Correspondence  |   July 2017
Accounting for Planned Postoperative Intubation
Author Notes
  • Emory University School of Medicine, Atlanta, Georgia (T.M.A.).
  • (Accepted for publication April 13, 2017.)
    (Accepted for publication April 13, 2017.)×
Article Information
Correspondence   |   July 2017
Accounting for Planned Postoperative Intubation
Anesthesiology 7 2017, Vol.127, 195-196. doi:10.1097/ALN.0000000000001695
Anesthesiology 7 2017, Vol.127, 195-196. doi:10.1097/ALN.0000000000001695
We read with interest the article by Bulka et al.1  regarding the use of intraoperative nondepolarizing muscle relaxants (NDMRs) and their association with postoperative pneumonia. We commend them for increasing knowledge in an area that is exceedingly important. In this article, postoperative pneumonia occurred more frequently in patients who received an NDMR versus propensity-matched patients who were not administered an NDMR. Furthermore, within the NDMR subset, lack of neostigmine administration was associated with a greater than twofold higher incidence of postoperative pneumonia than their propensity-matched counterparts.
Although not explicitly stated in the article, we wonder why these patients were not routinely reversed at the end of their procedure. As described in the accompanying editorial,2  this may have resulted from concerns of paradoxical muscle weakness and/or other side effects of acetylcholinesterase inhibitors. However, another plausible explanation may be that some of these patients were being transported to the intensive care unit for postoperative mechanical ventilation, thus not requiring NDMR reversal. In our experience, the overwhelming reason for nonreversal is predetermined postoperative intubation regardless of patient demographics, attending anesthesiologist, surgeon, or surgical procedure. Because endotracheal intubation and intensive care unit residence are both strongly associated with nosocomial pneumonia,3  there is a high likelihood that the effect of nonreversal on this outcome is confounded by continued postoperative intubation. To determine whether this manner of confounding exists, separate analyses should be performed that only include patients who were extubated at the end of the surgical procedure before leaving the operating room. Although tedious, these additional investigations would strengthen the argument about the importance of NDMR reversal.
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