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Updated: Nov 23, 2025
Deep Neuromuscular Blockade Leads to a Larger Intraabdominal Volume During Laparoscopy
Published on: June 25, 2013
Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective
Laura E Gilbertson1,2, Michael C Fiedorek1, Christopher S Fiedorek1
1Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
Insights
Rocuronium use in infants for pyloromyotomy can lead to prolonged neuromuscular blockade, even at low doses. Careful dosing or sugammadex may be needed to prevent delayed recovery after surgery.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
Background:
- Infants undergoing pyloromyotomy face high aspiration risk, necessitating rapid sequence induction.
- Succinylcholine complications in infants often lead to rocuronium substitution, despite its longer action.
Purpose of the Study:
- To assess neostigmine non-reversibility after rocuronium in laparoscopic pyloromyotomies.
- To correlate non-reversibility with rocuronium dose and out-of-operating-room time.
Main Methods:
- Bayesian logistic regression analyzed neostigmine non-reversibility in 306 infants.
- Bayesian median regression examined the link between rocuronium dose, non-reversibility, and out-of-operating-room time.
Main Results:
- 22.2% of patients experienced prolonged block.
- Increased rocuronium dose correlated with higher odds of neostigmine non-reversibility (OR 1.36 per 0.1 mg/kg).
- Non-reversibility significantly increased out-of-operating-room time, especially with higher rocuronium doses.
Conclusions:
- Rocuronium can cause prolonged blockade in infants undergoing pyloromyotomy, even at lower doses.
- Optimizing rocuronium dosage or considering sugammadex is recommended for improved patient recovery.
Background:
Infants undergoing pyloromyotomy are at a high risk of aspiration, making rapid sequence induction the preferred method of induction. Since succinylcholine use in infants can be associated with complications, rocuronium is frequently substituted despite its prolonged duration of action.
Aims:
To examine the likelihood of non-reversibility to neostigmine at the end of surgery in laparoscopic pyloromyotomies and its correlation to both rocuronium dose and out of operating room time.
Methods:
Patients who underwent laparoscopic pyloromyotomy for infantile hypertrophic pyloric stenosis, received rocuronium, and were reversed with neostigmine were included. Bayesian multivariable logistic regression was utilized to determine the probability of non-reversibility, and Bayesian multivariable median regression was performed to ascertain the correlation between out of operating room time and non-reversibility.
Results:
306 patients were analyzed with a median surgical duration of 19 min (interquartile range 16 to 23). 74% received succinylcholine for intubation followed by rocuronium, and the remaining received rocuronium alone. The median rocuronium dose was 0.41 mg/kg (interquartile range 0.27 - 0.56 mg/kg). Prolonged block occurred in 68 (22.2%) patients. There was a non-trivial probability of prolonged block with low rocuronium doses, and each 0.1 mg/kg increase in total rocuronium dose was associated with an odds ratio of 1.36 (95% credible interval: 1.17-1.58) of neostigmine non-reversibility at the end of surgery. Non-reversibility was correlated with a substantial increase in median out of operating room time (13.4 min, 95% credible interval: 5.5-20.8 min), which was compounded by high rocuronium dosing (2.2 min increase per 0.1 mg/kg for doses greater than 0.5 mg/kg, 95% credible interval: 0.7-3.6 min).
Conclusion:
Prolonged blockade can occur from rocuronium administration in infants undergoing pyloromyotomy even at low doses. Therefore, consideration of appropriate rocuronium dosing or the use of sugammadex should be considered.
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