Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
The authors' original study reported an association between intraoperative administration of muscle relaxants and postoperative respiratory morbidity.
That work, published and publicized by the BMJ in October 2012, triggered a large number of negative responses, which ranged from polite skepticism to frank condemnation. There was strong and repeated challenge to the validity of the research method, in particular the likely confounding by comparison of different operations. Crucial clinical questions also remained unanswered - in particular the doses and timing of administered relaxants, neostigmine, and opiates.
Despite the number and intensity of criticisms made, not one response was selected for publication in print. Instead, the BMJ has now published this letter from the authors outlining their secondary analyses from that controversial data set.
Unfortunately the same limitations apply. The comparisons are between different operations. There is still no information on opiate dosing. Both the doses and timing of relaxant and neostigmine administration remain unknown, as does any detail on the use of neuromuscular monitoring. Five months after the original publication, "neostigmine" is still not the same as "reversal" - especially when given too little and/or too late.
The month after the authors' original BMJ work, Anesthesiology published a prospective cohort study from Seattle which showed high rates of residual paralysis in Recovery after intraoperative neuromuscular blockers.(1) Up to 52% of patients - a majority - had residual paralysis. That number varied greatly with the site of intraoperative neuromuscular monitoring, being "only" 22% when patients were monitored at adductor pollicis. These findings were strongly supported by the accompanying editorial.(2)
Perhaps the original study by Gross-Sundrup and this secondary analysis simply demonstrate inadequacy in monitoring and reversal of muscle relaxation, rather than intrinsic dangers of intraoperative muscle blockade?
Finally, Meyer et al conclude that "our data show that the intraoperative use of neostigmine and neuromuscular transmission monitoring has little effect...". They do not. This research method does not meet the scientific standard of proof required to support that claim.
1) Thilen S.R., Hansen B.E., Ramaiah R. et al. Intraoperative Neuromuscular Monitoring Site and Residual Paralysis. Anesthesiology 117: 964-972.
2) Donati F. Neuromuscular Monitoring: More than Meets the Eye. Anesthesiology 117: 934-936
Re: Neostigmine reversal doesn’t improve postoperative respiratory safety
The authors' original study reported an association between intraoperative administration of muscle relaxants and postoperative respiratory morbidity.
That work, published and publicized by the BMJ in October 2012, triggered a large number of negative responses, which ranged from polite skepticism to frank condemnation. There was strong and repeated challenge to the validity of the research method, in particular the likely confounding by comparison of different operations. Crucial clinical questions also remained unanswered - in particular the doses and timing of administered relaxants, neostigmine, and opiates.
Despite the number and intensity of criticisms made, not one response was selected for publication in print. Instead, the BMJ has now published this letter from the authors outlining their secondary analyses from that controversial data set.
Unfortunately the same limitations apply. The comparisons are between different operations. There is still no information on opiate dosing. Both the doses and timing of relaxant and neostigmine administration remain unknown, as does any detail on the use of neuromuscular monitoring. Five months after the original publication, "neostigmine" is still not the same as "reversal" - especially when given too little and/or too late.
The month after the authors' original BMJ work, Anesthesiology published a prospective cohort study from Seattle which showed high rates of residual paralysis in Recovery after intraoperative neuromuscular blockers.(1) Up to 52% of patients - a majority - had residual paralysis. That number varied greatly with the site of intraoperative neuromuscular monitoring, being "only" 22% when patients were monitored at adductor pollicis. These findings were strongly supported by the accompanying editorial.(2)
Perhaps the original study by Gross-Sundrup and this secondary analysis simply demonstrate inadequacy in monitoring and reversal of muscle relaxation, rather than intrinsic dangers of intraoperative muscle blockade?
Finally, Meyer et al conclude that "our data show that the intraoperative use of neostigmine and neuromuscular transmission monitoring has little effect...". They do not. This research method does not meet the scientific standard of proof required to support that claim.
1) Thilen S.R., Hansen B.E., Ramaiah R. et al. Intraoperative Neuromuscular Monitoring Site and Residual Paralysis. Anesthesiology 117: 964-972.
2) Donati F. Neuromuscular Monitoring: More than Meets the Eye. Anesthesiology 117: 934-936
Competing interests: No competing interests