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• W4233217535 abstract "We appreciate Dr. Carron’s interest in our article, and we agree that “Optimal surgical conditions are the result of synergistic effects of anesthetics, analgesics, and neuromuscular blocking agents carefully titrated during general anesthesia.” However, in their letter, they quote the statement of Madsen et al.1 that “there is good evidence that deep neuromuscular block compared to moderate neuromuscular block is associated with optimal surgical conditions.” We do not concur with this assertion. Of the 3 references2–4 that Dr. Carron cites in support of Madsen et al.’s conclusion, 2 have serious flaws in their protocols.2,3 We discuss these deficiencies at considerable length in our review.5 To give 1 example, in the article by Staehr-Rye et al.,3 the authors conclude that “Deep neuromuscular blockade was associated with surgical space conditions that were marginally better than with moderate muscle relaxation during low-pressure laparoscopic cholecystectomy.” However, at a point half-way through the surgical procedure, twitch height (T1) in the moderate neuromuscular block group was 47% of control (a train-of-four count of 4 with fade); and at the 75% time point, T1 was 89% of control (a train-of-four ratio >0.40).6 Thus, the authors were really comparing deep versus very shallow or minimal block for a considerable portion of the surgical procedure. In response to de Boer et al., we think that they have misread our position. We do not deny that neuromuscular-blocking agents may have a valuable role to play in achieving satisfactory operating conditions for laparoscopic surgery. Thus, we fail to see the relevance of the study by Blobner et al.,7 in which the authors compared surgical conditions under deep block with no block at all. To repeat, we do not believe that Madsen et al.’s article is authoritative. Simply labeling an article a “systematic review” does not guarantee that the study was conducted or reported with due rigor. A review and its conclusions can only be as good as the references it includes and the data it attempts to analyze. The article by Martini et al.4 was the only study that Madsen et al. cites that reasonably supports the hypothesis that deep versus moderate block may achieve superior conditions for the surgeon. The mean difference (±SD) in the rating scores between deep block (a post-tetanic count of 1 or 2) and moderate block were, however, very modest—only 0.7 units (4.7 ± 0.4 vs 4.0 ± 0.4, respectively). Furthermore, a potential weakness of this protocol was its small sample size (n = 12 per group). The rating scale used is, at best, a surrogate marker. The study did not find any differences in patient outcome. In fact, to the best of our knowledge, no study has identified that maintaining deep neuromuscular blockade improves surgical outcome or reduces complication rates. We are not convinced that it is reasonable to generalize from a single study of limited sample size showing a weak difference in surrogate markers in lieu of clinically important differences in patient outcomes or incidence of adverse events. Indeed, the utter lack of important differences in clinical outcomes or incidence of adverse events in any of the cited studies is more consistent with the evidence showing no benefit. Regrettably, investigators keep asking the wrong questions. For example, we think it is rather pointless to compare clinical conditions for laparoscopy during deep neuromuscular block versus no block at all.8,9 Such protocols do not reflect the reality of routine anesthetic practice. To summarize our position, with the exception of the article by Martini et al.,4 we have not been able to identify any studies that compare operating conditions for laparoscopy performed under deep neuromuscular block versus moderate block maintained until the end of surgery. Thus, we stand by our statement that the relative benefits of a sustained deep neuromuscular block over a sustained moderate block for laparoscopy are as yet unproven. The available data suggest that there are no important clinical benefits. In our practice, where sugammadex is not available, if the surgeon says conditions are less than satisfactory, we then take action. We administer additional relaxant, opioid, hypnotic, change the ventilatory pattern, or some combination of these. Problem solved. None of the cited studies consider the possibility that the surgeon and the anesthesiologist might actually communicate during surgery to maintain optimal surgical conditions without overdosing the patient. Finally, de Boer et al. suggest that further studies regarding this question are required. We believe that a prerequisite for any additional research is identifying a clinical problem that needs to be addressed. We cannot countenance intentionally administering an overdose of rocuronium to research subjects undergoing laparoscopic surgery in hopes of solving a nonexistent problem. Aaron F. Kopman, MD [email protected] Mohamed Naguib, MD Department of General Anesthesiology Institute of Anesthesiology Cleveland Clinic Cleveland, Ohio" @default.
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• W4233217535 date "2016-01-01" @default.
• W4233217535 modified "2023-09-25" @default.
• W4233217535 title "In Response" @default.
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