Is neuromuscular blocker needed in children undergoing inguinal herniorrhaphy?

Abstract

Background:Intraoperative neuromuscular blocker is widely used, but is known to be associated with postoperative residual paralysis, which is known to be associated with increased risk of pulmonary complications. Hence, its use should be individualized and restricted to procedures where it is mandatory. We examined whether not using a neuromuscular blocker affects the surgical conditions in children undergoing inguinal herniorrhaphy.Methods:Anesthesia was induced and maintained with sevoflurane in 60% nitrous oxide, and the airway was maintained using an I-gel. In total, 66 children aged 1 to 6 years were randomized to receive rocuronium (rocuronium group, n = 33) or saline (control group, n = 33); 61 children of them finished the study. A single surgeon who performed the operation rated the surgical condition of each patient on a 4-point scale (1 = poor, 2 = acceptable, 3 = good, and 4 = excellent). Intraoperative patient movement, recovery time, emergence agitation, and postoperative pain scores were evaluated.Results:One patient in control group and no patient in rocuronium group showed intraoperative movement. When noninferiority test was done for intraoperative patient movement, with the noninferiority margin of 20%, the difference of absolute risk was 3.3% (95% confidence interval −8.0% to 16.7%) and saline group was noninferior to rocuronium group. All of the patients showed good to excellent surgical conditions, and no difference was found between the 2 groups. The recovery time was shorter in the control group than in the rocuronium group (4.5 ± 1.8 vs 5.6 ± 2.2 minutes, respectively; P = .028).Conclusion:In children aged 1 to 6 years undergoing inguinal herniorhaphy under sevoflurane anesthesia using an I-gel, not using neuromuscular blocker showed similar intraoperative condition and shortened recovery time compared with using neuromouscular blocker.

Effects of neuromuscular blocking agents on the clinical performance of i-gel® and surgical condition in elderly patients undergoing hand surgery: a prospective randomized controlled trial

“…This is inconsistent with previous findings, as not using an NMBA shortened recovery in children undergoing inguinal herniorrhaphy 10 and in adult women undergoing laparoscopic gynecological surgery 11 . The main reason for this discrepancy appears to be because additional intraoperative fentanyl administration was more frequent in patients who did not receive rocuronium in our study than in a previous study 10 . Fentanyl enhances the sedative effects of inhalation anesthetics, such as sevoflurane 31 .…”

“…Although NMBAs are commonly used to improve the surgical condition 2 , 3 , the effects of NMBAs on surgical condition are diverse, depending on the depth of the neuromuscular block (i.e., deep vs. moderate), type of surgery (e.g., laparoscopic vs. open surgery), age of the patient (e.g., children vs. adults), and airway management device (e.g., endotracheal tube vs. SAD) 10 , 11 , 30 . Therefore, it may be necessary to use NMBAs prudently depending on the characteristics of the surgery and of the patient when SADs are applied for airway management.…”

“…After completing the surgery, surgical condition scores using a four-point scale (1 = poor, surgery cannot proceed because of muscle contractions or gross patient movement; 2 = acceptable, muscle contractions causing some interference in the surgical procedure; 3 = good, only a few muscle contractions that do not affect the surgical procedure; and 4 = excellent, no muscle contractions.) 10 were assessed by a single (board-certified) surgeon who performed the surgery. Sevoflurane and nitrous oxide were stopped and manual ventilation with 100% O 2 at 6 L/min fresh gas was commenced.…”

“…Nevertheless, few studies have determined the effects of NMBAs on the clinical performance of SADs in elderly patients 16 . Moreover, it is unclear whether not using an NMBA affects the surgical condition of elderly patients undergoing hand surgery with SADs 10 , 17 . Therefore, we designed this study to evaluate the effects of an NMBA (rocuronium) on the clinical performance of the i-gel ® supraglottic device (i-gel) and surgical condition in elderly patients undergoing orthopedic hand surgery.…”

“…Advances in supraglottic airway devices (SADs) have reduced the need for NMBAs during general anesthesia as an alternative to conventional airway management using an endotracheal tube [2]. However, the need for NMBAs when inserting and maintaining SADs is controversial, and studies have reported varying results depending on the proficiency of the person who inserted the SAD, the type of surgery, the kind of SAD, and the characteristics of the patient, such as obesity and age [10][11][12][13]. Therefore, to avoid adverse events related to the use of NMBAs, their use in patients undergoing surgery under general anesthesia using SADs should be individualized and confined to surgeries where it is mandatory [11,14].…”