Avoiding Neuromuscular Blockers to Reduce Complications

Beth Israel Lahey Health

Status and phase: Terminated; Phase 4

Conditions: Respiratory Failure; Pneumonitis; Atelectasis; Aspiration Pneumonia; Bronchospasm; Respiratory Infection

Treatments: Drug: Anesthetic Adjuncts; Drug: Neuromuscular Blocking Agents

Study type: Interventional

Funder types: Other

Identifiers

NCT03962725

2019P000260

Details and patient eligibility

About

The goal of this study to evaluate whether eliminating the use of non-depolarizing neuromuscular blocking agents (NMBA) for maintenance of general anesthesia reduces postoperative pulmonary complications in higher risk patients.

Full description

Pragmatic prospective randomized controlled assessor-blinded effect-size finding trial involving approximately 100 patients total at two academic tertiary care hospitals: Beth Israel Deaconess Medical Center (BIDMC) and Massachusetts General Hospital (MGH). Patients will be randomized into one of two study groups: standard care group which uses Rocuronium (NMBA) as an adjunct for maintenance of general anesthesia and non-relaxant arm that avoids the use of NMBA and instead uses additional inhalational anesthetics, opioids, propofol, dexmedetomidine, or ketamine for maintenance of general anesthesia. Assessment of postoperative pulmonary complications and in-hospital mortality would be achieved by close review of the patient's medical records during the hospital stay, for a maximum of 28 days.

Enrollment: 3 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• At least 18 years of age
• Undergoing non-cardiac surgery under general anesthesia with an endotracheal tube
• those at higher risk of developing postoperative pulmonary complications (internally validated risk prediction score of >=20)

Exclusion criteria

• Emergency surgery
• Ambulatory (outpatient) surgery
• Scheduled for elective postoperative ventilation
• Planned return to operating room within 7 days of index procedure
• Exposure to general anesthesia within 7 days prior to planned procedure
• Requirement mechanical ventilation at baseline (not including stable use of CPAP/BiPAP)
• Pregnant patients: as detected by patient self-reporting or diagnosed by preoperative pregnancy testing according to institutional policies at BIDMC and MGH
• Allergy to either non-depolarizing muscle relaxants or sugammadex
• Clinician refusal
• Prisoner

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Double Blind

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3 participants in 2 patient groups

Control Group (C)

Active Comparator group

Description:

Endotracheal intubation would be facilitated by either Rocuronium (0.6-1mg kg-1) or Succinylcholine (1-1.5mg kg-1) and further dosing of Rocuronium would be left at the discretion of the anesthesia team members. Choice and technique of induction and maintenance of anesthesia, use of vasopressors, perioperative antibiotics, analgesics/adjunct regional techniques, prophylaxis for postoperative nausea and vomiting, fluid and blood component therapy would be left at the discretion of the anesthesia team. Neuromuscular blockade would be reversed with either Sugammadex or Neostigmine (based on institutional availability) and trachea would be extubated once patient meets criteria per attending anesthesiologist.

Treatment:

Drug: Neuromuscular Blocking Agents

No Relaxant Group (NR)

Experimental group

Description:

Endotracheal intubation would be facilitated by Succinylcholine (1-1.5mg/kg) or Remifentanil (1-2mcg kg-1) if Succinylcholine use is contraindicated. No non-depolarizing NMBA would be administered to the patients randomized to the NR group. Choice and technique of induction and maintenance of anesthesia, use of vasopressors, perioperative antibiotics, analgesics/adjunct regional techniques, prophylaxis for postoperative nausea and vomiting, fluid and blood component therapy would be left at the discretion of the anesthesia team. Use of deeper plane of inhaled anesthetics or adjuncts (opioids, propofol, dexmedetomidine or ketamine) either as boluses or infusion would be recommended in case of sustained high peak airway pressures (\>35mm Hg), high intra-abdominal pressure, involuntary patient/diaphragmatic movement hindering surgical exposure and dissection. Choice and dose of adjunct/s to optimize operating conditions would be left to the discretion of the anesthesia team.

Treatment:

Drug: Anesthetic Adjuncts