Impact of high-versus low-dose neuromuscular blocking agent adminstration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery1

Study article summarized by MSD


The main finding in the study was that deep neuromuscular block (NMB) was associated with significantly less incidences of readmissions within 30 days after surgery, compared to moderate NMB.

Given the study limitations, future prospective randomized studies in larger samples are needed to further investigate the benefit of high-dose relaxants on patient outcome.


  • Various recent studies show that deep NMB, induced by administration of a high dose of rocuronium, improves surgical conditions in certain procedures, such as retroperitoneal laparoscopic surgery and bariatric surgery
  • There is little or no information on the effect of deep NMB on postoperative outcome, such as readmittance within 30 days following discharge. A retrospective analysis were performed to compare unplanned 30-day readmissions in patients that received high-dose versus low-dose rocuronium administration during general anesthesia for laparoscopic retroperitoneal surgery
  • In Leiden University Medical Center, were this retrospective study was performed, it was routinely used deep NMB for various procedures since July 2015. Procedures included:
    • Laparoscopic surgery in urology
    • Open eye surgery
    • Neuroradiologic intervention
  • All deep NMBs are routinely reversed with sugammadex (4 mg/kg)


  • Deep NMB was defined as an induction dose of rocuronium (1 mg/kg), followed by a continous infusion, aimed at a post-tetanic count of 1-2. Deep NMB was reversed with suggamadex.
  • Patients were selected from a 51,000-patient cohort and resulted in 537 cases eligible for inclusion in the analysis. Following validation,407 cases were excluded
  • In the final analyses, it was performed a descriptive comparison of the perioperative data of 130 patients who received a deep NMB from July 2015 to December 2016 with a historic cohort of 130 gender and type of surgery matched patients who received a moderate NMB from January 2014 to July 2015


  • After matching for sex and type of surgery, patients who received deep or moderate NMB were also similar in their other characteristics (Table 1)

Table 1. Patient Characteristics of Study Population

Table 1

Adapted from Boon, PLOS One, 2018

  • Most surgery were laparoscopic surgery in kidney, followed by retroperitoneal lymf node resection, prostatectomy and pyeleumplasty (Table 2)

Table 2. Case Distribution of Surgical Procedures

Table 2

Adapted from Boon, PLOS One, 2018

  • There were no significant differences in duration of surgery, duration of anesthesia, length of stay, and other clinical parameters between deep and moderate NMB groups (Table 3)
  • Postoperative pain scores did not differ in the PACU and on the ward between deep NMB and moderate NMB.

Table 3. Clinical Parameters of Patients Who Received Deep versus Moderate NMB

Table 3

Adapted from Boon, PLOS One, 2018

  • Both cohorts were similar with respect to use of anesthetics and opioids but differed in use of relaxant and reversal agents. Rocuronium was the sole neuromuscular blocking agent used. In the deep NMB group, all 130 patients were reversed with sugammadex while in the matched moderate NMB cohort, 70 patients were reversed with either neostigmine (n=26) or sugammadex (n = 44) and the remaining patients were not reversed (Table 4)

Table 4. Use of NMB and NMB Reversal Agents

Table 4

Adapted from Boon, PLOS One, 2018

  • There were significantly less unplanned readmission rates within 30 days after surgery in patients who received deep NMB than those who received moderate NMB (Table 5)

Table 5. Unplanned 30-Day Readmission

Table 5

Adapted from Boon, PLOS One, 2018

Table 6. Reason for readmissions

Table 6

Adapted from Boon, PLOS One, 2018

Limitations to be considered:

  • Small retrospective study, single center, non-randomized
  • Study results can be due to high-dose rocuronium infusion, reversal with suggamadex or both
  • Higher opioid consumption in high-dose rocuronium group
  • Dataset lacks complete train of four data


  • 1. Boon M, Martini C, Yang HK, Sen SS, Bevers R, Warle´ M, et al. (2018), Impact of high-versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery. PLoS ONE 13(5): e0197036