Neuromuscular Blockade Group Research Articles

Surgical conditions in experimental laparoscopy: effects of pressure, neuromuscular blockade, and pre-stretching on workspace volume.

Establishing a pneumoperitoneum for laparoscopy is common surgical practice, with the goal to create an optimal surgical workspace within the abdominal cavity while minimizing insufflation pressure. Individualized strategies, based on neuromuscular blockade (NMB), pre-stretching routines, and personalized intra-abdominal pressure (IAP) to enhance surgical conditions are strategies to improve surgical workspace. However, the specific impact of each factor remains uncertain. This study explores the effects and side-effects of modifying intra-abdominal volume (IAV) through moderate and complete NMB in a porcine laparoscopy model. Thirty female Landrace pigs were randomly assigned to groups with complete NMB, regular NMB and a control group. Varying IAP levels were applied, and IAV was measured using CT scans. The study evaluated the maximum attainable IAV (Vmax), the pressure at which the cavity opens (p0), and the ease of expansion (λexp). Cardiorespiratory parameters, including peak inspiratory pressure (PIP), mean arterial pressure (MAP), heart rate (HR), and cardiac output (CO), were continuously recorded to evaluate side-effects. There were no significant weight differences between NMB groups (median 21.1kg). Observed volumes ranged from 0 to 4.7 L, with a mean Vmax of 3.82 L, mean p0 of 1.23mmHg, and mean λexp of 0.13hPa-1. NMB depth did not significantly affect these parameters. HR was significantly increased in the complete NMB group, while PIP, MAP, and CO remained unaffected. Repeated insufflation positively impacted Vmax; ease of opening; and expanding the cavity. In this porcine model, the depth of NMB does not alter abdominal mechanics or increase the surgical workspace. Cardiorespiratory changes are more related to insufflation pressure and frequency rather than NMB depth. Future studies should compensate for the positive effect of repeated insufflation on abdominal mechanics and surgical conditions.

Comparison of Deep and Moderate Neuromuscular Blockade for Major Laparoscopic Surgery in Children: A Randomized Controlled Trial.

Neuromuscular blocking agents are routinely used in laparoscopic surgery to optimize operative conditions. We compared the effect of a deep and moderate neuromuscular blockade (NMB) on surgical conditions and postoperative outcomes in children undergoing major laparoscopic surgery. Sixty children aged 2-14 years scheduled to undergo major laparoscopic surgery were randomly allocated to deep (post-tetanic count 1-2 twitches) or moderate (train-of-four 1-2 twitches) NMB groups. The anesthesia was maintained with propofol and remifentanil, and the NMB was maintained with a rocuronium continuous infusion. At the end of the operation, the NMB were antagonized with sugammadex. The intra-abdominal pressure, airway pressure, Leiden Surgical Rating Scale, intraoperative hemodynamics, drug usages, duration of surgery, postoperative recovery time, pain, and complications were compared between the groups. The maximum and mean intra-abdominal pressure, the peak inspiratory pressure, and mean airway pressure were significantly lower in the deep NMB group than in the moderate NMB group (p < 0.001). The Leiden Surgical Rating Scale and the dosage of rocuronium were significantly higher in the deep NMB group than the moderate NMB group (p < 0.001). The intraoperative hemodynamics, duration of surgery, post-operative recovery time, pain, and the incidence rate of complications were not significantly different between the groups (p > 0.05). A deep NMB provided better operative conditions and similar recovery profiles compared with a moderate NMB as reversed with sugammadex in children undergoing major laparoscopic surgery. Chinese Clinical Trial Registry, No. ChiCTR2100053821.

Deep versus Moderate Neuromuscular Blockade in Gynecologic Laparoscopic Operations: Randomized Controlled Trial.

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients’ postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p < 0.001). Moreover, when the consumption of analgesic drugs was compared, the moderate NMB group needed more extra opioid analgesia than the deep NMB group (18.3% vs. 4.1%, p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain.

Comparison of Deep and Moderate Neuromuscular Blockade on Intestinal Mucosal Barrier in Laparoscopic Gastrectomy: A Prospective, Randomized, Double-Blind Clinical Trial.

Deep neuromuscular blockade (NMB) improves the surgical conditions and is benefit for the postoperative recovery after laparoscopic surgery. However, the mechanisms of deep NMB in promoting the recovery of intestinal function have not been completely investigated. The objective of our study was to determine the impact of the deep NMB and moderate NMB strategy on the intestinal barrier function after laparoscopic gastrectomy. We collected patients undergoing elective laparoscopic gastrectomy. Patients were randomized to deep NMB (post-tetanic count 1–2) vs. moderate NMB (train-of-four count 1–2) during the surgery. Primary outcomes were time to flatus, serum diamine oxidase (DAO) and D-lactate, and gut microbiota. Other outcomes were surgical condition scores, postoperative visual analog pain scores, and length of hospital stay. Ninety patients in deep NMB group and sixty patients in moderate NMB group completed the study. Main results showed that the time to flatus was decreased in deep NMB group (74 ± 32 h) than that in moderate NMB group (93 ± 52 h, P = 0.006). The level of serum D-lactate was statistically increased in the moderate NMB group than that in the deep NMB group (1,209 ± 224 vs. 1,164 ± 185 ng/ml, p < 0.001). But no significant differences could be detected in the level of DAO between the groups. Additionally, the 16s rRNA analysis indicated that gut microbiota were similar in Alpha diversity but distinct in Beta diversity. Furthermore, the beneficial bacteria, such as genus Lactobacillus and Bifidobacterium, were more abundant in the deep NMB group, while the potentially harmful bacteria were more abundant in the moderate NMB group. Our findings suggested that the intestinal mucosal barrier and gut microbiota were better preserved in deep NMB, which greatly improved the postoperative recovery of intestinal function after laparoscopic gastrectomy.

Influence of Deep Neuromuscular Blockade on Perioperative Stress Response in Patients Undergoing Robot-Assisted Gastrectomy: A Prospective Double-Blinded Randomized-Controlled Trial.

Attenuating the intraoperative stress response is crucial; however, the effect of neuromuscular blockade (NMB) on surgical stress is not completely understood. We aimed to investigate the effects of NMB on the perioperative stress response during robot-assisted gastrectomy. Patients were assigned to the deep or moderate NMB group. Serum cortisol, prolactin, and interleukin-6 (IL-6) levels and natural killer (NK) cell percentage were measured before anesthesia induction, 90 min after pneumoperitoneum, operation end (OPEnd), and postoperative day 1. Additionally, C-reactive protein (CRP) and albumin levels were estimated. Additionally, intraoperative heart rate variability was evaluated. The deep NMB group showed significantly lower levels of low-frequency/high-frequency (HF) ratio at OPEnd compared to the moderate NMB group (1.4 ± 0.2 vs. 2.2 ± 0.3, respectively; Bonferroni corrected p = 0.039). Furthermore, HF power in the deep NMB group was significantly higher at OPEnd than that in the moderate NMB group (45.2 ± 3.6 vs. 33.8 ± 4.0, respectively; Bonferroni corrected p = 0.044). However, no significant differences in cortisol, prolactin, IL-6, CRP, and albumin levels and NK cell percentage were found between the two groups. The degree of NMB may have similar effects on stress-related biological markers in patients undergoing robot-assisted gastrectomy.

Effect of Neuromuscular Blockade on Intraoperative Respiratory Mechanics and Surgical Space Conditions during Robot-Assisted Radical Prostatectomy: A Prospective Randomized Controlled Trial.

The aim of this study was to investigate whether deep neuromuscular blockade (NMB) may affect intraoperative respiratory mechanics, surgical condition, and recovery profiles in patients undergoing robot-assisted radical prostatectomy (RARP). Patients were randomly assigned to the moderate or deep NMB groups. Pneumoperitoneum was maintained with carbon dioxide (CO2) insufflation at 15 mmHg during surgery. The primary outcome was peak inspiratory pressure (PIP) after CO2 insufflation. Mean airway pressure (Pmean) and dynamic lung compliance (Cdyn) were also recorded. The surgeon rated the surgical condition and surgical difficulty on a five-point scale (1 = extremely poor; 2 = poor; 3 = acceptable; 4 = good; 5 = optimal). Recovery profiles, such as pulmonary complications, pain scores, and recovery time, were recorded. We included 58 patients in this study. No significant differences were observed regarding intraoperative respiratory mechanics including PIP, Pmean and Cdyn, between the two groups. The number of patients with optimal surgical conditions was significantly higher in the deep than in the moderate NMB group (29 vs. 20, p = 0.014). We found no differences in recovery profiles. In conclusion, deep NMB had no significant effect on the intraoperative respiratory mechanics but resulted in optimal endoscopic surgical conditions during RARP compared with moderate NMB.

Comparisons of surgical conditions of deep and moderate neuromuscular blockade through multiple assessments and the quality of postoperative recovery in upper abdominal laparoscopic surgery

Study objectiveTo determine the effect of deep neuromuscular blockade (NMB) on surgical field conditions through multiple assessments during pneumoperitoneum and evaluate the effect of the depth of intraoperative NMB on the quality of postoperative recovery over multiple time periods. DesignProspective randomized study. SettingOperating room of a university hospital. PatientsEighty non-morbidly obese patients (ASA physical status 1–2) who were scheduled to undergo laparoscopic gastrectomy in the reverse Trendelenburg position. InterventionsPatients were allocated to either the deep or moderate NMB group. The depth of NMB was maintained at a post-tetanic count of 1 for deep NMB with a continuous infusion of rocuronium and at a train-of-four count of 1 for moderate NMB with a small intermittent bolus of cisatracurium. MeasurementsSingle-blinded scoring of the quality of the surgical field condition was performed by a surgeon using a five-point scale in a 15-min interval during pneumoperitoneum. The quality of postoperative recovery was assessed using the Postoperative Quality of Recovery Scale (PostopQRS) on the day before surgery (baseline) and 1 h, 1 day, and 6 days after surgery. Main resultsOptimal surgical field condition was rated in 87.0% (449/516) and 72.3% (370/512) of all measurements during deep and moderate NMB, respectively (P < 0.001). The percentage of patients maintaining a good-to-optimal condition throughout pneumoperitoneum was higher in the deep NMB group than in the moderate NMB group. There were no significant differences in the percentage of recovered patients between the two groups for all domains and all timepoints. ConclusionsMultiple assessments of the surgical field condition demonstrated that deep NMB provided a more satisfactory surgical field condition than moderate NMB during laparoscopic gastrectomy. However, the quality of postoperative recovery, assessed using the PostopQRS, was not different between the two groups according to the depth of NMB.

Neuromuscular blockade management and postoperative outcomes in enhanced recovery colorectal surgery: secondary analysis of POWER trial.

We evaluated the impact of neuromuscular blockade (NMB) management, monitoring and reversal on postoperative outcomes in colorectal surgical patients included in an enhanced recovery program. We performed a predefined analysis in 2084 patients undergoing elective colorectal surgery who participated in POWER study. We analyzed them for complications, length of hospital stay and mortality. Two groups were defined: 1) monitoring + reversal of the neuromuscular blockade (M+R) group: all patients receiving neuromuscular blockade monitoring plus reversal of it with any drug (neostigmine or sugammadex) were included; and 2) no monitoring nor reversal (noM+noR) group. In this group all the patients who did not receive monitoring and reversal of the neuromuscular blockade were allocated. Multivariate analysis found no statistically significant differences in moderate-severe complications (174 [25.7%] vs. 124 [27.1%]; P=0.607), length of hospital stay (10.8±11.1 vs. 11.0 ±12.6 days; P=0.683) and mortality (6 [0.9%] vs. 5 [1.1%]; P=0.840) between the group receiving optimal neuromuscular management (M+R) and the one did not receive it (noM+noR). Univariate analysis showed patients reversed with neostigmine died more than those reversed with sugammadex (3 [2.7%] vs. 3 [0.5%]; P=0.048). Our data suggest optimal neuromuscular blockade management in colorectal surgery is not associated with less moderate-severe complications, length of hospital stay or death during postoperative period in an enhanced recovery program. Neostigmine reversal seems to be linked to higher rate of mortality than sugammadex.

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (Pgroup*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (Pgroup*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

Effect of deep neuromuscular blockade on serum cytokines and postoperative delirium in elderly patients undergoing total hip replacement: A prospective single-blind randomised controlled trial.

Deep neuromuscular blockade (NMB) may reduce muscle injury and related inflammation. The inflammation is one of the pathophysiological processes of peri-operative complications. To compare the degree of inflammation and related postoperative complications including postoperative delirium (POD) and peri-operative bleeding according to the degree of NMB during general anaesthesia for total hip replacement. A prospective, single-blind, randomised controlled trial. Tertiary, university hospital, single centre. Eighty-two patients undergoing total hip replacement surgery were included in the final analysis. Moderate (Mod) and deep (Deep) NMB groups. The changes in inflammatory cytokines were measured. The incidence of POD was evaluated by using confusion assessment method (CAM). The differences of postoperative bleeding and peri-operative oxygenation in both groups were also measured. The NMB reversal duration was significantly longer in the Mod NMB group than in the Deep NMB group. Changes in interleukin-6 were significantly smaller in the Deep NMB group than in the Mod NMB group (P < 0.001). The incidence of POD was not significantly different between groups (34 versus 17% in Mod and Deep NMB groups, respectively; P = 0.129). The amount of postoperative bleeding until postoperative day 2 was significantly greater in the Mod NMB group than in the Deep NMB group (P = 0.027). Our findings suggest that inflammation related to peri-operative complications could be associated with the depth of NMB during total hip replacement. However, the incidence of POD might not be associated to the depth of NMB. National Library of Medicine (NLM) at the National Institutes of Health (NIH) of United States. (Identifier: NCT02507609). Online address: http://clinicaltrials.gov.

Does Deep Neuromuscular Blockade Improve Operating Conditions during Minimally Invasive Anterolateral Total Hip Replacements?: A Randomized Controlled Trial.

BackgroundNeuromuscular blockade (NMB) is thought to improve operative conditions during certain procedures. Published descriptions of minimally invasive hip replacement techniques specify the need for “excellent relaxation”, however, the optimal degree of NMB required for such cases has not been studied. We performed a randomized, single-blind study comparing the effect of moderate and deep neuromuscular blockade on surgical conditions and operating time during minimally invasive anterolateral hip replacement. Vecuronium was administered to maintain moderate NMB (train-of-four count of 1-2) or deep NMB (train-of-four count of 0, post-tetanic count of 1-2).MethodsIn this study, 116 patients were randomized to receive moderate or deep neuromuscular blockade; depth of blockade was monitored using acceleromyography. The primary outcome was the number of requests from the surgeon for additional blockade intraoperatively. Secondary outcomes included operative times and assessment of the operative conditions by the surgeon utilizing the Leiden-Surgical Rating Scale.ResultsCases with additional requests for blockade did not differ between the deep and moderate NMB groups (11/58, 19.0% vs 8/58, 13.8%); relative risk, 1.22 (95% CI [confidence interval], 0.70-2.15), p=0.62. Neither time from incision to prosthesis reduction (33.8±1.2 min vs. 32.6 ±1.2 min; difference in geometric mean, 0.96 [95% CI, 0.90-1.04] minutes, p=0.33), nor the surgeon’s assessment of operative conditions (p=0.88), differed between the deep or moderate NMB groups, respectively. ConclusionsDeep NMB did not produce significantly improved operative conditions compared with moderate NMB. Routine use of deep NMB during minimally invasive anterolateral hip arthroplasty is not supported by this study.

Reversal of Deep Effect of Rocuronium by Sugammadex or Neostigmine after Abdominal Laparoscopic Surgery: A Single Center Experience in Vietnam

BACKGROUND: Using sugammadex allows to quickly reverse deep neuromuscular blockade with rocuronium in laparoscopic surgery, which results in great benefits during and after surgery by minimizing the problem of postoperative residual curarization.&#x0D; AIM: The aims of this study are comparing the efficacy of reversing neuromuscular blockade between sugammadex and neostigmine and evaluating its unwanted effects after laparoscopic abdominal surgery.&#x0D; METHODS: Subject of this prospective clinical comparative trial was patients who underwent abdominal laparoscopic surgery at 103 Military Hospital from October 2017 to October 2018. Eighty-four patients suffering from abdominal laparoscopic surgery under deep neuromuscular blockade were enrolled and divided randomly into two groups with 42 patients in each: Group N used neostigmine for neuromuscular blockade reversal and Group S applied sugammadex. At the end of surgery, neuromuscular blockade was reversed with either sugammadex or neostigmine.&#x0D; RESULTS: The reversal time to achieve train-of-four ratio &gt;0.9 in the sugammadex group was 2.42 ± 0.58 min, which was shorter than in the neostigmine group (11.83 ± 2.19 min) (p &lt; 0.05). The time until extubation in the sugammadex group was 3.69 ± 0.67 min, which was shorter than in the neostigmine group 11.90 ± 2.22 min (p &lt; 0.05). Reversal with sugammadex resulted in statistical significance of less sputum production (0% vs. 11.9%), dry mouth (0% vs. 28.57%), headache (2.38% vs. 7.14%), and nausea (4.76% vs. 14.28%) compared with neostigmine. However, 26.19% of patients in the neostigmine group presented bradycardia, whereas the concurrent administration of atropine in the neostigmine group resulted in increased heart rate.&#x0D; CONCLUSION: Sugammadex reversed neuromuscular blockade more rapidly and effectively than neostigmine in abdominal laparoscopic surgeries. The unwanted effects of sugammadex group were fewer than neostigmine group.

Deep neuromuscular blockade during spinal surgery reduces intra-operative blood loss: A randomised clinical trial.

Spinal surgery is usually performed in the prone position using a posterior approach. However, the prone position may cause venous engorgement in the back and thus increase surgical bleeding with interruption of surgery. The prone position also affects cardiac output since large vessels are compressed decreasing venous return to the heart. We hypothesised that deep neuromuscular blockade would be associated with less surgical bleeding during spinal surgery in the prone position. Randomised, single blinded trial. University teaching hospital. Eighty-eight patients in two groups. Patients were randomly assigned to moderate neuromuscular blockade or deep neuromuscular blockade. In the moderate neuromuscular blockade group, administration of rocuronium was adjusted such that the train-of-four count was one to two. In the deep neuromuscular blockade group, rocuronium administration was adjusted such that the train-of-four count was zero with a posttetanic count 2 or less. The primary outcome was the volume of intra-operative surgical bleeding. The surgeon's satisfaction with operating conditions, haemodynamic and respiratory status, and postoperative pain scores were evaluated. The median [IQR] volume of intra-operative surgical bleeding was significantly less in the deep neuromuscular blockade group than in the moderate neuromuscular blockade group; 300 ml [200 to 494] vs. 415 ml [240 to 601]; difference: 117 ml (95% CI, 9 to 244; P = 0.044). The mean ± SD surgeon's satisfaction with the intra-operative surgical conditions was greater in the deep neuromuscular blockade group than in the moderate neuromuscular blockade group; 3.5 ± 1.0 vs. 2.9 ± 0.9 (P = 0.004). In intergroup comparisons of respiratory variables, peak inspiratory pressure was lower in the deep neuromuscular blockade group overall (P < 0.001). The median [IQR] postoperative pain score was lower in the deep neuromuscular blockade group than the moderate neuromuscular blockade group; 50 [36 to 60] vs. 60 [50 to 70], (P = 0.023). Deep neuromuscular blockade reduced intra-operative surgical bleeding in patients undergoing spinal surgery. This may be related to greater relaxation in the back muscles and lower intra-operative peak inspiratory pressure when compared with moderate neuromuscular blockade. KCT0001264 (http://cris.nih.go.kr).

Respiratory muscle activity after spontaneous, neostigmine- or sugammadex-enhanced recovery of neuromuscular blockade: a double blind prospective randomized controlled trial

BackgroundThe use of neostigmine after neuromuscular blockade (NMB) has been associated with postoperative respiratory complications. In previous studies, we found lower diaphragmatic activity after neostigmine reversal of NMB, compared to sugammadex. It is still unclear whether the adequate use of neostigmine guarantees normal respiratory muscle function after NMB. In this study, we wanted to assess the effect of commonly used degrees of NMB and their possible reversal strategies on respiratory muscle activity after the return of normal neuromuscular transmission.MethodsThis is a randomized, controlled, parallel-group, single-centre, double-blind study in patients scheduled for intracranial surgery at a tertiary academic hospital in Belgium. All participants received target controlled propofol/remifentanil anesthesia and were randomized into one of five groups, receiving either a shallow NMB with no reversal (shallow/saline), a shallow NMB with sugammadex reversal (shallow/sugammadex), a moderate NMB with neostigmine reversal (moderate/neostigmine), a moderate NMB with sugammadex reversal (moderate/sugammadex), or a deep NMB with sugammadex reversal (deep/sugammadex). Primary and secondary outcome parameters were diaphragm and intercostal electromyographic (EMG) activity at the moment of resumed spontaneous breathing activity, defined as a maximal interval of 10 min after the first spontaneous breath.ResultsFor the five groups, a total of 55 patients could be included in the final analysis. Median time of spontaneous breathing analyzed was 5 min (IQR 3–9.5 min). Both the moderate/sugammadex and the moderate/neostigmine groups had lower levels of diaphragm EMG compared to the shallow/sugammadex group. The moderate/neostigmine group had lower levels of intercostal EMG activity compared to the shallow/saline group.ConclusionsIn this study, the depth of neuromuscular blockade and type of reversal strategy impacts respiratory muscle activity at the moment of resumed spontaneous breathing and recovery of neuromuscular blockade. Both groups that received moderate NMB had lower levels of diaphragm EMG, compared to the shallow NMB group with sugammadex reversal. Compared to the shallow NMB group with no reversal, the moderate NMB with neostigmine reversal group had lower intercostal EMG activity.Trial registrationClinicaltrials.gov NCT01962298 on October 9, 2013 and EudraCT 2013–001926-25 on October 10, 2013.

Electromyographic Response of Facial Nerve Stimulation Under Partial Neuromuscular Blockade During Resection of Vestibular Schwannoma

To evaluate whether use of partial nondepolarizing neuromuscular blocking agents, at a train-of-four level 1, compromise facial nerve monitoring during vestibular schwannoma (VS) resection. Sixty consecutive patients undergoing VS resection were enrolled into a partial peripheral neuromuscular blockade group or free of neuromuscular blockade group. Stimulation threshold to elicit an electromyographic response amplitude of at least 100 μV was recorded at the proximal and distal facial nerve after VS removal. The proximal-to-distal ratio of amplitude of the orbicularis oculi and oris muscles was calculated. All patients successfully passed the electromyography monitoring test. Mean electrical stimulation thresholds were higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group (0.12 mA vs. 0.06 mA at proximal site, P= 0.001; 0.08 mA vs. 0.03 mA at distal site, P= 0.0002). The differences in median proximal-to-distal amplitude ratios were not statistically significant in both groups. There was a trend toward more patients needing phenylephrine. Recovery profiles were comparable in the 2 groups. Although mean stimulation threshold to elicit a response amplitude was higher in the peripheral neuromuscular blockade group than in the free of neuromuscular blockade group at the proximal site, the stimulation thresholds in both groups were sufficient for facial nerve monitoring in VS surgery, indicating no clinical difference in both groups.

Effects of deep neuromuscular blockade on the stress response during laparoscopic gastrectomy Randomized controlled trials

Maintaining deep neuromuscular block during surgery improves surgical space conditions. However, its effects on patient outcomes have not been well documented. We examined whether maintaining deep neuromuscular blockade during surgery could decrease the stress response compared to moderate neuromuscular blockade. Patients undergoing laparoscopic gastrectomy were randomly allocated to either the moderate (train-of-four counts of 1–2) or deep (post-tetanic counts of 1–2) neuromuscular blockade group. The primary outcome variable was the postoperative blood level of interleukin-6, and the secondary outcome variables were intraoperative or postoperative blood levels of tumor necrosis factor-α, interleukin-1β, interleukin-8, and C-reactive protein. A total of 96 patients were recruited and 88 (44 in each group) were included in the analyses. The levels of tumor necrosis factor-α and interleukin-1β measured at the end of surgery, interleukin-6 and interleukin-8 measured at 2 h postoperatively, and C-reactive protein measured at 48 h postoperatively were all significantly increased compared to the preoperative values, but there were no differences between the moderate and deep neuromuscular block groups. We found no differences in surgical stress response measured using determining levels of interleukin-6 and other mediators released between the moderate and deep neuromuscular blockade groups in patients undergoing laparoscopic gastrectomy.

Efficacy of deep neuromuscular blockade combined with low-pressure pneumoperitoneum for gynecological laparoscopic surgery in obese patients

Objective To evaluate the efficacy of deep neuromuscular blockade (NMB) combined with low-pressure pneumoperitoneum for gynecological laparoscopic surgery in the obese patients. Methods Sixty obese patients, aged 34-64 yr, with body mass index 28.7-32.0 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective laparoscopic hysterectomy, were allocated into 2 groups (n=30 each) using a random number table method: deep NMB plus low-pressure pneumoperitoneum group (group A) and moderate NMB plus high-pressure pneumoperitoneum group (group B). Cis-atracurium sulfamate was intravenously infused to maintain NMB under monitoring in both group.Group A was to maintain train-of-four (TOF) count of 0, post-tetanic count of 1 or 2, and pneumoperitoneum pressure of 10 mmHg.Group B was to maintain TOF count of 1 or 2 and pneumoperitoneum pressure of 14 mmHg.Satisfaction with surgical field was evaluated.The recovery index and time for TOF ratio returning to 0.7 and 0.9 were recorded.Peak airway pressure was recorded at 5 min before pneumoperitoneum (T0), 5 min of pneumoperitoneum-supine position(T1), 5 min of pneumoperitoneum-surgical position (T2), and 5 min after deflation at the end of surgery (T3). The development of hypoxemia, shoulder pain, and abdominal pain was recorded within 48 h after surgery. Results There was no significant difference in the satisfaction with surgical field between the two groups (P>0.05). Compared with group B, the recovery index and time for TOF ratio returning to 0.7 and 0.9 were significantly prolonged, peak airway pressure was decreased at T1 and T2, and the incidence of postoperative shoulder pain and abdominal pain was decreased in group A (P<0.05). Conclusion Compared with moderate NMB combined with high-pressure pneumoperitoneum, deep NMB combined with low-pressure pneumoperitoneum can provide a satisfactory surgical field and reduce postoperative pain, however, it prolongs the recovery time of NMB for gynecological laparoscopic surgery in the obese patients. Key words: Neuromuscular blockade; Pneumoperitoneum, artificial; Obesity; Laparoscopy

Effect of partial neuromuscular blockade on efficacy and safety of nerve monitoring during microvascular decompression of facial nerve

Objective To evaluate the effect of partial neuromuscular blockade (NMB) on the efficacy and safety of nerve monitoring during microvascular decompression (MVD) of facial nerve. Methods Seventy American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients of both sexes, aged 39-78 yr, weighing 44-84 kg, scheduled for elective MVD, were divided into 2 groups (n=35 each) using a random number table method: control group and partial NMB group.Anesthesia was induced by intravenous injection of 3-fold ED95 cisatracurium.In control group, muscle relaxants were not used after intubation.In partial NMB group, cisatracurium was continuously infused intravenously to maintain partial NMB, and the T1/Tc ratio was maintained at 20%-40%.Intraoperative neuroelectrophysiological monitoring was performed using lateral spread response (LSR). The success rates of LSR monitoring, occurrence of body movement, requirement for anesthetics and cardiovascular agents were recorded during operation, and the patients were followed up on day 7 after surgery, and the therapeutic efficacy and occurrence of neurological complications were recorded. Results Compared with control group, the incidence of intraoperative body movement was significantly decreased, the intraoperative consumption of propofol and remifentanil was decreased, and the intraoperative requirement for vasopressors was decreased in partial NMB group (P 0.05). Conclusion Partial NMB (T1/Tc=20%-40%) can be effectively used for MVD monitored by LSR, decrease the occurrence of the body movement, and raise the perioperative safety in patients. Key words: Muscle relaxation; Facial nerve; Microvascular decompression surgery; Monitoring, intraoperative

Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events.

To determine the impact of premedication for tracheal intubation (TI) on adverse TI associated events, severe oxygen desaturations, and first attempt success STUDY DESIGN: Retrospective cohort study in neonatal intensive care units (NICU) participating in the National Emergency Airway Registry for Neonates from 10/2014 to 6/2017. Premedication for TI was categorized as sedation with neuromuscular blockade, sedation only, or no medication. 2260 TIs were reported from 11 NICUs. Adverse TI associated events occurred less often in sedation with neuromuscular blockade group (10%) as compared to sedation only (29%), or no medication group (23%), p < 0.001. The adjusted odds ratio (aOR) for adverse TI associated events were: sedation with neuromuscular blockade aOR 0.48 (95%CI 0.34-0.65, p < 0.001) compared to no medication. Use of sedation with neuromuscular blockade was associated with favorable TI outcomes. This study supports the recommendation for the standard use of sedation with neuromuscular blockade in non-emergency TIs.

Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial.

IntroductionThe aim of this trial was to investigate the effect of a continuous infusion of a neuromuscular blockade (NMB) in comatose out-of-hospital cardiac arrest (OHCA) subjects who underwent targeted temperature management (TTM).MethodsIn this open-label, multicenter trial, subjects resuscitated from OHCA were randomly assigned to receive either NMB (38 subjects) or placebo (43 subjects) for 24 hours. Sedatives and analgesics were given according to the protocol of each hospital during TTM. The primary outcome was serum lactate levels at 24 hours after drug infusion. The secondary outcomes included in-hospital mortality, a poor neurological outcome at hospital discharge, changes in lactate levels, changes in the PaO2:FiO2 ratio over time and muscle weakness as assessed by the Medical Research Council (MRC) scale.ResultsEighty-one subjects (NMB group: median age, 65.5 years, 30 male patients; placebo group: median age, 61.0 years, 29 male patients) were enrolled in this trial. No difference in the serum lactate level at 24 hours was observed between the NMB (2.8 [1.2–4.0]) and placebo (3.6 [1.8–5.2]) groups (p = 0.238). In-hospital mortality and a poor neurologic outcome at discharge did not differ between the two groups. No significant difference in the PaO2:FiO2 ratio over time (p = 0.321) nor the MRC score (p = 0.474) was demonstrated.ConclusionsIn OHCA subjects who underwent TTM, a continuous infusion of NMB did not reduce lactate levels and did not improve survival or neurological outcome at hospital discharge. Our results indicated a limited potential for the routine use of NMB during early TTM. However, this trial may be underpowered to detect clinical differences, and future research should be conducted.