Postoperative Pulmonary Complications' Association With Sugammadex Versus Neostigmine

A Retrospective Registry Analysis

Gen Li, M.Stat., M.Chem.; Robert E. Freundlich, M.D., M.S., M.S.C.I.; Rajnish K. Gupta, M.D., Christina J. Hayhurst, M.D.; Chi H. Le, B.S., Barbara J. Martin, R.N., M.B.A.; Matthew S. Shotwell, Ph.D.; Jonathan P. Wanderer, M.D., M.Phil., F.A.S.A., F.A.M.I.A.

Disclosures

Anesthesiology. 2021;134(6):862-873. 

In This Article

Abstract and Introduction

Abstract

Background: Postoperative residual neuromuscular blockade related to nondepolarizing neuromuscular blocking agents may be associated with pulmonary complications. In this study, the authors sought to determine whether sugammadex was associated with a lower risk of postoperative pulmonary complications in comparison with neostigmine.

Methods: Adult patients from the Vanderbilt University Medical Center National Surgical Quality Improvement Program database who underwent general anesthesia procedures between January 2010 and July 2019 were included in an observational cohort study. In early 2017, a wholesale switch from neostigmine to sugammadex occurred at Vanderbilt University Medical Center. The authors therefore identified all patients receiving nondepolarizing neuromuscular blockades and reversal with neostigmine or sugammadex. An inverse probability of treatment weighting propensity score analysis approach was applied to control for measured confounding. The primary outcome was postoperative pulmonary complications, determined by retrospective chart review and defined as the composite of the three postoperative respiratory occurrences: pneumonia, prolonged mechanical ventilation, and unplanned intubation.

Results: Of 10,491 eligible cases, 7,800 patients received neostigmine, and 2,691 received sugammadex. A total of 575 (5.5%) patients experienced postoperative pulmonary complications (5.9% neostigmine vs. 4.2% sugammadex). Specifically, 306 (2.9%) patients had pneumonia (3.2% vs. 2.1%), 113 (1.1%) prolonged mechanical ventilation (1.1% vs. 1.1%), and 156 (1.5%) unplanned intubation (1.6% vs. 1.0%). After propensity score adjustment, the authors found a lower absolute incidence rate of postoperative pulmonary complications over time (adjusted odds ratio, 0.91 [per year]; 95% CI, 0.87 to 0.96; P < .001). No difference was observed on the odds of postoperative pulmonary complications in patients receiving sugammadex in comparison with neostigmine (adjusted odds ratio, 0.89; 95% CI, 0.65 to 1.22; P = 0.468).

Conclusions: Among 10,491 patients at a single academic tertiary care center, the authors found that switching neuromuscular blockade reversal agents was not associated with the occurrence of postoperative pulmonary complications.

Introduction

Neuromuscular blocking agents are commonly administered during general anesthesia to facilitate endotracheal intubation and to optimize surgical conditions.[1] However, residual neuromuscular blockade remains a complication of nondepolarizing neuromuscular blocking agents. Clinically, residual neuromuscular blockade is associated with adverse physiologic effects, including impaired pharyngeal function, decreased functional residual capacity, and impaired hypoxic ventilatory response,[2,3] which contribute to multiple postoperative complications, including weakness, aspiration, reintubation, and pneumonia.[4–8] Thus, appropriate reversal guided by neuromuscular transmission monitoring is critical to decreasing the risk of postoperative pulmonary complications.[9]

Neostigmine, an acetylcholinesterase inhibitor reversal agent, may decrease the likelihood of postoperative pneumonia.[10] However, it is ineffective in reversing deep neuromuscular blockade.[11] Additionally, neostigmine may be associated with paradoxical muscle weakness if administered when full recovery of neuromuscular function has occurred.[12] Moreover, muscarinic side effects, including bradycardia, double vision, and postoperative nausea and vomiting, are an important consideration in routine use.[13] Sugammadex, a novel reversal agent, has been approved by the Food and Drug Administration (Silver Spring, Maryland) in 2015 as an alternative to neostigmine and entered broad usage. Reversal using sugammadex has been reported to lower the incidence of residual paralysis,[14] with more rapid reversal, less bradycardia,[15] and a lower hospital readmission rate.[16] The association between postoperative pulmonary complications and sugammadex reversal, however, remains unclear.

The primary aim of this analysis is to determine whether reversal with sugammadex is associated with a lower risk of pulmonary complications within the 30-day postoperative period compared with reversal with neostigmine. We hypothesized that use of sugammadex was protective for the development of postoperative pulmonary complications.

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