Deep Neuromuscular Block Improves Surgical Conditions during Bariatric Surgery and Reduces Postoperative Pain: A Randomized Double Blind Controlled Trial

<div><p>Background</p><p>It remains unknown whether the administration of a deep neuromuscular block (NMB) during bariatric surgery improves surgical conditions and patient outcome. The authors studied the effect of deep <i>versus</i> moderate NMB in laparoscopic bariatric surgery on surgical conditions and postoperative pain.</p><p>Methods and Results</p><p>One hundred patients scheduled to undergo elective bariatric surgery were randomized to a deep NMB (post-tetanic-count 2–3) or a moderate NMB (train-of-four 1–2). The quality of the surgical field was scored using the Leiden-Surgical Rating Scale (L-SRS), a 5-point scale ranging from 1 (extremely poor conditions) to 5 (optimal conditions). Three surgeons scored the L-SRS at 10-min intervals during surgery; postoperative pain scores were obtained in the postanesthesia-care-unit (PACU) and on the ward. Mean (95% confidence interval) L-SRS scores in moderate NMB 4.2 (4.0–4.4) <i>versus</i> 4.8 (4.7–4.9) in deep NMB (p < 0.001). Moderate NMB resulted in 17% of scores at L-SRS scores of 1–3, while deep NMB resulted in 100% scores at the high end of the L-SRS (4–5). Deep NMB led to improved pain scores in the PACU (4.6 (4.2–4.9) <i>versus</i> 3.9 (3.6–4.4), p = 0.03) and reduced shoulder pain on the ward (1.8 (1.5–2.1) <i>versus</i> 1.3 (1.1–1.5), p = 0.03). A composite score of pain and opioid use in the PACU favoured deep NMB (p = 0.001).</p><p>Conclusions</p><p>In bariatric surgery, deep relaxation has advantages for surgeon and patient. Compared to moderate NMB, deep NMB produced stable and improved surgical conditions with less postoperative pain.</p></div

Patient characteristics.

<p>Patient characteristics.</p

Measurements obtained during and following surgery.

<p>Measurements obtained during and following surgery.</p

Consort flow diagram.

<p>Consort flow diagram.</p

Influence of deep relaxation on surgical conditions.

<p>Leiden-surgical rating scale (L-SRS) values of patients during a deep neuromuscular block (target PTC 2–3; orange, <i>n</i> = 50) and during a moderate neuromuscular block (target TOF 1–2; blue, <i>n</i> = 50). Values are mean (95% confidence interval) with confidence intervals derived from bootstrap analyses. * Mann-Whitney-U test p < 0.01 <i>versus</i> moderate block.</p

The Leiden Surgical Rating Scale (L-SRS).

<p>The Leiden Surgical Rating Scale (L-SRS).</p

Distribution of L-SRS scores.

<p><b>A</b>. Distribution of the individual Leiden-surgical rating scale (L-SRS) scores across the 5 possible categories (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0167907#pone.0167907.t001" target="_blank">Table 1</a>). <b>B</b>. Percentage of L-SRS values of 5 over time in single, moderate and deep blocks. Orange depicts deep NMB, blue moderate NMB and grey single NMB.</p

Operation compared with watchful waiting in elderly male inguinal hernia patients: a review and data analysis.

Item does not contain fulltex