Do patients undergoing cholecystectomy need to be paralyzed? Okay, perhaps the answer is “yes” for an open cholecystectomy, but is paralysis also needed for the procedure when it is performed laparoscopically? If the answer is “yes”, is deep paralysis required?
Dr. Anne K. Staehr-Rye, Department of Anesthesiology, University of Copenhagen, Herlev Hospital, Herlev, Denmark, and colleagues randomized 48 patients undergoing laparoscopic cholecystectomy to receive either deep, continuous neuromuscular blockade or moderate neuromuscular blockade with stratification for body mass index (obese vs. not obese). The results of their study are published in this month’s issue of Anesthesia & Analgesia in the article titled “Surgical Space Conditions During Low-Pressure Laparoscopic Cholecystectomy with Deep Versus Moderate Neuromuscular Blockade: A Randomized Clinical Study.” The authors used acceleromyography quantitative EMG neuromuscular monitoring (see the AA2day post “What evidence do we need to show that quantitative EMG neuromuscular monitoring should be a standard of care?” on why quantitative EMG neuromuscular monitoring is the preferred technique to monitor intraoperative paralysis).
Rocuronium 0.3 mg/kg was used during anesthesia induction. Additional doses of rocuronium were used in the deep blockade group. No additional rocuronium was used in the moderate blockade group unless surgical conditions were considered inadequate. The authors used sugammadex 2 to 8 mg/kg at the end of the procedure if the train-of-four (TOF) ratio was <0.90. In the moderate paralysis group, a TOF count ≥2 was present during 87% of the procedure.
Although ratings of optimal exposure during the entire procedure, and ability to complete the procedure at pneumoperitoneum 8 mm Hg, favored the deep blockade group, the differences were not significant. There was no difference in pain at 21 days, consumption of oxycodone within 24 hours, time to resume normal activities, postoperative nausea, vomiting, or administered ondansetron within 24 hours postoperatively.
Dr. François Donati, Department of Anesthesiology, Hôpital Maisonneuve-Rosemont and Université de Montréal, Montréal, Québec, Canada, and Dr. Sorin J. Brull, Department of Anesthesiology, Mayo Clinic College of Medicine, Jacksonville, Florida, note in the accompanying editorial titled “More Muscle Relaxation Does Not Necessarily Mean Better Surgeons or ‘The Problem of Muscle Relaxation in Surgery,’” “Perhaps the words of the now-famous Harold R. Griffith are still applicable today: ‘The best surgeon is the one who handles tissues gently, does it quickly, and gets out of the abdomen or chest with no time wasted in ”puttering”. The expert should not need “wet rag relaxation” for every laparotomy.’”
Dr. Griffith’s quote was published in 1947. It still rings true.