Residual neuromuscular block is a risk factor for postoperative pulmonary complications A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium

TLDR

Pancuronium use during anaesthesia is associated with a high incidence of residual neuromuscular block and postoperative pulmonary complications. The study compared postoperative pulmonary complication rates after pancuronium, atracurium, and vecuronium and examined how residual neuromuscular block influences those rates. 691 adults undergoing abdominal, gynaecological, or orthopaedic surgery were randomized to pancuronium, atracurium, or vecuronium; intra‑operative train‑of‑four responses were manually assessed, post‑operative TOF ratios were measured mechanomyographically, and patients were followed for six days for pulmonary complications. Residual block (TOF < 0.7) occurred in 26 % of pancuronium patients versus 5.3 % with atracurium/vecuronium, and was associated with a higher postoperative pulmonary complication rate (16.9 % vs 4.8 %); in the other groups POPC was unrelated to residual block, and multivariate analysis identified abdominal surgery, older age, longer procedures, and pancuronium‑induced residual block as risk factors for POPC.

Abstract

Background: After anaesthesia involving pancuronium a high incidence of both residual neuromuscular block and postoperative pulmonary complications (POPC) has been reported. The aim of this study was to compare the incidence of POPC following the use of pancuronium, atracurium, and vecuronium, and to examine the effect of residual neuromuscular block on the incidence of POPC. Methods: A total of 691 adult patients undergoing abdominal, gynaecological, or orthopaedic surgery under general anaesthesia were randomised to receive either pancuronium, atracurium, or vecuronium. Perioperatively, the response to train‐of‐four (TOF) nerve stimulation was evaluated manually. Post‐operatively, the TOF ratios were measured mechanomyograph‐ically, and through a 6‐day follow‐up the patients were examined for pulmonary complications. Results: The incidence of residual block, defined as a TOF ratio &lt;0.7, was significantly higher in the pancuronium group (59/226: 26%) than in the atracurium/vecuronium groups (24/450: 5.3%). In the pancuronium group, significantly more patients with residual block developed POPC (10/59: 16.9%) as compared to patients without residual block (8/167 4.8%). In the atracurium/vecuronium groups, the incidence of POPC was not significantly different in patients with (1/24: 4.2%) or without (23/426: 5.4%) residual block. Multiple regression analysis indicated that abdominal surgery, age, long‐lasting surgery, and a TOF ratio&lt;0.7 following the use of pancuronium were potential risk factors for the development of POPC. Conclusion: Postoperative residual block caused by pancuronium is a significant risk factor for development of POPC.