issue of the European Journal of Anaesthesiology, Madsen et al. 1 presented a randomised controlled trial, evaluating the effect of deep neuromuscular blockade and low-pressure pneumoperitoneum in laparoscopic hysterectomy. The authors concluded that deep neuromuscular blockade and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of postoperative shoulder pain as compared to standard pressure pneumoperitoneum (12 mmHg) with standard neuromuscular blockade. This finding is in accordance with a recent review and meta-analysis, showing that the use of lowpressure pneumoperitoneum correlates with clinically relevant, lower overall and referred shoulder pain scores. 2 In this meta-analysis, all included studies were performed with standard neuromuscular blockade regardless of the intraperitoneal pressure. Therefore, it seems reasonable to assume that the use of deep neuromuscular blockade does not influence postoperative pain scores and that it only facilitates the use of low-pressure pneumoperitoneum. However, in a recent study by Castro et al. 3 it was shown that sugammadex, in combination with deep neuromuscular blockade, reduced postoperative pain after laparoscopic bariatric surgery.Based on current evidence, postoperative pain scores may be reduced by the use of low-pressure pneumoperitoneum as well as the use of deep neuromuscular blockade. In our view, the study by Madsen et al. 1 does not reveal whether lower referred pain scores after laparoscopy should be attributed to the use of deep neuromuscular blockade, low-pressure pneumoperitoneum or a combination of both. In the discussion section, Madsen et al. 1 state that their results were mainly because of the lower insufflation pressure, as there seems no rational explanation for an analgesic effect of deep neuromuscular blockade or sugammadex. Although it remains speculative, deep neuromuscular blockade may in theory have an analgesic effect during laparoscopy. Deep neuromuscular blockade facilitates maximum stretching of abdominal wall muscle fibres during laparoscopy. This leads to an increased abdominal wall compliance that may reduce pressure-related postoperative pain.In conclusion, current evidence shows that the use of lowpressure pneumoperitoneum reduces pain scores after laparoscopy. The question of whether the use of deep neuromuscular blockade influences postoperative pain scores after laparoscopy remains unanswered. This issue should be pursued in future clinical trials.Acknowledgements relating to this article

Comparative analysis of remifentanil versus dexmedetomidine in the incidence of pain in a post-anesthesia care unit after bariatric surgery

“…In bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to the moderate neuromuscular blockade, deep neuromuscular blockade produced stable and improved surgical conditions with less postoperative pain 15 . Deep neuromuscular blockade was used in all patients, and this may be a factor that contributed equally among groups to reduce pain score in the PACU.…”

“…Deep neuromuscular blockade was used in all patients, and this may be a factor that contributed equally among groups to reduce pain score in the PACU. However, intraabdominal pressure (pneumoperitoneum) was maintained in 15mmHg, which limited the result of the deep neuromuscular blockade to decrease the incidence of pain 15 . Although a previous study 16 found reduced recovery times in the PACU, the current study groups exhibited no differences when delayed discharge from the PACU and recovery time longer than 90 minutes were considered.…”

Vollrelaxation: „magic bullet“ oder Marketing-Gag?

“…Dies änderte sich erst vor einigen Jahren mit der Einführung von Sugammadex; erstmals konnten nun auch tiefe neuromuskuläre Blockaden antagonisiert werden [11]. Es ist daher nicht überraschend, dass in der Folge der mögliche klinische Nutzen einer Vollrelaxierung Gegenstand zahlreicher Untersuchungen wurde [12]. Grundlage für die Annahme, dass eine tiefe Blockade möglicherweise die Operationsbedingungen verbessern könnte, ist die Resistenz des Diaphragmas gegenüber der Wirkung von Muskelrelaxanzien; das Diaphragma ist bereits zu einem Zeitpunkt wieder vollständig neuromuskulär erholt, an dem der M. adductor pollicis noch eine ausreichende neuromuskuläre Blockade aufweist [13].…”