Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia

Bulka, Catherine M.; Terekhov, Maxim A.; Martin, Barbara J.; Dmochowski, Roger R.; Hayes, Rachel M.; Ehrenfeld, Jesse M.

doi:10.1097/sa.0000000000000290

Cited by 32 publications

(48 citation statements)

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“…These results have recently been substantiated by a singlecentre study from Nashville, TN, USA, which also found that POPCs were less frequent if neostigmine had been used (Table 4). 40 Importantly, this study suggested that POPCs were more common in patients who had received a NDNMBD. From 13 100 cases, 1455 patients who had received an intermediateacting NDNMBD were propensity score-matched to 1455 who had not.…”

Section: Effect Of Reversal Of Residual Block On Popcsmentioning

confidence: 68%

“…: not significant compared with reversal). TOFR, train-of-four ratio 40 5.22 9.0 1.88 4.22 (per 10 000 person-days at risk) Bronsert and colleagues, 2017 41 1.40% 5.70% 3.60% 13.50% 37 Use of these NDNMBDs was associated with an increased risk of postoperative desaturation after tracheal extubation and an increased incidence of tracheal reintubation. These adverse effects were not reduced by use of subjective evaluation of neuromuscular monitoring.…”

Section: Questioning the Use Of Neostigminementioning

confidence: 97%

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Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

Hunter

2017

British Journal of Anaesthesia

174

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The use of anticholinesterases to reverse residual neuromuscular block at the end of surgery became routine practice in the 1950s. These drugs could only be used when recovery from block was established [two twitches of the train-of-four (TOF) count detectable] and concern was expressed about their cholinergic side-effects. By the 1990s, it was recognized that failure to reverse residual block adequately to a TOF ratio (TOFR) >0.7 was associated with increased risk of postoperative pulmonary complications (POPCs) following the long-acting non-depolarizing neuromuscular blocking drug (NDNMBD) pancuronium. By 2003, and the introduction of acceleromyography, a TOFR ≥0.9 was considered necessary to protect the airway from aspiration before tracheal extubation. It was also considered that four, not two, twitches of the TOF should be detectable before neostigmine was given. Use of any NDNMBD was subsequently shown to be associated with increased risk of POPCs, but it was thought that neostigmine reduced that risk. Recently, there has been conflicting evidence that use of neostigmine might increase the incidence of POPCs. Although sugammadex has been shown to rapidly reverse profound neuromuscular block from aminosteroidal agents, there is currently no evidence that sugammadex is superior to neostigmine in its effect on POPCs. Other new antagonists, including cysteine to degrade CW002 and calabadion 1 and 2 to antagonize aminosteroidal and benzylisoquinolium NDNMBDs, are being studied in preclinical and clinical trials. Quantitative neuromuscular monitoring is essential whenever a NDNMBD is used to ensure full recovery from neuromuscular block.

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Section: Effect Of Reversal Of Residual Block On Popcsmentioning

confidence: 68%

Section: Questioning the Use Of Neostigminementioning

confidence: 97%

Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

Hunter

2017

British Journal of Anaesthesia

174

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“…Recently, Bronsert et al and Bulka et al reported increased postoperative pulmonary complications in patients who did not receive neostigmine for reversal of neuromuscular blockade. In contrast to these reports, Grosse‐Sundrup et al , Meyer et al , Sasaki et al and McLean et al showed increased incidence of respiratory complications when neostigmine is administered or when administration is unwarranted, defined as doses of greater than 60 μg.kg −1 or without the guidance of neuromuscular function monitoring.…”

Section: Discussionmentioning

confidence: 99%

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

et al. 2018

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Neostigmine reverses non-depolarising neuromuscular blockade, but may cause muscle weakness when administered after full recovery of neuromuscular function. We hypothesised that neostigmine in therapeutic doses impairs muscle strength and respiratory function in awake healthy volunteers. Twenty-one volunteers were randomised to receive two doses of either intravenous (i.v.) neostigmine 2.5 mg with glycopyrrolate 450 μg (neostigmine group, n = 14) or normal saline 0.9% (placebo group, n = 7). The first dose was administered immediately after obtaining baseline measurements, and the second dose was administered 15 min later. All 14 volunteers in the neostigmine group received the first dose, mean (SD) 35 (5.8) μg.kg , but only nine of these volunteers agreed to receive the second dose, 34 (3.5) ?g.kg . The primary outcome was hand grip strength. Secondary outcomes were train-of-four ratio, single twitch height, forced expiratory volume in 1 s, forced vital capacity, forced expiratory volume in 1 s/forced vital capacity ratio, oxygen saturation, heart rate and mean arterial pressure. The first dose of intravenous neostigmine with glycopyrrolate resulted in reduced grip strength compared with placebo, -20 (20) % vs. +4.3 (9.9) %, p = 0.0016; depolarising neuromuscular blockade with decreased single twitch height, -14 (11) % vs. -3.8 (5.6) %, p = 0.0077; a restrictive spirometry pattern with decreased predicted forced expiratory volume in 1 s, -15 (12) % vs. -0.47 (3.4) %, p = 0.0011; and predicted forced vital capacity, -20 (12) % vs. -0.59 (3.2) %, p < 0.0001 at 5 min after administration. The second dose of neostigmine with glycopyrrolate further decreased grip strength mean (SD) -41 (23) % vs. +1.0 (15) %, p = 0.0004; single twitch height -25 (15) % vs. -2.5 (6.6) %, p = 0.0030; predicted forced expiratory volume in 1 s -23 (24) % vs. -0.7 (4.4) %, p = 0.0063; and predicted forced vital capacity, -27.1 (22.0) % vs. -0.66 (3.9) %, p = 0.0010. Train-of-four ratio remained unchanged (p = 0.22). In healthy volunteers, therapeutic doses of neostigmine induced significant and dose-dependent muscle weakness, demonstrated by a decrease in maximum voluntary hand grip strength and a restrictive spirometry pattern secondary to depolarising neuromuscular blockade.

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“…During anaesthesia mivacurium and other non‐depolarizing muscle relaxants (NMDR) may be used to facilitate tracheal intubation and establish muscle relaxation in surgical procedures. However, administration of NDMRs may cause postoperative residual neuromuscular block (NMB), presumably causing respiratory complications and higher morbidity and mortality . The NMB induced by long‐acting and intermediate‐acting NDMR can be antagonized with cholinesterase inhibitors such as neostigmine, pyridostigmine or edrophonium.…”

Section: Introductionmentioning

confidence: 99%

Reversal of mivacurium‐induced neuromuscular blockade with a cholinesterase inhibitor: A systematic review

Brinch

Söderström

Gätke

et al. 2018

Acta Anaesthesiol Scand

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Background: Mivacurium is a short-acting non-depolarizing muscle relaxant, which is hydrolyzed by butyrylcholinesterase. The neuromuscular block (NMB) can be antagonized with cholinesterase inhibitors (CHEI), but the short duration of action of mivacurium questions the need. This systematic review evaluated if the use of CHEIs (neostigmine, pyridostigmine or edrophonium) facilitates reversal of mivacurium-induced NMB. Method:Randomized controlled trials and crossover-studies comparing spontaneous recovery with CHEI reversal in patients with mivacurium-induced NMB, assessed with quantitative neuromuscular monitoring, were included. Mean time from injection of the CHEI or allowing of spontaneous recovery to an endpoint representing full recovery was used as outcome. First response to train-of-four nerve stimulation (T 1 ) described the level of NMB for administration of the CHEI. Moderate NMB refers to T 1 ≥ 5% and deeper NMB refers to T 1 < 5%. Systematic critical appraisal was performed using the Scottish Intercollegiate Guidelines Network guidelines.Overall quality assessment was done using the Grading of Recommendations Assessment, Development and Evaluation approach.Results: Sixteen studies with data from 546 patients were included. Low quality of evidence was found that neostigmine and edrophonium administered at moderate NMB accelerated recovery with up to approximately 5.5-6.5 and 6.5-9.0 minutes, respectively. At deeper NMB only edrophonium accelerated recovery. The effect of neostigmine was not clarified at deeper mivacurium-induced NMB. No studies with reversal by pyridostigmine were identified.Conclusion: Low quality of evidence supports that neostigmine and edrophonium accelerate the recovery of mivacurium-induced NMB with 5-6.5 and 6-9.0 minutes respectively, when administered at moderate NMB. At deeper NMB only edrophonium accelerated the recovery.

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Nondepolarizing Neuromuscular Blocking Agents, Reversal, and Risk of Postoperative Pneumonia

Cited by 32 publications

References 0 publications

Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

Reversal of mivacurium‐induced neuromuscular blockade with a cholinesterase inhibitor: A systematic review

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