Effect of neuromuscular blockade on opioid consumption in high-risk children undergoing adenotonsillectomy: A randomized-controlled trial.

BACKGROUND

Protective reflexes like coughing occur frequently during pediatric adenotonsillectomy (AT) and are difficult to blunt with anesthetics, potentially leading to higher than necessary opioid administration. Our objective was to evaluate if nondepolarizing neuromuscular blockade reduces opioid consumption and postoperative respiratory events, compared to no blockade, in children at high-risk for respiratory complications after AT.

METHODS

We conducted a patient- and assessor-blinded, superiority, randomized, controlled trial at a pediatric hospital between April and September 2024. We enrolled 172 children, 2-12 years of age, undergoing AT with pre-planned postoperative admission due to: age < 3 years, severe obstructive sleep apnea, or obesity. Participants were randomized to receive neuromuscular blockade or no blockade. Our primary outcome was cumulative intra- and postoperative opioid consumption until 24 h post-AT, or discharge, whichever occurred first. Secondary outcomes included respiratory events in PACU and on the ward until 24 h post-AT or discharge, whichever occurred first, and low minute ventilation (MV) in the PACU measured using a respiratory volume monitor.

RESULTS

There was no difference in cumulative opioid consumption between groups (0.209 [SE, 0.009] versus 0.188 [SE, 0.009] IV MME kg-1; difference 0.021; 95% CI -0.005 to 0.047) or intraoperative opioid administration (0.144 [SE, 0.006] versus 0.133 [SE, 0.006] IV MME kg-1; difference 0.011; 95% CI -0.007 to 0.029). Postoperative respiratory events occurred in 32/86 (49%) in the blockade group versus 38/86 (59%) in the no blockade group (aOR 0.55 95% CI 0.26 to 1.12). Low MV events occurred in 33/86 (38%) in the blockade group and 21/84 (25%) in the no blockade group (difference 13%, 95% CI -1 to 27%).

DISCUSSION: Among children at high risk of post-AT respiratory events, anesthesia with neuromuscular blockade compared with no blockade did not reduce opioid consumption. The findings do not support the use of neuromuscular blockade for this purpose.

TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT06225466 FUNDING: Merck Investigator Studies Program.