Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum: A randomised controlled trial

TY - JOUR

T1 - Postoperative shoulder pain after laparoscopic hysterectomy with deep neuromuscular blockade and low-pressure pneumoperitoneum

T2 - A randomised controlled trial

AU - Madsen, Matias Vested

AU - Istre, Olav

AU - Staehr-Rye, Anne K

AU - Springborg, Henrik H

AU - Rosenberg, Jacob

AU - Lund, Jørgen

AU - Gätke, Mona R

PY - 2016/5/1

Y1 - 2016/5/1

N2 - BACKGROUND Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO 2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8-mmHg). OBJECTIVE The aim of this study was to investigate whether low-pressure pneumoperitoneum (8-mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12-mmHg) and moderate NMB (single bolus of rocuronium 0.3-mg-kg -1 with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy. DESIGN A randomised, controlled, double-blinded study. SETTING Private hospital in Denmark. PARTICIPANTS Ninety-nine patients. INTERVENTIONS Randomisation to either deep NMB and 8-mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12-mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days. MAIN OUTCOME MEASURES The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery. RESULTS Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P-=-0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores. CONCLUSION Deep NMB and low-pressure pneumoperitoneum (8-mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12-mmHg). TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01722097.

AB - BACKGROUND Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO 2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8-mmHg). OBJECTIVE The aim of this study was to investigate whether low-pressure pneumoperitoneum (8-mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12-mmHg) and moderate NMB (single bolus of rocuronium 0.3-mg-kg -1 with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy. DESIGN A randomised, controlled, double-blinded study. SETTING Private hospital in Denmark. PARTICIPANTS Ninety-nine patients. INTERVENTIONS Randomisation to either deep NMB and 8-mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12-mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days. MAIN OUTCOME MEASURES The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery. RESULTS Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P-=-0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores. CONCLUSION Deep NMB and low-pressure pneumoperitoneum (8-mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12-mmHg). TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT01722097.

KW - Activities of Daily Living

KW - Adult

KW - Analgesics, Opioid

KW - Denmark

KW - Double-Blind Method

KW - Female

KW - Hospitals, Private

KW - Humans

KW - Hysterectomy

KW - Laparoscopy

KW - Length of Stay

KW - Middle Aged

KW - Neuromuscular Blockade

KW - Pain Measurement

KW - Pneumoperitoneum, Artificial

KW - Pressure

KW - Recovery of Function

KW - Shoulder Pain

KW - Time Factors

KW - Treatment Outcome

KW - Journal Article

KW - Randomized Controlled Trial

KW - Research Support, Non-U.S. Gov't

U2 - 10.1097/EJA.0000000000000360

DO - 10.1097/EJA.0000000000000360

M3 - Journal article

C2 - 26479510

SN - 0952-1941

VL - 33

SP - 341

EP - 347

JO - European Journal of Anaesthesiology, Supplement

JF - European Journal of Anaesthesiology, Supplement

IS - 5

ER -