Neuromuscular blockade and BMI-related postoperative pulmonary complications

We read with great interest the large retrospective cohort study by Qin et al. [1], which provides valuable insights into the association between BMI and postoperative pulmonary complications in adults undergoing non-cardiac, non-obstetric surgery. It highlights the so-called ‘obesity paradox’ and its possible influence on postoperative pulmonary complications, and challenges conventional assumptions that being overweight and living with obesity are unequivocal risk factors.

Given that postoperative pulmonary complications arise from multifactorial influences—anaesthetic, surgical and patient-related—neuromuscular considerations may be a relevant addition to the discussion on BMI-related risk [2]. A large, single-centre investigation showed a dose-dependent rise in postoperative pulmonary complications following the use of intermediate-acting neuromuscular blocking drugs [3]. Moreover, sugammadex should be dosed according to total body weight [4]. Quantitative neuromuscular monitoring is vital to confirm complete recovery from neuromuscular blockade and prevent potential complications [5].

Further investigation of how pharmacological and monitoring strategies interact with BMI-related risk could provide deeper insights into the authors' findings. In particular, optimising neuromuscular blocking drug dosing, ensuring appropriate antagonism of neuromuscular blockade and employing quantitative neuromuscular monitoring warrant closer examination to elucidate the impact of obesity on postoperative pulmonary complications.

We suggest that a more detailed analysis of neuromuscular blocking drug choice, dosing regimen, monitoring technique and timing of antagonism could further strengthen this important work.