Intraoperative Use of Nondepolarizing Neuromuscular Blocking Agents During Cardiac Surgery and Postoperative Pulmonary Complications: A Prospective Randomized Trial

J Cardiothorac Vasc Anesth. 2019 Jun;33(6):1673-1681. doi: 10.1053/j.jvca.2018.11.043. Epub 2018 Nov 28.


Objective: Nondepolarizing neuromuscular blocking agents (NMBAs) are associated with perioperative complications in noncardiac surgery; however, little is known about their effect on cardiac surgery. This study assessed the effect of neuromuscular blockade (NMB) on the incidence of postoperative pulmonary complications (PPCs) after cardiac surgery and operating conditions.

Design: Prospective, randomized clinical trial with blinded outcomes assessment.

Setting: University hospital, single institution.

Participants: Adult patients having cardiac surgery requiring cardiopulmonary bypass.

Interventions: One hundred patients were randomized to receive succinylcholine (group SUX) for intubation with no further NMB administered or cisatracurium (group CIS) for intubation and maintenance NMB. The primary outcome was a composite incidence of PPCs in the 72 hours after elective cardiac surgery. PPCs included failure to extubate within 24 hours, need for reintubation, pneumonia, aspiration, unanticipated need for noninvasive respiratory support, acute respiratory distress, and mortality from respiratory arrest. The secondary outcome was the adequacy of operating conditions as assessed by blinded surgeon survey (including a rating of surgical conditions on a Likert scale from 1 = poor to 5 = excellent), anesthesiologist report, and patient questionnaire.

Measurements and main results: The composite incidence of PPCs did not differ between groups (8 of 50 patients in both groups; 16%). Mean surgeon rating of surgical conditions was lower in the SUX group (4.65 ± 0.85 v 4.96 ± 0.20, p = 0.02).

Conclusion: Although avoiding nondepolarizing NMBA is feasible, doing so worsened operating conditions and did not reduce the incidence of postoperative pulmonary complications.

Keywords: cardiac surgery; cisatracurium; neuromuscular blocking agents; postoperative complications; postoperative pulmonary complication; residual neuromuscular blockade.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Atracurium / adverse effects
  • Atracurium / analogs & derivatives
  • Cardiac Surgical Procedures*
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Intraoperative Care / adverse effects*
  • Male
  • Middle Aged
  • Neuromuscular Blockade / adverse effects*
  • Neuromuscular Blocking Agents / adverse effects*
  • Pneumonia
  • Pneumonia, Aspiration / epidemiology
  • Pneumonia, Aspiration / etiology*
  • Postoperative Complications*
  • Prospective Studies
  • Respiratory Distress Syndrome / epidemiology
  • Respiratory Distress Syndrome / etiology*
  • Succinylcholine / adverse effects
  • United States / epidemiology
  • Young Adult


  • Neuromuscular Blocking Agents
  • Atracurium
  • Succinylcholine
  • cisatracurium