Deep vs. moderate neuromuscular blockade during laparoscopic surgery: A systematic review and meta-analysis

Area of Science:

• Anesthesiology
• Surgical Technology
• Evidence-Based Medicine

Background:

• Previous studies suggest deep neuromuscular block (post-tetanic count 1-2 twitches) enhances laparoscopic surgical conditions over moderate block (train-of-four count 1-2 twitches).
• However, inconsistent results exist due to varying assessment scales and intervals in prior comparisons.

Purpose of the Study:

• To investigate the heterogeneity in previous comparisons of deep versus moderate neuromuscular block.
• To systematically analyze the impact of neuromuscular block depth on surgical conditions during laparoscopy.

Main Methods:

• A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted.
• Searches included Medline, EMBASE, and Cochrane Central Register of Controlled Trials up to October 2017.
• Eleven RCTs involving 844 patients compared deep versus moderate neuromuscular block for laparoscopic surgery, assessing surgical field conditions.

Main Results:

• Deep block was associated with a higher frequency of excellent or good operating conditions (OR 2.83; 95% CI 1.34-5.99).
• Subgroup analyses revealed significant differences in surgical rating with multiple assessments and variable abdominal pressures, but not with single assessments or fixed pressures.
• Trial sequential analysis indicated the trend favored deep block, but the required information size was not met.

Conclusions:

• Deep neuromuscular block appears more effective for achieving excellent or good surgical ratings in laparoscopy.
• The benefit is inconsistent across different assessment frequencies and abdominal pressure management strategies.
• Further high-quality RCTs are needed to resolve heterogeneity and address the power shortage identified in the trial sequential analysis.