Implementation of a new strategy to improve the peri-operative management of neuromuscular blockade and its effects on postoperative pulmonary complications

M. I. Rudolph, H. V. Chitilian, P. Y. Ng, F. P. Timm, A. V. Agarwala, A. B. Doney, S. K. Ramachandran, T. T. Houle, M. Eikermann

Research output: Contribution to journalArticlepeer-review

29 Scopus citations


Inappropriate dosing of neostigmine for antagonism of neuromuscular blockade has been associated with postoperative pulmonary complications. We evaluated the effects of a quality improvement initiative tailored to optimise the use of neostigmine in antagonising neuromuscular blockade on postoperative pulmonary complications, costs and duration of hospital stay. The quality improvement initiative consisted of: a reduction in available neostigmine aliquot sizes; a cognitive aid; an educational component; and a financial incentive for the intra-operative documentation of train-of-four measurement before administration of neostigmine. We conducted a pre-specified analysis of data obtained in our quality improvement study. Additional analyses were conducted in a propensity-matched cohort. An interrupted time series design was used to discriminate between the intervention and a counterfactual scenario. We analysed 12,025 consecutive surgical cases performed in 2015. Postoperative pulmonary complications occurred in 220 (7.5%) of 2937 cases pre-intervention and 568 (6.3%) of 9088 cases post-intervention. Adjusted regression analyses showed significantly a lower risk of postoperative pulmonary complications (OR 0.73 (95%CI 0.61–0.88); p = 0.001), lower costs (incidence rate ratio 0.95 (95%CI 0.93–0.97); p < 0.001) and shorter duration of hospital stay (incidence rate ratio 0.91 (95%CI 0.87–0.94); p < 0.001) after implementation of the quality improvement initiative. Analyses in a propensity-matched sample (n = 2936 per group) and interrupted time series analysis (n = 27,202 cases) confirmed the findings. Our data show that a local, multifaceted quality improvement initiative can enhance the quality of intra-operative neuromuscular blocking agent utilisation, thereby reducing the incidence of postoperative pulmonary complications.

Original languageEnglish (US)
Pages (from-to)1067-1078
Number of pages12
Issue number9
StatePublished - Sep 2018
Externally publishedYes


  • neostigmine: dose rationale
  • neuromuscular block: assessment
  • patient care
  • quality measures

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine


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