Sugammadex for Fast-Track Surgery in Children Undergoing Cardiac Surgery: A Randomized Controlled Study

A Retrospective Pilot Comparison Trial Investigating Clinical Outcomes in Cardiac Surgical Patients Who Received Sugammadex Reversal During 2018 to 2021

OBJECTIVES

To compare the number of eligible urgent and elective cardiac surgical patients who could be extubated successfully within 6 hours of surgery and who received sugammadex versus those who did not.

DESIGN

This retrospective pilot study compared outcomes in cardiac surgical patients undergoing cardiopulmonary bypass between 2018 to 2021 who received sugammadex versus those who did not.

SETTING

At a tertiary-care hospital in the Northshore of Chicago.

PARTICIPANTS

A total of 358 elective or urgent cardiac surgical patients who underwent cardiopulmonary bypass (by 1 cardiac surgeon) and were extubated within 24 hours of the end of surgery at Evanston Hospital in Evanston, IL, were included.

INTERVENTIONS

Data were examined in the following 2 groups of patients: those who were administered sugammadex and those who were not.

MEASUREMENTS AND MAIN RESULTS

After performing propensity matching for age, sex, body mass index, kidney or liver disease, the number of preoperative conditions (defined as the sum of the presence of the following medical conditions: diabetes, immunosuppressive disease, on home oxygen, on inhaled bronchodilator, or sleep apnea), number of patients who underwent elective or urgent surgery in each group, surgery time, cardiopulmonary bypass duration, number of intraoperative blood products, use of intraoperative midazolam and propofol, a statistically significant increase in the percentage of patients in the sugammadex group were extubated within 6 hours of the end of surgery versus those who did not receive sugammadex (96.67% v 81.33%, p = 0.0428). In addition, there was a statistically significant reduction in time to extubation (hours) (4.72 ± 2.92) v (3.57± 1.96 p = 0.0098) in the sugammadex group. All other outcomes did not meet statistical significance.

CONCLUSION

This retrospective study suggested that using sugammadex reversal in cardiac surgical patients undergoing cardiopulmonary bypass may result in more patients meeting the Society of Thoracic Surgery benchmark extubation criteria within 6 hours of the end of surgery.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

OBJECTIVES

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.

INTERVENTIONS

An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.

MEASUREMENTS AND MAIN RESULTS

The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.

CONCLUSIONS

The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

Efficacy and safety of sugammadex for neuromuscular blockade reversal in pediatric patients: an updated meta-analysis of randomized controlled trials with trial sequential analysis

BACKGROUND

A recent survey revealed that extensive off-label use of sugammadex in pediatric anesthesia deserved particular attention. The present study with trial sequential analysis (TSA) aimed to evaluate the effects of sugammadex for antagonizing neuromuscular blockade (NMB) in pediatric patients, and to investigate whether the findings achieved the required information size to draw conclusions.

METHODS

PubMed, Embase, Cochrane Library and China National Knowledge Infrastructure (CNKI) were searched from inception to April 2021. All randomized controlled trials used sugammadex as reversal agent in pediatric patients were enrolled. Time from NMB reversal to recovery of the train-of-four ratio (TOFr) to 0.9 and extubation time were considered as co-primary outcomes, and incidences of adverse events were considered as secondary outcomes. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to rate the quality of evidences.

RESULTS

Data from 18 studies involving 1,065 pediatric patients were acquired. The results revealed that use of sugammadex was associated with shorter duration from administration of reversal agents to TOFr > 0.9 (MD = -14.42, with 95% CI [-17.08, -11.75]) and shorter interval from reversal from NMB to extubation (MD = -13.98, with 95% CI [-16.70, -11.26]) compared to control groups. TSA also indicated that the current sample sizes were sufficient with unnecessary further trials. Analysis of secondary outcomes indicated that administration of sugammadex was associated with less incidence of postoperative nausea and vomiting (PONV), bradycardia, and dry mouth compared to control groups.

CONCLUSION

Considering of satisfactory and rapid neuromuscular blockade reversal with low incidences of adverse events, sugammadex might be considered as the preferred option for children in clinical anesthesia practice compared to acetylcholinesterase inhibitors. However, overall low-quality evidences in present study rated by GRADE system indicated that superiority of sugammadex employed in pediatric patients needs to be confirmed by more studies with high quality and large sample size in future.

Analysis of the Rehabilitation Efficacy and Nutritional Status of Patients After Endoscopic Radical Thyroidectomy by Fast Track Surgery Based on Nutritional Support

Objective

To investigate and analyze the effect of fast track surgery (FTS) based on nutritional support on the improvement of rehabilitation efficacy and nutritional status of patients after radical lumpectomy for thyroid cancer.

Methods

Eighty-six patients admitted to our hospital for radical lumpectomy for thyroid cancer between April 2018 and April 2021 were selected, of which 40 patients admitted between April 2018 and April 2019 were included in the control group with conventional perioperative care. Forty-six patients admitted between May 2019 and April 2021 were included in the trial group with FTS care based on nutritional support. The two groups of patients were compared in terms of postoperative feeding time, length of stay, time out of bed, VAS scores, albumin (ALB), total protein (TP) and prealbumin (PA) levels, negative emotions [Mental Health Test Questionnaire (DCL-90)], quality of life [General Quality of Life Inventory (GQOLI-74)] and complication rates.

Results

The patients in the trial group had shorter feeding time, hospitalization time and time out of bed than the control group (P < 0.05). After the intervention, ALB, TP and PA levels were higher in the trial group than in the control group vs. preoperatively (P < 0.05); VAS scores in the trial group were lower than VAS scores in the control group during the same period (P < 0.05). The postoperative DCL-90 scores of the trial group were lower than those of the control group (P < 0.05); the GQOLI-74 scores and total scores of the trial group were higher than those of the control group at the 3-month postoperative follow-up (P < 0.05). The overall incidence of complications such as hoarseness, choking on water, hand and foot numbness, wound infection, and hypocalemia was lower in the trial group than in the control group (P < 0.05).

Conclusion

The implementation of FTS care based on nutritional support for patients after endoscopic radical thyroidectomyr can effectively improve the postoperative recovery and reduce their pain level, as well as help improve their nutritional status, negative emotions and improve their quality of life, which is worth promoting.

Initial results from an enhanced recovery program for pediatric cardiac surgical patients

BACKGROUND

Over recent years, a number of enhanced recovery programs have appeared in first, adult colorectal surgery, and subsequently many other adult surgical specialties. Increasing interest in this approach to perioperative management in children culminated in the recent development of the first enhanced recovery pathway for pediatric intestinal surgery, endorsed by Enhanced Recovery after Surgery Society (ERAS®). In parallel, there has been increasing interest in the refinement of perioperative management of selected pediatric cardiac surgical patients, invariably referred to as "fast track" management. Initiatives have largely focused on duration of postoperative ventilation rather than on a much wider range of perioperative interventions to optimize recovery and ensure timely discharge after surgery. In our institution, a "Level 1" pediatric cardiac surgical center, we assembled a multidisciplinary team to design a comprehensive enhanced recovery pathway, based on ERAS® methodology, for selected cardiac surgical patients. After a lengthy period of planning, staff education, and preparation, we implemented the pathway at the end of November 2019.

METHODS

We conducted a prospective audit of the perioperative management and outcomes of the first 88 patients managed according to this enhanced recovery pathway over a 25-month period in our institution.

RESULTS

The mean age of the patients was 5.8 years (range 0.5-17.9), and the mean weight was 22.4 kg (range 6.6-57.2). Sixty-eight of the 88 patients were cardiopulmonary bypass cases. A total of 54% of patients received all four defined intraoperative anesthetic interventions (intravenous paracetamol, non-steroidal anti-inflammatory drug, antiemetic if aged more than 4 years, and use of a local anesthetic technique). A total of 89% of patients met the target extubation time of 6 h after administration of protamine. Median postoperative intensive care unit length of stay was 23.5 h (range 15.2-89.5). When compared to a historic control group, this represented a 22% reduction in median intensive care unit stay, although the total hospital length of stay remained unchanged. A total of 83% of patients met the target hospital discharge target of the fifth postoperative day.

CONCLUSIONS

These preliminary results suggest that enhanced recovery pathway implementation for selected pediatric cardiac surgical patients is feasible, with acceptable outcomes. They suggest areas for further development and the potential for wider implementation.

Choice of neuromuscular block reversal agent to reduce postoperative pulmonary complications

The definition of postoperative pulmonary complications (PPCs) is inconsistent in literature; however, PPCs include pulmonary abnormalities that adversely affect patient outcomes, such as respiratory failure, atelectasis, pneumonia, pleural effusion, and exacerbation of underlying lung conditions. Furthermore, although the incidence of PPCs varies according to its definition, surgery type, and patient population, they can lead to increased morbidity, mortality, duration of hospitalization, and medical costs; thus, efforts to identify and reduce the risk factors are important to improve patient outcomes. Among the risk factors for PPCs, residual neuromuscular block is a representative and preventable anesthesia-related risk factor that is affected by the choice of the reversal agent. However, it is not clear whether the chosen reversal agent, i.e., sugammadex, reduces PPCs better when compared to anticholinesterases. Additionally, the effects of the reversal agents on PPCs in high-risk patients, such as elderly patients, pediatric patients, those with end-stage renal disease, obesity, obstructive sleep apnea, or those undergoing specific surgeries, are diverse. To reduce the PPCs associated with the use of neuromuscular blocking agents, it is important to confirm complete reversal of the neuromuscular block under neuromuscular monitoring. Additionally, efforts to reduce the incidence of PPCs through interdisciplinary communication are required.

Recovery profile of sugammadex versus neostigmine in pediatric patients undergoing cardiac catheterization: A randomized double-blind study

Background:

Sugammadex is a selective reversal agent which has the ability to reverse deep neuromuscular blockade. However, there are still controversial results as regard sugammadex effects on the quality of recovery. We hypothesized that Sugammadex may have better recovery profile compared to neostigmine in pediatric patients with congenital heart diseases undergoing cardiac catheterization.

Patients and Methods:

This prospective randomized double-blind study included 50 pediatric patients aged <2 years who were divided into two groups according to the reversal agent used; Group S (Sugammadex) and Group N (Neostigmine). Both groups received the same anesthetic technique during cardiac catheterization, and basic hemodynamic monitoring was ensured in both groups. After the procedure, reversal was done using 4 mg.kg^‒1 sugammadex or 0.04 mg. kg^‒1 neostigmine plus 0.02 mg. kg^‒1 atropine according to the group allocation. Recovery time and side effects were recorded.

Results:

The two groups showed comparable findings regarding demographics. Nonetheless, the total time of anesthesia had mean values of 91.06 and 101.25 min in the two groups, respectively (P = 0.003), while recovery time had mean values of 1.61 and 9.23 min in the same groups, respectively (P < 0.001). Hemodynamic profile (heart rate and mean arterial pressure) was better after reversal with sugammadex. Blood sugar levels and side effects showed no significant difference between both groups.

Conclusion:

Sugammadex can be a more rapid and effective alternative to neostigmine for reversal of rocuronium-induced neuromuscular blockade in pediatric patients undergoing cardiac catheterization.