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Background: Duration of action increases with repeated administration of neuromuscular-blocking agents, and intraoperative use of high doses of neuromuscular-blocking agent may affect respiratory safety.Methods: In a hospital-based registry study on 48,499 patients who received intermediate-acting neuromuscular-blocking agents, the authors tested the primary hypothesis that neuromuscular-blocking agents are dose dependently associated with the risk of postoperative respiratory complications. In the secondary analysis, the authors evaluated the association between neostigmine dose given for reversal of neuromuscular-blocking agents and respiratory complications. Post hoc, the authors evaluated the effects of appropriate neostigmine reversal (neostigmine =60 µg/kg after recovery of train-of-four count of 2) on respiratory complications. The authors controlled for patient-, anesthesia-, and surgical complexity–related risk factors.Results: High doses of neuromuscular-blocking agents were associated with an increased risk of postoperative respiratory complications (n = 644) compared with low doses (n = 205) (odds ratio [OR], 1.28; 95% CI, 1.04 to 1.57). Neostigmine was associated with a dose-dependent increase in the risk of postoperative respiratory complications (OR, 1.51; 95% CI, 1.25 to 1.83). Post hoc analysis revealed that appropriate neostigmine reversal eliminated the dose-dependent association between neuromuscular-blocking agents and respiratory complications (for neuromuscular-blocking agent effects with appropriate reversal: OR, 0.98; 95% CI, 0.63 to 1.52).Conclusions: The use of neuromuscular-blocking agents was dose dependently associated with increased risk of postoperative respiratory complications. Neostigmine reversal was also associated with a dose-dependent increase in the risk of respiratory complications. However, the exploratory data analysis suggests that the proper use of neostigmine guided by neuromuscular transmission monitoring results can help eliminate postoperative respiratory complications associated with the use of neuromuscular-blocking agents.
1.00 AMA PRA Category 1 Credit™
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Activity Release Date:05/19/2015
Activity Expiration Date:05/18/2018
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After successfully completing this activity, the learner will be able to do the following:
- Identify the risks of residual blockade after the administration of an intermediate-acting neuromuscular-blocking agent (NMBA) - Define the appropriate dose and timing of the...
- Identify the risks of residual blockade after the administration of an intermediate-acting neuromuscular-blocking agent (NMBA) - Define the appropriate dose and timing of the administration of the acetylcholinesterase inhibitor neostigmine for reversal of an intermediate-acting NMBA - Select the most appropriate intermediate-acting NMBA
Faculty & Credentials:
Editor-in-Chief: James C. Eisenach, M.D., receives consulting fees from Aerial BioPharma LLC and Cubist Pharmaceuticals, Inc. CME Editors: Leslie C. Jameson, M.D., receives honoraria from GE Medical International and Masimo Corporation. Dan J. Kopacz, M.D., has an equity position in SoloDex, LLC. Authors: Duncan J. McLean, M.B.Ch.B., Daniel Diaz-Gil, Cand. Med., Hassan N. Farhan, M.B.B.S., Karim S. Ladha, M.D., and Tobias Kurth, M.D., Sc.D., have reported no financial relationships with commercial interests. Matthias Eikermann, M.D., Ph.D., received funding for investigator-initiated research from Merck, Whitehouse Station, New Jersey, and from Massimo, Irvine, California. Dr. Eikermann has also filed a patent application for a new drug to reverse the effects of neuromuscular-blocking agents.
Authors: Sorin J. Brull, M.D., F.C.A.R.C.S.I. (Hon.), has reported to be a Member, Anesthesia Patient Safety Foundation Executive Committee and Board of Directors, and shareholder in ADBV (Amsterdam, The Netherlands), a medical device company. Richard C. Prielipp, M.D., M.B.A., F.C.C.M., has reported to be a Member, Anesthesia Patient Safety Foundation Executive Committee and Board of Directors.
ASA Staff: Kari L. Lee, Editorial Manager, has reported no financial relationships with commercial interests. Ginger Yarger, Editor, has an equity position in Merck & Co.
Disclosure Statement The American Society of Anesthesiologists remains strongly committed to providing the best available evidence-based clinical information to participants of this educational activity and requires an open disclosure of any potential conflict of interest identified by our faculty members. It is not the intent of the American Society of Anesthesiologists to eliminate all situations of potential conflict of interest, but rather to enable those who are working with the American Society of Anesthesiologists to recognize situations that may be subject to question by others. All disclosed conflicts of interest are reviewed by the educational activity course director/chair to ensure that such situations are properly evaluated and, if necessary, resolved. The American Society of Anesthesiologists educational standards pertaining to conflict of interest are intended to maintain the professional autonomy of the clinical experts inherent in promoting a balanced presentation of science. Through our review process, all American Society of Anesthesiologists CME activities are ensured of independent, objective, scientifically balanced presentations of information. Disclosure of any or no relationships will be made available for all educational activities.
The information provided at this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.
The American Society of Anesthesiologists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The American Society of Anesthesiologists designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Non-physicians may receive a Certificate of Completion stating that this activity was designated for 1.00 AMA PRA Category 1 Credit(s)™.
05/13/2015 (All day)
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