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

Abstract

Background Residual postoperative paralysis from nondepolarizing neuromuscular blocking agents (NMBAs) is a known problem. This paralysis has been associated with impaired respiratory function, but the clinical significance remains unclear. The aims of this analysis were two-fold: (1) to investigate if intermediate-acting NMBA use during surgery is associated with postoperative pneumonia and (2) to investigate if nonreversal of NMBAs is associated with postoperative pneumonia. Methods Surgical cases (n = 13,100) from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who received general anesthesia were included. The authors compared 1,455 surgical cases who received an intermediate-acting nondepolarizing NMBA to 1,455 propensity score–matched cases who did not and 1,320 surgical cases who received an NMBA and reversal with neostigmine to 1,320 propensity score–matched cases who did not receive reversal. Postoperative pneumonia incidence rate ratios (IRRs) and bootstrapped 95% CIs were calculated. Results Patients receiving an NMBA had a higher absolute incidence rate of postoperative pneumonia (9.00 vs. 5.22 per 10,000 person-days at risk), and the IRR was statistically significant (1.79; 95% bootstrapped CI, 1.08 to 3.07). Among surgical cases who received an NMBA, cases who were not reversed were 2.26 times as likely to develop pneumonia after surgery compared to cases who received reversal with neostigmine (IRR, 2.26; 95% bootstrapped CI, 1.65 to 3.03). Conclusions Intraoperative use of intermediate nondepolarizing NMBAs is associated with developing pneumonia after surgery. Among patients who receive these agents, nonreversal is associated with an increased risk of postoperative pneumonia.

Intubation following high-dose rocuronium in a cat with protracted laryngospasm

“…9,10 This is based on difficulty assuring adequate laryngeal and respiratory function in the presence of an apparently normal TOF response (visual evaluation is imprecise), with an associated risk of pneumonia. It was felt that 2.5 h after rocuronium administration, the likelihood of residual blockade was low.…”

Parálisis residual posoperatoria tras anestesia general sin monitorización neuromuscular objetiva: un estudio observacional en el Hospital Regional Docente de Cajamarca, Perú

“…La parálisis residual posoperatoria es un factor de riesgo bien establecido para el desarrollo de complicaciones pulmonares en el posoperatorio temprano [1][2][3][4] . La disfunción de la musculatura respiratoria y de la vía aérea superior predispone a obstrucción de la vía aérea, atelectasias, aspiración pulmonar y neumonía, al mismo tiempo que produce un deterioro de la respuesta ventilatoria a la hipoxia [2,3,[16][17][18] . En el paciente despierto, además, provoca síntomas desagradables de debilidad muscular (disturbios visuales, debilidad facial, dificultad para hablar y deglutir y sensación de fatiga generalizada) [19,20] .…”

“…En el paciente despierto, además, provoca síntomas desagradables de debilidad muscular (disturbios visuales, debilidad facial, dificultad para hablar y deglutir y sensación de fatiga generalizada) [19,20] . De manera consistente, numerosos estudios han establecido una relación entre la parálisis residual y un incremento en la morbimortalidad posoperatoria, eventos respiratorios críticos y un incremento de la estancia en la UCPA [1][2][3][4][16][17][18][19][20][21][22] .…”

“…La monitorización objetiva y cuantitativa de la función neuromuscular permite no solo mantener condiciones adecuadas de relajación muscular en el intraoperatorio, sino también identificar oportunamente la parálisis residual y reducir su incidencia mediante el uso apropiado de fármacos antagonistas [1][2][3][16][17][18][19] . El uso de criterios clínicos o subjetivos para valorar la recuperación de la función neuromuscular se ha mostrado insuficiente para identificar adecuadamente la parálisis residual posoperatoria [1][2][3][22][23][24] .…”

Neuromuscular Block and Blocking Agents in 2018

“…However current studies identified that appropriate dosing of neostigmine for reversing of residual paralysis is able to eleminate effectively the incidence of respiratory complications and that the application of sugammadex 1.0 mg kg -1 at a TOFR ≥0.9 does not improve patient´s motor function (9,12,35,66). Murphy and colleagues revealed in a clinical setting that application of neostigmine 0.04 mg kg -1 at a TOFR of ≥0.9 did not raise the incidence of postoperative muscle weakness, hypoxemia and airway obstruction (74).…”