On-demand versus continuous rocuronium infusion for deep neuromuscular relaxation in patients undergoing thoraco-laparoscopic esophagectomy: a randomized-controlled clinical trial (DEPTH)

Abstract

Purpose Deep neuromuscular blockade (NMB) can improve surgical conditions and possibly pain after lowrisk laparoscopic surgery. We hypothesized that targeting a deep level of NMB by a continuous compared with an on-demand infusion of rocuronium could improve surgical conditions in patients undergoing thoraco-laparoscopic esophagectomy. Methods In this single-centre, randomized-controlled, double-blind trial, patients received either a continuous infusion of rocuronium 0.6 mgÁkg-1 Áhr-1 (intervention) or NaCl 0.9% (control). Both surgeon and anesthesiologist were blinded to group assignment and the train-of-four measurements. Open-label rocuronium was given if requested (i.e., on-demand) by the surgeon. At the end of surgery, sugammadex was given if necessary to reverse the NMB. The primary outcome was the quality of surgical conditions during the abdominal phase of the operation as measured by the surgical rating scale (SRS). Secondary outcomes included the thoracic SRS, number of on-demand boluses, intraoperative surgical events, pain scores (up to 12 hr postoperatively), and duration of surgery. Results The median [interquartile range] abdominal SRS was not different between the intervention (4 [4-5]) and control (4 [4-5]) groups (median difference, 0; 95% confidence interval, 0 to 0; P = 0.45). The thoracic SRS was 4 [4-4] in both groups (P = 0.23). The median number of rocuronium bolus requests was higher in the control group compared with the intervention group (3 [3-6] vs 1 [0-2], respectively; P \ 0.01). There were no between-group Electronic supplementary material The online version of this article (

Peri-operative management of neuromuscular blockade

“…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.…”

“…With very few exceptions, 56,63 the used surgical technique was a laparoscopic procedure; patients were managed with either volatile or total intravenous anaesthesia. Twenty-three studies compared dNMB with mNMB as the standard of care, 45–55,57–60,62–66,68,69 three studies used no neuromuscular block as control 56,61,67 and one study performed on-demand relaxation control 70 . In our analysis, 23 out of 26 studies were classified as having a low risk of bias.…”

Deep neuromuscular block does not improve surgical conditions in patients receiving sevoflurane anaesthesia for laparoscopic renal surgery

“… 28 , 29 , 30 , 31 , 32 , 33 In addition, 10 studies were identified that used an inhalation agent. 14 , 15 , 16 , 17 , 18 , 20 , 21 , 22 , 23 , 24 Seven out of these 10 studies reported a benefit of deep neuromuscular block during inhalation anaesthesia on surgical working conditions. 14 , 15 , 16 , 17 , 18 , 20 , 21 …”

“… Comparator to deep NMB Hypnotic agent Depth of anaesthesia: BIS/MAC/vol.% Low pressure pneumoperitoneum? Inhalation anaesthesia Blobner and colleagues 14 Yes No NMB Desflurane BIS 40–50 No Dubois and colleagues 15 Yes Single Shot Desflurane MAC 1.0 No Fuchs-Buder and colleagues 16 Yes Moderate Desflurane 4.0–6.0% No Kim and colleagues 17 Yes∗ Moderate Desflurane 4.0–7.0% Yes Koo and colleagues 18 Yes∗ Moderate Desflurane BIS 40–60 Yes Ozdemir-van Brunschot and colleagues 20 Yes Moderate Sevoflurane MAC 1.0 Yes Yoo and colleagues 21 Yes∗ Moderate Sevoflurane BIS 40–60 Yes Veelo and colleagues 22 No On Demand Sevoflurane MAC 1.0 No Williams and colleagues 23 No∗ Moderate Unknown Unknown No Kim and colleagues 24 No∗ Moderate Desflurane 4.0–8.0% No Total intravenous anaesthesia Koo and colleagues 25 Yes∗ Moderate Propofol …”

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

“…Continuous infusion may limit the NMB effect of rocuronium. In addition, a previous study demonstrated that the surgical condition was comparable between continuous rocuronium infusion and a bolus of rocuronium [22]. Second, the urologist evaluated the surgical space conditions and surgical difficulties as soon as at the surgery ended.…”