Effects of high neuromuscular blocking agent dose on post‐operative respiratory complications in infants and children

Abstract

BackgroundThis study evaluated the association between neuromuscular blocking agent dose and post‐operative respiratory complications in infants and children.MethodsData from 6507 general anaesthetics provided to children aged 0‐10 years undergoing surgery were analysed to examine the effects of neuromuscular blocking agent dose on post‐operative respiratory complications (primary endpoint) and secondary endpoints. Confounder‐adjusted analyses addressed age, surgical duration, and comorbidity burden.ResultsIn confounder‐adjusted analyses, high doses of neuromuscular blocking agents were associated with higher risk of post‐operative respiratory complications (OR 2.27; 95% CI 1.12‐4.59; P = .022). The effect was modified by age (P‐for‐interaction = .016) towards a more substantial risk in infants ≤1 year (OR 3.84; 95% CI 1.35‐10.94; P = .012), by duration of surgery (P‐for‐interaction = .006) towards a higher difference in odds for surgeries <90 minutes (OR 4.25; 95% CI 1.19‐15.18; P = .026), and by ASA physical status (P‐for‐interaction = .015) with a greater effect among patients with higher operative risk (ASA >1: OR 3.17; 95% CI 1.43‐7.04; P = .005). Neostigmine reversal did not modify the association between neuromuscular blocking agents and post‐operative respiratory complications (P‐for‐interaction = .38). Instrumental variable analysis confirmed that high doses of neuromuscular blocking agents were associated with post‐operative respiratory complications (probit coefficient 0.25; 95% CI 0.04‐0.46; P = .022), demonstrating robust results regarding concerns of unobserved confounding.ConclusionsHigh dose of neuromuscular blocking agents is associated with post‐operative respiratory complications. We have identified subcohorts of paediatric patients who are particularly vulnerable to the respiratory side‐effects of neuromuscular blocking agents: infants, paediatric patients undergoing surgeries of short duration, and those with a high ASA risk score.

Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in Pediatric Anesthesia—Part 2: Anesthesia‐related risk and treatment options

“…35,36 Outside of induction and securing the airway, the current thought on the risks of using neuromuscular blockade and preventing the occurrence of perioperative respiratory adverse events in children continues to evolve with published data on residual neuromuscular blockade in children. 37 Depending on age, children have markedly variable sensitivities to neuromuscular blocking drugs due to immaturity of neuromuscular transmission and volume of distribution differences with residual blockade decreasing respiratory control resulting in hypoventilation, aspiration, and fatigue potentially leading to hypoxia and hypercapnia 13,38 In a retrospective analysis of over 6500 children, aged 0-10 years, comparing use and dose of neuromuscular blocking drugs for noncardiac surgical procedures, the rates of respiratory failure, pulmonary edema, reintubation, or pneumonia in the first 3 days postoperatively were 1.1% with a higher intraoperative neuromuscular blocking drugs dose associated with these events. 38 Those particularly at risk included infants, shorter duration procedures (<90 min) and those with a higher ASA score.…”

Residual Neuromuscular Blockade and Postoperative Pulmonary Complications: What Does the Recent Evidence Demonstrate?

“…The past evidence that PPCs are associated with the use of NMBAs and even more with residual paralysis is clear in the adult surgical population, as described in the first part of this review. Very recently, a study in 6507 non-cardiac surgical procedures was performed in children aged 0 to 10 years, and a high intraoperative NMBA dose seemed to be significantly associated with an increased risk of PPCs within 3 days of surgery [33]. Furthermore, the NMBA dose was significantly associated with an increased risk of intensive care admission, as well as increased costs and prolonged hospital stay.…”

Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks

“…Recent studies reported that use of NMBAs was associated with increased risk of POPC 3,4,12,26 ; however, those findings were limited to non-depolarising NMBAs. A small RCT trial involving 100 cardiac surgery patients reported no difference in POPC between the depolarising succinylcholine and nondepolarising NMBAs.…”