LAUSR

To the Editor: We read with interest the article by Bulka et al.1 regarding the relationship between the management of intraoperative neuromuscular blockade and postoperative pneumonia. The use of large databases to address rare outcomes has increased in recent years. The value in using these databases is the large number of patients who can be assessed. Such large numbers would be extremely challenging to achieve in a randomized controlled study. However, a major limitation and concern with database studies like this one is subsequent confusion between correlation and causation. With regard to residual paralysis, we believe that these challenges can be bypassed with one simple technique—the objective monitoring of the effects of a neuromuscular blocking agent. Although the incidence of residual neuromuscular blockade at extubation is significant,2 currently, monitoring of neuromuscular blockade is still not an explicitly articulated American Society of Anesthesiologists basic monitoring standard.3 Whereas many practitioners use such monitoring in their practice, others rely on clinical signs of strength or other outdated measures, such as the 5-s head lift or 50-Hz sustained tetanus to determine adequate recovery from neuromuscular blockade before extubation. Still others simply rely on time from reversal agents being given.4 Perhaps the reluctance to consistently monitor the effects of neuromuscular blocking agent and, most importantly, the adequacy of recovery before extubation, represents a peculiar psychologic phenomenon. The practice of anesthesiology is replete with situations in which parameters are monitored at baseline and for the effects of any intervention. In addition, many of our routine practices could be deemed unnecessary in the majority of patients, yet are performed to prevent devastating outcomes in the remaining small percentage of patients. Examples include preoxygenation before the induction of anesthesia, maintenance of blood pressure within certain parameters to prevent stroke or myocardial ischemia, and maintenance of normothermia to prevent wound infection and cardiovascular complications. These practices have become routine or standard because they protect patients from rare but serious complications. As Perrow5 points out, Murphy’s law is wrong: everything that can go wrong usually goes right, and then we draw the wrong conclusion. The ability to adequately ventilate 1,000 successive patients could Although the use of a more procedurally specific type of matching would most likely lead to a decrease in statistical power within a given data set, selection bias with regard to surgical procedure cannot be properly controlled for without doing so. In addition, variables that are known to be correlated with postoperative pneumonia need to be accounted for in the analysis to better elucidate the real impact of NMDR and neostigmine reversal on this outcome. These include patient functional status, smoking history, and presence of chronic obstructive pulmonary disease.3,6,7 Although these variables were indirectly accounted for in this study through the American Society of Anesthesiologists classification, a previous investigation revealed that each of these aforementioned factors were still associated with postoperative pneumonia even after controlling for American Society of Anesthesiologists class.7 Also, this analysis does not account for the beneficial effects of optimum postoperative analgesia, specifically epidural analgesia,9 on the occurrence of postoperative pneumonia. Lastly, several references in this article are erroneous. In fact, all four citations in the second paragraph of page 649 do not confirm the ideas expressed in their respective sentences.