Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER)

Abstract

Background Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications. Methods Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure. Results Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine. Conclusions Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Advantages and pitfalls of clinical application of sugammadex

“…Recent multicenter trials revealed that sugammadex defiantly decreased postoperative pulmonary complications in 45,712 adult patients undergoing noncardiac surgery [ 105 ]. The incidence of postoperative pulmonary complications such as pneumonia, respiratory failure, and pneumothorax was lower in the sugammadex group than that in the neostigmine group (3.5% vs. 4.8%; odds ratio, 0.70; 95% confidence interval, 0.63–0.77).…”

Comparison of the Effects of Sugammadex, Neostigmine, and Pyridostigmine on Postoperative Nausea and Vomiting: A Propensity Matched Study of Five Hospitals

“…Recovery of muscle tone affects the diaphragm, upper respiratory strength, and chest wall strength, and may also improve coughing ability, attenuate secretions, reduce alveolar collapse (associated with pneumonia), and prevent microaspiration [31,32]. A recent multicenter matched cohort study showed that sugammadex can reduce the likelihood of postoperative pneumonia compared to neostigmine [33].…”

Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19)

“…Contraindications include but are not limited to a nonfasted state, achalasia, difficult airway, gastric outlet or bowel obstruction, gastroparesis, ileus, impaired swallowing, morbid obesity, and pregnancy. Of note, the use of sugammadex instead of neostigmine to reverse muscle relaxation was associated with a 30%-50% lower risk of postoperative pneumonia and respiratory failure in a recent large multi-center study, suggesting that incomplete reversal of muscle relaxant may play a larger role than previously recognized in pulmonary complications including aspiration [23].…”