深肌松对腹腔镜结直肠手术中依托咪酯麻醉时 NOL 指导下瑞芬太尼需求的影响：一项随机对照试验。

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

机构信息

Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montréal, Montréal, Canada; Department of Anesthesiology and Pain Medicine, University of Montréal, Canada.

出版信息

J Clin Anesth. 2024 Dec;99:111659. doi: 10.1016/j.jclinane.2024.111659. Epub 2024 Oct 23.

DOI:10.1016/j.jclinane.2024.111659

PMID:39447530

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 in the deep NMB group compared to 494 (392-618) μg.h 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.

摘要

研究目的

评估深度神经肌肉阻滞对术中痛觉的影响。与腹腔镜手术中的中度神经肌肉阻滞相比，深度神经肌肉阻滞已被证明可改善手术条件和术后结果。然而，其对术中痛觉和阿片类药物需求的影响从未被评估过。

设计

单中心随机对照试验。

设置

手术室。

患者

我们纳入了 100 例 ASA I 至 III 级接受地氟烷-瑞芬太尼麻醉行腹腔镜结直肠手术的患者。

干预措施

患者被随机分为两组，分别采用罗库溴铵重复推注实现中度（1-3 个四肌反应）或深度（1-2 个强直后计数）神经肌肉阻滞（NMB）。两组均采用 Nociception Level（NOL）指数指导术中瑞芬太尼的给药。

测量

主要终点是手术每小时瑞芬太尼的总用量。次要终点包括 Leiden 手术评分量表（L-SRS）、腹腔内压、术后疼痛评分和阿片类药物的消耗。

主要结果

93 例患者进行了分析。深度 NMB 组 45 例，中度 NMB 组 48 例。深度 NMB 组术中瑞芬太尼的用量为 348（228-472）μg.h，而中度 NMB 组为 494（392-618）μg.h（P<0.001）。深度 NMB 组最低的 L-SRS 为 5（4-5），而中度 NMB 组为 3（2-5）（P<0.001）。深度 NMB 组的平均腹腔内压为 11.9（1.3）mmHg，而中度 NMB 组为 13（1.3）mmHg（P<0.001）。次要的术后结局，包括疼痛评分和镇痛药的使用，无明显差异。