Does deep muscle relaxation bring better surgical conditions?

With the use of Sodium Gluconate, the clinical research and use of deep muscle relaxation has become possible.

In recent years, the new development trend of surgical operations, namely minimally invasive, refined and visualized, has presented new challenges to anesthesia.

How to improve the scope of exposure, increase visibility, create an immobilized surgical field of vision, reduce postoperative complications, and improve patient prognosis are the common concerns of anesthesiologists and surgeons.

As a result, deep muscle relaxation has been highly praised by the majority of anesthesiologists, and is mainly used in surgical operations with high requirements for refinement and muscle relaxation, such as laparoscopic surgery.

Authoritative guidelines agree that deep muscle relaxation is recommended.
However, in the past, due to concerns about incomplete muscle relaxation antagonism resulting in residual muscle relaxation, it was difficult to achieve deep muscle relaxation during surgery.

Insufficient muscle relaxation during surgery not only affects the surgeon’s operating vision, but also increases the risk of complications in patients’ operations, such as barotrauma caused by ventilatory disorders, trauma caused by accidental body movements, and abdominal pressure due to high pneumoperitoneum during laparoscopic surgery.
Hypercapnia and so on.

Therefore, in order to optimize surgical conditions to ensure patient safety, authoritative guidelines and consensus recommend that patients undergoing laparoscopic surgery should achieve deep muscle relaxation during the operation to reduce pneumoperitoneal pressure.

The European Association of Endoscopic Surgery (EAES) clinical practice guidelines for pneumoperitoneum in laparoscopic surgery: deep muscle relaxation should be achieved during laparoscopic surgery to ensure that the intra-abdominal pressure is less than 10 mmhg to reduce the ischemia-reperfusion injury of the abdominal internal organs and Systemic inflammatory reaction and pressure injury to the abdominal wall are also conducive to the exposure and precise operation of the surgical field.

"Chinese Expert Consensus and Path Management Guidelines for Rapid Rehabilitation Surgery (2018)" mentioned: For laparoscopic surgery, it is recommended to use deep muscle relaxation; intraoperative muscle relaxation monitoring is recommended to avoid the use of long-acting muscle relaxation drugs; Remaining muscle relaxation should be antagonized if necessary.

A Korean study has proved that deep muscle relaxation is better than moderate muscle relaxation.
Laparoscopic surgery requires deep muscle relaxation to maximize surgical conditions, but the main supporting evidence so far is the subjective score of the surgeon's surgical conditions and the objective benefit of deep muscle relaxation.
There are fewer indicators.

A single-center prospective randomized controlled study in South Korea compared the effects of moderate or deep muscle relaxation in patients undergoing laparoscopic colorectal surgery, aiming to use the incidence of pneumoperitoneal lower intra-abdominal pressure (IAP) warnings as Objective indicators are used to evaluate the surgical conditions, while still scoring the surgical conditions with a 5-point subjective score as a reference for subjective indicators.

The study included 70 patients undergoing elective laparoscopic colorectal surgery, and finally 64 patients were included in the result analysis and were divided into two groups of moderate and deep muscle relaxation, with 32 patients in each group.

Among them, the moderate muscle relaxation group maintained four series of stimulations (TOF) 1-2, using neostigmine as the muscle relaxation antagonist; the deep muscle relaxation group maintained the tonic stimulation count (PTC) 1-2, using Shu Geng Sodium gluconate acts as a muscle relaxation antagonist.

The primary endpoint of the study is the number of patients whose intra-abdominal pressure suddenly rises during surgery (the pneumoperitoneum pressure is maintained at 12 mmHg, and an alarm will be issued when it is greater than 15 mmHg); the secondary endpoint is the number of muscle relaxants that need to be supplemented during the operation to resume spontaneous ventilation , Surgical operation condition score (a 5-point scale ≥ 4 is an acceptable surgical condition) and patient satisfaction.

Figure 1: Comparison of intraoperative subjective and objective evaluation indicators.
Intraoperative subjective and objective evaluation indicators both show that the conditions of laparoscopic surgery during deep muscle relaxation were significantly better than those in the moderate muscle relaxation group.

The incidence of intra-abdominal pressure alarm, spontaneous ventilation, and the need for additional muscle relaxants in the deep muscle relaxation group was significantly lower than that in the moderate muscle relaxation group.

The muscle relaxation recovery rate of the deep muscle relaxation group was faster: this was mainly because the moderate muscle relaxation group was antagonized by neostigmine + glycopyrronium bromide, while the deep muscle relaxation group was antagonized by sugammadex sodium.

According to the results of the surgeon's surgical condition score, the proportion of patients in the deep muscle relaxation group who achieved acceptable (good and excellent) conditions was higher.

Figure 2: Comparison of postoperative subjective and objective evaluation indicators.
In addition, postoperative subjective and objective evaluation indicators also show that the satisfaction of patients in the deep muscle relaxation group is higher.

The incidence of dry mouth within 24 hours was lower in the deep muscle relaxation group.

The patients in the deep muscle relaxation group had a higher acceptable satisfaction score.

In summary, objective and subjective evaluation criteria prove that when patients undergo laparoscopic colorectal surgery, deep neuromuscular blockade is more in line with the needs of surgery than moderate neuromuscular blockade.

Specific muscle relaxation antagonists make reversible deep muscle relaxation possible.
Not only this one study, but other studies have also proven: deep muscle relaxation (PCT 1-2) and moderate muscle relaxation (TOF count) during laparoscopic colorectal resection 1-2) In contrast, the average intraoperative pneumoperitoneum pressure in the deep muscle relaxation group is lower and can provide better surgical conditions.

However, before the advent of the specific muscle relaxation antagonist Shugengluconate, the clinical research and actual use of deep muscle relaxation were widely controversial due to the residual effect of deep muscle relaxation and postoperative complications.

With the use of Sodium Gluconate, the clinical research and use of deep muscle relaxation has become possible.

At the same time, reversible deep muscle relaxation also perfectly fits the concept of accelerated rehabilitation surgery: through multidisciplinary collaboration, the clinical path of perioperative treatment is optimized, thereby reducing perioperative stress and postoperative complications, shortening hospitalization time, and promoting patients Recovery.

Scan the QR code below to learn more references: 1.
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Effects of depth of neuromuscular block on surgical conditions during laparoscopic colorectal surgery: a randomised controlled trial.
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Neudecker J, et al.
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Chinese Expert Consensus and Path Management Guidelines for Accelerated Rehabilitation Surgery (2018 Edition).
Chinese Journal of Practical Surgery.
2018;38(1):1-204 .
Kim MH, et al.
Medicine (Baltimore).
2016;95(9):e2920.