Low-pressure pneumoperitoneum with deep neuromuscular blockade in metabolic surgery to reduce postoperative pain: a randomized pilot trial

Leeman, M.; Biter, L. Ulas; Apers, Jan A.; Birnie, Erwin; Verbrugge, Serge; Dunkelgrün, Martin

doi:10.1007/s00464-020-07719-w

Cited by 9 publications

(13 citation statements)

References 19 publications

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“…In evaluating the need for muscle relaxants for optimal surgical conditions, 26 randomised clinical trials were included 45–70 . We considered studies that investigated deep (dNMB) vs. moderate (mNMB) or no neuromuscular block in the adult population.…”

Section: Evidence Summary and Commentmentioning

confidence: 99%

Peri-operative management of neuromuscular blockade

Fuchs‐Buder

Romero

Lewald

et al. 2022

European Journal of Anaesthesiology

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Recent data indicated a high incidence of inappropriate management of neuromuscular block, with a high rate of residual paralysis and relaxant-associated postoperative complications. These data are alarming in that the available neuromuscular monitoring, as well as myorelaxants and their antagonists basically allow well tolerated management of neuromuscular blockade. In this first European Society of Anaesthesiology and Intensive Care (ESAIC) guideline on peri-operative management of neuromuscular block, we aim to present aggregated and evidence-based recommendations to assist clinicians provide best medical care and ensure patient safety. We identified three main clinical questions: Are myorelaxants necessary to facilitate tracheal intubation in adults? Does the intensity of neuromuscular blockade influence a patient's outcome in abdominal surgery? What are the strategies for the diagnosis and treatment of residual paralysis? On the basis of this, PICO (patient, intervention, comparator, outcome) questions were derived that guided a structured literature search. A stepwise approach was used to reduce the number of trials of the initial research (n = 24 000) to the finally relevant clinical studies (n = 88). GRADE methodology (Grading of Recommendations, Assessment, Development and Evaluation) was used for formulating the recommendations based on the findings of the included studies in conjunction with their methodological quality. A two-step Delphi process was used to determine the agreement of the panel members with the recommendations: R1 We recommend using a muscle relaxant to facilitate tracheal intubation (1A). R2 We recommend the use of muscle relaxants to reduce pharyngeal and/or laryngeal injury following endotracheal intubation (1C). R3 We recommend the use of a fast-acting muscle relaxant for rapid sequence induction intubation (RSII) such as succinylcholine 1 mg kg−1 or rocuronium 0.9 to 1.2 mg kg−1 (1B). R4 We recommend deepening neuromuscular blockade if surgical conditions need to be improved (1B). R5 There is insufficient evidence to recommend deep neuromuscular blockade in general to reduce postoperative pain or decrease the incidence of peri-operative complications. (2C). R6 We recommend the use of ulnar nerve stimulation and quantitative neuromuscular monitoring at the adductor pollicis muscle to exclude residual paralysis (1B). R7 We recommend using sugammadex to antagonise deep, moderate and shallow neuromuscular blockade induced by aminosteroidal agents (rocuronium, vecuronium) (1A). R8 We recommend advanced spontaneous recovery (i.e. TOF ratio >0.2) before starting neostigmine-based reversal and to continue quantitative monitoring of neuromuscular blockade until a TOF ratio of more than 0.9 has been attained. (1C)

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Section: Evidence Summary and Commentmentioning

confidence: 99%

Peri-operative management of neuromuscular blockade

Fuchs‐Buder

Romero

Lewald

et al. 2022

European Journal of Anaesthesiology

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“…[5][6][7] While other studies have shown no difference between pain scores using low pressure pneumoperitoneum. [9][10][11][12][13] Because the nurses at our hospital only have to document pain scores if they are going to administer pain medications, our study had much fewer nurse recorded pain scores at discharge than the number of patients with recorded MME. Therefore, we postulate, the lack of significance of nurse recorded pain scale in our study could be attributed to the smaller data set of pain scores and thus result in a type 2 error.…”

Section: Discussionmentioning

confidence: 99%

“…One study of low pressure pneumoperitoneum found the need to increase to standard pressure from low pressure in a large percentage of patients undergoing bariatric surgery. 11 Due to the operative challenges that come with bariatric patients, a study assessing the usage low pressure usage could be further explored in this specific subset of patients.…”

Section: Discussionmentioning

confidence: 99%

“…IRB review and approval was obtained for this single institution study of outcomes from patient chart review and survey of physicians' opinion/experience. A total of 83 patients undergoing laparoscopic surgery performed by two surgeons (WOR, DM) were studied and divided into 2 groups-insufflated at either standard (15 mmHg) or low pressure (8)(9)(10)(11)(12). The standard pressure cases were performed first to establish a control group.…”

Section: Methodsmentioning

confidence: 99%

“…Review of the literature revealed evidence for reduced post-op pain in patients undergoing laparoscopic cholecystectomy utilizing a low insufflation pressure. 1 Our surgical group reviewed patients' outcomes using standard pressure (15 mmHg) and then after a quality improvement project implemented low pressure pneumoperitoneum (8)(9)(10)(11)(12). This study was designed to evaluate the differences in postoperative pain and intra-operative physiology across a variety of laparoscopic cases comparing standard and low-pressure pneumoperitoneum.…”

Section: Introductionmentioning

confidence: 99%

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Review of Outcomes of Low Verses Standard Pressure Pneumoperitoneum in Laparoscopic Surgery

Saway

McCaul

Mulekar

et al. 2022

The American Surgeon™

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Background Carbon dioxide pneumoperitoneum during laparoscopy changes cardiorespiratory physiology and contributes to post-op pain. We studied outcomes before and after implementing low-pressure pneumoperitoneum QI project. Methods Forty-two patients were insufflated at standard pressures (15 mmHg) while 41 were insufflated using low (8-12 mmHg) during laparoscopic procedures. These variables were obtained from the patient chart: pain scores, intravenous morphine milligram equivalents (MME), peak inspiratory pressures (PIP), end-tidal CO2 (EtCO2), surgery duration, and patient demographics. The study was conducted after IRB approval. Results Low-pressure pneumoperitoneum is feasible and the surgeon can increase to 10-12 mmHg as needed. The mean post-op IV MME was significantly decreased in the low-pressure group (11.75 ± 10.41) compared to the standard pressure group (17.36 ± 18.1) (t-test, P = .047). Mean peak inspiratory pressures during insufflation were significantly higher for procedures conducted at standard pressure (31.40 ± 4.82) compared to the 8 mmHg (24.68 ± 4.19) and 12 mmHg (27.33± 3.85) low pressure groups (one-way ANOVA, P < .0001). During insufflation, there was a significant increase in the average EtCO2 in the standard pressure group (42.07 ± 5.60) compared to the 8 mmHg low pressure group (37.59 ± 5.05) (ANOVA, P = .0096). Constant flow insufflation was more likely to be performed at low pressure than demand mode (58% v. 33%). Conclusion Low pressure pneumoperitoneum decreases PIP pressure and CO2 absorption evidenced by lower ETCO2 intra-operatively. Patients have significant improvement in postoperative pain evidenced by decreased narcotics needed. Low pressure pneumoperitoneum using a constant flow insufflator is safe and results in improved patient outcomes.

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