一个前瞻性,倾向得分匹配队列研究中效非去极化神经肌肉阻断剂与术后呼吸道并发症风险的关系

RESEARCHIntermediateactingnon-depolarizingneuromuscularblockingagentsandriskofpostoperativerespiratorycomplications:prospectivepropensityscorematchedcohortstudyBMJ2012;345doi:(Published16October2012)Citethisas:BMJ2012;345:e6329AbstractObjectiveTodeterminewhetheruseofintermediateactingneuromuscularblockingagentsduringgeneralanesthesiaincreasestheincidenceofpostoperativerespiratorycomplications.DesignProspective,propensityscorematchedcohortstudy.SettingGeneralteachinghospitalinBoston,Massachusetts,UnitedStates,2006-10.Participants18 579surgicalpatientswhoreceivedintermediateactingneuromuscularblockingagentsduringsurgerywerematchedbypropensityscoreto18 579referencepatientswhodidnotreceivesuchagents.MainoutcomemeasuresThemainoutcomemeasureswereoxygendesaturationafterextubation(hemoglobinoxygensaturation90%withadecreaseinoxygensaturationafterextubationof3%)andreintubationsrequiringunplannedadmissiontoanintensivecareunitwithinsevendaysofsurgery.Wealsoevaluatedeffectsontheseoutcomevariablesofqualitativemonitoringofneuromusculartransmission(train-of-fourratio)andreversalofneuromuscularblockadewithneostigminetopreventresidualpostoperativeneuromuscularblockade.ResultsTheuseofintermediateactingneuromuscularblockingagentswasassociatedwithanincreasedriskofpostoperativedesaturationlessthan90%afterextubation(oddsratio1.36,95%confidenceinterval1.23to1.51)andreintubationrequiringunplannedadmissiontoanintensivecareunit(1.40,1.09to1.80).Qualitativemonitoringofneuromusculartransmissiondidnotdecreasethisriskandneostigminereversalincreasedtheriskofpostoperativedesaturationlessthan90%(1.32,1.20to1.46)andreintubation(1.76,1.38to2.26).ConclusionTheuseofintermediateactingneuromuscularblockingagentsduringanesthesiawasassociatedwithanincreasedriskofclinicallymeaningfulrespiratorycomplications.Ourdatasuggestthatthestrategiesusedinourtrialtopreventresidualpostoperativeneuromuscularblockadeshouldberevisited.IntroductionTensofmillionsofpeopleworldwideundergogeneralanesthesiaeveryday.Anesthetistsuseawidevarietyofdrugstoestablishthereversiblestateofanesthesia,whichischaracterisedbyhypnosis,amnesia,analgesia,hemodynamicstabilitywithcontrolofthestressresponse,andimmobility.1Deepanesthesiaprovidesallcomponents23;however,toachieveimmobilitywithlowerlevelsofanestheticagents,anesthetistsmaycoadministercurare-typeneuromuscularblockingagents.Thesedrugsinhibitneuromusculartransmissionfromnervestomusclesbycompetitivelyblockingthebindingofacetylcholinetoitspostsynapticreceptorsatthemotorendplate,therebycausingparalysisofthemuscle.Morethan400millionpeoplereceiveneuromuscularblockingagentsannually(IntercontinentalMarketingServices(IMS)Health,MultinationalIntegratedDataAnalysisSystem(MIDAS),September2010),eitherintheoperatingtheatretooptimizesurgicalconditions,orintheintensivecareunittofacilitatemechanicalventilationinthosewithpatient-ventilatorasynchrony.4Neuromuscularblockingagentsarealsocommonlyadministeredbeforetrachealintubationtoensurehigherqualityoftheprocedureandfewercomplications.Thesedrugsdecreaseintubationassociatedlaryngealmorbidityaswellasprocedurerelatedcomplicationswhenusedbyexperiencedintensivistsforemergencyintubations.5678Fullrestorationofapatient’smusclestrengthisessentialtoensureasafepostoperativerecovery.Lingeringeffectsofneuromuscularblockingagents,however,maycausepartialparalysis,aconditioninwhichsymptomsofmuscleweaknessprevailinthepostoperativeperiod.9Thismayimpairbreathing,upperairwaypatency,protectiveairwayreflexes,swallowing,andcoughing,therebyputtingpatientsatriskforseriouscomplicationsinthevulnerablepostoperativeperiod.101112131415Unanticipatedpostoperativeintubationisassociatedwithincreasedmortalityandincreasinghealthcarecosts.1617Thelongactingneuromuscularblockingagentpancuroniumhasbeenassociatedwithahigherriskofpostoperativerespiratoryfailure.1819Consequently,longactingcompoundshavealmostquantitativelydisappearedfromthemarket,beingreplacedbymodernintermediateactingnon-depolarizingneuromuscularblockingagents,butitisuncleariftheuseofthesedrugsrepresentsariskfactorforadverseperioperativerespiratoryoutcomes.20Inadditiontocarefulclinicalassessment,anesthetistscommonlyusetwostrategiestocontroltheeffectsofnon-depolarizingneuromuscularblockingagentsandrestorepatients’optimalmusclestrength.Firstly,themonitoringofneuromusculartransmissionisappliedduringsurgerytoassessthedegreeofapatient’sneuromuscularblock.Mostoftensubjective(qualitative)visualortactile(palpation)assessmentofamuscleresponsetoatrain-of-fourstimulation(seriesoffourelectricstimulideliveredat2Hz)ofaperipheralnerveismeasured.Afterneuromuscularblockingagentshavebeenadministered,musclesshowadecrease(fade)ofmuscularcontractionfromfirsttofourthresponseasopposedtomuscleswithintactorfullyrestoredneuromusculartransmission,whichshowthesameresponsetoeachstimulus.Secondly,reversalofneuromuscularblockadewithacetylcholinesteraseinhibitorsisusedtoantagonisepotentiallylingeringeffectsofnon-depolarizingneuromuscularblockingagentsattheendofsurgery.Ac