The Effects of Postoperative Residual Neuromuscular Blockade on Hospital Costs and Intensive Care Unit Admission: A Population-Based Cohort Study

Grabitz, Stephanie D.; Rajaratnam, Nishan; Chhagani, Khushi; Thevathasan, Tharusan; Teja, Bijan; Deng, Hao; Eikermann, Matthias; Kelly, Barry

doi:10.1213/ane.0000000000004028

Cited by 54 publications

(36 citation statements)

References 19 publications

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“…Likewise, although this review evaluates the best available RCT evidence for PPCs, other forms of evidence are available. For example, the adverse influence of neuromuscular blocking drugs is now well established,149150151152153 especially when they are associated with inadequate reversal (a train of four ratio of <0.9). Furthermore, active intraoperative warming, airway suctioning, and choice of airway device are all relevant interventions with an effect on PPCs.…”

Section: Discussionmentioning

confidence: 99%

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Odor

Bampoe

Gilhooly

et al. 2020

BMJ

135

130

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OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGNSystematic review and meta-analysis of randomised controlled trials. DATA SOURCESMedline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIARandomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESISReviewers independently identified studies, extracted data, and assessed the quality of evidence. Metaanalyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONSPredominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGIS...

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Section: Discussionmentioning

confidence: 99%

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Odor

Bampoe

Gilhooly

et al. 2020

BMJ

135

130

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“…Second, NMBA reversal with neostigmine and anticholinesterases might be associated with increased risk of cardiovascular complications in the high-risk group (age > 70 years, undergoing vascular surgery, prior history of atrial fibrillation) [29,35]. Furthermore, a recent cohort study reported that PORC in the post-anesthesia care unit is associated with higher rates of ICU admission [36]. Therefore, the results of our current study suggested that efforts to minimize PORC using sugammadex could result in improvement of fatal outcomes, such as 90-day mortality.…”

Section: Discussionmentioning

confidence: 99%

Association of neuromuscular reversal by sugammadex and neostigmine with 90-day mortality after non-cardiac surgery

Ryu

Nam

et al. 2020

BMC Anesthesiol

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Background: Reversing a neuromuscular blockade agent with sugammadex is known to lessen postoperative complications by reducing postoperative residual curarization. However, its effects on 90-day mortality are unknown. Therefore, this study aimed to compare the effects of sugammadex and neostigmine in terms of 90-day mortality after non-cardiac surgery. Methods: This retrospective cohort study analyzed the medical records of adult patients aged 18 years or older who underwent non-cardiac surgery at a single tertiary care hospital between 2011 and 2016. Propensity score matching and Cox regression analysis were used to investigate the effectiveness of sugammadex and neostigmine in lowering 90-day mortality after non-cardiac surgery. Results: A total of 65,702 patients were included in the analysis (mean age: 52.3 years, standard deviation: 15.7), and 23,532 of these patients (35.8%) received general surgery. After propensity score matching, 14,179 patients (3906 patients from the sugammadex group and 10,273 patients from the neostigmine group) were included in the final analysis. Cox regression analysis in the propensity score-matched cohort showed that the risk of 90-day mortality was 40% lower in the sugammadex group than in the neostigmine group (hazard ratio: 0.60, 95% confidence interval: 0.37, 0.98; P = 0.042). These results were similar in the multivariable Cox regression analysis of the entire cohort (hazard ratio: 0.62, 95% confidence interval: 0.39, 0.96; P = 0.036). Conclusions: This retrospective cohort study suggested that reversing rocuronium with sugammadex might be associated with lower 90-day mortality after non-cardiac surgery compared to neostigmine. However, since this study did not evaluate quantitative neuromuscular function in the postoperative period due to its retrospective design, the results should be interpreted carefully. Future prospective studies with quantitative neuromuscular monitoring in the postoperative period should be performed to confirm these results.

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“…10,12,13,17 Recent data suggest that reversal of neuromuscular block with neostigmine and an anticholinesterase may be associated with increased risk of cardiovascular complications in selected populations, such as patients >70 yr old, undergoing vascular surgery, or with prior history of atrial fibrillation. 18 These complications could in part explain why patients with residual neuromuscular block demonstrate an increase in ICU admission rate and prolonged hospital length of stay, 19 and increased rates of readmission among ambulatory patients. 7 The findings of Oh and colleagues 4 are interesting and thought provoking in this context.…”

Section: Methodological Issues In Observational Studies Of Readmissiomentioning

confidence: 99%

Does reversal of neuromuscular block with sugammadex reduce readmission rate after surgery?

Bose

Eikermann

2019

British Journal of Anaesthesia

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The Effects of Postoperative Residual Neuromuscular Blockade on Hospital Costs and Intensive Care Unit Admission: A Population-Based Cohort Study

Cited by 54 publications

References 19 publications

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

Association of neuromuscular reversal by sugammadex and neostigmine with 90-day mortality after non-cardiac surgery

Does reversal of neuromuscular block with sugammadex reduce readmission rate after surgery?

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