Does reversal of neuromuscular block with sugammadex reduce readmission rate after surgery?

Impact of sugammadex and neostigmine on outcome after major orthopaedic surgery: A population-based analysis

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.

Sugammadex Is Associated With Reduced Pulmonary Complications in Patients With Respiratory Dysfunction

INTRODUCTION

Use of sugammadex is associated with fewer postoperative pulmonary complications (PPCs). This study investigated the relationship between sugammadex and PPCs in specific patients with respiratory dysfunction.

MATERIALS AND METHODS

We reviewed the electronic medical and anesthesia records of patients with respiratory dysfunction who underwent laparoscopic gastric or intestinal surgery at a single center between May 1, 2018 and December 31, 2019. The patients were divided into the sugammadex group and the nonsugammadex group, based on whether they received sugammadex or neostigmine. Binary logistic regression analyses were used to characterize the differences in incidence of PPC.

RESULTS

A total of 112 patients were included, of which 46 patients (41.1%) received sugammadex. In the logistic regression analysis, the incidences of PPC were fewer in the sugammadex group. Postoperative fever (odds ratio [OR] 0.330; 95% confidence interval [CI] 0.137-0.793, P = 0.0213), postoperative intensive care unit admission (OR 0.204; 95% CI 0.065-0.644, P = 0.007), cough (OR 0.143; 95% CI 0.061- 0.333, P < 0.001), pleural effusion (all) (OR: 0.280; 95% CI 0.104- 0.759, P = 0.012), pleural effusion (massive) (OR: 0.142; 95% CI 0.031- 0.653, P = 0.012), and difficulty in breathing (OR: 0.111; 95% CI 0.014-0.849, P = 0.039) showed significant differences between the two groups.

CONCLUSIONS

Sugammadex is associated with a reduction in PPC in patients with respiratory dysfunction.

Model for predicting early and late-onset postoperative pulmonary complications in perioperative patients receiving neuromuscular blockade: a secondary analysis

Pulmonary complications continue to be the most common adverse event after surgery. The main objective was to carry out two independent predictive models, both for early pulmonary complications in the Post-Anesthesia Care Unit and late-onset pulmonary complications after 30 postoperative days. The secondary objective was to determine whether presenting early complications subsequently causes patients to have other late-onset events. This is a secondary analysis of a cohort study. 714 patients were divided into four groups depending on the neuromuscular blocking agent, and spontaneous or pharmacological reversal. Incidence of late-onset complications if we have not previously had any early complications was 4.96%. If the patient has previously had early complications the incidence of late-onset complications was 22.02%. If airway obstruction occurs, the risk of atelectasis increased from 6.88 to 22.58% (p = 0.002). If hypoxemia occurs, the incidence increased from 5.82 to 21.79% (p < 0.001). Based on our predictive models, we conclude that diabetes mellitus and preoperative anemia are two risk factors for early and late-onset postoperative pulmonary complications, respectively. Hypoxemia and airway obstruction in Post-Anesthesia Care Unit increased four times the risk of the development of pneumonia and atelectasis at 30 postoperative days.

General anesthetic techniques for enhanced recovery after surgery: Current controversies

General anesthesia technique can influence not only immediate postoperative outcomes, but also long-term outcomes beyond hospital stay (e.g., readmission after discharge from hospital). There is lack of evidence regarding superiority of total intravenous anesthesia over inhalation anesthesia with regards to postoperative outcomes even in high-risk population including cancer patients. Optimal balanced general anesthetic technique for enhance recovery after elective surgery in adults includes avoidance of routine use preoperative midazolam, avoidance of deep anesthesia, use of opioid-sparing approach, and minimization of neuromuscular blocking agents and appropriate reversal of residual paralysis. Given that the residual effects of drugs used during anesthesia can increase postoperative morbidity and delay recovery, it is prudent to use a minimal number of drug combinations, and the drugs used are shorter-acting and administered at the lowest possible dose. It is imperative that the discerning anesthesiologist consider whether each drug used is really necessary for accomplishing perioperative goals.

Enhanced recovery pathways for ambulatory surgery

PURPOSE OF REVIEW

Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes.

RECENT FINDINGS

Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis.

SUMMARY

Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.

Association of neuromuscular reversal by sugammadex and neostigmine with 90-day mortality after non-cardiac surgery

Background

Reversing a neuromuscular blockade agent with sugammadex is known to lessen postoperative complications by reducing postoperative residual curarization. However, its effects on 90-day mortality are unknown. Therefore, this study aimed to compare the effects of sugammadex and neostigmine in terms of 90-day mortality after non-cardiac surgery.

Methods

This retrospective cohort study analyzed the medical records of adult patients aged 18 years or older who underwent non-cardiac surgery at a single tertiary care hospital between 2011 and 2016. Propensity score matching and Cox regression analysis were used to investigate the effectiveness of sugammadex and neostigmine in lowering 90-day mortality after non-cardiac surgery.

Results

A total of 65,702 patients were included in the analysis (mean age: 52.3 years, standard deviation: 15.7), and 23,532 of these patients (35.8%) received general surgery. After propensity score matching, 14,179 patients (3906 patients from the sugammadex group and 10,273 patients from the neostigmine group) were included in the final analysis. Cox regression analysis in the propensity score-matched cohort showed that the risk of 90-day mortality was 40% lower in the sugammadex group than in the neostigmine group (hazard ratio: 0.60, 95% confidence interval: 0.37, 0.98; P = 0.042). These results were similar in the multivariable Cox regression analysis of the entire cohort (hazard ratio: 0.62, 95% confidence interval: 0.39, 0.96; P = 0.036).

Conclusions

This retrospective cohort study suggested that reversing rocuronium with sugammadex might be associated with lower 90-day mortality after non-cardiac surgery compared to neostigmine. However, since this study did not evaluate quantitative neuromuscular function in the postoperative period due to its retrospective design, the results should be interpreted carefully. Future prospective studies with quantitative neuromuscular monitoring in the postoperative period should be performed to confirm these results.