Changes in duration of action of rocuronium following decrease in hepatic blood flow during pneumoperitoneum for laparoscopic gynaecological surgery

Abstract

BackgroundA moderate insufflation pressure and deep neuromuscular blockade (NMB) have been recommended in laparoscopic surgery in consideration of the possible reduction in splanchnic perfusion due to the CO2-pneumoperitoneum. Since the liver is the major organ for rocuronium metabolism, the question of whether NMB of rocuronium would change with the variation of liver perfusion during pneumoperitoneum during laparoscopic surgery merits investigation.MethodsIn this prospective study, a total of sixty female patients scheduled for either selective laparoscopic gynaecological surgery (group laparoscopy) or laparotomy for gynaecological surgery (group control) were analyzed. Rocuronium was administered with closed-loop feedback infusion system, which was also applied to monitor NMB complied with good clinical research practice (GCRP). The onset time, clinical duration, and recovery index were measured. Hepatic blood flow was assessed by laparoscopic intraoperative ultrasonography before insufflation/after entering the abdominal cavity (T1), 5 min after insufflation in the Trendelenburg position/5 min after skin incision (T2), 15 min after insufflation in the Trendelenburg position/15 min after skin incision (T3), 30 min after insufflation in the Trendelenburg position/30 min after skin incision (T4), and 5 min after deflation/before closing the abdomen (T5) in group laparoscopy/group control respectively. The relationship between the clinical duration of rocuronium and portal venous blood flow was analyzed using linear or quadratic regression.ResultThe clinical duration and RI of rocuronium were both prolonged significantly in group laparoscopy (36.8 ± 8.3 min; 12.8 ± 5.5 min) compared to group control (29.0 ± 5.8 min; 9.8 ± 4.0 min) (P < 0.0001; P = 0.018). A significant decrease was found in portal venous blood flow during the entire pneumoperitoneum period in group laparoscopy compared with group control (P < 0.0001). There was a significant correlation between the clinical duration of rocuronium and portal venous blood flow (Y = 51.800-0.043X + (1.86E-005) X 2; r2 = 0.491; P < 0.0001).ConclusionRocuronium-induced NMB during laparoscopic gynaecological surgery might be prolonged due to the decrease in portal venous blood flow induced by CO2-pneumoperitoneum. Less rocuronium could be required to achieve a desirable NMB in laparoscopic gynaecological surgery.Trial registrationChiCTR. Registry number: ChiCTR-OPN-15007524. Date of registration: December 4, 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-017-0335-1) contains supplementary material, which is available to authorized users.

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“…No simple tests will, unfortunately, allow an accurate estimation of liver function. Hepatic blood flow can also be important for duration of action of NMBAs, and one study found that pneumoperitoneum during laparoscopic surgery was associated with a prolonged duration of action of rocuronium 19 . An explanation might be a decrease in hepatic blood flow related to the increase in intraperitoneal pressure.…”

First genome-wide association study on rocuronium dose requirements shows association with SLCO1A2

“…7 Several reports have demonstrated major inter-individual differences in the duration of action of rocuronium. 8e11 Advanced age, 12 female sex, 13 conditions and treatments that alter the skeletal muscle acetylcholine receptors, 14 decrease in hepatic blood flow during surgery, 15 smoking, 16 and ethnic background 17e19 can also affect the pharmacokinetics or pharmacodynamics of rocuronium.…”

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