Effects of Depth of Neuromuscular Block on Surgical Operating Conditions and on Time to Discharge From Post-anesthesia Care Unit in Patients Undergoing Gynecologic Laparoscopic Surgery: a Randomized Prospective Clinical Trial

Objectives.

The primary outcome of the study is to compare the impact of a deep neuromuscular blockade (TOF count = 0 and posttetanic count [PTC] 1-2) and a moderate neuromuscular blockade (TOF count= 1 - 3) on intraoperative surgical conditions assessed by the surgeon as a 5 points scale (Optimal= 5 points/ Good= 4 points / Adequate= 3 points / Poor = 2 points / Inadequate = 1 point).

The use of low intraabdominal pressure (IAP) and its impact on the surgical operating conditions has not yet been adequately defined in the literature, although, it is reasonable to consider that a deep neuromuscular blockade may be beneficial1, especially in gynecologic laparoscopic surgery.2, 3

Secondary outcome is to compare the time to discharge from post-anesthesia care unit (PACU) assessed with the WAKE© score.4 As per protocol adopted in our institution, patients are evaluated with the Modified Aldrete Score5 before discharging from PACU. However the WAKE© score , whichis constructed from the basic 10-point Modified Aldrete Score, addsthe "Zero Tolerance Criteria". In fact, the WAKE© score assigns a score from 0 to 2 to motor function, blood pressure, level of consciousness, respiratory function and oxygen saturation (with a maximum score of 10), plus the Zero Tolerance Criteria which address the presence or absence of pain, postoperative nausea and vomiting (PONV), shivering, pruritus, and orthostatic symptoms. A patient can be discharged from PACU when the WAKE© score is ≥ 9 and when there are not present any zero tolerance criteria (no pain, PONV, shivering, pruritus, and orthostatic symptoms).

The use of low IAP associated with the use of a deep neuromuscular blockade may improve the respiratory function and reduce the postoperative pain and PONV,1, 6-8 thus reducing the time spent in PACU.