Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study

Abstract

Objective: To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications.

Design: Prospective, propensity score matched cohort study.

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

Participants: 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.

Main outcome measures: 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).

Conclusion: 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.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: that this study has been funded only by academic research funds; TK has received investigator initiated research funding from the French National Research Agency, the US National Institutes of Health, the Migraine Research Foundation, and the Parkinson’s Disease Foundation. He has received honorariums from Allergan, the American Academy of Neurology, and Merck for educational lectures, from the BMJ for editorial services, and from MAP Pharmaceutical for contributing to a scientific advisory panel. ME has received investigator initiated research funding from Merck, Pfizer, and the ResMed Foundation, as well as the Department of Anesthesia and Critical Care and Pain Medicine of the Massachusetts General Hospital. He has received honorariums from Hill-Rom for giving advise, and from the American Thoracic Society, Brown University, Michigan University, and Vanderbilt University for educational lectures, and from the Journal Anesthesiology for editorial services; the authors have no financial relationships with any organisation or company that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1 Study design

Fig 2 Time of extubation to reintubation based on chart review

Fig 3 Reasons for reintubation in patients undergoing surgical procedures and reintubated after surgery in post-anesthesia care unit, on the surgical floor, or on the intensive care unit. Data taken from chart review. Data given from patients only with clear documentation of cause and effect relation between mechanism of respiratory disease and intubation (n=177). Multiple reasons (on average 2.5 per reintubation) were provided