Effect of depth of neuromuscular blockade on the abdominal space during pneumoperitoneum establishment in laparoscopic surgery.
OBJECTIVE
To evaluate the effect of neuromuscular blockade (NMB) upon the abdominal space during pneumoperitoneum establishment in laparoscopic surgery, comparing moderate NMB and deep NMB.


METHODS
Prospective, randomized, crossover clinical trial.


METHODS
Operating room.


METHODS
Seventy-six American Society of Anesthesiologists 1 to 2 patients scheduled for elective laparoscopic surgery.


METHODS
Two independent evaluations were performed at the establishment of pneumoperitoneum for a preset intraabdominal pressures (IAPs) of 8 and 12 mm Hg, both during moderate NMB (train-of-four count, 1-3) and deep NMB (posttetanic count, <5). Rocuronium was used to induce NMB, and sugammadex was used for reversal.


METHODS
We evaluated (i) the volume of CO2 introduced in 41 patients and (ii) the skin-sacral promontory distance in 35 patients, at pneumoperitoneum establishment.


RESULTS
Compared to moderate NMB, deep NMB increased, in a significant manner, both the intraabdominal volume of CO2 insufflated (mean [SD], 2.24 [1.10] vs 2.81 [1.13] L at 8 mm Hg IAP, P<.001, and 3.52 [1.31] vs 4.09 [1.31] L at 12 mm Hg IAP, P<.001) and the skin-sacral promontory distance (11.78 [1.52] vs 12.16 [1.51] cm at 8 mm Hg IAP, P=.002, and 13.34 [1.87] vs 13.80 [1.81] cm at 12 mm Hg IAP, P<.001). Increase in intraabdominal volume after inducing deep NMB was observed in 88% and 81.7% of patients at 8 and 12 mm Hg pneumoperitoneum, with a volume increase of mean of 36.8% (95% confidence interval [CI], 22.8-50.8) and 25% (95% CI, 13.7-36.4), respectively (P=.003). Increase in distance was observed in 61% and 82% of patients at 8 and 12 mm Hg pneumoperitoneum, with a mean distance increase of 3.3% (95% CI, 1.3-5.4) and 3.6% (95% CI, 1.9-5.2), respectively (P=.840).


CONCLUSIONS
Deep NMB, in comparison to moderate NMB, increased in a significant manner the abdominal space at pneumoperitoneum establishment. However, the effective increase in the abdominal cavity dimensions could be low, the increase showed a great interindividual variability, and it was not observed in every patient. Clinical significance of this increase on surgical conditions is yet to be demonstrated.
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain. Electronic address: jbarrio.ma@gmail.com.
Javier
J
Barrio
Consorcio Hospital General Universitario de Valencia, Av. Tres Cruces, 2, 46014, Valencia, Spain.
Carlos L
CL
Errando
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain.
Guillermo
G
San Miguel
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain.
Boris I
BI
Salas
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain.
Juan
J
Raga
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain.
José L
JL
Carrión
Hospital Arnau de Vilanova de Valencia, C/ San Clement 12, 46015, Valencia, Spain.
Jaime
J
García-Ramón
Department of Surgery, Faculty of Medicine and Odontology, University of Valencia, Avda. Blasco Ibáñez 15, 46010, Valencia, Spain.
Juan
J
Gallego
D034841:Abdominal Cavity; D000328:Adult; D000732:Androstanols / Q000008:administration & dosage* / Q000009:adverse effects; D017081:Cholecystectomy, Laparoscopic; D018592:Cross-Over Studies; D017558:Elective Surgical Procedures; D005260:Female; D013509:Gynecologic Surgical Procedures; D006801:Humans; D007274:Injections, Intraperitoneal; D007327:Insufflation; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D019148:Neuromuscular Blockade / Q000009:adverse effects / Q000379:methods*; D003473:Neuromuscular Nondepolarizing Agents / Q000008:administration & dosage* / Q000009:adverse effects; D011028:Pneumoperitoneum, Artificial; D011446:Prospective Studies; D000077123:Rocuronium; D000077122:Sugammadex; D047408:gamma-Cyclodextrins / Q000008:administration & dosage
D000732:Androstanols; D003473:Neuromuscular Nondepolarizing Agents; D047408:gamma-Cyclodextrins; D000077122:Sugammadex; D000077123:Rocuronium
Laparoscopy; Neuromuscular blockade; Pneumoperitoneum; Rocuronium