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The Effects of Postoperative Residual Neuromuscular Blockade on Hospital Costs and Intensive Care Unit Admission

A Population-Based Cohort Study

Grabitz, Stephanie D., MD*; Rajaratnam, Nishan, MD*; Changani, Khushi, BS*; Thevathasan, Tharusan, Med Can*; Teja, Bijan J., MD, MBA; Deng, Hao, MD, MPH*; Eikermann, Matthias, MD, PhD; Kelly, Barry J., MD, MSc

doi: 10.1213/ANE.0000000000004028
Anesthetic Clinical Pharmacology: PDF Only

BACKGROUND: Postoperative residual neuromuscular blockade continues to be a frequent occurrence with a reported incidence rate of up to 64%. However, the effect of postoperative residual neuromuscular blockade on health care utilization remains unclear. We conducted a retrospective cohort study to investigate the effects of postoperative residual neuromuscular blockade on hospital costs (primary outcome), intensive care unit admission rate, and hospital length of stay (secondary outcomes).

METHODS: We performed a prespecified secondary analysis of data obtained in 2233 adult patients undergoing surgery under general anesthesia. Postoperative residual neuromuscular blockade was defined as a train-of-four ratio <0.9 in the postanesthesia care unit (PACU). Our confounder model adjusted for a variety of patient, surgical, and anesthesia-related factors. We fitted truncated negative binomial regression models for hospital cost and hospital length of stay analyses and a logistic regression model for our intensive care unit admission analysis.

RESULTS: Overall, 457 (20.5%) patients in our cohort had residual neuromuscular blockade on admission to the PACU. Postoperative residual neuromuscular blockade was not independently associated with increased hospital costs (adjusted incidence rate ratio, 1.04, CI, 0.98–1.11; P = .22). There were significantly higher odds of intensive care unit admission in those with postoperative residual neuromuscular blockade compared to those without (adjusted odds ratio, 3.03, CI, 1.33–6.87; P < .01). Further, we found a trend toward increased hospital length of stay in patients with postoperative residual neuromuscular blockade (adjusted incidence rate ratio, 1.09; P = .06). Sensitivity analysis using the same model in the day of surgery admissions and ambulatory surgery confirmed our findings.

CONCLUSIONS: Postoperative residual neuromuscular blockade at PACU admission was not significantly associated with increased hospital costs, but was associated with higher rates of intensive care unit admission. These findings support the view that clinicians should continue to work to standardize reversal practices to reduce the rate of postoperative residual neuromuscular blockade.

From the *Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Accepted for publication December 12, 2018.

Funding: Dr Eikermann reports receipt of grants from Merck; personal fees (honoraria) from Merck; funding from Jeffrey and Judith Buzen; holds equity in Calabash Bioscience and an investigator-initiated grant (IISP# 39442) was provided by Schering-Plough Research Institute, Kenilworth, NJ, a Division of Schering Corporation, to the Massachusetts General Hospital.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

S. D. Grabitz and N. Rajaratnam contributed equally and share first authorship.

Clinical trial number and registry URL: (NCT01718860).

Reprints will not be available from the authors.

Address correspondence to Barry J. Kelly, MD, MSc, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Address e-mail to

© 2019 International Anesthesia Research Society
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