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Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study.

ABSTRACT: The use of low intra-abdominal pressure (<10 mmHg) reduces postoperative pain scores after laparoscopic surgery.To investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN).In a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12 mmHg insufflation pressure. A deep neuromuscular block was used in both groups. Surgical conditions were rated by the five-point Leiden-surgical rating scale (L-SRS), ranging from 5 (optimal) to 1 (extremely poor) conditions. If the L-SRS was insufficient, the pressure was increased stepwise.The primary outcome measure was the overall score on the quality of recovery-40 (QOR-40) questionnaire at postoperative day 1.The difference in the QOR-40 scores on day 1 between the low- and standard-pressure group was not significant (p = .06). Also the overall pain scores and analgesic consumption did not differ. Eight procedures (24%), initially started with low pressure, were converted to a standard pressure (?10 mmHg). A L-SRS score of 5 was significantly more prevalent in the standard pressure as compared to the low-pressure group at 30 min after insufflation (p < .01).Low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade during LDN does not reduce postoperative pain scores nor improve the quality of recovery in the early postoperative phase. The question whether the use of deep neuromuscular blockade during laparoscopic surgery reduces postoperative pain scores independent of the intra-abdominal pressure should be pursued in future studies.The trial was registered at clinicaltrial.gov before the start of the trial (NCT02146417).

SUBMITTER: Ozdemir-van Brunschot DMD

PROVIDER: S-EPMC5643361 | biostudies-literature | 2017 Nov

REPOSITORIES: biostudies-literature

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Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study.

Özdemir-van Brunschot Denise M D DMD Scheffer Gert J GJ van der Jagt Michel M Langenhuijsen Hans H Dahan Albert A Mulder Janneke E E A JEEA Willems Simone S Hilbrands Luuk B LB Donders Rogier R van Laarhoven Cees J H M CJHM d'Ancona Frank A FA Warlé Michiel C MC

World journal of surgery 20171101 11

<h4>Background</h4>The use of low intra-abdominal pressure (<10 mmHg) reduces postoperative pain scores after laparoscopic surgery.<h4>Objective</h4>To investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN).<h4>Design, setting and participants</h4>In a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12 mmHg insufflation pressure. A deep neuromusc ...[more]

PMID: 28608013

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Project description:BACKGROUND:Profound neuromuscular blockade (NMB) during anaesthesia has been shown to reduce postoperative pain scores, when compared with a moderate block. We hypothesised that profound NMB during laparoscopic donor nephrectomy (LDN) could also improve the early quality of recovery after surgery. OBJECTIVES:To compare the effectiveness of profound versus moderate NMB during LDN in enhancing postoperative recovery. DESIGN:A phase IV, double-blinded, randomised controlled trial. SETTING:Multicentre trial, from November 2016 to December 2017. PATIENTS:A total of 101 living kidney donors scheduled for LDN were enrolled, and 96 patients were included in the analyses. INTERVENTIONS:Patients were randomised to receive profound (posttetanic count 1 to 3) or moderate (train-of-four count 1 to 3) neuromuscular block. MAIN OUTCOME MEASURES:The primary outcome was the early quality of recovery at postoperative day 1, measured by the Quality of Recovery-40 Questionnaire. Secondary outcomes were adverse events, postoperative pain, analgesic consumption and length-of-stay. RESULTS:The intention-to-treat analysis did not show a difference with regard to the quality of recovery, pain scores, analgesic consumption and length-of-stay. Less intra-operative adverse events occurred in patients allocated to profound NMB (1/48 versus 6/48). Five patients allocated to a profound NMB received a moderate block and in two patients neuromuscular monitoring failed. The as-treated analysis revealed that pain scores were significantly lower at 6, 24 and 48 h after surgery. Moreover, the quality of recovery was significantly better at postoperative day 2 in patients receiving a profound versus moderate block (179.5 ± 13.6 versus 172.3 ± 19.2). CONCLUSION:Secondary analysis indicates that an adequately maintained profound neuromuscular block improves postoperative pain scores and quality of recovery. As the intention-to-treat analysis did not reveal a difference regarding the primary endpoint, future studies should pursue whether a thoroughly maintained profound NMB during laparoscopy improves relevant patient outcomes. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT02838134.

Project description:Study objectiveTo assess whether different intensities of intra-abdominal pressure and deep neuromuscular blockade influence the risk of intra-operative surgical complications during laparoscopic donor nephrectomy.DesignA pooled analysis of ten previously performed prospective randomized controlled trials.SettingLaparoscopic donor nephrectomy performed in four academic hospitals in the Netherlands: Radboudumc, Leiden UMC, Erasmus MC Rotterdam, and Amsterdam UMC.PatientsFive hundred fifty-six patients undergoing a transperitoneal, fully laparoscopic donor nephrectomy enrolled in ten prospective, randomized controlled trials conducted in the Netherlands from 2001 to 2017.InterventionsModerate (tetanic count of four > 1) versus deep (post-tetanic count 1-5) neuromuscular blockade and standard (≥10 mmHg) versus low (<10 mmHg) intra-abdominal pressure.MeasurementsThe primary endpoint is the number of intra-operative surgical complications defined as any deviation from the ideal intra-operative course occurring between skin incision and closure with five severity grades, according to ClassIntra. Multiple logistic regression analyses were used to identify predictors of intra- and postoperative complications.Main resultsIn 53/556 (9.5%) patients, an intra-operative complication with ClassIntra grade ≥ 2 occurred. Multiple logistic regression analyses showed standard intra-abdominal pressure (OR 0.318, 95% CI 0.118-0.862; p = 0.024) as a predictor of less intra-operative complications and moderate neuromuscular blockade (OR 3.518, 95% CI 1.244-9.948; p = 0.018) as a predictor of more intra-operative complications. Postoperative complications occurred in 31/556 (6.8%), without significant predictors in multiple logistic regression analyses.ConclusionsOur data indicate that the use of deep neuromuscular blockade could increase safety during laparoscopic donor nephrectomy. Future randomized clinical trials should be performed to confirm this and to pursue whether it also applies to other types of laparoscopic surgery.Trial registrationClinicaltrials.gov LEOPARD-2 (NCT02146417), LEOPARD-3 trial (NCT02602964), and RELAX-1 study (NCT02838134), Klop et al. ( NTR 3096 ), Dols et al. 2014 ( NTR1433 ).

Project description:BackgroundAnesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery.MethodsThis is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9).ResultsTwo groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05).ConclusionsThere was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.

Dataset Information

Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study.

Publications

Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study.

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