Title page Article Title

Title page
Article Title:
The impact of deep versus moderate neuromuscular block on respiratory System mechanics during laparoscopic cholecystectomy a double?blind randomized clinical trial.

Authors:
Khaled Salah Mohamed. MD
First name: Khaled
Middle name: Salah
Last name: Mohamed
Address: Anesthesia and intensive care department, Assiut university hospital, faculty of medicine, Assiut University, Egypt.
Email address: [email protected]
Mostafa Samy Abbas. MD
First name: MostafaMiddle name: SamyLast name: Abbas
Address: Anesthesia and intensive care department, Assiut university hospital, faculty of medicine, Assiut University, Egypt.
Email address: [email protected]
Osama Ali Ibraheim. MD
First name: Osama
Middle name: Ali
Last name: IbraheimAddress: Anesthesia and intensive care department, Assiut university hospital, faculty of medicine, Assiut University, Egypt
Email address: [email protected] Mohamed Taha. MD
First name: Ahmed
Middle name: Mohamed
Last name: TahaAddress: Rajhy Liver Hospital, Assiut University, Assiut, Egypt.

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Email address: [email protected] Ibraheem. MD
First name: TameemLast name: IbraeemAddress: Rajhy Liver Hospital, Assiut University, Assiut, Egypt.

Email address: [email protected] A. Fadel. MD
First name: Bashir
Last name: FadelAddress: Rajhy Liver Hospital, Assiut University, Assiut, Egypt.

Email address: [email protected] Author:
Khaled Salah Mohamed
Mailing address: Second floor, Anesthesia and intensive care department, faculty of medicine, Assiut University, Assiut, Egypt.
Tel.:+ 201003060187
Fax: +2 088 2333327
E-mail address: [email protected] Com
Keywords: Neuromuscular Blockade, Neuromuscular Monitoring, Respiratory Mechanics.

Number of figures: 2
Number of tables: 2

Abstract
Purpose:
Deep neuromuscular block (NMB) has been suggested to improve surgical conditions during laparoscopy; but, there is little evidence to support that. However, to our knowledge, no published studies have investigated the impact of deep NMB on respiratory mechanics. Our hypothesis that the possibility of deep NMB to improve respiratory mechanics during low-pressure laparoscopic surgery in comparison with moderate NMB.

Methods:
In a randomized, prospective, parallel, controlled trial, 76 patients undergoing elective laparoscopic cholecystectomy under general anesthesia were randomized 1:1 to either continuous deep or moderate neuromuscular blockade. The primary outcome was Static respiratory compliance. Secondary outcomes included peak airway pressure, mean airway pressure, surgeon satisfaction, the proportion of procedures completed at Pneumoperitoneum 8 mm Hg, visual analogue scale (VAS) and postoperative nausea and vomiting.
Results:
After insufflation static compliance was significantly lower in moderate blockade group than that in deep blockade group (p=0. 001). Also, after insufflation, both Peak airway pressure and mean airway pressure in deep blockade group were significantly lower. Optimal surgical space conditions were found in 15 of 38 (39.5%) patients allocated to deep blockade and in 5 of 38 (13.6%) patients allocated to moderate blockade (P = 0.009). the procedure was completed at Pneumoperitoneum 8 mm Hg in 35 (92%) patients in the deep group compared with 29 (76.3%) patients in the moderate group (P = 0.059). There were No differences in nausea or vomiting, or postoperative pain, between both groups.
Conclusion:
Deep neuromuscular blockade was associated with better respiratory mechanics than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy.
Keywords: Neuromuscular Blockade, Neuromuscular Monitoring, Respiratory Mechanics.

INTRODUCTION
Laparoscopic surgery has become more efficient and safer over the years due to reductions in intraabdominal pressure (IAP), modifications in surgical technique, selection of the type of insufflation gas, and improvements in anaesthetic management. Despite this, laparoscopic surgery continues to cause specific pathophysiological effects, such as cardiovascular, pulmonary, and splanchnic perfusion changes, where IAP appears to be the primary determinant.(1-3) Lowering insufflations pressures may also result in a reduction in postoperative pain (including shoulder tip pain)(4) and a better quality of life 5 days after surgery.(5, 6) IAP is commonly maintained at around 12 mmHg for most laparoscopic procedures. In order to keep intraperitoneal pressures low, neuromuscular blocking agents (NMBA) are frequently used.
There is some evidence that NMB improves surgical space and operating conditions during laparoscopic surgery (7-9). However, to our knowledge, no published studies have investigated the impact of muscle relaxation on respiratory mechanics during low-pressure laparoscopic surgery.
We designed this study to evaluate the effect of deep, continuous neuromuscular blockade on respiratory mechanics during low-pressure laparoscopic cholecystectomy. We hypothesized that deep, continuous neuromuscular blockade compared to moderate blockade was associated with better lung compliance and airway pressures.

Methods
Study Design
This randomized, double-blinded study was approved by the local Ethical Committee of Assiut University. The study was carried out between October 2014 and January 2016 at Al Rajhy liver hospital in Assiut University and registered at ClinicalTrials.gov (NCT02469831) before patient enrollment. Written informed consent was signed by all patients.
Participants
Eligible patients their age were older than 18 years of age, American Society of Anesthesiology (ASA) classification class I and II scheduled for elective laparoscopic cholecystectomy. Exclusion criteria were Patients older than 60 years of age with heart or chest disease, previous abdominal surgeries, a history of arterial or venous diseases, allergy to muscle relaxant (Rocuronium), , known neuromuscular disorders that might impair neuromuscular blockade, patients who were indicated for rapid sequence induction ,breastfeeding , pregnancy, BMI (?30 kg/m2), and significant liver or renal dysfunction. A negative urine pregnancy test within 24 hours prior to surgery for all patients who were in the childbearing period.

Interventions
A standardized protocol including mode of ventilation strategy, antibiotics ,fluid therapy, control of temperature as well as administration of analgesics and antiemetics was carried out. Standard hemostatic and respiratory monitoring (3-lead ECG, noninvasive blood pressure manometer, and pulse oximeter) was used. Induction of anesthesia was by Fentanyl 1-2 ?g/kg and propofol 2-3 mg/kg and maintenance with inhalational anesthesia (Sevoflurane). Volume controlled ventilation was performed in all patients and the ventilator was set to deliver 6 -8 mL/kg tidal volume, 12/ min frequency, I/E 1:2, inspiratory pause 20 % of inspiration, and a constant inspiratory flow rate.

Acceleromyography with the TOF-watch-SX monitor (MSD BV, Haarlem, The Netherlands) was used for neuromuscular function monitoring. The left arm and hand were secured to the arm board. Electrodes were placed over the course of the ulnar nerve at the wrist, we have placed the ipsilateral thumb in a flexible adaptor to generate preload and placed a sensor on the tip of the thumb to detect adduction of the thumb through contractions of the adductor pollicis brevis muscle. After induction of anesthesia but prior to administration of rocuronium, the device was calibrated according to the following steps to standardize the neuromuscular monitoring: (a) application of a tetanic ulnar nerve stimulation (50 Hz for 5 s); (b) calibration of the TOF watch; and (c) performance of a series of TOF readings to ensure that the TOF ratio differs by less than 5% in-between measurements. Recalibration of the TOF watch was done if the TOF ratio differed by >5%. The TOF ratio was normalized to the values obtained during calibration. After these procedures, the neuromuscular blocking agent 9 rocronium) was given according to protocol. Upon electrical stimulation, the number of thumb twitches of the ulnar nerve was measured and recorded. At 10 min intervals, the TOF was measured and in the case of TOF = 0, PTC was done.

After calibration, a dose of rocuronium of 0.6 mg/kg was administered for Intubation. Assessment of NMB was performed every 5 minutes.

For the depth of NMB, we used the definitions by Kopman and Naguib( HYPERLINK l “_3dy6vkm” h 10) (deep NMB: no response to a TOF stimulation and PTC >1 ; moderate NMB: TOF count of 1–3). In the deep NMB group, a continuous rocuronium infusion of 0.6 mg/kg/h was used and titrated to a PTC of 1 to 2 twitches. In the deep NMB group, sugammadex 4 mg/kg was used for reversal of NMB at the end of surgery.

In the moderate NMB group, top-up doses of rocuronium (10 mg) were given to maintain a TOF count of 1 to 2. NMB was reversed with a combination of neostigmine 50 ?g/kg and atropine 0.01 mg/kg at the end of surgery. In both groups, patients were extubated when the TOF ratio was >0.9.
After the introduction of the 4 Trocars, Pneumoperitoneum was reduced from 12 into 8 mm Hg. The position of the Patients was 30° reverse Trendelenburg after insufflation.

All laparoscopic surgeries were done by 1 of 2 experienced surgeons, In case of inadequate surgical space conditions, the following interventions were used in both groups: 1st to?Increase intraabdominal pressure from 8 to 12 mm Hg, then If still inadequate, the surgeon would decide according to usual practice.

Outcome Measures
As a primary outcome The Avance® Carestation – GE Healthcare patient spirometry was used to record respiratory mechanics. Static respiratory compliance, peak airway pressure (PAWP) and mean airway pressure (MAWP) were measured at three-time points: 10 min after anesthesia induction (T1: induction), 10 min after pneumoperitoneum (T2: pneumoperitoneum), and 10 min after the end-pneumoperitoneum (T3: end-pneumoperitoneum).

The secondary outcomes were surgeon satisfaction (Optimal surgical space conditions), assessed by a single surgeon using a 5-point rating scale (1 = extremely poor, 2 = poor, 3 = acceptable, 4 = good, 5 = optimal) (11) proportion of procedures completed at Pneumoperitoneum 8 mm Hg, visual analog scale (VAS) at arrival in the postoperative care unit and postoperative nausea and vomiting up to 24 hours after operation.

Systolic arterial pressure (SAP), mean arterial pressure (MAP), diastolic arterial pressure (DAP) and heart rate (HR) were recorded at the same 3-time intervals as respiratory mechanics.

Before the operation, all patients included in the study were carefully instructed by the same investigator in the use of a visual analogue scale (VAS) (VAS 0 = no pain, VAS 10 = worst possible pain).

Blinding and Randomization
The randomization of the patients was done before arrival in the operating room by a computer randomization system to ensure adequate allocation concealment. Patients allocated to either continuous deep neuromuscular blockade or moderate neuromuscular blockade.

The surgeons, surgical staff, patients, personnel in the postoperative care unit as well as the investigator collecting postoperative data all of them were blinded to group allocation. The syringes containing NaCl Rocuronium, and were prepared in a separate room. To blind the surgeon, each patient had a syringe marked “Rocuronium” in a syringe pump attached to the intravenous line. In the moderate NMB group, the syringe contained normal saline 0.9%. Whereas, in the deep NMB group, the syringe contained actual rocuronium. During surgery, the “Rocuronium” syringe pumps in both groups were operated by the anesthesiologist as if they contained the active drug. The patient’s hand with the neuromuscular monitoring equipment and the connecting neuromuscular monitor were covered from the surgeon to keep him blinded to group allocation. However, the person who gave Rocuronium could follow the level of neuromuscular blockade. Information about, the doses of Rocuronium, group allocation and neuromuscular data were recorded on a separate paper and put in a sealed opaque envelope when the patient left the theater room.
Statistical Analysis:
All outcomes were reported with the mean ± (standard deviation) or number (%) and compared with the Mann-Whitney U test, student t-test, or the ?2 test. A P value lower than 0.05 was considered statistically significant. Analyses were performed using SPSS software version 16.

Sample size:
Power analysis was carried out before the study to determine the minimum patient number. The sample size, n=38, in each group was required based on the following four assumptions: (a) significant difference such as 20 % difference in the percentage decrease in static compliance; (b) 20 % variability in sample; (c) a type I (?) error of 5 %; and (d) a type II (?) error of 20 % (12)

Results
Eighty-four patients were assessed for eligibility. Eight patients were excluded: 1 patient declined to participate and 7 patients not meeting inclusion criteria. Seventy-six patients were randomized, 38 to each treatment group. All patients received the allocated treatment and none were lost to follow-up. In total, 76 patients completed the study (Fig. 1). Demographic and perioperative characteristics were similar in both groups (Table 1).
During insufflation, static compliance was significantly lower in moderate NMB group than that in deep NMB group (p=0. 001). After insufflation, both Peak airway pressure (PAWP) and mean airway pressure (MAWP) in moderate NMB group were significantly higher than that in deep NMB group (Table 2). MAWP was significantly higher after desufflation compared to baseline in both groups. Static compliance (TV / PlatoP -PEEP) was decreased significantly during insufflation, compared to baseline in both groups. Also, it has been increased significantly after desufflation, compared to that during insufflation in both groups.

Optimal surgical space conditions during the entire procedure were found in 15 of 38 (39.5%) patients allocated to deep blockade and in 5 of 38 (13.6%) patients allocated to moderate blockade (P = 0.009).
Laparoscopic cholecystectomy was completed at Pneumoperitoneum 8 mm Hg in 35 (92%) patients in the deep group compared with 29 (76.3%) patients in the moderate group (P = 0.059).

There were no significant differences between both groups in postoperative pain according to VAS score . Also, there were no significant differences in postoperative nausea or vomiting, within 24 hours postoperatively between both groups. There were no documented adverse reactions or serious adverse reactions considered related to rocuronium by the investigators.

Discussion
The present study showed that deep, continuous neuromuscular blockade was associated with lower airway pressures and better static compliance than that with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy.
During laparoscopic surgery pneumoperitoneum increases intra-abdominal pressure and elevates the diaphragm upwards, so increase peak airway pressure and decrease both lung and chest wall compliance. In contrary, reduction of intra-abdominal pressure decreases airway pressure and improves respiratory system compliance. Deepening the level of NMB may be also useful, as it increases the level of muscle relaxation and decreases chest wall stiffening.( HYPERLINK l “_2s8eyo1” h 3)
PTC monitoring can be used to determine the level of relaxation in muscles of the abdomen and the chest, including the diaphragm, which is the most resistant to NMB. PTC less than 5 indicates adequate NMB, even for the diaphragm.(13) in Comparison with moderate or shallow NMB, deep NMB with a low insufflation pressure during pneumoperitoneum facilitates the recruitment of lung and gas exchange, lowers the release of inflammatory mediator, respiratory system elastance, and lung hyperinflation,(3, 14)
Several studies (15, 16) have investigated the changes in ventilatory mechanics during pneumoperitoneum during laparoscopic surgery. But, to our knowledge, there is no data comparing the effect of deep, continuous neuromuscular blockade on respiratory mechanics during low-pressure laparoscopic cholecystectomy.
Carron M (17) has reported his experience with deep NMB in a 24-yr-old Woman with an end stage lung disease undergoing laparoscopic appendectomy. Carron concluded that deep NMB improves respiratory patterns and should be recommended in high-risk respiratory patients undergoing laparoscopic surgery. Also in context with our results regarding neuromuscular blockade, Gainnier et al showed decreased Peak and plateau pressures in patients with acute respiratory distress syndrome when a deep level of neuromuscular blockade was obtained by abolition of all twitches of the train-of-four. (18)
In contrary to the present study, in an experimental animal study Chassard et al, evaluated the Effects of Neuromuscular Block on Peak Airway Pressure and Abdominal Elastance during Pneumoperitoneum of 15 mmHg and concluded that high peak inspiratory airway pressures and intraabdominal pressures during laparoscopy are not affected by neuromuscular block. (19)
In our study, deep continuous neuromuscular blockade was associated with better surgical space conditions during the entire procedure than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy. Also, there tended to be more procedures completed at Pneumoperitoneum 8 mm Hg (92%) of patients in the deep group compared with (76.3%) patients in the moderate group. Anne K. et al (8) found that laparoscopic cholecystectomy was completed at pneumoperitoneum 8 mm Hg in 60% and 34.8% patients in the deep and moderate group, respectively, However, Anne K. et al compared deep NMB (PTC 0-1) with a group that received 0.3 mg/kg Rocuronium followed by spontaneous recovery. This cannot be considered a moderate NMB.( HYPERLINK l “_3dy6vkm” h 10)
An article by Baete et al. compared the effect of deep neuromuscular block against moderate neuromuscular block on surgical conditions and postsurgical pulmonary function in bariatric laparoscopic surgery failed to document any differences between moderate NMB versus deep NMB with respect to surgical conditions during laparoscopic bariatric surgery or postoperative pulmonary function. (20) Several explanations are possible for the discrepancy with our results. First is that we did exclude patients with BMI ?30. The increased abdominal wall mass and intraperitoneal fat can lead to decreased intraperitoneal volume expansion and therefore visibility for equal pneumoperitoneum pressures. Second, the study by Baete et al. was underpowered. As such, negative results should not be interpreted as lack of an effect. Finally, we measured intraoperative respiratory mechanics while they measured Postoperative Respiratory Function where no paralysis or increased intraabdominal pressure is there.

We found no difference in postoperative pain or incidence of postoperative nausea or vomiting within 24 hours postoperatively between patients, who had received a deep or a moderate neuromuscular blockade during laparoscopic cholecystectomy, Low-pressure pneumoperitoneum has been associated with significantly lower postoperative pain,(6, 21-23) including shoulder tip pain.(6, 23-25) Many factors contribute to pain after laparoscopic cholecystectomy with pain coming from the incision sites, the dissected viscera, and from the pneumoperitoneum.
Strengths of this trial include many items as, the methods used to decrease bias (blinded randomization assignments, a well-defined study protocol, and complete follow-up). Also, two experts conducted neuromuscular monitoring in accordance with “Good Clinical Research Practice in Pharmacostatic Studies of Neuromuscular Blocking Agents II.( HYPERLINK l “_4i7ojhp” h 26)
A limitation to the current study is that our sample was otherwise healthy patients undergoing elective laparoscopic surgery and therefore more studies are required to study the effects of deep NMB on respiratory mechanics in patients with coexisting cardiopulmonary diseases.

In conclusion, we found that deep, continuous neuromuscular blockade improves both airway pressure and static compliance than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy. Further studies are required to validate these results especially in patients with coexisting cardiopulmonary diseases.
References
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Table 1: Demographic data
Group I (n=38) Group II (n=38) P value
Age 40.59±11.97 42.53±13.12 0.508
Weight 77.05±9.97 75.37±10.923 0.485
Height 159.95±6.43 161.24±8.44 0.466
Sex (male/female) 28/10 31/7 0.409
Surgeries not completed as low pressure (n) 3/38 9/38 0.059
Values are mean ± standard deviation or numbers.

Table2: The respiratory mechanics of the patients (mean ± standard deviation)
Baseline 15 min. Postinsuflation10 min. Post-deflation
Group I Group II Group I Group II Group I Group II
Compliance 33.39±7.16 32.34±6.89 28.08±5.9 23.79±4.67* 33±6.18 31.24±4.9
MAWP 7.32±1.7 7.79±1.75 9.47±1.84 11.76±2.22* 8.21±1.44** 8.66±2**
PAWP 20.42±3.83 20.03±4.16 24.13±3.9 26.63±5.35* 19.8±3.25 20.32±3.48
Mean BP
85.08±12.47 82.88±9.21 87.73±7.67 84.73±5.72 85.57±9.3 82.24±10.78
Heart Rate 80.03±11.85 78.7±12 81.63±11.9 81.03±16.14 81.6±13.26 79±15
*The change was significant (p<0.05) when compared to group I at the same time frame.

** The change was significant (p<0.05) when compared to the same group at baseline.

Figure Ligands:
Fig 1: Consort Flow Chart.

Fig 2: Mean compliance difference between groups in the 3-time points of measurement.

Figures:
Figure 1:
Figure 2:

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