DI-025 Evaluation of a new protocol to induce/reverse neuromuscular blockade in bariatric surgery. (24th February 2014) - Descout, J
Abstract : Background: Bariatric surgery includes surgical interventions to reduce severe obesity (BMI > 35). For these procedures, anaesthesia with neuromuscular blockade is a high-risk step for the patient and especially obese patients. Intubation is based on rapid sequence induction (RSI) for two reasons: firstly obese patients are considered as 'full stomachs' and secondly they are potentially difficult to intubate. In addition, bariatric surgery requires a profound neuromuscular blockade to be maintained until the end of the intervention. In protocol 1 (P1), the drugs used to induce/reverse neuromuscular blockade were suxamethonium, atracurium, atropine and neostigmine. A new protocol (P2) using a new drug, sugammadex was introduced with rocuronium. Purpose: The first objective of this study was to assess a possible reduction in the length of the operation [operating theatre (OT) and/or post anaesthesia care unit (PACU)]. The second was to analyse the potential impact of this new protocol on the intervention safety. Materials and methods: A new anaesthesia protocol was written for bariatric surgery. The procedures for bariatric surgery in our hospital were investigated and data collected: population characteristics, time spent in OT and PACU, timing of drugs injection to reverse neuromuscular blockade, extubation time, place of extubation (OT or PACU). Results: Fifty-seven patients treated with the sleeve procedure were divided into 2 groups: 29 from September to December 2011 (retrospective study) with P1, 28 from March to May 2012 (prospective study) with P2. Patients were similar in the two groups. There was no significant difference in the length of time spent in the OT between the two protocols (the mean operating time was 175.4 min (P1) vs. 160.5 min (P2)). The monitoring time in the PACU was significantly reduced (p < 0.05) with sugammadex (154.2 min (P1) vs. 126.7 min (P2)). The time spent in PACU decreased by 30 min per patient allowing the possibility of more effective patient rotation in the unit. The average injection/extubation time was 13.4 min (P1) vs. 5.4 min (P2). Regarding intervention safety, extubations were systematic in OT thanks to sugammadex (extubation percentage in OT was 21% (P1) vs 100% (P2)). Furthermore, for all patients, reversal of blockade effect is possible with P2 and in less than 5 min. This protocol also decreased the residual paralysis risk after extubation (serious postoperative respiratory complications). Finally, sugammadex (P2) allows the eviction of drugs (P1) responsible for adverse events. Conclusions: Using this new protocol with sugammadex appears to offer many advantages: obtain a safe anaesthetic protocol for bariatric surgery and save time in PACU to optimise use of the unit. However sugammadex is expensive. For this reason, we also conducted an economic study. No conflict of interest.