Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen

Abstract

The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons’ verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA− group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation‐Sedation Scale (RASS) score, mechanical ventilation‐free days, and delirium‐coma‐free days. Delirium‐coma‐free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA− 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1–2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103–10,573 mg; NMBA− 3601 mg, IQR 1605–6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation‐free days (NMBA+ 20 days vs NMBA− 18 days, p=0.960) and delirium‐coma‐free days (NMBA+ 18 days vs NMBA− 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium‐coma‐free days (β‐coefficient −0.007, 95% confidence interval −0.015 to −0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.

More medications, more problems: results from the Sedation Level after Emergent Exlap with Packing for TRAUMA (SLEEP-TRAUMA) study

“…Patients receiving NMBA also required more sedation (typically with propofol) than non-NMBA patients, but not more analgesia (typically with fentanyl). Furthermore, the group noted that increased cumulative propofol dose was associated with a decrease in DF/CF-ICU days, corroborating the information in our study [15]. In our series, only three patients underwent treatment with paralytic infusion, all of whom were in the LE group.…”

“…They also published data indicating that chemical paralysis did not affect time to DFC after trauma DCL, with no significant difference in mortality [14]. Additionally, their study showed that patients with neuromuscular blockade had higher sedation requirements [15].…”

The Median Effective Dose (ED50) of cis-Atracurium for Laryngeal Mask Airway Insertion during General Anaesthesia for Patients Undergoing Urinary Surgery

“…This change was not a clinical effect and required no vasopressor agents. Using an appropriate NMBA did not affect the extubation time, but it did reduce the stress reaction [28]. cis-Atracurium did not cause harmful autonomic nervous system effects and resulted in reduced secretion of histamine.…”

The median effective dose (ED50) of cis-Atracurium for laryngeal mask airway insertion during general Anaesthesia for patients undergoing urinary surgery

“…Therefore, administration of additional doses of propofol and sufentanil was needed to achieve satisfactory insertion. The combination of an appropriate dose of muscle relaxants can improve laryngeal mask placement without increasing the incidence of associated adverse reactions, while reducing the amount of propofol or sufentanil anaesthetics and reducing their inhibitory effect on the circulation [27]. Without the use of muscle relaxants, it is necessary to increase the depth of anaesthesia, which prolongs the time of the patient's recovery of consciousness.…”