Sugammadex Versus Neostigmine for Reversal of Residual Neuromuscular Blocks After Surgery: A Retrospective Cohort Analysis of Postoperative Side Effects

Comparative efficacy of sugammadex and neostigmine in postoperative nausea and vomiting management: a meta-analysis of randomized controlled trials

Postoperative nausea and vomiting (PONV) are frequent complications that can occur after surgical procedures. Sugammadex, known for its effectiveness as a muscle relaxant antagonist, offers several advantages over neostigmine, however, there is still insufficient evidence to demonstrate its superiority in reducing PONV. This meta-analysis sought to assess the efficacy of sugammadex versus neostigmine in the management of PONV. Two independent investigators conducted a comprehensive review of randomized controlled trials (RCTs) across PubMed, Embase, and the Cochrane Library. The meta-analysis was performed using Review Manager software. Our meta-analysis scrutinized twenty studies that included 3248 participants. The results showed that sugammadex was effective in reducing postoperative nausea (RR = 0.65, 95% CI 0.48 to 0.88) versus neostigmine. Sugammadex reduced the dosage of opioids (SMD = 0.55, 95% CI -0.18 to 1.27) compared with neostigmine when the time of administration is T2 (RR = 0.54, 95% CI 0.31 to 0.93). The use of sugammadex markedly lowered the occurrence of nausea during non-laparoscopic surgical procedures (RR = 0.42, 95% CI 0.27 to 0.65). This study demonstrated that sugammadex outperformed neostigmine in reducing PONV. Various factors, including the type of surgical procedure, timing of drug administration and dosage, might influence the efficacy of sugammadex.

Comparison of postoperative oxygenation in children receiving sugammadex versus neostigmine for reversal of neuromuscular blockade: a retrospective cohort study

PURPOSE

Residual neuromuscular blockade can impair postoperative respiratory mechanics, promoting hypoxemia and pulmonary complications. Sugammadex, with its unique mechanism of action, may offer a more effective reversal of neuromuscular blockade and respiratory function than neostigmine. We sought to test the primary hypothesis that children undergoing noncardiac surgery exhibit better initial recovery oxygenation when administered sugammadex than those administered neostigmine. Furthermore, we aimed to investigate if children administered sugammadex experience fewer in-hospital pulmonary complications.

METHODS

In a retrospective cohort study, we analyzed data from children aged 2-17 yr who underwent noncardiac surgery with general anesthesia and received neostigmine or sugammadex between January 2017 and April 2023 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative oxygenation defined by the mean SpO2/FIO2 ratio during the initial hour in the postanesthesia care unit. The secondary outcome was a composite of postoperative pulmonary complications during the hospital stay.

RESULTS

Among 3,523 cases, 430 (12.5%) involved sugammadex and 3,081 (87.5%) involved neostigmine. The median [interquartile range] of the mean SpO2/FIO2 ratio during the first postoperative hour was 403 [356-464] in the sugammadex group and 408 [357-462] in the neostigmine group, resulting in an estimated difference in means of -6.2 (95% confidence interval, -12.8 to 0.41; P = 0.07) after inverse probability of treatment weighting. Overall, 22/1,916 (1.1%) inpatients experienced postoperative pulmonary complications; 2.0% of patients given sugammadex and 1.0% of patients administered neostigmine developed postoperative pulmonary complications (P = 0.19).

CONCLUSION

In this retrospective cohort study, postoperative oxygenation was similar in children after reversal of neuromuscular blockade with sugammadex versus neostigmine.

Sugammadex Safely Reduces Total Intubation Time in the Intensive Care Unit Following Coronary Artery Bypass Grafting (CABG) at a Real-World Community Hospital

Background/Objectives: Early extubation is crucial for enhancing recovery from coronary artery bypass grafting (CABG). Residual neuromuscular blockade (NMB) effects can hinder early extubation, potentially leading to reintubation, lung infection, and prolonged post-anesthesia stay. Sugammadex, a modified gamma-cyclodextrin, reverses the non-depolarizing NMB effects of the steroidal muscle relaxants rocuronium and vecuronium. The American Society of Anesthesiologists recommends sugammadex administration when patients display a train-of-four (TOF) ratio of less than 0.9. Previous studies show that sugammadex decreases extubation times, reduces postoperative complications, and enhances patient comfort. Methods: This single-center, retrospective cohort study evaluated the efficacy of sugammadex in achieving extubation within six hours of intensive care unit (ICU) arrival post-CABG, defined as fast-track extubation (FTE). Results: Here, we report that although the total time of intubation in the ICU following CABG did not drop to the six-hour benchmark, it was substantially reduced by the administration of sugammadex in accordance with an FTE protocol. Furthermore, the risks of adverse events (e.g., anaphylaxis, heart failure) and postoperative complications (e.g., acidemia, hypoxemia, tachypnea) were unaltered. Conclusions: The use of sugammadex could, thus, reduce costs associated with prolonged intubation time and related complications without increasing morbidity or mortality.

Neuromuscular Blockade Antagonism for Thyroid Surgery During Intraoperative Neural Monitoring-An Anesthesia Perspective

Background and Objectives: Thyroid surgery with intraoperative neural monitoring (IONM) of the recurrent laryngeal nerve (RLN) requires precise anesthetic management. This narrative review compares non-selective (neostigmine) and selective (sugammadex) reversal agents for neuromuscular blockade (NMB), discussing their mechanisms of action and the challenges of achieving optimal NMB reversal without compromising surgical conditions or IONM quality. Materials and Methods: A literature search was conducted using PubMed, MEDLINE, and Google Scholar for studies published up to November 2023. Relevant case studies, clinical trials, systematic reviews, and guidelines focusing on NMB reversal in thyroid surgery with IONM were included, prioritizing investigations involving sugammadex and neostigmine. Results: Clinical evidence indicates that sugammadex (0.5-1 mg/kg) provides the rapid and reliable return of neuromuscular function, benefiting electromyography (EMG) signal quality preservation. However, overshooting the reversal can precipitate patient movement, compromising surgical precision. Neostigmine (0.03-0.04 mg/kg), while less selective, remains a cost-effective alternative, with recent studies suggesting adequate support for IONM signal integrity when carefully dosed and timed. Conclusions: This review underscores the need for balanced NMB reversal strategies tailored to intraoperative monitoring requirements in thyroidectomy. Further randomized trials and large-scale studies are needed to refine and standardize NMB reversal strategies in thyroid surgery with IONM.

Association between reversal agents (sugammadex vs. neostigmine) for neuromuscular block and postoperative pulmonary complications: A retrospective analysis

AIMS

Residual neuromuscular blockade has been linked to pulmonary complications in the postoperative period. This study aimed to determine whether sugammadex was associated with a lower risk of postoperative pulmonary complications (PPCs) compared with neostigmine.

METHODS

This retrospective cohort study was conducted in a tertiary academic medical center. Patients ≥18 year of age undergoing noncardiac surgical procedures with general anesthesia and mechanical ventilation were enrolled between January 2019 and September 2021. We identified all patients receiving rocuronium and reversal with neostigmine or sugammadex via electronic medical record review. The primary endpoint was a composite of PPCs (including pneumonia, atelectasis, respiratory failure, pulmonary embolism, pleural effusion, or pneumothorax). The incidence of PPCs was compared using propensity score analysis.

RESULTS

A total of 1786 patients were included in this study. Among these patients, 976 (54.6%) received neostigmine, and 810 (45.4%) received sugammadex. In the whole sample, PPCs occurred in 81 (4.54%) subjects (7.04% sugammadex vs. 2.46% neostigmine). Baseline covariates were well balanced between groups after overlap weighting. Patients in the sugammadex group had similar risk (overlap weighting OR: 0.75; 95% CI: 0.40 to 1.41) compared to neostigmine. The sensitivity analysis showed consistent results. In subgroup analysis, the interaction P-value for the reversal agents stratified by surgery duration was 0.011.

CONCLUSION

There was no significant difference in the rate of PPCs when the neuromuscular blockade was reversed with sugammadex compared to neostigmine. Patients undergoing prolonged surgery may benefit from sugammadex, which needs to be further investigated.

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-induced bronchospasm: a case report

Sugammadex has shown faster reversal of steroidal neuromuscular blockade (NMB) than neostigmine, a traditional reversal agent for NMB, even in the intense block phase. This efficiency is possible because of the unique mechanism of action by encapsulating the NMB molecules. Therefore, with the use of sugammadex, we can also expect to avoid direct interactions with the cholinergic system and its subsequent side effects, which are disadvantages of traditional drugs. However, despite these benefits and US Food and Drug Administration (FDA) approval in 2015, rare adverse events associated with sugammadex have been reported. Herein, we report a case of bronchospasm that developed immediately after sugammadex administration.

Clarifying the grey space of sugammadex induced bradycardia

PURPOSE OF REVIEW

This review describes recent prospective and retrospective work exploring the incidence and clinical consequence of sugammadex-induced bradycardia and an update of recent evidence and adverse event reports to the United States Food and Drug Administration regarding the incidence of sugammadex induced bradycardia.

RECENT FINDINGS

This work suggests that the incidence of sugammadex-induced bradycardia can range from 1 to 7% depending on the definition to reverse moderate to deep neuromuscular blockade. For most instances, the bradycardia is inconsequential. For those instances that have hemodynamic instability, the adverse physiology is easily treated with appropriate vasoactive agents. One study demonstrated that the incidence of bradycardia from sugammadex is less than with neostigmine. There are several case reports that describe marked bradycardia with cardiac arrest from reversal with sugammadex. The incidence of this type of reaction to sugammadex appears to be very rare. Data from the United States Food and Drug Administration's Adverse Event Reporting System public dashboard corroborates this presence of this rare finding.

SUMMARY

Sugammadex-induced bradycardia is common and, in most instances, of minimal clinical consequence. Nevertheless, anesthesia providers should maintain proper monitoring and vigilance to treat hemodynamical instability with each administration of sugammadex.

Postoperative Risk of Transfusion After Reversal of Residual Neuromuscular Block With Sugammadex Versus Neostigmine: A Retrospective Cohort Study

BACKGROUND

Sugammadex and neostigmine are routinely used to reverse residual neuromuscular blocks at the end of surgery. Sugammadex has been linked with prolongation of laboratory coagulation markers, but clinical relevance on postoperative blood loss and transfusions remains unclear.

METHODS

In this retrospective, single-center, cohort study, we analyzed medical records of adult patients having noncardiac surgery who were given sugammadex or neostigmine from May 2016 to December 2020. Our primary outcome was the incidence of any postoperative transfusion of red blood cells, and/or fresh-frozen plasma, and/or platelets. Secondary outcomes were duration of hospitalization, need for resurgery, and postoperative intensive care unit (ICU) admission. After propensity score weighting, the odds ratio (OR) for postoperative transfusion was assessed in both groups (sugammadex versus neostigmine) using a generalized estimation equation to count within-subject correlation weighted by the inverse propensity score.

RESULTS

Out of 39,325 eligible surgeries, 33,903 surgeries in 29,062 patients were included in the analysis; with 4581 patients receiving sugammadex and 29,322 patients receiving neostigmine. The raw incidence of postoperative transfusion was 7.40% in sugammadex and 7.45% in the neostigmine group. After weighting by propensity score, the incidence of postoperative transfusion was 8.01% in the sugammadex and 7.38% in the neostigmine group (OR, 1.11 [95% confidence interval [CI], 0.97-1.26; P = .118]). There was no difference in duration of hospitalization and need for resurgery, but odds of postoperative ICU admission were significantly higher for patients receiving sugammadex than those receiving neostigmine (OR, 1.33 [98.33% CI, 1.17-1.52; P < .0001]). Our a priori planned analysis of coagulation laboratory parameters could not be completed because of a high amount of missing laboratory data.

CONCLUSIONS

There is no statistically significant nor clinically important difference in the risk of postoperative transfusion in patients receiving sugammadex or neostigmine.

Does deep neuromuscular blockade provide improved perioperative outcomes in adult patients? A systematic review and meta-analysis of randomized controlled trials

Deep neuromuscular blockade provides better surgical workspace conditions in laparoscopic surgery, but it is still not clear whether it improves perioperative outcomes, not to mention its role in other types of surgeries. We performed this systematic review and meta-analysis of randomized controlled trials to investigate whether deep neuromuscular blockade versus other more superficial levels of neuromuscular blockade provides improved perioperative outcomes in adult patients in all types of surgeries. Medline, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception to June 25, 2022. Forty studies (3271 participants) were included. Deep neuromuscular blockade was associated with an increased rate of acceptable surgical condition (relative risk [RR]: 1.19, 95% confidence interval [CI]: [1.11, 1.27]), increased surgical condition score (MD: 0.52, 95% CI: [0.37, 0.67]), decreased rate of intraoperative movement (RR: 0.19, 95% CI: [0.10, 0.33]), fewer additional measures to improve the surgical condition (RR: 0.63, 95% CI: [0.43, 0.94]), and decreased pain score at 24 h (MD: -0.42, 95% CI: [-0.74, -0.10]). There was no significant difference in the intraoperative blood loss (MD: -22.80, 95% CI: [-48.83, 3.24]), duration of surgery (MD: -0.05, 95% CI: [-2.05, 1.95]), pain score at 48 h (MD: -0.49, 95% CI: [-1.03, 0.05]), or length of stay (MD: -0.05, 95% CI: [-0.19, 0.08]). These indicate that deep neuromuscular blockade improves surgical conditions and prevents intraoperative movement, and there is no sufficient evidence that deep neuromuscular blockade is associated with intraoperative blood loss, duration of surgery, complications, postoperative pain, and length of stay. More high-quality randomized controlled trials are needed, and more attention should be given to complications and the physiological mechanism behind deep neuromuscular blockade and postoperative outcomes.

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

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.