Supraglottic airway, tracheal intubation, and neuromuscular block: will the ménage à trois endure?
2021; Elsevier BV; Volume: 127; Issue: 2 Linguagem: Inglês
10.1016/j.bja.2021.05.009
ISSN1471-6771
AutoresManfred Blobner, Jennifer M. Hunter,
Tópico(s)Medical History and Innovations
ResumoIt must not be forgotten that neuromuscular blocking agents were first introduced into anaesthesia in 1912 mainly to improve surgical conditions.1Läwen A. Über die Verbindung der Lokalanästhesie mit der Narkose, über hohe Extraduralansthesie und epidurale Injektionen anästhesierender Lösungen bei tabischen Magenkrisen.Beitr Klin Chir. 1912; 80: 168-189Google Scholar The key paragraph of Arthur Läwen's manuscript written in German reads: “A major problem with superficial anaesthesia is that the patient tenses the abdominal muscles excessively, especially when suturing the abdominal wall, so that a proper layered suture is made very difficult … I have now tried to prevent this tension of the abdominal muscles in another way. I have used curarine, the active substance produced by Boehm from the curare preparations. Curarine has the great advantage over the curare drugs of being a preparation that can be dosed exactly, where with absolute reliability the same dose always corresponds to the same effect … My intention was that anaesthesia and curarine effects should, in a way, meet each other … The effect on the abdominal wall was very clear and pleasant. Unfortunately, the curare drug is currently not available in sufficient quantities”.1Läwen A. Über die Verbindung der Lokalanästhesie mit der Narkose, über hohe Extraduralansthesie und epidurale Injektionen anästhesierender Lösungen bei tabischen Magenkrisen.Beitr Klin Chir. 1912; 80: 168-189Google Scholar However, even more than the lack of industrial production of curarine, Läwen's lack of scientific reputation and assertiveness in the eyes of the leading German surgeon of the time, Ferdinand Sauerbruch, were unfortunately responsible for this technique falling into oblivion. A similar fate affected the introduction of tracheal intubation. Franz Kuhn had published 15 manuscripts on this technique between 1901 and 1911 and summarised his collected findings in a book the year before Läwen's publication on curarine, but he also could not convince Sauerbruch of its benefits.2Kuhn F. Die perorale Intubation. Ein Leitfaden zur Erlernung und Ausführung der Methode mit reicher Kasuistik. S. Karger, Berlin1911Google Scholar In 1951, Läwen's findings were rediscovered by the British anaesthetist Cyril Scurr, who wrote in the British Journal of Anaesthesia3Scurr C.F. A comparative review of the relaxants.Br J Anaesth. 1951; 23: 103-116Abstract Full Text PDF PubMed Scopus (4) Google Scholar: “Such enlightened observations unfortunately attracted little notice at the time, and owing to shortage of supplies of the drug Läwen's work was curtailed.” However, by then the marriage of tracheal intubation and neuromuscular block had been delayed by two World Wars and 35 years. It is therefore not surprising that the seminal entry of neuromuscular block into the anaesthetist's armamentarium was again aimed at improving surgical conditions.4Griffith H.R. Johnson G.E. The use of curare in general anesthesia.Anesthesiology. 1942; 3: 418-420Crossref Google Scholar In the initial description of Intocostrin™ in Montreal, Canada in 1942, Griffith and Johnson4Griffith H.R. Johnson G.E. The use of curare in general anesthesia.Anesthesiology. 1942; 3: 418-420Crossref Google Scholar reported 25 operations in which small doses of the natural product had been used but without mention of tracheal intubation (or artificial ventilation). It was the perspicacity of Gray and Halton5Gray T.C. Halton J. A milestone in anaesthesia? (d-tubocurarine chloride).Proc R Soc Med. 1946; 39: 400-410Crossref Scopus (58) Google Scholar in England in 1946 that recognised the additional benefit of using neuromuscular blocking agents for effecting tracheal intubation as well as improving surgical conditions. An inseparable and eminently successful marriage of neuromuscular block and tracheal intubation was then born that lasted, largely unquestioned, for the next 50 years. This is because good to excellent intubating conditions6Scheller M.S. Zornow M.H. Saidman L.J. Tracheal intubation without the use of muscle relaxants: a technique using propofol and varying doses of alfentanil.Anesth Analg. 1992; 75: 788-793Crossref PubMed Google Scholar and atraumatic intubation7Mencke T. Echternach M. Kleinschmidt S. et al.Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial.Anesthesiology. 2003; 98: 1049-1056Crossref PubMed Scopus (322) Google Scholar are almost impossible without the use of neuromuscular blocking agents. Unsurprisingly, therefore, when Brain8Brain A.I. The laryngeal mask – a new concept in airway management.Br J Anaesth. 1983; 55: 801-805Abstract Full Text PDF PubMed Scopus (756) Google Scholar published his pilot study of airway management with the laryngeal mask airway (LMA™) in 1983, he had given small doses of neuromuscular blocking agents to aid its insertion. However, Brain8Brain A.I. The laryngeal mask – a new concept in airway management.Br J Anaesth. 1983; 55: 801-805Abstract Full Text PDF PubMed Scopus (756) Google Scholar stressed that the LMA™ could be successfully placed without the use of neuromuscular blocking agents. The original reason for introducing neuromuscular blocking agents into clinical anaesthesia in 1912, however, had by this time largely been forgotten. There had only been a few non-randomised trials that investigated the benefit of neuromuscular block for improving surgical conditions over several decades,9Foldes F.F. McNall P.G. Borrego-Hinojosa J.M. Succinylcholine: a new approach to muscular relaxation in anesthesiology.N Engl J Med. 1952; 247: 596-600Crossref PubMed Scopus (51) Google Scholar,10De Jong R.H. Controlled relaxation. II. Clinical management of muscle-relaxant administration.JAMA. 1966; 198: 1163-1166Crossref PubMed Scopus (9) Google Scholar until in 2000 King and colleagues11King M. Sujirattanawimol N. Danielson D.R. Hall B.A. Schroeder D.R. Warner D.O. Requirements for muscle relaxants during radical retropubic prostatectomy.Anesthesiology. 2000; 93: 1392-1397Crossref PubMed Scopus (68) Google Scholar compared the surgical conditions for radical retropubic prostatectomy in paralysed patients (train-of-four count ≤1) with those of non-paralysed patients. In two-thirds of patients receiving isoflurane and fentanyl alone, good to excellent operating conditions were obtained without the use of neuromuscular blocking agents.11King M. Sujirattanawimol N. Danielson D.R. Hall B.A. Schroeder D.R. Warner D.O. Requirements for muscle relaxants during radical retropubic prostatectomy.Anesthesiology. 2000; 93: 1392-1397Crossref PubMed Scopus (68) Google Scholar Typical of the low regard for the importance of surgical conditions still prevalent at the turn of the millennium was the authors' interpretation of the number needed to treat (95% confidence intervals): 16 (2–120) patients to be paralysed in order to avoid unacceptable conditions. They state “These findings suggest that anesthesiologists should at least consider whether muscle relaxants should be used routinely in some procedures, or whether more selective application when inadequate surgical conditions are actually present might be more appropriate”.11King M. Sujirattanawimol N. Danielson D.R. Hall B.A. Schroeder D.R. Warner D.O. Requirements for muscle relaxants during radical retropubic prostatectomy.Anesthesiology. 2000; 93: 1392-1397Crossref PubMed Scopus (68) Google Scholar As discussion of the risks of postoperative residual muscle weakness attributable to neuromuscular blocking agents12Viby-Mogensen J. Jorgensen B.C. Ording H. Residual curarization in the recovery room.Anesthesiology. 1979; 50: 539-541Crossref PubMed Scopus (238) Google Scholar and the related possibility of pulmonary complications13Berg H. Roed J. Viby-Mogensen J. et al.Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium.Acta Anaesthesiol Scand. 1997; 41: 1095-1103Crossref PubMed Scopus (529) Google Scholar gained momentum, there was speculation about removing both of the original partners in the marriage, neuromuscular block and tracheal intubation, by avoiding tracheal intubation and using a supraglottic airway device.14Kretz F.J. Reimann B. Stelzner J. Heumann H. Lange-Stumpf U. The laryngeal mask in pediatric adenotonsillectomy. A meta-analysis of medical studies.Anaesthesist. 2000; 49: 706-712Crossref PubMed Scopus (27) Google Scholar Furthermore, considerable efforts have been made, especially since the introduction of propofol and remifentanil,15Grant S. Noble S. Woods A. Murdoch J. Davidson A. Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil.Br J Anaesth. 1998; 81: 540-543Abstract Full Text PDF PubMed Scopus (76) Google Scholar to intubate patients whose airway needed to be secured for surgery without use of neuromuscular blocking agents.16Woods A.W. Allam S. Tracheal intubation without the use of neuromuscular blocking agents.Br J Anaesth. 2005; 94: 150-158Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Particularly in paediatric anaesthesia, it has become common clinical practice to perform tracheal intubation without neuromuscular blocking agents, despite concerns about laryngeal injury.17Simon L. Boucebci K.J. Orliaguet G. Aubineau J.V. Devys J.M. Dubousset A.M. A survey of practice of tracheal intubation without muscle relaxant in paediatric patients.Paediatr Anaesth. 2002; 12: 36-42Crossref PubMed Scopus (59) Google Scholar In addition to the surgical and patient-related causes of postoperative pulmonary complications, considerable blame has been levelled at the inappropriate use of neuromuscular blocking agents and reversal agents, and at the lack of quantitative neuromuscular monitoring.18Miskovic A. Lumb A.B. Postoperative pulmonary complications.Br J Anaesth. 2017; 118: 317-334Abstract Full Text Full Text PDF PubMed Scopus (294) Google Scholar In contrast, consideration of the role of airway management, and in particular tracheal intubation, in the development of pulmonary complications has been limited to avoiding the very rare complication of bronchial aspiration of gastric contents during rapid sequence induction.19Stept W.J. Safar P. Rapid induction-intubation for prevention of gastric-content aspiration.Anesth Analg. 1970; 49: 633-636Crossref PubMed Scopus (136) Google Scholar In paediatric anaesthesia, however, pulmonary morbidity from tracheal intubation is well recognised.20Engelhardt T. Virag K. Veyckemans F. Habre W. APRICOT Group of the European Society of Anaesthesiology Clinical Trial NetworkAirway management in paediatric anaesthesia in Europe-insights from APRICOT (anaesthesia practice in children observational trial): a prospective multicentre observational study in 261 hospitals in Europe.Br J Anaesth. 2018; 121: 66-75Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar In the Anaesthesia PRactice In Children Observational Trial (APRICOT) study, a large, multicentre study of critical anaesthetic events in children, tracheal intubation for securing the airway was associated with a higher risk of pulmonary complications compared with use of a supraglottic airway (adjusted odds ratio: 3.36 (2.41–4.67).21Habre W. Disma N. Virag K. et al.Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe.Lancet Respir Med. 2017; 5: 412-425Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar Another important finding in this study was the univariate association between the use of neuromuscular blocking agents and reduced combined risk of bronchospasm, laryngospasm, bronchial aspiration, and stridor in children during and soon after anaesthesia was no longer significant when adjusted for a number of relevant cofactors including age, sex, history of airway or environmental sensitivity, physical condition, anaesthesia plan, and, of particular note, the device used for airway management.21Habre W. Disma N. Virag K. et al.Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe.Lancet Respir Med. 2017; 5: 412-425Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar Moreover, observational studies in adults have recently cast doubt on the widely held belief that tracheal intubation causes negligible side-effects but neuromuscular block is harmful, hypothesising that a relevant fraction of postoperative pulmonary complications can be attributed to tracheal intubation.22Hammer M. Santer P. Schaefer M.S. et al.Supraglottic airway device versus tracheal intubation and the risk of emergent postoperative intubation after general anaesthesia in adults: a retrospective cohort study.Br J Anaesth. 2021; 126: 738-745Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In the POst-operative PULmonary Complications After Use of Muscle Relaxants in Europe (POPULAR) study it was not even possible to separate these two risks because of the narrow correlation between their use (r=0.831).23Kirmeier E. Eriksson L.I. Lewald H. et al.Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study.Lancet Respir Med. 2019; 7: 129-140Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar One almost always occurred with the other. What is more, use of a specific reversal agent was not associated with a better pulmonary outcome in analysis of the POPULAR data.23Kirmeier E. Eriksson L.I. Lewald H. et al.Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study.Lancet Respir Med. 2019; 7: 129-140Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar Even greater recovery of the train-of-four ratio to >0.95 was shown in a post-hoc analysis to be necessary to observe fewer pulmonary complications.24Blobner M. Hunter J.M. Meistelman C. et al.Use of a train-of-four ratio of 0.95 versus 0.9 for tracheal extubation: an exploratory analysis of POPULAR data.Br J Anaesth. 2020; 124: 63-72Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Conflicting observations on the benefit of sugammadex on postoperative pulmonary outcomes in recent observational studies in the USA support the notion that there may be an additional or different cause for these complications than residual neuromuscular block or the choice of a specific reversal agent.25Kheterpal S. Vaughn M.T. Dubovoy T.Z. et al.Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (STRONGER): a multicenter matched cohort analysis.Anesthesiology. 2020; 132: 1371-1381Crossref PubMed Scopus (85) Google Scholar,26Li G. Freundlich R.E. Gupta R.K. et al.Postoperative pulmonary complications' association with sugammadex versus neostigmine: a retrospective registry analysis.Anesthesiology. 2021; 134: 862-873Crossref PubMed Scopus (18) Google Scholar In 2020, the Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER) study suggested there were 30% fewer postoperative respiratory complications when sugammadex rather than neostigmine was used for reversal.25Kheterpal S. Vaughn M.T. Dubovoy T.Z. et al.Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (STRONGER): a multicenter matched cohort analysis.Anesthesiology. 2020; 132: 1371-1381Crossref PubMed Scopus (85) Google Scholar In contrast, a recent retrospective US study found no difference between the two reversal agents in this respect,26Li G. Freundlich R.E. Gupta R.K. et al.Postoperative pulmonary complications' association with sugammadex versus neostigmine: a retrospective registry analysis.Anesthesiology. 2021; 134: 862-873Crossref PubMed Scopus (18) Google Scholar as did the European POPULAR study.23Kirmeier E. Eriksson L.I. Lewald H. et al.Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study.Lancet Respir Med. 2019; 7: 129-140Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar It is therefore apposite to suspect that tracheal intubation, as the long-term partner of neuromuscular block, is a cofactor in the cause of postoperative pulmonary complications. With the availability of sugammadex, residual neuromuscular block can be prevented.27Bom A. Bradley M. Cameron K. et al.A novel concept of reversing neuromuscular block: chemical encapsulation of rocuronium bromide by a cyclodextrin-based synthetic host.Angew Chem Int Ed Engl. 2002; 41: 266-270Crossref PubMed Scopus (374) Google Scholar This reassuring development revives consideration of the importance of neuromuscular block for improving surgical conditions, in respect of both necessity and the required depth of neuromuscular block.28Blobner M. Frick C.G. Stauble R.B. et al.Neuromuscular blockade improves surgical conditions (NISCO).Surg Endosc. 2015; 29: 627-636Crossref PubMed Scopus (94) Google Scholar,29Martini C.H. Boon M. Bevers R.F. Aarts L.P. Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block.Br J Anaesth. 2014; 112: 498-505Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Nevertheless, postoperative pulmonary complications from the combination of neuromuscular block and tracheal intubation remain. It would seem that Wu and colleagues30Wu L. Wei S.W. Xiang Z. Yu E.Y. Qu S.Q. Du Z. Evaluation of surgical conditions during short-duration paediatric laparoscopic surgery using a ProSeal laryngeal mask airway with vs without a neuromuscular block.Br J Anaesth. 2021; 172: 281-282Abstract Full Text Full Text PDF Scopus (1) Google Scholar recognised the original indication for the use of neuromuscular blocking agents to improve surgical conditions, and that tracheal intubation is not mandatory just because neuromuscular blocking agents are given, certainly in paediatric practice. They present in this issue of the BJA a small, single-centre comparison of surgical conditions during short-duration paediatric laparoscopic herniotomy in patients with or without neuromuscular block.30Wu L. Wei S.W. Xiang Z. Yu E.Y. Qu S.Q. Du Z. Evaluation of surgical conditions during short-duration paediatric laparoscopic surgery using a ProSeal laryngeal mask airway with vs without a neuromuscular block.Br J Anaesth. 2021; 172: 281-282Abstract Full Text Full Text PDF Scopus (1) Google Scholar Importantly, in all children the airway was secured by a ProSeal LMA™ (Teleflex Incorporated, Wayne, PA, USA) during inhalational anaesthesia. It is perhaps less relevant that they found improved surgical conditions in the children who received a neuromuscular blocking agent to produce moderate neuromuscular block. More importantly, the children who received neuromuscular block had fewer intraoperative complications (12%) than those who did not (45%), even without tracheal intubation. Of course, the small number of children studied in no way establishes evidence. Nevertheless, the numbers allow for planning a large randomised, prospective, multicentre study that is capable of generating evidence. Hence, we have the first suggestion that (in children) the long-standing relationship between neuromuscular block and insertion of a tracheal tube can be separated. Larger randomised clinical trials in children and adults are necessary to prove the safety of surgically required paralysis in patients with only the use of a supraglottic airway, especially in terms of postoperative pulmonary complications. Both authors contributed equally to the writing of this manuscript. MB has received funding from MSD, Grünenthal, and GE Healthcare to give international lectures and to chair CME meetings within the past 5 yr. JMH was editor-in-chief of the British Journal of Anaesthesia from 1997 to 2005 and chair of the BJA board from 2006 to 2012. She has received funding from MSD and GE Healthcare to give international lectures and to chair CME meetings within the past 5 yr. Effect of neuromuscular block on surgical conditions during short-duration paediatric laparoscopic surgery involving a supraglottic airwayBritish Journal of AnaesthesiaVol. 127Issue 2PreviewUse of an LMA ProSeal™ laryngeal mask airway (P-LMA; Teleflex) with no neuromuscular block is considered a safe alternative to tracheal intubation in short-duration paediatric laparoscopic surgery. However, few studies have evaluated surgical conditions of short-duration paediatric laparoscopic surgery using this anaesthetic technique. We assessed surgical conditions for paediatric laparoscopic inguinal hernia repair using P-LMA with and without neuromuscular block. Full-Text PDF Open Access
Referência(s)