To the Editor:-Lubarsky et al.  are to be congratulated on a very nice and timely study on the implementation of pharmaceutical practice guidelines. However, their study was only concerned with immediate postanesthesia care (PACU) outcomes, and as they themselves point out in the discussion, this does not necessarily reflect the entire perioperative course for inpatients. Anesthetic agents and not the lesser muscle relaxants may have significant effects that last beyond the PACU period. I would like to draw attention to our resent randomized controlled trial of postoperative pulmonary complications after the use of pancuronium, atracurium, and vecuronium in nearly 700 adult patients undergoing abdominal, orthopedic, and gynecologic operations. [2,3] All patients were monitored during anesthesia using tactile evaluation of the response to train-of-four nerve stimulation, and all were blindly evaluated for postoperative pulmonary complications 2, 4, and 6 days after surgery. Not only was the incidence and the degree of residual block in the PACU significantly increased in the pancuronium group, but also significantly more patients in this group developed postoperative pulmonary complications in the ward (16.9%) as compared with the two other groups (5.4%). The findings may not apply directly to other departments using other methods of administration of muscle relaxants. They do, however, indicate that any investigation of the effect of practice guidelines on clinical outcome (and including cost-benefit analyses) should include the period after the patients are discharged to the ward.
Jorgen Viby-Mogensen, M.D., D.M.Sc., F.R.C.A.
Professor and Chairman; Department of Anesthesia and Intensive Care; Copenhagen University Hospital; Rigshospitalet; 2100 Copenhagen; Denmark
(Accepted for publication August 25, 1997.)