Dose-dependent Association between Intermediate-acting Neuromuscular-blocking Agents and Postoperative Respiratory Complications.
BACKGROUND
Duration of action increases with repeated administration of neuromuscular-blocking agents, and intraoperative use of high doses of neuromuscular-blocking agent may affect respiratory safety.


METHODS
In a hospital-based registry study on 48,499 patients who received intermediate-acting neuromuscular-blocking agents, the authors tested the primary hypothesis that neuromuscular-blocking agents are dose dependently associated with the risk of postoperative respiratory complications. In the secondary analysis, the authors evaluated the association between neostigmine dose given for reversal of neuromuscular-blocking agents and respiratory complications. Post hoc, the authors evaluated the effects of appropriate neostigmine reversal (neostigmine ≤ 60 μg/kg after recovery of train-of-four count of 2) on respiratory complications. The authors controlled for patient-, anesthesia-, and surgical complexity-related risk factors.


RESULTS
High doses of neuromuscular-blocking agents were associated with an increased risk of postoperative respiratory complications (n = 644) compared with low doses (n = 205) (odds ratio [OR], 1.28; 95% CI, 1.04 to 1.57). Neostigmine was associated with a dose-dependent increase in the risk of postoperative respiratory complications (OR, 1.51; 95% CI, 1.25 to 1.83). Post hoc analysis revealed that appropriate neostigmine reversal eliminated the dose-dependent association between neuromuscular-blocking agents and respiratory complications (for neuromuscular-blocking agent effects with appropriate reversal: OR, 0.98; 95% CI, 0.63 to 1.52).


CONCLUSIONS
The use of neuromuscular-blocking agents was dose dependently associated with increased risk of postoperative respiratory complications. Neostigmine reversal was also associated with a dose-dependent increase in the risk of respiratory complications. However, the exploratory data analysis suggests that the proper use of neostigmine guided by neuromuscular transmission monitoring results can help eliminate postoperative respiratory complications associated with the use of neuromuscular-blocking agents.
From the Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts (D.J.M., D.D.-G., H.N.F., K.S.L., M.E.); Inserm Research Center for Epidemiology and Biostatistics (U897)-Team Neuroepidemiology, Bordeaux, France (T.K.); University of Bordeaux, College of Health Sciences, Bordeaux, France (T.K.); Division of Preventive Medicine, Brigham and Women's Hospital, Boston, Massachusetts (T.K.); and Universitaetsklinkum Duisburg-Essen, Essen, Germany (M.E.).
Duncan J
DJ
McLean
Daniel
D
Diaz-Gil
Hassan N
HN
Farhan
Karim S
KS
Ladha
Tobias
T
Kurth
Matthias
M
Eikermann
D000316:Adrenergic alpha-Agonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002800:Cholinesterase Inhibitors / Q000009:adverse effects; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009388:Neostigmine / Q000009:adverse effects; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage* / Q000009:adverse effects*; D009638:Norepinephrine / Q000627:therapeutic use; D011183:Postoperative Complications / Q000139:chemically induced* / Q000453:epidemiology*; D012120:Respiration Disorders / Q000139:chemically induced* / Q000453:epidemiology*; D012307:Risk Factors; D016896:Treatment Outcome; D055815:Young Adult
D000316:Adrenergic alpha-Agonists; D002800:Cholinesterase Inhibitors; D009466:Neuromuscular Blocking Agents; D009388:Neostigmine; D009638:Norepinephrine