• Br J Anaesth · May 2020

    Randomized Controlled Trial

    Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery.

    Sugammadex used for NMBD reversal in older adults after prolonged surgery reduced residual blockade but did not reduce pulmonary complications when compared to neostigmine.

    pearl
    • Brandon M Togioka, David Yanez, Michael F Aziz, Janna R Higgins, Praveen Tekkali, and Miriam M Treggiari.
    • Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. Electronic address: togioka@ohsu.edu.
    • Br J Anaesth. 2020 May 1; 124 (5): 553-561.

    BackgroundResidual neuromuscular block has been associated with postoperative pulmonary complications. We hypothesised that sugammadex reduces postoperative pulmonary complications in patients aged ≥70 yr having surgery ≥3 h, compared with neostigmine.MethodsPatients were enrolled in an open-label, assessor-blinded, randomised, controlled trial. At surgical closure, subjects were equally randomised to receive sugammadex 2 mg kg-1 or neostigmine 0.07 mg kg-1 (maximum 5 mg) for rocuronium reversal. The primary endpoint was incidence of postoperative pulmonary complications. Secondary endpoints included residual paralysis (train-of-four ratio <0.9 in the PACU) and Phase 1 recovery (time to attain pain control and stable respiratory, haemodynamic, and neurological status). The analysis was by intention-to-treat.ResultsOf the 200 subjects randomised, 98 received sugammadex and 99 received neostigmine. There was no significant difference in the primary endpoint of postoperative pulmonary complications despite a signal towards reduced incidence for sugammadex (33% vs 40%; odds ratio [OR]=0.74; 95% confidence interval [CI]=[0.40, 1.37]; P=0.30) compared with neostigmine. Sugammadex decreased residual neuromuscular block (10% vs 49%; OR=0.11, 95% CI=[0.04, 0.25]; P<0.001). Phase 1 recovery time was comparable between sugammadex (97.3 min [standard deviation, sd=54.3]) and neostigmine (110.0 min [sd=62.0]), difference -12.7 min (95% CI, [-29.2, 3.9], P=0.13). In an exploratory analysis, there were fewer 30 day hospital readmissions in the sugammadex group compared with the neostigmine group (5% vs 15%; OR=0.30, 95% CI=[0.08, 0.91]; P=0.03).ConclusionsIn older adults undergoing prolonged surgery, sugammadex was associated with a 40% reduction in residual neuromuscular block, a 10% reduction in 30 day hospital readmission rate, but no difference in the occurrence of postoperative pulmonary complications. Based on this exploratory study, larger studies should determine whether sugammadex may reduce postoperative pulmonary complications and 30 day hospital readmissions.Clinical Trial RegistrationNCT02861131.Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

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    Notes

    pearl
    1

    Sugammadex used for NMBD reversal in older adults after prolonged surgery reduced residual blockade but did not reduce pulmonary complications when compared to neostigmine.

    Daniel Jolley  Daniel Jolley
    comment
    0

    Though these findings are in stark contrast to Kheterpal’s (2020) massive 45,000 subject matched cohort study that did show sugammadex reduced postop respiratory complications.

    Daniel Jolley  Daniel Jolley
     
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