Background

The number of trials investigating the effects of deep neuromuscular blockade (NMB) on surgical conditions and patient outcomes is steadily increasing. Consensus on which surgical procedures benefit from deep NMB (a posttetanic count [PTC] of 1 to 2) and how to implement it has not been reached. The European Society of Anaesthesiology and Intensive Care does not advise routine application but recommends use of deep NMB to improve surgical conditions on indication. This study investigates the optimal dosing strategy to reach and maintain adequate deep NMB during total intravenous anesthesia.

Methods

Data from three trials investigating deep NMB during laparoscopic surgery with total intravenous anesthesia (n = 424) were pooled to analyze the required rocuronium dose, when to start continuous infusion, and how to adjust. The resulting algorithm was validated (n = 32) and compared to the success rate in ongoing studies in which the algorithm was not used (n = 180).

Results

The mean rocuronium dose based on actual bodyweight for PTC 1 to 2 was (mean ± SD) 1.0 ± 0.27 mg · kg−1 ·h−1 in the trials, in which mean duration of surgery was 116 min. An induction dose of 0.6 mg ·kg−1 led to a PTC of 1 to 5 in a quarter of patients after a mean of 11 min. The remaining patients were equally divided over too shallow (additional bolus and direct start of continuous infusion) or too deep; a 15-min wait after PTC of 0 for return of PTC to 1 or higher. Using the proposed algorithm, a mean 76% of all 5-min measurements throughout surgery were on target PTC 1 to 2 in the validation cohort. The algorithm performed significantly better than anesthesiology residents without the algorithm, even after a learning curve from 0 to 20 patients (42% on target, P ≤ 0.001, Cohen’s d = 1.4 [95% CI, 0.9 to 1.8]) to 81 to 100 patients (61% on target, P ≤ 0.05, Cohen’s d = 0.7 [95% CI, 0.1 to 1.2]).

Conclusions

This study proposes a dosing algorithm for deep NMB with rocuronium in patients receiving total intravenous anesthesia.

Editor’s Perspective
What We Already Know about This Topic
  • Deep neuromuscular blockade may be required for the safe execution of some surgeries
  • The optimal dosing strategy to reliably achieve deep neuromuscular blockade has not been defined
What This Article Tells Us That Is New
  • Application of a proposed practical dosing algorithm enabled the optimal level of deep neuromuscular blockade to be achieved in over three quarters of patients.
  • Use of the algorithm significantly increased the achievement of the target level of neuromuscular blockade compared to when clinical judgment alone was used.