Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study.
OBJECTIVE
To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications.


METHODS
Prospective, propensity score matched cohort study.


METHODS
General teaching hospital in Boston, Massachusetts, United States, 2006-10.


METHODS
18,579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18,579 reference patients who did not receive such agents.


METHODS
The main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation <90% with a decrease in oxygen saturation after extubation of >3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade.


RESULTS
The use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26).


CONCLUSIONS
The use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited.
Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, 02114, USA.
Martina
M
Grosse-Sundrup
Justin P
JP
Henneman
Warren S
WS
Sandberg
Brian T
BT
Bateman
Jose Villa
JV
Uribe
Nicole Thuy
NT
Nguyen
Jesse M
JM
Ehrenfeld
Elizabeth A
EA
Martinez
Tobias
T
Kurth
Matthias
M
Eikermann
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D002800:Cholinesterase Inhibitors / Q000627:therapeutic use; D005260:Female; D006801:Humans; D000860:Hypoxia / Q000139:chemically induced; D007223:Infant; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000187:drug effects; D009388:Neostigmine / Q000627:therapeutic use; D003473:Neuromuscular Nondepolarizing Agents / Q000009:adverse effects*; D011183:Postoperative Complications / Q000139:chemically induced*; D011379:Prognosis; D057216:Propensity Score; D011446:Prospective Studies; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000139:chemically induced*; D019233:Retreatment / Q000706:statistics & numerical data; D012307:Risk Factors; D055815:Young Adult
D002800:Cholinesterase Inhibitors; D003473:Neuromuscular Nondepolarizing Agents; D009388:Neostigmine