Impact of deep neuromuscular blockade on intraoperative NOL-guided remifentanil requirement during desflurane anesthesia in laparoscopic colorectal surgeries: A randomised controlled trial

Abstract

Study objective: Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed.

Design: Monocentric randomised controlled trial.

Setting: Operating room.

Patients: We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia.

Interventions: Patients were randomised into two groups to achieve either moderate (1-3 train of four response) or deep (1-2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups.

Measurements: The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption.

Main results: Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228-472) μg.h^-1 in the deep NMB group compared to 494 (392-618) μg.h^-1 in the moderate NMB group (P < 0.001). Lowest L-SRS was 5 (4-5) in the deep NMB group versus 3 (2-5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different.

Conclusions: This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions.

Trial registration: The study was registered at ClinicalTrials.gov under NCT03910998.

Keywords: Colorectal surgery; Deep neuromuscular blockade; Laparoscopy; Nociception level index; Remifentanil; Surgical conditions.