Avoiding Neuromuscular Blockers to Reduce Complications

Study Overview
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Brief Summary
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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.

Detailed Description
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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.

Official Title
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Eliminating Use of Non Depolarizing Neuromuscular Blocking Agents to Reduce Postoperative Pulmonary Complications: A Multi-center, Randomized Control Trial

Conditions
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Pneumonitis, Respiratory Failure, Respiratory Infection, Aspiration Pneumonia, Atelectasis, Bronchospasm

Intervention / Treatment
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* Drug: Neuromuscular Blocking Agents
* Drug: Anesthetic Adjuncts


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Control Group (C)<br>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. | Drug: Neuromuscular Blocking Agents<br>* Use of non depolarizing neuromuscular blocking agents for maintenance of general anesthesia.<br>* Other names: Rocuronium;|
| Experimental: No Relaxant Group (NR)<br>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. | Drug: Anesthetic Adjuncts<br>* Use of deeper plane of inhaled anesthetics or adjuncts (opioids, propofol, dexmedetomidine or ketamine for maintenance of general anesthesia.<br>* Other names: opioids, propofol, dexmedetomidine or ketamine;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants who either had postoperative pulmonary complications or died in hospital within 28 days of index procedure. | Composite of respiratory failure, suspected respiratory infection, aspiration pneumonia or pneumonitis, atelectasis, bronchospasm, reintubation and all cause in-hospital mortality | 28 Days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Vasopressor Use Between Groups | Vasopressor equivalent dose | During the surgery | 
| Duration of Intraoperative Hypotension | Mean arterial pressure <55mmHg | During the surgery | 
| Surgeon's Assessment of surgical field | Was the operative condition optimal for the surgeon graded qualitatively using a numerical rating scale of 1-4. A score of 1 indicates excellent operating conditions whereas 4 indicates conditions unacceptable to the surgeon. | During the surgery | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Neuromuscular Blocker Avoidance, Post Operative Pulmonary Complications, General Anesthesia Maintenance, Inhaled Anesthetics