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Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study
Open accessAbstract
Background Results from retrospective studies suggest that use of neuromuscular blocking agents during general anaesthesia might be linked to postoperative pulmonary complications. We therefore aimed to assess whether the use of neuromuscular blocking agents is associated with postoperative pulmonary complications.Methods We did a multicentre, prospective observational cohort study. Patients were recruited from 211 hospitals in 28 European countries. We included patients (aged ≥18 years) who received general anaesthesia for any in-hospital procedure except cardiac surgery. Patient characteristics, surgical and anaesthetic details, and chart review at discharge were prospectively collected over 2 weeks. Additionally, each patient underwent postoperative physical examination within 3 days of surgery to check for adverse pulmonary events. The study outcome was the incidence of postoperative pulmonary complications from the end of surgery up to postoperative day 28. Logistic regression analyses were adjusted for surgical factors and patients' preoperative physical status, providing adjusted odds ratios (OR adj) and adjusted absolute risk reduction (ARR adj). This study is registered with ClinicalTrials.gov, number NCT01865513.Findings Between June 16, 2014, and April 29, 2015, data from 22 803 patients were collected. The use of neuromuscular blocking agents was associated with an increased incidence of postoperative pulmonary complications in patients who had undergone general anaesthesia (1658 [7·6%] of 21 694); OR adj 1·86, 95% CI 1·53-2·26; ARR adj -4·4%, 95% CI -5·5 to -3·2). Only 2·3% of high-risk surgical patients and those with adverse respiratory profiles were anaesthetised without neuromuscular blocking agents. The use of neuromuscular monitoring (OR adj 1·31, 95% CI 1·15-1·49; ARR adj -2·6%, 95% CI -3·9 to -1·4) and the administration of reversal agents (1·23, 1·07-1·41; -1·9%, -3·2 to -0·7) were not associated with a decreased risk of postoperative pulmonary complications. Neither the choice of sugammadex instead of neostigmine for reversal (OR adj 1·03, 95% CI 0·85-1·25; ARR adj -0·3%, 95% CI -2·4 to 1·5) nor extubation at a train-of-four ratio of 0·9 or more (1·03, 0·82-1·31; -0·4%, -3·5 to 2·2) was associated with better pulmonary outcomes.Interpretation We showed that the use of neuromuscular blocking drugs in general anaesthesia is associated with an increased risk of postoperative pulmonary complications. Anaesthetists must balance the potential benefits of neuromuscular blockade against the increased risk of postoperative pulmonary complications.Funding European Society of Anaesthesiology.
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Patients having surgery are a vulnerable group at risk of SARS-CoV-2 exposure in hospital and might be particularly susceptible to subsequent pulmonary complications, due to pro-inflammatory cytokine and immunosuppressive responses to surgery and mechanical ventilation.
“Patients having surgery are a vulnerable group at risk of SARS-CoV-2 exposure in hospital and might be particularly susceptible to subsequent pulmonary complications, due to the pro-inflammatory cytokine and immunosuppressive responses to surgery and mechanical ventilation.3, 4”
From Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study (2020) · cites this paper as [4]
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Preoperative Evaluation of Patients With Interstitial Lung Disease
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The effects of acetylcholinesterase inhibitors on morbidity after general anesthesia and surgery
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The latest trend in neuromuscular monitoring: return of the electromyography
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Recent advances in understanding and managing postoperative respiratory problems
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Acute Pain Service: A 10‐Year Experience
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Neostigmine versus sugammadex: the tide may be turning, but we still need to navigate the winds
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Cohort profile: the China surgery and anesthesia cohort (CSAC)
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Considerations in Neuromuscular Blockade in the ICU: A Case Report and Review of the Literature
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Reversing Neuromuscular Blockade: Not Just the Diaphragm, but Carotid Body Function Too
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Does reversal of neuromuscular block with sugammadex reduce readmission rate after surgery?
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Supraglottic airway versus tracheal intubation and the risk of postoperative pulmonary complications
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Non-intubated video-assisted thoracic surgery for subxiphoid anterior mediastinal tumor resection
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Metadata
- Authors
- Kirmeier, E., Eriksson, L. I., Lewald, H., Jonsson Fagerlund, M., Hoeft, A., Hollmann, M., Meistelman, C., Hunter, J. M., Ulm, K., Blobner, M., Abad Gurumeta, A., Abernethy, C., Abigail, P., Achaibar, K., Adam, E., Afshari, A., Agudelo Montoya, M. E., Akgün, F. N., Aletti, G., Alkış, N., Allan, K., Allan, A., Allaouchiche, B., Allcock, C., Almasy, E., Amey, I., Amigoni, M., Andersen, E., Andersson, P., Anipchenko, N., Antunes, P., Armstrong, E., Aslam, T. N., Aslin, B., Assunção, J. P., Ausserer, J., Avvai, M., Awad, N., Ayas Montero, B., Ayuso, M., Azevedo, P., Badarau, V., Badescu, R., Baiardo Redaelli, M., Baird, C., Baird, Y., Baker, T., Balaji, P., Bălan, C., Balandin, A., Balescu-Arion, C., Baliuliene, V., Baltasar Isabel, J., Baluch, S. N., Bandrabur, D., Bankewitz, C., Barber, K., Barbera, F., Barcraft-Barnes, H., Barletti, V., Barnett, G., Baron, K., Barros, A., Barsan, V., Bartlett, P., Batistaki, C., Baumgarten, G., Baytas, V., Beauchamp, N., Becerra Cayetano, I. A., Bell, S., Bellandi, M., Belletti, A., Belmonte Cuenca, J., Benitez-Cano, A., Beretta, L., Berger, M., Bergmann, N., Bergmark, K., Bermudez Lopez, M., Bernotaite, M., Beurskens, C., Bidd, H., Bifulco, F., Bignami, E., Bilic, A., Bilskiene, D., Bischoff, P., Bishop, L., Bjonness, T., Blaylock, H., Blethyn, K., Blincoe, T., Blokhin, I., Blunt, N., Boer, C., Bois, G., Bonicolini, E., Booth, J., Borecka-Kedzierska, M., Borstnar, K., Borys, M., Boselli, E., Bouvet, L., Bouwman, A., Bowen, L., Bowrey, S., Boxall, L., Božić, T., Bradley, T., Branco, T., Brazzi, L., Brazzoni, M., Brear, T., Brogly, N., Brohi, F., Broms, J., Bubliauskas, A., Bucolo, G. E., Buerkle, H., Buggy, D., Buhre, W., Bukauskas, T., Butturini, F., Byttner, A., Cabrera Díaz, I., Calderon, A., Calhau, R., Callejo, A., Cammu, G., Campesato, M., Can, Ö. S., Candeias, M., Cantor, A., Carise, E., Carmona, C., Carreteiro, J., Carrieri, C., Carter, A., Casal, M., Casanova, I., Cascella, M., Casero, L. M., Casiraghi, G. M., Castelo-Branco, L., Castro Arranz, C., Cernea, D. D., Cervantes, J., Chandler, B., Charnock, R., Chatzimicali, A., Chinery, E., Chishti, A., Chondhury, P., Christie, E., Christodoudiles, G., Ciardo, S., Cimpeanu, L., Cindea, I., Cinnella, G., Clark, S., Clayton, M., Cocu, S., Collyer, T., Colvin, C., Cope, S., Copeta, F., Copotoiu, S.-M., Correia de Barros, F., Corso, R. M., Cortegiani, A., Costa, G., Cowton, A., Cox, N., Craig, J., Cricca, V., Cronin, J., Cunha, M., Cuomo, A., Curley, K., Czuczwar, M., Dabrowska, D., Damster, S., Danguy des Déserts, M., Daniliuc, A., Danninger, T., Darwish, I., Dascalu, C., Davies, K., Davies, S., De Boer, H., De Flaviis, A., De Selincourt, G., Deana, C., Debaene, B., Debreceni, G., Dedhia, J., Delgado Garcia, I., Della Rocca, G., Delroy-Buelles, L., Desai, T., Dhillon, P., Di Giacinto, I., Di Mauro, P., Diaz Gomez, T. V., Dimitrovski, A., Dinic, V., Dîrzu, D.-S., Divander, M. B., Dolinar, J., Domingues, S., Doolan, J., Downes, C., Dragoescu, N. A., Droc, G., Dum, E., Dumitrescu, A., Duncan, L., Dzurňáková, P., Eberl, S., Edwards, J., Edwards, M., Ekelund, K., Ekengren, P., Elghouty, E., Ellerkmann, R., Ellis, H., Elme, A., Ernst, T., Errando, C. L., Estenes, S., Ewaldsson, C., Farid, N., Featherstone, J., Febres, D., Fedorov, S., Feggeler, J., Feijten, P., Fellmann, T., Fernandez Candil, J., Fernandez Castineira, A., Fernández Castineira, J., Fernando, A., Ferrando, C., Ferreira, L., Ferreira, P., Feyling, A., Filipescu, D., Fleischer, A., Floris, L., Foerster, U., Fox, B., Franke, U., Frasca, D., Frey, C., Frost, V., Fullin, G., Fumagalli, J., Furneval, J., Fusari, M., Gallacher, S., Galushka, S., Gambale, G., Gambino, I., Garcia-Perez, M. L., Garg, S., Garlak, J., Gavranovic, Z., Gavrilov, R., Gaynor, L., Gecaj Gashi, A., Georghiou, M., Gerjevic, B., Gferer, G., Giarratano, A., Gibson, A., Gievski, V., Giles, J., Gillberg, L., Gilowska, K., Gilsanz Rodriguez, F., Gioia, A., Giovannoni, C., Girotra, V., Gkinas, D., Gkiokas, G., Godoroja, D., Goebel, U., Goel, V., Gonzalez, M., Goranovic, T., Gornik-Wlaszczuk, E., Gosavi, S., Gottfridsson, P., Gottschalk, A., Granell, M., Granstrom, A., Grassetto, A., Greenwood, A., Grigoras, I., Grintescu, I., Gritsan, A., Gritsan, G., Grynyuk, A., Guadagnin, G. M., Guarnieri, M., Güçlü, Ç., Guerrero Diez, M., Gunenc, F., Günther, U., Gupta, P., Guttenthaler, V., Hack, Y., Hafisayena, A., Hagau, N., Haldar, J., Hales, D., Hancı, V., Hanna-Jumma, S., Harazim, H., Harlet, P., Harper, D., Harris, B., Harvey, O., Hashimi, M., Hawkins, L., Hayes, C., Heaton, J., Heier, T., Helliwell, L., Hemmes, S., Henderson, K., Hermanides, J., Hermanns, H., Herrera Hueso, B., Hestenes, S., Hettiarachchi, R., Highgate, J., Hodgson, K., Hoelbling, D., Holland, J., Horhota, L., Hormis, A., Hribar, R., Hua, A., Humphreys, S., Humphries, R., Humpliková, S., Hunt, J., Husnain, A., Hussein, A., Hyams, B., Iannuccelli, F., Ilette, K., Ilyas, C., Inan, T., India, I., Ionițăv, V., Irwin, F., Jain, V., Janez, B., Jankovic, R., Jenkins, S., Jenko, M., Jimenez, R., Jiménez Gomez, B., Joachim, S., Joelsson-Alm, E., John, J., Jonikaite, L., Jovic, M., Jungwirth, B., Junke, E., Kabakov, B., Kadaoui, S.-D., Kanski, A., Karadag, S., Karbonskiene, A., Karjagin, J., Kasnik, D., Katanolli, F., Katsika, E., Kaufmann, K., Keane, H., Kelly, M., Kent, M., Keraitiene, G., Khudhur, A., Khuenl-Brady, K., Kidd, L., King, S., Kirchgäßner, K., Klancir, T., Klucniks, A., Knotzer, J., Knowlden, P., Koers, L., Kompan, J., Koneti, K. K., Kooij, F., Koolen, E., Koopman - van Gemert, A. W. M. M., Kopp, K., Korfiotis, D., Korolkov, O., Kosinová, M., Köstenberger, M., Kotzinger, O., Kovačević, M., Kranke, P., Kranke, E., Kraus, C., Kraus, S., Kubitzek, C., Kucharski, R., Kucukguclu, S., Kudrashou, A., Kumar, V., Kummen, L., Kunit, C., Kushakovsky, V., Kuvaki, B., Kuzmanovska, B., Kyttari, A., Landoni, G., Lau, G., Lazarev, K., Legett, S., Legrottaglie, A. M., Leonardi, S., Leong, M., Lercher, H., Leuvrey, M., Leva, B., Levstek, M., Limb, J., Lindholm, E., Linton, F., Liperi, C., Lipski, F., Lirk, P., Lisi, A., Lišková, K., Lluch Oltra, A., Loganathan, V., Lombardi, S., Lopez, E., Lopez Rodríguez, M., Lorenzini, L., Lowicka, M., Lugovoy, A., Luippold, M., Lumb, A., Macas, A., Macgregor, M., Machado, H., Maciariello, M., Madeira, I., Maitan, S., Majewski, J., Maldini, B., Malewski, G., Manfredini, L., Männer, O., Marchand, B., Marcu, A., Margalef, J., Margarson, M., Marinheiro, L., Markic, A., Markovic Bozic, J., Marrazzo, F., Martin, J., Martin Ayuso, M., Martinez, E., Martino, E. A., Martinson, V., Marusic-Gaser, K., Mascarenhas, C., Mathis, C., Matsota, P., Mavrommati, E., Mazul Sunko, B., McCourt, K., McGill, N., McKee, R., Meço, B. C., Meier, S., Melbourne, S., Melbybråthen, G., Meli, A., Melia, A., Melotti, R. M., Menga, M. R., Mercer, P., Merotra, S., Mescolini, S., Metterlein, T., Michalov, M., Michlig, S., Midgley, S., Milić, M., Milojevic, M., Miñana, A., Minto, G., Mirabella, L., Mirea, L., Mittelstädt, L., Moeglen, A., Moise, A., Mokini, Z., Molin, A., Moltó, L., Monea, M. C., Montalto, F., Montgomery, J., Montgomery, C., Montillo, G., Moore, S., Moore, F., Moreira, Z., Moreno, T., Moreno, R., Moret, E., Moreton, S., Morgan, M., Moro Velasco, C., Morri, D., Moull, A., Moura, F., Mráz, P., Mrozek, K., Mukhtar, K., Muniyappa, S., Murray, H., Murthy, B. 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- Affiliations
- Technical University of Munich (DE)
- Karolinska University Hospital (SE)
- University Hospital Bonn (DE)
- Amsterdam UMC Location University of Amsterdam (NL)
- University of Liverpool (GB)
- Corresponding author
- Blobner, Manfred
- ORCID
- Lewald, Heidrun
- Hoeft, Andreas
- Hollmann, Markus
- Meistelman, Claude
- Hunter, Jennifer M
- Ulm, Kurt
- Blobner, Manfred
- Afshari, Arash
- Alkış, Neslihan
- Allaouchiche, Bernard
- Anipchenko, Natalya
- Aslam, Tayyba Naz
- Baker, Tim
- Balaji, Packianathaswamy
- Balandin, Alina
- Batistaki, Chrysanthi
- Baumgarten, Georg
- Bellandi, Mattia
- Belletti, Alessandro
- Beretta, Luigi
- Berger, Marc
- Bifulco, Francesca
- Bignami, Elena
- Boer, Christa
- Bonicolini, Eleonora
- Borys, Michał
- Boselli, Emmanuel
- Bouvet, Lionel
- Brazzi, Luca
- Brogly, Nicolas
- Broms, Jacob
- Bubliauskas, Andrius
- Buerkle, Hartmut
- Buggy, Donal
- Bukauskas, Tomas
- Cammu, Guy
- Campesato, Manuela
- Can, Özlem S
- Candeias, Margarida
- Carreteiro, Joana
- Casal, Manuela
- Cascella, Marco
- Cinnella, Gilda
- Corso, Ruggero Massimo
- Cortegiani, Andrea
- Cricca, Valentina
- Cuomo, Arturo
- Czuczwar, Mirosław
- Danninger, Thomas
- Davies, Simon
- Deana, Cristian
- Debaene, Bertrand
- Dimitrovski, Aleksandar
- Dinic, Vesna
- Dîrzu, Dan-Sebastian
- Downes, Charlotte
- Droc, Gabriela
- Dumitrescu, Alexandra
- Eberl, Susanne
- Edwards, Mark
- Ekelund, Kim
- Ellerkmann, Richard
- Errando, Carlos Luis
- Fedorov, Sergey
- Ferrando, Carlos
- Feyling, Anders
- Frasca, Denis
- Fumagalli, Jacopo
- Fusari, Maurizio
- Gallacher, Stuart
- Garg, Sanjeev
- Giarratano, Antonino
- Gioia, Antonio
- Gkiokas, George
- Godoroja, Daniela
- Goebel, Ulrich
- Granell, Manuel
- Grassetto, Alberto
- Gritsan, Alexey
- Guadagnin, Giovanni Maria
- Guarnieri, Marcello
- Güçlü, Çiğdem
- Gunenc, Ferim
- Guttenthaler, Vera
- Hancı, Volkan
- Harazim, Hana
- Harlet, Pierre
- Harris, Benjamin
- Heier, Tom
- Hemmes, Sabrine
- Hermanides, Jeroen
- Hermanns, Henning
- Hormis, Anil
- Hua, Alina
- Humphreys, Sally
- Husnain, Ali
- Hussein, Ahmed
- Jankovic, Radmilo
- Jenkins, Sarah
- Jenko, Matej
- Jovic, Miomir
- Jungwirth, Bettina
- Kaufmann, Kai
- Keane, Helen
- Koers, Lena
- Koneti, Kiran K
- Korolkov, Oleg
- Kosinová, Martina
- Köstenberger, Markus
- Kranke, Peter
- Kuvaki, Bahar
- Landoni, Giovanni
- Leva, Brigitte
- Lindholm, Espen
- Lirk, Philipp
- Lugovoy, Alexander
- Lumb, Andrew
- Macas, Andrius
- Marrazzo, Francesco
- Matsota, Paraskevi
- Meço, Başak Ceyda
- Melotti, Rita Maria
- Milojevic, Milan
- Miñana, Amanda
- Mirabella, Lucia
- Mirea, Liliana
- Mokini, Zhirajr
- Moltó, Luis
- Montgomery, Jane
- Moura, Fernando
- Nardelli, Pasquale
- Oldner, Anders
- Ovezov, Alexey
- Paal, Peter
- Papaioannou, Alexandra
- Papapostolou, Konstantinos
- Pasin, Laura
- Pereira, Manuela
- Pina, Pedro
- Pistidda, Laura
- Piwowarczyk, Paweł
- Popescu, Mihai
- Pota, Vincenzo
- Preckel, Benedikt
- Pugh, Richard
- Radoeshki, Aleksandar
- Ragazzi, Riccardo
- Ramessur, Suneil
- Rich, Nathalie
- Rimaitis, Marius
- Ringvold, Else-Marie
- Ristescu, Irina
- Romagnoli, Stefano
- Rundgren, Malin
- Russotto, Vincenzo
- Rypulak, Elżbieta
- Sales, Gabriele
- Santos, Sofia
- Schaller, Stefan
- Scheffer, Gert Jan
- Schreiber, Jan-Uwe
- Schultz, Marcus
- Semenas, Egidijus
- Sinclair, Rhona
- Singh, Rajendra
- Smee, Elizabeth
- Smith, Neil
- Smole, Daniel
- Sojčić, Nataša
- Soro, Marina
- Spadaro, Savino
- Spaeth, Johannes
- Stera, Caterina
- Stevens, Markus
- Stroumpoulis, Konstantinos
- Tartaglione, Marco
- Tbaily, Lee
- Theodoraki, Kassiani
- Tomescu, Dana
- Tommasino, Concezione
- Tsaousi, Georgia
- Turan, Güldem
- Turhan, Sanem Çakar
- Unic-Stojanovic, Dragana
- Unterbuchner, Christoph
- Verheyen, Veerle
- Vico, Manuel
- Vizcaychipi, Marcela Paola
- Volta, Carlo Alberto
- Wallberg, Hanna
- Weber, Stefan
- Wirth, Steffen
- Wright, Stella
- Zachoval, Christian
- Zambon, Massimo
- Zangrillo, Alberto
- Zani, Gianluca
- Żukowski, Maciej
- Venue
- The Lancet Respiratory Medicine
- Publisher
- Elsevier BV
- Published
- 2019-02
- Volume
- 7
- Issue
- 2
- Pages
- 129-140
- ISSN
- 2213-2600 (ISSN-L)
- OpenAlex
- W2891017301
- Cited by
- 372
- References
- 38
- Citations by year
- 2026: 35 · 2025: 44 · 2024: 35 · 2023: 51 · 2022: 49 · 2021: 71 · 2020: 54 · 2019: 31
- FWCI
- 57.48
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Lancet Respiratory Medicine (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (publishedVersion)
- Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- HAL (submittedVersion)
- BOA (University of Milano-Bicocca) (submittedVersion)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- Institutional Research Information System University of Ferrara (University of Ferrara) (submittedVersion)
- Florence Research (University of Florence) (submittedVersion)
- IrInSubria (University of Insubria) (submittedVersion)
- Archivio Istituzionale della Ricerca - Università degli Studi della Campania "Luigi Vanvitelli" (submittedVersion)
- Nova Science Publishers (Nova Science Publishers, Inc.) (submittedVersion)
- Archivio Istituzionale della Ricerca - Università Vita-Salute San Raffaele (submittedVersion)
- UnissResearch (Università degli Studi di Sassari) (submittedVersion)
- Institutional Research Information System University of Turin (University of Turin) (submittedVersion)
- Lithuanian University of Health Sciences (submittedVersion)
- mediaTUM – the media and publications repository of the Technical University Munich (Technical University Munich) (submittedVersion)
- Carl von Ossiezky University of Oldenburg (submittedVersion)
- Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
- Institutional Research Information System University of Ferrara (University of Ferrara) (submittedVersion, other-oa)
- Funders
- National Institute for Health and Care Research (ACF-2017-17-016)
- European Society of Anaesthesiology
- Topics
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Pain Management
- Keywords
- neuromuscular blocking agents, general anesthesia, postoperative pulmonary complications, neuromuscular monitoring, neuromuscular reversal agents, sugammadex, neostigmine, postoperative respiratory failure, postoperative pneumonia, postoperative atelectasis, postoperative pleural effusion
- MeSH terms
- Adult, Aged, Anesthesia, General, Cause of Death, Europe, Female, Humans, Lung Diseases, Male, Middle Aged, Neuromuscular Blocking Agents, Postoperative Complications, Prospective Studies, Retrospective Studies, Cohort Studies, Logistic Models, Odds Ratio, Survival Analysis, Hospital Mortality, Risk Assessment
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