Laparoscopic ventral hernia repair is a common surgical procedure. However, muscle contractions and general muscle tension may impair the surgical view and cause difficulties suturing the hernial defect. Deep neuromuscular blockade (NMB) paralyses the abdominal wall muscles and may help to create better surgical conditions.The current study investigated if deep compared with no NMB improved the surgical view during laparoscopic ventral hernia repair.Crossover study.The study was carried out at Herlev and Gentofte Hospital, University of Copenhagen, Denmark and conducted from May 2015 until February 2017.A total of 34 patients were randomised in an investigator-initiated, assessor-blinded crossover design of deep vs. no NMB during laparoscopic ventral hernia repair.Adults scheduled for elective laparoscopic ventral hernia repair.Known allergy to any study medication, known homozygous variants in the butyrylcholinesterase gene, severe renal disease, neuromuscular disease, lactating or pregnant women, any indication for rapid sequence induction.Deep NMB was established with rocuronium and reversed with sugammadex. Anaesthesia was conducted with propofol and remifentanil.The primary outcome was evaluation of surgical view assessed on a five-point rating scale. Other outcomes included the surgical conditions during laparoscopic suturing of the hernia defect.We found no difference in ratings for the surgical view when comparing deep with no NMB: mean -0.1 (95% confidence interval -0.4 to 0.2) (P = 0.521, paired t test). However, deep compared with no NMB improved the rating score for surgical conditions while suturing the hernia defect (P = 0.012, Mann-Whitney U test). No differences were found in either total length of surgery (P = 0.76) or hernia suturing time (P = 0.81).Deep compared with no NMB did not change the rating score of the surgical view immediately after introduction of trocars during laparoscopic ventral hernia repair, but the surgical condition were improved during suturing of the hernia.ClinicalTrials.gov, NCT02247466.
INTRODUCTION. Studies have shown varying patient adherence to long-term non-invasive positive airway pressure therapy (nPAP). We aimed to investigate adherence to long-term nPAP in a Danish cohort of patients with chronic respiratory insufficiency and/or sleep-disordered breathing (SDB) due to neuromuscular disorders (NMD), obesity-hypoventilation syndrome (OHS) or other reasons. METHODS. This cohort study included all adult patients with association to the Respiratory Center East treated with long-term nPAP: bilevel (BiPAP), automatic (APAP) and continuous (CPAP) or adaptive servo-ventilation (ASV) with a remote monitoring system in April 2022. The primary outcome was adherence, defined as a median use of nPAP ≥ 4 hrs/day in April 2022. A preplanned extended subgroup analysis was conducted for patients with data on adherence from initiation and six months onwards. RESULTS. The primary analysis included 241 patients, of whom 90% were diagnosed with NMD (54%) or OHS (36%). The nPAP was used ≥ 4 hrs/day by 175 patients (73%), including 22 (100%) with ASV, 129 (72%) with BiPAP and 24 (59%) with APAP/CPAP. Treatment adherence was seen in 75% of patients with NMD, 64% with OHS and 84% with other reasons for SDB. The proportion of adherent subjects in the subgroup analysis of 55 patients was relatively stable throughout the six-month period, ranging from 67% to 75% with slight intraindividual variation. CONCLUSION. In this retrospective analysis of adults primarily with NMD and OHS, 73% used the prescribed nPAP therapy ≥ 4 hrs/day. FUNDING. None TRIAL REGISTRATION. ClinicalTrials.gov(NCT05379309).
Background Recently, studies have focused on how to optimize laparoscopic surgical workspace by changes in intra‐abdominal pressure, level of muscle relaxation or body position, typically evaluated by surgeons using subjective rating scales. We aimed to validate two rating scales by having surgeons assess surgical workspace in video sequences recorded during laparoscopic surgery. Method Video sequences were obtained from laparoscopic procedures. Eight experienced surgeons assessed the video sequences on a categorical 5‐point scale and a numerical 10‐point rating scale. Intraclass correlations coefficients ( ICC ) and 95% confidence intervals ( CI ) were calculated for intra‐ and inter‐rater reliability. Results The 5‐point rating scale had an intra‐rater ICC of 0.76 (0.69; 0.83) and an inter‐rater ICC of 0.57 (0.45; 0.68), corresponding to excellent and fair reliability, respectively. The 10‐point scale had an intra‐rater ICC of 0.86 (0.82; 0.89) and an inter‐rater ICC of 0.54 (0.39; 0.68), corresponding to excellent and fair as well. All surgeons used the full range of the 5‐point scale, but only one surgeon used the full range of the 10‐point scale. Conclusion In conclusion, both scales showed excellent intra‐rater and fair inter‐rater reliability for assessing surgical workspace in laparoscopy. The 5‐point surgical rating scale had all categories employed by all surgeons.
Editor, Drs Warlé and Dahan1 raise some interesting suggestions regarding what caused the results in our study investigating the effect of deep neuromuscular blockade in combination with low insufflation pressure on postoperative shoulder pain.2 As a starting point it is important to underline that we investigated a combination of two interventions (i.e. deep neuromuscular blockade and low-pressure pneumoperitoneum) and therefore only are able to reach conclusions about this combination. Whether one intervention contributed more than another therefore remains speculation. In this matter we speculate that the effect was mainly because of the lower insufflation pressure as we are uncertain that there exists a rational explanation of an analgesic effect of either deep neuromuscular blockade or sugammadex based on the current evidence. Warlé and Dahan refer to an interesting study reporting an analgesic effect of a patient group receiving sugammadex after bariatric laparoscopy.3 The study found an analgesic effect on visual analogue scale scores within 30 to 60 min postoperatively in patients administered sugammadex 2 mg kg−1 compared with patients receiving neostigmine 0.05 mg kg−1 along with atropine 0.02 mg kg−1.3 When interpreting the results from this study3 some important issues must be highlighted. In their discussion the authors suggest that their findings may be because of the effect of neostigmine on gastrointestinal motility which may promote movements through the anastomosis causing pain. The results may therefore not be because of an analgesic effect of sugammadex but instead it might be neostigmine causing the pain. Nevertheless, the results are interesting findings, but based on this study we still do not believe that sugammadex per se has an analgesic effect. Finally, it is important to underline that the study does not report the level of neuromuscular blockade under which the laparoscopy was performed. The authors only report that the neuromuscular blockade was reversed when train-of-four counts exceeded two. Also it is unclear if patients and assessors were blinded to the intervention. Warlé and Dahan suggest that deep neuromuscular blockade may have an analgesic effect as deep neuromuscular blockade facilitates maximum stretching of the abdominal muscles. In theory this may lead to an increased abdominal wall compliance that may reduce pressure-related postoperative shoulder pain. It was because of this hypothesis, based on preliminary observations,4 that we conducted our study.2 While performing our study we also performed another study investigating the effect of deep neuromuscular blockade on the size of the abdominal wall during gynaecologic laparoscopy.5 In a blinded, randomised, cross-over design, we found that deep neuromuscular blockade increases the size of the insufflated abdomen by approximately 3 mm (when measuring from the edge of trocar to the sacral promontory) during a pneumoperitoneum of 8 and 12 mmHg, respectively.5 The clinical effect of this increase is still unknown. However, in our study the employment of deep neuromuscular blockade may have allowed a reduction in the pneumoperitoneum pressure to 8 mmHg which led to a reduced incidence of postoperative shoulder pain. In conclusion, we agree that low insufflation pressure reduces pain after laparoscopy. However, we are uncertain based on the current evidence that either sugammadex or deep neuromuscular blockade has an analgesic effect per se. Acknowledgements relating to this article Assistance with the reply: none. Financial support and sponsorship: the original study was supported in part by a research grant from the Investigator Initiated Studies Program of Merck Sharp & Dohme Corp, USA. The opinions expressed in this reply are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp. Conflicts of interest: MRG, OI and MVM have received research grants from Merck. MVM, MRG, JR and OI have received speakers’ fees and honoraria from Merck. None of the authors have shares or options in any pharmaceutical company.
Neuromuscular blocking agents are commonly used during general anaesthesia but can lead to postoperative residual neuromuscular blockade and associated morbidity. With appropriate objective neuromuscular monitoring (objNMM) residual blockade can be avoided. In this survey, we investigated the use of objNMM in Denmark.We conducted an anonymous Internet-based survey distributed through e-mails to Danish public anaesthesia departments. The survey consisted of 15-17 short questions regarding the use of objNMM.A total of 653 (27%) anaesthetists from 90% of the hospitals answered the questionnaire. ObjNMM was always used by 58% of the anaesthetists and 86% used objNMM at least 75% of the times. Despite the frequent use, 75% of the anaesthetists experienced difficulties with objNMM in at least 25% of the cases. The likelihood of using objNMM was higher among nurse anaesthetists vs. anaesthesiologists (odds ratio (OR) 2.24 [95% confidence interval (CI): 1.62-3.08]), if the department had an employee with special interest in objNMM (OR 1.66 [95% CI: 1.12-2.47]), if the anaesthetist had < 5 years of experience (OR 1.88 [95% CI: 1.29-2.73]), or if experiencing difficulties with objNMM < 25% of the cases (OR 1.60 [95% CI: 1.00-2.57]).In this survey, Danish anaesthetists frequently, in an international perspective, use objNMM, but the use is often associated with technical difficulties.
Succinylcholine is usually metabolized quickly by the butyrylcholinesterase enzyme (BChE) but genetic variants of BChE may prolong the duration of action. The Kalow (K) variant is the most common mutation in the butyrylcholinesterase gene (BCHE), being present in 25% of Caucasians. The significance of the K-variant for the duration of action of succinylcholine has not been well studied. Our hypothesis was that the duration of action of succinylcholine would be prolonged in patients heterozygous for the K-variant genotype compared with the normal genotype (wild-type).We included 70 adult surgical patients who received succinylcholine 1 mg/kg for rapid sequence induction. Neuromuscular monitoring was performed using ulnar nerve stimulation and acceleromyography. Duration of action of succinylcholine was defined as the time to 90% recovery of first twitch in train-of-four (T(1) 90%), BChE activity was determined, and the presence of BCHE K and A (atypical) variants were determined using DNA analysis.The wild-type BCHE was present in 38 patients, and 21 were heterozygous for the K-variant. Mean (SD) T(1) 90% in patients heterozygous for the K-variant, 11.6 (3.5) minutes, was longer than in patients with the wild-type genotype, 9.5 (2.7) minutes (P = 0.023), with a mean (95% confidence interval) difference of 2.1 (0.3-4.0) minutes. Patients heterozygous for the K-variant had a BChE activity of 5978 U/L compared with 7703 U/L in the wild-type group (P = 0.0045).We conclude that the mean duration of action of succinylcholine is prolonged for the patient heterozygous for the K-variant allele by at most 4 minutes relative to the wild-type, but this difference is small relative to the wide variability and overlap in recovery times among all patients.
Flexible fibreoptic endoscopic (FFE) intubation is considered the 'gold-standard' when difficult airway management is anticipated. Several videolaryngoscopes have been developed to facilitate intubation by laryngoscopy.The aim of the study was to compare the performance of the McGrath series 5 videolaryngoscope (McGrath videolaryngoscope) and the FFE for tracheal intubation in manikins with a simulated difficult airway, hypothesizing that the McGrath videolaryngoscope intubation would prove faster than FFE intubation.A randomised controlled study.The Danish Institute for medical simulation between December 2009 and June 2010.Twenty-eight anaesthesia residents participating in the Danish mandatory 3-day airway management course.All participants received instructions and training in the use of the McGrath videolaryngoscope and FFE. The participants then performed tracheal intubation on a SimMan manikin once with the McGrath videolaryngoscope and once with the FFE in three difficult airway scenarios: (1) pharyngeal obstruction; (2) pharyngeal obstruction and cervical rigidity; (3) tongue oedema.We measured successful intubations, defined as intubation within 120 s, and time to tracheal intubation.The trachea was intubated within 120 s with the McGrath videolaryngoscope in 25 out of 27 (93%), 25 out of 28 (89%) and 18 out of 28 (64%) occasions compared with 11 out of 28 (40%), 11 out of 28 (40%) and 16 out of 28 (57%) with the FFE in scenarios (1), (2) and (3), respectively. Time to tracheal intubation was shorter with the McGrath videolaryngoscope in scenarios (1) and (2) than with the FFE (Wilcoxon signed rank sum test, P < 0.0001).The McGrath videolaryngoscope is a valuable device with higher success rate and a quicker performance in simulated difficult airways. In patients, videolaryngoscopy may have a role in difficult airway algorithms, but the optimal device has yet to be found.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)
'%3e%3cpath fill='%23001489' d='M0 0v6h9V0z'/%3e%3cpath fill='%23e03c31' d='M0 0v3h9V0z'/%3e%3cg stroke='%23fff' stroke-width='2'%3e%3cpath id='d' d='m0 0 4.5 3L0 6m4.5-3H9'/%3e%3cuse xlink:href='%23b' stroke='%23ffb81c' clip-path='url(%23c)'/%3e%3c/g%3e%3cuse xlink:href='%23d' fill='none' stroke='%23007749' stroke-width='1.2'/%3e%3c/g%3e%3c/svg%3e)
'/%3e%3cuse xlink:href='%23a' transform='rotate(23.036 .093 25.536)'/%3e%3cuse xlink:href='%23a' transform='rotate(45.87 1.273 16.18)'/%3e%3cuse xlink:href='%23a' transform='rotate(69.945 .996 12.078)'/%3e%3cuse xlink:href='%23a' transform='rotate(20.66 -19.689 31.932)'/%3e%3c/svg%3e)