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

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6329 (Published 16 October 2012) Cite this as: BMJ 2012;345:e6329
  1. Martina Grosse-Sundrup, research fellow1,
  2. Justin P Henneman, research assistant1,
  3. Warren S Sandberg, professor2,
  4. Brian T Bateman, assistant professor13,
  5. Jose Villa Uribe, research assistant1,
  6. Nicole Thuy Nguyen, research assistant1,
  7. Jesse M Ehrenfeld, assistant professor2,
  8. Elizabeth A Martinez, associate professor1,
  9. Tobias Kurth, director of research456,
  10. Matthias Eikermann, associate professor17
  1. 1Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
  2. 2Department of Anaesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA
  3. 3Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School
  4. 4Inserm Unit 708-Neuroepidemiolgy, Bordeaux, France
  5. 5University of Bordeaux, Bordeaux
  6. 6Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School
  7. 7Universitaetsklinikum Essen, Klinik fuer Anaesthesie und Intensivmedizin, Essen, Germany
  1. Correspondence to: M Eikermann meikermann{at}partners.org
  • Accepted 11 September 2012

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.

Footnotes

  • Contributors: MG-S carried out the data analysis and wrote substantial parts of the manuscript. She presented the study at the ASA annual meeting. JPH acquired the data and was involved in data analysis and writing the manuscript. MG-S and JPH contributed equally to the study. EM and BTB were involved in data analysis and revising the manuscript. JV-U was involved in data acquisition, analysis, and revising the manuscript. NTN was involved in data acquisition and revising the manuscript. JE was involved in designing the study, data acquisition, analysis, and writing. WS was involved in designing the study, data analysis, and revising the manuscript. TK was involved in designing the study, data analysis and interpretation, and writing. All authors had access to the data. ME was involved in all parts of the study and is the guarantor.

  • Funding: This study was funded by the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, United States.

  • 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.

  • Ethical approval: This study was approved by Partners’ human research committee in Boston, Massachusetts, USA (protocol No 2011P001300).

  • Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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