Neuromuscular Blocking Agents and Rapid Sequence Induction for Laparoscopic Pyloromyotomy: Impact on Time to Extubation and Perioperative Complications

Abstract

Introduction Infants with hypertrophic pyloric stenosis have gastric outlet obstruction, indicating a pyloromyotomy. To prevent aspiration, a rapid sequence induction (RSI) of anesthesia used to be preferred. However, due to concerns about the side-effects of this technique in infants, a modified RSI with gentle mask ventilation is nowadays mostly used. This research investigates if induction with succinylcholine (classic RSI), cisatracurium (modified RSI), or no neuromuscular blocking agent (NMBA) influences time until extubation and incidence of complications in infants undergoing laparoscopic pyloromyotomy. Materials and Methods A retrospective chart review was performed, observing infants undergoing laparoscopic pyloromyotomy in Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, from January 2007 until July 2015. Baseline preoperative data, anesthesia and operation details, time to extubation, and reported complications were gathered. Inclusion criteria were maintenance of anesthesia with sevoflurane and a registered extubation time. Exclusion criteria were the use of combinations of NMBAs, repyloromyotomy, and conversion to laparotomy. Results A total of 168 patients were included, of which 21 received succinylcholine, 107 cisatracurium, and 40 no NMBA. Mean duration of surgery was 29 minutes in all three groups; mean duration of anesthesia was 89, 82, and 77 minutes; mean time to extubation was 26, 25, and 23 minutes, respectively, without statistically significant difference. Complications were evenly distributed, no aspiration occurred. Conclusion The use of succinylcholine, cisatracurium, or no NMBA at induction of anesthesia in infants undergoing laparoscopic pyloromyotomy had no statistically significant effect on time until extubation and complication rates. A modified RSI seems to be safe and effective in these cases.

Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective bayesian regression analysis

“…While no untoward events occurred in the mRSI mivacurium study, 19 the potential for residual gastric contents and pulmonary aspiration typically warrants securing the airway as quickly as possible 2,20 . In addition, there has not been any consensus on what level of positive pressure mask ventilation is safe and when an increased incidence for gastric insufflation and potential aspiration may occur in these situations.…”

“…suggests that mRSI may be associated with significantly less hypoxemia without an observed risk of aspiration in pyloromyotomy patients 18 . In addition, mRSI with mivacurium, a non‐RSI NMBA, has been performed safely in this population 19 . By incorporating PPV after intravenous induction, smaller doses of rocuronium may be used in this patient population potentially without worsening outcomes.…”

“…However, the overall risk of perioperative aspiration is remarkably low in these patients even when utilizing inhaled anesthetic inductions 21 . In fact, pyloromyotomies have been safely intubated without the use of a NMBA at induction 19 . Thus, the mRSI technique with gentle PPV and non‐RSI doses of non‐depolarizing NMBAs may be a safe alternative in these cases.…”