Deep versus Moderate Neuromuscular Blockade During Total Hip Replacement Surgery on Postoperative Recovery and Immune Function: A Randomized Controlled Trial

Citation: Bijkerk V, Jacobs LMC, Rijnen WHC, Keijzer C, Warlé MC, Visser J. Deep versus Moderate Neuromuscular Blockade During Total Hip Replacement Surgery on Postoperative Recovery and Immune Function: A Randomized Controlled Trial. Anesthesia & Analgesia. 2026;142(2):355-364.

Study at a glance:

- Design and setting: Single-centre double-blind RCT (Netherlands) in adults undergoing elective primary or revision total hip arthroplasty under general anaesthesia (n=100; 50 deep vs 50 moderate block).

- Interventions: Rocuronium-based moderate neuromuscular blockade (TOF 1–2, bolus dosing, sugammadex 2 mg/kg) vs deep blockade (PTC 1–2 with absent TOF, infusion, sugammadex 4 mg/kg), both with opioid-based anaesthesia and standard perioperative care.

- Primary outcome (QoR-40 POD1): Mean QoR-40 scores were similar (163 with moderate vs 167 with deep block; mean difference −4.1 points, 95% CI −10.9 to 2.8; p=0.241), not reaching the minimally important difference and indicating no clear benefit of deep block; moderate-certainty evidence.

- Key secondary outcomes: Deep block showed slightly lower pain at rest on POD1 (about 1 NRS point) and lower PACU opioid use (~2 mg morphine equivalent), but estimates were imprecise; pain on movement, QoR-40 at day 30, opioid use over 24 h, surgical field rating, time to mobilisation, and length of hospital stay were all similar.

- Immune function and complications: Ex vivo TNF and IL-1β production on POD1 did not differ meaningfully between groups, and 30-day infectious (4/50 vs 1/50) and non-infectious complications (20/50 vs 18/50) were comparable, though the trial was too small for precise safety estimates.

- Certainty and applicability: Overall risk of bias was judged as “some concerns”, with GRADE rating mostly moderate but limited by imprecision; findings apply to elective hip arthroplasty in centres using quantitative neuromuscular monitoring and sugammadex and do not clearly support routine deep blockade solely to improve recovery or immune outcomes.