title: Effects of neostigmine reversal of nondepolarizing neuromuscular blocking agents on postoperative respiratory outcomes: a prospective study.
abstract: BACKGROUND
  We tested the hypothesis that neostigmine reversal of neuromuscular blockade reduced the incidence of signs and symptoms of postoperative respiratory failure.
  
  
  METHODS
  We enrolled 3,000 patients in this prospective, observer-blinded, observational study. We documented the intraoperative use of neuromuscular blocking agents and neostigmine. At postanesthesia care unit admission, we measured train-of-four ratio and documented the ratio of peripheral oxygen saturation to fraction of inspired oxygen (S/F). The primary outcome was oxygenation at postanesthesia care unit admission (S/F). Secondary outcomes included the incidence of postoperative atelectasis and postoperative hospital length of stay. Post hoc, we defined high-dose neostigmine as more than 60 μg/kg and unwarranted use of neostigmine as neostigmine administration in the absence of appropriate neuromuscular transmission monitoring.
  
  
  RESULTS
  Neostigmine reversal did not improve S/F at postanesthesia care unit admission (164 [95% CI, 162 to 164] vs. 164 [161 to 164]) and was associated with an increased incidence of atelectasis (8.8% vs. 4.5%; odds ratio, 1.67 [1.07 to 2.59]). High-dose neostigmine was associated with longer time to postanesthesia care unit discharge readiness (176 min [165 to 188] vs. 157 min [153 to 160]) and longer postoperative hospital length of stay (2.9 days [2.7 to 3.2] vs. 2.8 days [2.8 to 2.9]). Unwarranted use of neostigmine (n = 492) was an independent predictor of pulmonary edema (odds ratio, 1.91 [1.21 to 3.00]) and reintubation (odds ratio, 3.68 [1.10 to 12.4]).
  
  
  CONCLUSIONS
  Neostigmine reversal did not affect oxygenation but was associated with increased atelectasis. High-dose neostigmine or unwarranted use of neostigmine may translate to increased postoperative respiratory morbidity.
authors.affiliation: From the Department of Emergency and Critical Care Medicine, Showa General Hospital, Tokyo, Japan (N.S.); Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (M.J.M.); Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (S.A.M., A.B.S., A.H.H.); MGH Anesthesia Research Grants, BWH Department of Preventive Medicine, and Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (A.I.); Massachusetts General Hospital, Boston, Massachusetts (T.M., M.E.D.); and Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, and Klinik fuer Anaesthesie und Intensivmedizin, Universitaetsklinikum Essen, Essen, Germany (M.E.).
authors.forename: Nobuo
authors.initials: N
authors.lastname: Sasaki
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Meyer
authors.forename: Sanjana A
authors.initials: SA
authors.lastname: Malviya
authors.forename: Anne B
authors.initials: AB
authors.lastname: Stanislaus
authors.forename: Teresa
authors.initials: T
authors.lastname: MacDonald
authors.forename: Mary E
authors.initials: ME
authors.lastname: Doran
authors.forename: Arina
authors.initials: A
authors.lastname: Igumenshcheva
authors.forename: Alan H
authors.initials: AH
authors.lastname: Hoang
authors.forename: Matthias
authors.initials: M
authors.lastname: Eikermann
mesh_terms: D000328:Adult; D000368:Aged; D060666:Airway Extubation; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009388:Neostigmine / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D003473:Neuromuscular Nondepolarizing Agents / Q000037:antagonists & inhibitors*; D010277:Parasympathomimetics / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D011183:Postoperative Complications / Q000503:physiopathology* / Q000517:prevention & control*; D001261:Pulmonary Atelectasis / Q000139:chemically induced; D012131:Respiratory Insufficiency / Q000503:physiopathology* / Q000517:prevention & control*; D016896:Treatment Outcome
chemical_list: D003473:Neuromuscular Nondepolarizing Agents; D010277:Parasympathomimetics; D009388:Neostigmine