A Practical Dosing Algorithm for Deep Neuromuscular Blockade during Total Intravenous Anesthesia: ROCURITHM

Anesthesiology, vol. 141, pp. 365–374

Abstract

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.

Authors 10

1. Kim I. Albers corresponding

   Radboud University Nijmegen · Radboud University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

   Resident, department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

2. Gabby T. J. A. Reijnders‐Boerboom corresponding

   Radboud University Nijmegen · Radboud University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

   Resident, department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

3. Veerle Bijkerk corresponding

   Radboud University Nijmegen · Radboud University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

   Resident, department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

4. Bart Torensma corresponding Aachen Department of Anesthesiology, Leiden University Medical Centre Clinical Epidemiologist

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands

   Clinical epidemiologist, department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands

5. Ivo F. Panhuizen corresponding

   Canisius-Wilhelmina Ziekenhuis

   Affiliation as printed

   Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

   Anesthesiologist, department of Anesthesiology, Canisius Wilhelmina hospital, Nijmegen, The Netherlands

6. Marc M. J. Snoeck corresponding

   Canisius-Wilhelmina Ziekenhuis

   Affiliation as printed

   Department of Anesthesiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands

   Anesthesiologist, department of Anesthesiology, Canisius Wilhelmina hospital, Nijmegen, The Netherlands

7. Thomas Fuchs‐Buder corresponding

   Centre Hospitalier Régional et Universitaire de Nancy

   Affiliation as printed

   Département d’Anesthésie et de Réanimation, Centre Hospitalier Universitaire Nancy/Brabois, Nancy, France

   7Département d’Anesthésie et de Réanimation, Centre Hospitalier Universitaire Nancy/Brabois, Nancy, France

8. Christiaan Keijzer

   Radboud University Nijmegen · Radboud University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

   Anesthesiologist, department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands

9. Albert Dahan corresponding Aachen Department of Anesthesiology, Leiden University Medical Centre Professor and anesthesiologist

   Leiden University · Leiden University Medical Center

   Affiliation as printed

   Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands

   Professor and anesthesiologist, department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands

10. Michiel C. Warlé corresponding

    Radboud University Nijmegen · Radboud University Medical Center

    Affiliation as printed

    Department of Surgery, Radboudumc, Nijmegen, The Netherlands

    Associate professor and vascular surgeon, department of Surgery, Radboudumc, Nijmegen, The Netherlands