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Cozowicz C, Zhong H, Poeran J, Illescas A, Liu J, Poultsides LA, Athanassoglou V, Memtsoudis SG. Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis. Eur J Anaesthesiol 2024; 41:374-380. [PMID: 38497249 DOI: 10.1097/eja.0000000000001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Residual neuromuscular blockade after surgery remains a major concern given its association with pulmonary complications. However, current clinical practices with and the comparative impact on perioperative risk of various reversal agents remain understudied. OBJECTIVE We investigated the use of sugammadex and neostigmine in the USA, and their impact on postoperative complications by examining national data. DESIGN This population-based retrospective study used national Premier Healthcare claims data. SETTING AND PARTICIPANTS Patients undergoing total hip/knee arthroplasty (THA, TKA), or lumbar spine fusion surgery between 2016 and 2019 in the United States who received neuromuscular blocking agents. INTERVENTION The effects of sugammadex and neostigmine for pharmacologically enhanced reversal were compared with each other and with controls who received no reversal agent. MAIN OUTCOMES included pulmonary complications, cardiac complications, and a need for postoperative ventilation. Mixed-effects regression models compared the outcomes between neostigmine, sugammadex, and controls. We report odds ratios (OR) and 95% confidence intervals (CI). Bonferroni-adjusted P values of 0.008 were used to indicate significance. RESULTS Among 361 553 patients, 74.5% received either sugammadex (20.7%) or neostigmine (53.8%). Sugammadex use increased from 4.4% in 2016 to 35.4% in 2019, whereas neostigmine use decreased from 64.5% in 2016 to 43.4% in 2019. Sugammadex versus neostigmine or controls was associated with significantly reduced odds for cardiac complications (OR 0.86, 95% CI, 0.80 to 0.92 and OR 0.83, 95% CI, 0.78 to 0.89, respectively). Both sugammadex and neostigmine versus controls were associated with reduced odds for pulmonary complications (OR 0.85, 95% CI, 0.77 to 0.94 and OR 0.91, CI 0.85 to 0.98, respectively). A similar pattern of sugammadex and neostigmine was observed for a reduction in severe pulmonary complications, including the requirement of invasive ventilation (OR 0.54, 95% CI, 0.45 to 0.64 and OR 0.53, 95% CI, 0.46 to 0.6, respectively). CONCLUSIONS Population-based data indicate that sugammadex and neostigmine both appear highly effective in reducing the odds of severe life-threatening pulmonary complications. Sugammadex, especially, was associated with reduced odds of cardiac complications.
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Affiliation(s)
- Crispiana Cozowicz
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (CC, SGM), Hospital for Special Surgery, Department of Anesthesiology, Critical Care & Pain Management, Weill Cornell Medical College, New York, USA (HZ, AI, JL, SGM), Department of Orthopaedic Surgery/Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, USA (JP), Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA (JL, SGM), Academic Orthopaedic Department, Aristotle University Medical School, General Hospital Papageorgiou (LAP), Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece (LAP) and Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, United Kingdom (VA)
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Liu HM, Yu H, Zuo YD, Liang P. Postoperative pulmonary complications after sugammadex reversal of neuromuscular blockade: a systematic review and meta-analysis with trial sequential analysis. BMC Anesthesiol 2023; 23:130. [PMID: 37081384 PMCID: PMC10116764 DOI: 10.1186/s12871-023-02094-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 04/17/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Sugammadex has been reported to lower the incidence of postoperative residual neuromuscular blockade. Despite the advantages, until recently the effects of sugammadex on postoperative pulmonary complications (PPCs) were controversial. We conducted a systematic review and meta-analysis to determine whether reversal with sugammadex was associated with a lower risk of PPCs compared with neostigmine. METHODS PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to May 2022. Randomized controlled trials (RCTs) and observational studies comparing PPCs in patients receiving sugammadex or neostigmine as reversal agent at the end of surgery were included. The primary outcomes focused on PPCs including desaturation, pneumonia, atelectasis, noninvasive ventilation (NIV) and reintubation. Trial sequential analysis was performed on the primary outcomes to confirm whether firm evidence was reached. RESULTS Meta-analysis of included studies showed that the rate of desaturation (43.2% vs 45.0%, RR = 0.82; 95% CI 0.63 to 1.05; p = 0.11) were comparable between the two groups. When looking at other primary outcomes, significantly lower risk of pneumonia (1.37% vs 2.45%, RR = 0.65; 95% CI 0.49 to 0.85; p = 0.002), atelectasis (24.6% vs 30.4%, RR = 0.64; 95% CI 0.42 to 0.98; p = 0.04), NIV (1.37% vs 2.33%, RR = 0.65; 95% CI 0.43 to 0.98; p = 0.04) and reintubation (0.99% vs 1.65%, RR = 0.62; 95% CI 0.43 to 0.91; p = 0.01) in the sugammadex group were detected compared with the neostigmine group. CONCLUSIONS We concluded that sugammadex is more effective at reducing the incidence of PPCs including pneumonia, atelectasis, NIV and reintubation compared with neostigmine. Further evidence, preferably from RCTs, is required to confirm these findings.
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Affiliation(s)
- Hong-Mei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Sichuan, Chengdu 610041, China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Sichuan, Chengdu 610041, China
| | - Yi-Ding Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Sichuan, Chengdu 610041, China
| | - Peng Liang
- Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Sichuan, Chengdu 610041, China.
- Day Surgery Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Liu H, Luo R, Cao S, Zheng B, Ye L, Zhang W. Superiority of sugammadex in preventing postoperative pulmonary complications. Chin Med J (Engl) 2023:00029330-990000000-00478. [PMID: 37027443 DOI: 10.1097/cm9.0000000000002381] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Postoperative pulmonary complications often lead to increasing mortality and financial burden. Residual paralysis plays a critical role in postoperative pulmonary complications. This meta-analysis was performed to determine whether sugammadex overmatch neostigmine in reducing postoperative pulmonary complications. METHODS PubMed, Embase, Web of Science, Medline through Ovid, Cochrane Library, Wan fang, China National Knowledge Infrastructure, and Chinese BioMedical Literature Databases were searched from their inception to 24 June 2021. Random effects models were used for all analyses. Cochrane risk of bias tool was used to assess the quality of RCTs, while Newcastle Ottawa Quality Assessment Scale was used to assess for the quality of cohort studies. RESULTS Seventeen studies were included in the meta-analysis. Pooled data from cohort studies showed reversing neuromuscular blocking with sugammadex had less risk of compound postoperative pulmonary complications [relative risk (RR): 0.73; 95% confidence interval (CI): 0.60-0.89; P = 0.002; I2 = 81%], pneumonia (RR: 0.64; 95% CI: 0.48-0.86; I2 = 42%) and respiratory failure (RR: 0.48, 95% CI: 0.41-0.56, I2 = 0%). However, pooled data from RCTs did not show any difference between the two groups in pneumonia (RR: 0.58; 95% CI: 0.24-1.40; I2 = 0%) and respiratory failure. The difference was not found between sugammadex and neostigmine about atelectasis in pooled data from either RCTs (RR: 0.85; 95% CI: 0.69-1.05; I2 = 0%) or cohort studies (RR: 1.01; 95% CI: 0.87 to 1.18; I2 = 0%). CONCLUSION The evidence of superiority of sugammadex was limited by the confounding factors in cohort studies and small scale of RCTs. Whether sugammadex precedes neostigmine in preventing pulmonary complications after surgery is still unknown. Well-designed RCTs with large scale are needed. REGISTRATION PROSPERO CRD 42020191575.
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Affiliation(s)
- Haibei Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Rong Luo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Shuangjiao Cao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
| | - Bixing Zheng
- Department of Pain, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Ling Ye
- Department of Pain, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Wensheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Translational Neuroscience Center, Sichuan University, Chengdu, Sichuan 610041, China
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Yu H, Zuo Y, Xu Z, Zhao D, Yue J, Liu L, Guo Y, Huang J, Deng X, Liang P. Comparison effects of two muscle relaxant strategies on postoperative pulmonary complications in transapical transcatheter aortic valve implantation: a propensity score-matched analysis. J Cardiothorac Surg 2023; 18:50. [PMID: 36721168 PMCID: PMC9890810 DOI: 10.1186/s13019-023-02166-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/24/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prior studies have reported conflicting results on the effect of sugammadex on postoperative pulmonary complications (PPCs) and research on this topic in transapical-transcatheter aortic valve implantation (TA-TAVI) was sparse. The current study aimed to investigate whether there were differences in the incidence of PPCs between two muscle relaxant strategies (rocuronium/sugammadex vs. cisatracurium/neostigmine) in patients undergoing TA-TAVI. METHODS This retrospective observational study enrolled 245 adult patients underwent TA-TAVI between October 2018 and January 2021. The patients were grouped according to the type of muscle relaxant strategies (115 with rocuronium/sugammadex in the R/S group and 130 with cisatracurium/neostigmine in the C/N group, respectively). Pre- and intraoperative variables were managed by propensity score match (PSM) at a 1:2 ratio. PPCs (i.e., respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm and aspiration pneumonitis) were evaluated from the radiological and laboratory findings. RESULTS After PSM, 91 patients in the R/S group were selected and matched to 112 patients in the C/N group. Patients in the R/S group showed lower PPCs rate (45.1% vs. 61.6%, p = 0.019) compared to the C/N group. In addition, the R/S group showed significant shorter extubation time (7.2 ± 6.2 vs. 10.3 ± 8.2 min, p = 0.003) and length of hospital stay (6.9 ± 3.3 vs. 8.0 ± 4.0 days, p = 0.034). CONCLUSION The rocuronium/sugammadex muscle relaxant strategy decreases the incidence of PPCs in patients undergoing TA-TAVI when compared to cisatracurium/neostigmine strategy. Trial registration ChiCTR, ChiCTR2100044269. Registered March 14, 2021-Prospectively registered, http://www.Chictr.org.cn .
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Affiliation(s)
- Hong Yu
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Yiding Zuo
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Zhao Xu
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Dailiang Zhao
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Jianming Yue
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Lulu Liu
- grid.13291.380000 0001 0807 1581Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Yingqiang Guo
- grid.13291.380000 0001 0807 1581Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041 China
| | - Jiapeng Huang
- grid.266623.50000 0001 2113 1622Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY USA
| | - Xiaoqian Deng
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
| | - Peng Liang
- grid.13291.380000 0001 0807 1581Department of Anesthesiology, Day Surgery Center, West China Hospital, Sichuan University, No.37 Guoxue Alley, Chengdu, 610041 China
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Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13-41. [PMID: 36520073 DOI: 10.1097/aln.0000000000004379] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.
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Togioka BM, Schenning KJ. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 2022; 39:749-761. [PMID: 35934764 DOI: 10.1007/s40266-022-00969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
| | - Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Yu J, Park JY, Hong JH, Hwang JH, Kim YK. Effect of pneumoperitoneum and Trendelenburg position on internal carotid artery blood flow measured by ultrasound during robotic prostatectomy. Clin Physiol Funct Imaging 2022; 42:139-145. [PMID: 35018713 DOI: 10.1111/cpf.12742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/20/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3±44.7 [T2] vs. 188.0±49.6 mL/min [T1], P=0.002; 163.1±39.9 [T3] vs. 188.0±49.6 mL/min [T1], P=0.009). The ICA blood flow also differed significantly between Ta and T1 (236.8±58.3 vs. 188.0±49.6 mL/min, P<0.001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Influence of steep Trendelenburg position on postoperative complications: a systematic review and meta-analysis. J Robot Surg 2021; 16:1233-1247. [PMID: 34972981 PMCID: PMC9606098 DOI: 10.1007/s11701-021-01361-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022]
Abstract
Intraoperative physiologic changes related to the steep Trendelenburg position have been investigated with the widespread adoption of robot-assisted pelvic surgery (RAPS). However, the impact of the steep Trendelenburg position on postoperative complications remains unclear. We conducted a meta-analysis to compare RAPS to laparoscopic/open pelvic surgery with regards to the rates of venous thromboembolism (VTE), cardiac, and cerebrovascular complications. Meta-regression was performed to evaluate the influence of confounding risk factors. Ten randomized controlled trials (RCTs) and 47 non-randomized controlled studies (NRSs), with a total of 380,125 patients, were included. Although RAPS was associated with a decreased risk of VTE and cardiac complications compared to laparoscopic/open pelvic surgery in NRSs [risk ratio (RR), 0.59; 95% CI 0.51–0.72, p < 0.001 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively], these differences were not confirmed in RCTs (RR 0.92; 95% CI 0.52–1.62, p = 0.77 and RR 0.93; 95% CI 0.58–1.50, p = 0.78, respectively). In subgroup analyses of laparoscopic surgery, there was no significant difference in the risk of VTE and cardiac complications in both RCTs and NRSs. In the meta-regression, none of the risk factors were found to be associated with heterogeneity. Furthermore, no significant difference was observed in cerebrovascular complications between RAPS and laparoscopic/open pelvic surgery. Our meta-analysis suggests that the steep Trendelenburg position does not seem to affect postoperative complications and, therefore, can be considered safe with regard to the risk of VTE, cardiac, and cerebrovascular complications. However, proper individualized preventive measures should still be implemented during all surgeries including RAPS to warrant patient safety.
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