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Deep neuromuscular blockade improves surgical conditions during gastric bypass surgery for morbid obesity

A randomised controlled trial

Fuchs-Buder, Thomas; Schmartz, Denis; Baumann, Cédric; Hilt, Ludovic; Nomine-Criqui, Claire; Meistelman, Claude; Brunaud, Laurent

European Journal of Anaesthesiology (EJA): July 2019 - Volume 36 - Issue 7 - p 486–493
doi: 10.1097/EJA.0000000000000996
Neuromuscular blocking agents

BACKGROUND There is a controversy in the literature whether deep compared with moderate neuromuscular block (NMB) improves surgical conditions for laparoscopic surgery.

OBJECTIVES The primary outcome measure was to examine whether switching from moderate to deep NMB improves surgical conditions for laparoscopic surgery in the obese; secondary outcome measures were changes in intra-abdominal pressure, time required to perform the gastrojejunal anastomosis and peri-operative surgical complications.

DESIGN A single-centre, randomised controlled study. Each patient was taken as their own control and examined twice: at the first evaluation (E1), all patients had a moderate NMB, thereafter patients were randomised to deep or moderate block and a second evaluation (E2) was performed within 10 min. Patients with excellent rating at E1 were excluded from E2, as their surgical condition could not be further improved.

SETTING University Hospital France.

PATIENTS Patients undergoing laparoscopic gastric bypass surgery under general anaesthesia were included. Main exclusion criteria were hypersensitivity to the drugs used and absence of written informed consent.

INTERVENTIONS According to the group assignment, patients received bolus doses of rocuronium or 0.9% saline.

MAIN OUTCOME MEASURES Surgical conditions were assessed with a 4-point rating scale. Intra-operative adverse events were assessed with the Kaafarani-classification and postoperative complications with the Clavien-Dindo classification.

RESULTS Eighty-nine patients were initially included and data from 85 could be assessed at E1; surgical rating was excellent in 20, good in 35, acceptable in 18, poor in 12. After excluding those with an excellent rating, the remaining 65 patients were randomly assigned to deep or moderate block. At E2, an improvement of surgical conditions was observed in 29 out of 34 patients with deep block and in four out of 31 with moderate block; P < 0.0001. Poor surgical conditions were more frequently associated with surgical complications (61.5 versus 15.3%; P < 0.001).

CONCLUSION Switching from moderate to deep block improves surgical conditions. Poor surgical conditions were associated with a higher incidence of surgical complications.

TRIAL REGISTRATION identifier: NCT02118844

From the Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy (TF-B, DS, LH, CM), the Clinical Research Support Facility PARC, Brabois University Hospital (CB), the Multidisciplinary Unit of Bariatric Surgery, UMCO, Brabois University Hospital, University de Lorraine, CHRU Nancy (CN-C, LB), University de Lorraine, INSERM U954, Faculty of Medicine, Nancy, France (LB), and Department of Anesthesiology, Université Libre de Bruxelles, CHU Brugmann, Bruxelles, Belgium (DS)

Correspondence to Prof. Thomas Fuchs-Buder, University de Lorraine, CHRU Nancy, Brabois University Hospital, Department of Anesthesiology & Critical Care, 7 allée du Morvan, Vandoeuvre-les-Nancy 54511, France; E-mail:

Published online 12 April 2019

© 2019 European Society of Anaesthesiology