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A 2-month-old infant is scheduled for a laparoscopic gastrostomy tube placement. According to a recent study of the effects of neuromuscular blockade (NMB) on surgical conditions during laparoscopic surgeries in neonates and small infants, all of whom received 2 µg/kg of remifentanil at induction, which of the following outcomes is MOST likely in patients who received NMB compared with those who did not receive NMB?
(A) Lower rate of adverse events during induction of anesthesia ✔
(B) Better quality of laparoscopic surgical conditions X
(C) Higher rate of adverse events in the postanesthesia care unit X
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It is well known that using neuromuscular blockade (NMB) optimizes laparoscopic surgical conditions in the adult patient population, but only limited data are available regarding its effects in neonates and small infants. Because of a high incidence of residual NMB in neonates and infants, anesthesia care providers are relatively conservative in administering muscle relaxants to young children. The authors of a recent study sought to determine the effect of NMB on laparoscopic surgical conditions in neonates and small infants.
In this single-center, prospective, parallel-design, randomized controlled trial from China, 102 neonates and small infants aged up to 60 weeks’ postmenstrual age scheduled for laparoscopic Ladd’s procedure were enrolled from November 2021 to December 2022. Children with any of the following were excluded: gestational age of less than 26 weeks, abnormal development, developmental delay, known or suspected neuromuscular disease, chromosomal abnormality, allergy to anesthesia medications, congenital airway malformation, respiratory disease (including asthma, pneumonia, congenital pulmonary abnormality, and upper respiratory tract infections within the previous 2 weeks), previous intrabdominal surgery, and severe obesity.
The primary outcome was the quality of the surgical conditions, as evaluated by the operating surgeon at 0, 15, 30, 45, and 60 minutes after CO2 insufflation using the Leiden-Surgical Rating Scale (L-SRS). This is a 5-point scale where 1 = extremely poor, 2 = poor, 3 = acceptable, 4 = good, 5 = excellent. Secondary outcomes were perioperative data and adverse events. Perioperative data included surgical duration, pneumoperitoneum duration, peak airway pressure during insufflation, train-of-four count, drug dosages, time to tracheal extubation, and duration of postanesthesia care unit (PACU) stay. Adverse events included laryngospasm or bronchospasm, clinically unacceptable intubation conditions, transient hypoxemia, intraoperative movement, peak pressure of 25 cm H2O or greater, breathing against the ventilator, L-SRS less than 3, and apnea and delayed recovery in the PACU.
Patients were randomly assigned to 1 of 3 groups: no NMB, shallow NMB (0.45 mg/kg of rocuronium at intubation with no maintenance dose unless poor surgical conditions occurred), or moderate NMB (0.6 mg/kg of rocuronium at intubation followed by continuous rocuronium infusion to maintain train-of-four count at 1 to 2 twitches). The surgeon, intubating anesthesiologist, and research team collecting the data were all blinded to the group assignments. Of note, all intubations and surgical procedures were performed by the same anesthesiologist and the same surgeon. Inhalational induction with sevoflurane was used for all participants. In addition to rocuronium dosage based on the assigned groups, 2 µg/kg of remifentanil was also administered at the time of induction.
The 3 groups were similar in L-SRS scores and distribution at all assessment times, which indicates no difference was found in laparoscopic surgical conditions. Similarly, the rate of adverse events in the PACU was not found to be different among the 3 groups. The rate of adverse events was higher in the no NMB group (51.4%) than in the shallow NMB (13.6%) and moderate NMB (14.7%) groups during induction of anesthesia. The most common adverse event was clinically unacceptable intubation conditions, occurring in 34.3% of patients in the no NMB group versus 6.1% in the shallow NMB group and 2.9% in the moderate NMB group.
In conclusion, this study found that laparoscopic surgical conditions were not improved substantially with the use of NMB in neonates and small infants. However, shallow and moderate NMB reduced the risk of adverse events during induction of anesthesia, mainly, the occurrence of clinically unacceptable intubation conditions.
Reference
Date of last update: January 15, 2025
