Impact of neuromuscular block monitoring and reversal on postoperative pulmonary complications in thoracic surgery: a Bayesian analysis of the iPROVE-OLV trial

Abstract

Background: Postoperative pulmonary complications (PPCs) are a significant concern in thoracic surgery. A modifiable factor influencing PPCs is postoperative residual neuromuscular block (NMB), which impairs respiratory muscle function.

Methods: We performed a post hoc Bayesian analysis of data from the iPROVE-OLV study, a multicentre randomised controlled trial involving patients undergoing thoracic surgery with one-lung ventilation. We compared participants managed with any neuromuscular monitoring and any reversal vs those managed without either. The primary outcome was the occurrence of a composite of PPCs within the first 7 postoperative days.

Results: Of the 698 patients included, 657 received any neuromuscular monitoring and any reversal, while 41 did not. Patients managed with any neuromuscular monitoring and any reversal had a lower incidence of PPCs (20%) compared with those without either (34%). Bayesian random effect logistic regression indicated that the use of any neuromuscular monitoring and any reversal reduced PPCs with an odds ratio (OR) ranging from 0.67 (95% credibility interval, CrI, 0.39-1.11) to 0.84 (95% CrI 0.48-1.37), depending on the prior model used. The probability of benefit (OR <1) was between 77% and 94%. Subgroup analysis indicated that sugammadex was more effective than neostigmine in reducing PPCs, with a high probability of benefit (97%), and both neuromuscular monitoring and reversal reduced PCCs when evaluated separately with a high probability of benefit.

Conclusion: Utilising neuromuscular monitoring and reversal agents significantly reduced the risk of PPCs in thoracic surgery. Sugammadex was more efficacious in reducing PPCs compared with neostigmine. These findings support the combined use of neuromuscular monitoring and reversal drugs.

Clinical trial registration: NCT03182062.

Keywords: neuromuscular block; neuromuscular monitoring; one-lung ventilation; postoperative pulmonary complications; reversal agents; sugammadex; thoracic surgery.

Fig 1

Study analysis flow-chart. ARISCAT, Assess Respiratory Risk in Surgical Patients in Catalonia; NMB, neuromuscular block.

Fig 2

Effect of monitoring and reversal administration shown using the OR scale. Left column panels: graphs show the probability distributions for the effect of monitoring and reversal before and after estimating the model on the data, that is, prior and posterior distributions. Each panel reports the mean (95% CI) of the prior distribution in the OR scale representing different types of beliefs for the treatment effect. Right column panels: the posterior distributions, that is, treatment effect estimates, for how neuromuscular monitoring and reversal agent use affect the chance of developing PPCs. The blue area highlights where the OR suggests a benefit (OR <1), meaning reduced risk of PPCs. CI, confidence interval; OR, odds ratio; PPC, postoperative pulmonary complication; ROPE, region of practical equivalence.

Fig 3

Posterior probability distributions for the conditional effect of sugammadex compared with neostigmine in the any neuromuscular monitoring and any reversal agent group. Light blue area: probability mass for the benefit threshold (OR <1). Black vertical dashed lines: region of practical equivalence boundaries (OR 0.9−1.1). OR, odds ratio; PPC, postoperative pulmonary complication; ROPE, region of practical equivalence.