title: Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: A randomised controlled trial.
abstract: BACKGROUND
  Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg).
  
  
  OBJECTIVE
  The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.
  
  
  METHODS
  A randomised, controlled, double-blinded study.
  
  
  METHODS
  Private hospital in Denmark.
  
  
  METHODS
  Ninety-nine patients.
  
  
  METHODS
  Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.
  
  
  METHODS
  The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.
  
  
  RESULTS
  Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.
  
  
  CONCLUSIONS
  Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg).
  
  
  BACKGROUND
  Clinicaltrials.gov identifier: NCT01722097.
authors.affiliation: From the Department of Anaesthesiology, Herlev Hospital, University of Copenhagen, Herlev, Denmark (MVM, AKS-R, MRG), Department of Anaesthesiology and Center for Minimal Invasive Gynaecology, Aleris-Hamlet Hospitals Copenhagen, Søborg, Denmark (OI, HHS, JL), and Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark (JR).
authors.forename: Matias V
authors.initials: MV
authors.lastname: Madsen
authors.forename: Olav
authors.initials: O
authors.lastname: Istre
authors.forename: Anne K
authors.initials: AK
authors.lastname: Staehr-Rye
authors.forename: Henrik H
authors.initials: HH
authors.lastname: Springborg
authors.forename: Jacob
authors.initials: J
authors.lastname: Rosenberg
authors.forename: Jørgen
authors.initials: J
authors.lastname: Lund
authors.forename: Mona R
authors.initials: MR
authors.lastname: Gätke
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use; D003718:Denmark; D004311:Double-Blind Method; D005260:Female; D016304:Hospitals, Private; D006801:Humans; D007044:Hysterectomy / Q000009:adverse effects* / Q000379:methods; D010535:Laparoscopy / Q000009:adverse effects*; D007902:Length of Stay; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000009:adverse effects; D010147:Pain Measurement; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects / Q000379:methods*; D011312:Pressure; D020127:Recovery of Function; D020069:Shoulder Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid