A randomised controlled trial comparing deep neuromuscular blockade reversed with sugammadex with moderate neuromuscular block reversed with neostigmine

Abstract

Summary Deep neuromuscular block aims to improve operative conditions during laparoscopic surgery with a lower intra‐abdominal pressure. Studies are conflicting on whether meaningful improvements in quality of recovery occur beyond emergence, and whether lower intra‐abdominal pressure is achieved. In this pragmatic randomised trial with 1:1 allocation, adults undergoing elective laparoscopic surgery were allocated to moderate neuromuscular block reversed with neostigmine, or deep neuromuscular block reversed with sugammadex. Allocation was revealed to the anaesthetist only. Primary outcome was cognitive recovery of the Postoperative Quality of Recovery Scale, 7 days after surgery. Secondary outcomes included recovery in other domains of the Postoperative Quality of Recovery Scale at 15 min and 40 min; days 1, 3, 7, 14; and 1 and 3 months after surgery. Chi‐square test was used for the primary outcome, and generalised linear mixed model for recovery over time between groups. Of 350 participants randomised, 140 (deep) and 144 (moderate) were analysed for the primary outcome. There was no difference in the Postoperative Quality of Recovery Scale cognitive domain at day 7 (deep 92.9% vs. moderate 91.8%, OR 1.164; 95%CI 0.486–2.788, p = 0.826), or at any other time‐point. No significant difference was observed for physiological, emotive, activities of daily living, nociception, or overall recovery. Length of stay in the recovery area (mean (SD) deep 108 (58) vs. moderate 109 (57) min, p = 0.78) and hospital (1.8 (1.9) vs. 2.6 (3.5) days, p = 0.019) was not different. Intra‐abdominal pressure and surgical operating conditions were not different between groups. Deep neuromuscular block did not improve quality of recovery compared with moderate neuromuscular block in operative laparoscopic surgery over a 1‐h duration.

Sugammadex in awakening from general anesthesia: systematic review and meta-analysis

“…In total, 265 studies were retrieved (Medline via PubMed), as well as 65 from the EMBASE database. After applying the eligibility criteria and evaluating titles and abstracts, 55 studies were selected, of which 36 were included 5-40 for evaluation of the full text and inclusion in the meta-analysis, with 19 studies excluded [41][42][43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59] (Figure 1). Three studies retrieved from EMBASE (Quang 5 , Lemmens 6 and Woo 7 ) were also found in the Medline search via PubMed.…”

Deep Neuromuscular Blockade Combined with Low Pneumoperitoneum Pressure for Nociceptive Recovery After Major Laparoscopic Gastrointestinal Surgery: Study Protocol for a Randomized Controlled Trial

“…34 However, several studies reported that the use of deep NMB alone without the application of a low IAP did not improve surgical conditions, postoperative pain, or quality of recovery after laparoscopic surgery. [35][36][37] A previous study suggested that the combination of deep NMB and low IAP reduced shoulder pain after laparoscopic hysterectomy. 38 A recent study showed that a low IAP did not lead to lower postoperative pain scores but reduced fentanyl requirement and the incidence of PONV in the recovery room after laparoscopic cholecystectomy.…”

Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials

“…Seven studies were judged to be at low risk of bias [17,23,26,28,31,40,53], 23 studies were judged to raise some concerns [12, 15, 16, 19, 24, 29, 32, 34, 36, 38, 41-47, 49-52, 54, 55], and 10 studies were judged to be at high risk of bias [13,14,25,27,30,33,35,37,39,48]. The details of judgments for each risk-of-bias domain are demonstrated in Fig 2.…”

“…In terms of the risk of bias, there were few studies at low risk of bias (7 RCTs, 17.5%) [17,23,26,28,31,40,53]. Some studies were judged to have some concerns about the risk of bias (23 RCTs, 57.1%) [12, 15, 16, 19, 24, 29, 32, 34, 36, 38, 41-47, 49-52, 54, 55].…”