Efficacy of deep versus moderate neuromuscular blockade in enhancing intra-operative safety and post-operative recovery after laparoscopic donor nephrectomy: a randomised controlled trial

M.H.D. Bruintjes, P. Krijtenburg, C.H. Martini, P.P. Poyck, F.C.H. d' Ancona, V.A.L. Huurman, M. van der Jagt, J.F. Langenhuijsen, W.N. Nijboer, C.J.H.M. van Laarhoven, A. Dahan, M.C. Warlé

Wednesday 13 march 2019

14:06 - 14:08h at Mauritszaal

Categories: Basaal, Parallelsessie

Parallel session: Parallelsessie IV - Klinisch I

Background: Laparoscopic donor nephrectomy is the gold standard to procure living donor kidneys. Postoperative recovery after laparoscopic donor nephrectomy is largely determined by the consequences of postoperative pain and analgesic consumption. It has been shown that deep neuromuscular blockade reduces postoperative pain scores, when compared to a moderate block. The aim of this study was to compare the effectiveness of deep versusmoderate neuromuscular blockade during laparoscopic donor nephrectomy in enhancing postoperative recovery.

Methods: We performed a phase IV, multicentre, double-blinded, randomised controlled trial in which ninety-six live kidney donors were randomly allocated to receive deep (PTC 1-2) or moderate (TOF 1-2) neuromuscular block. Our primary outcome was the early quality of recovery at postoperative day 1, measured by the Quality of Recovery-40 questionnaire. The QoR-40 is a validated patient-rated questionnaire, measuring 5 dimensions of recovery after surgery, including comfort, emotions, physical independence, pain, and patient support. Secondary outcome measures were: intra-operative adverse events, the quality of recovery at postoperative day 2, post-operative pain scores, the cumulative use of analgesics and length of hospital stay.

Results: The intention-to-treat analysis did not show a difference with regard to the quality of recovery, pain scores, analgesic consumption and length-of-stay. Significantly less intra-operative adverse events occurred in patients allocated to a deep NMB (1/48 versus6/48). Despite a clear protocol regarding neuromuscular monitoring and rocuronium dosing, we failed to establish and maintain a deep block in 7/48 patients. Therefore, we performed both an intention-to-treat analysis and a per-protocol analysis. The per-protocol analysis revealed that pain scores were significantly lower at 6h, 24h and 48h after surgery. Moreover the quality of recovery was significantly better at postoperative day 2 in patients receiving a deep versusmoderate block (179.5 ± 13.6 versus172.3 ± 19.2).

Conclusions: Our results show that an adequately maintained deep neuromuscular block improves intra-operative safety, post-operative pain scores and quality of recovery. As the intention-to-treat analysis did not reveal a difference regarding the primary endpoint, future studies should pursue if a thoroughly maintained deep NMB during laparoscopy improves relevant patient outcomes.