Deep neuromuscular block with pipecuronium in patients undergoing laparoscopic surgery - A prospective case series

We tested the feasibility of maintaining low intraabdominal pressures during pipecuronium-induced deep block (post-tetanic count ≥1, train-of-four count = 0) in patients undergoing laparoscopic surgery.

Ten adult patients awaiting cardiac surgery or heart transplantation and requiring non-elective abdominal surgery were included. Pipecuronium bromide 0.09 mg/kg was used for muscle relaxation and maintenance of deep block. Top-up doses of pipecuronium (0.01-0.02 mg/kg) were administered when post-tetanic count was 4-8. Intraabdominal pressures were kept below 10 mmHg. Mean arterial pressure was measured intra-arterially. Surgical field view was rated on a 5-point scale (1 = extremely poor, 5 = optimal).

Induction dose of 0.09 mg/kg pipecuronium had an onset time of 5.3 (2.3-6.3, 25-75% IQR) min. Deep block was maintained for 51.2 ± 19.7 min. Top-up pipecuronium doses were necessary in 5 patients, 56.0 ± 28.1 min after the first dose. At the end of surgery, neuromuscular block was deep (post-tetanic count 0-6). Administration of 2 mg/kg of sugammadex induced recovery to train-of-four ratio ≥0.9 in 3.5 ± 1.6 min, and to train-of-four ratio = 1.0 in 4.3 ± 1.2 min. Mean intraabdominal pressure was 8.1 ± 1.1 mmHg during pneumoperitoneum. There was no significant change in heart rate (0.0, -2.6 to 0) beats/min.

Pipecuronium is a rational alternative when deep neuromuscular block is necessary, because of its long-acting neuromuscular blocking effect that may be antagonized quickly and safely with sugammadex.

European Clinical Trials Database registration number: 2022-004114-11, Clinical Trials Database registration number: NCT06517524.