The effects of sugammadex vs. neostigmine on postoperative respiratory complications and advanced healthcare utilisation: a multicentre retrospective cohort study

Abstract

Reversing neuromuscular blockade with sugammadex can eliminate residual paralysis, which has been associated with postoperative respiratory complications. There are equivocal data on whether sugammadex reduces these when compared with neostigmine. We investigated the association of the choice of reversal drug with postoperative respiratory complications and advanced healthcare utilisation. We included adult patients who underwent surgery and received general anaesthesia with sugammadex or neostigmine reversal at two academic healthcare networks between January 2016 and June 2021. The primary outcome was postoperative respiratory complications, defined as post-extubation oxygen saturation < 90%, respiratory failure requiring non-invasive ventilation, or tracheal re-intubation within 7 days. Our main secondary outcome was advanced healthcare utilisation, a composite outcome including: 7-day unplanned intensive care unit admission; 30-day hospital readmission; or non-home discharge. In total, 5746 (6.9%) of 83,250 included patients experienced postoperative respiratory complications. This was not associated with the reversal drug (adjusted OR (95%CI) 1.01 (0.94-1.08); p = 0.76). After excluding patients admitted from skilled nursing facilities, 8372 (10.5%) patients required advanced healthcare utilisation, which was not associated with the choice of reversal (adjusted OR (95%CI) 0.95 (0.89-1.01); p = 0.11). Equivalence testing supported an equivalent effect size of sugammadex and neostigmine on both outcomes, and neostigmine was non-inferior to sugammadex with regard to postoperative respiratory complications or advanced healthcare utilisation. Finally, there was no association between the reversal drug and major adverse cardiovascular events (adjusted OR 1.07 (0.94-1.21); p = 0.32). Compared with neostigmine, reversal of neuromuscular blockade with sugammadex was not associated with a reduction in postoperative respiratory complications or post-procedural advanced healthcare utilisation.

Prevalence and association of non-medical cannabis use with post-procedural healthcare utilisation in patients undergoing surgery or interventional procedures: a retrospective cohort study

“…We then conducted the primary analysis to test the research hypothesis that cannabis use, differentiated into patients with a cannabis use disorder and patients with reported ongoing non-medical cannabis use, is associated with advanced post-procedural healthcare utilisation using multivariable logistic regression analyses. Advanced post-procedural healthcare utilisation 23 was defined as a composite outcome consisting of non-home discharge (post-procedural discharge to a skilled nursing home or long-term care facility), 24 , 25 , 26 , 27 30-day hospital readmission, 28 or seven-day unplanned ICU admission. 29 Patients who died within the hospital stay of the index procedure were considered as having the outcome.…”

Sugammadex and neostigmine: when better may not be best

“…But doing such a trial would require considerable resources and be logistically challenging, particularly now that sugammadex is in widespread use. Using for example, the absolute risk difference of 1% and baseline risk of 6.6% for respiratory complications as observed by Suleiman et al [1], a randomised trial would require approximately 25,000 participants to achieve 90% power at a two-sided a of 0.05.…”

“…Using for example, the absolute risk difference of 1% and baseline risk of 6.6% for respiratory complications as observed by Suleiman et al. [1], a randomised trial would require approximately 25,000 participants to achieve 90% power at a two‐sided α of 0.05. Few large multicentre trials in anaesthesia report significant results [11].…”

“…Twitter: @DASidebotham Suleiman et al [1] report the non-association between postoperative respiratory complications and the use of either neostigmine or sugammadex for reversal of neuromuscular blockade. Retrospective data were obtained from two hospital networks in the USA over a fiveand-a-half-year period to June 2021.…”

“…Therefore, the opportunity for a randomised controlled trial may well have passed. Under these circumstances, the results from well-conducted and appropriately analysed observational studies, such as this study by Suleiman et al[1], remain the only possibility to determine the relative merits of these two drugs for the reversal of neuromuscular blockade.What can we conclude from the study by Suleiman et al? Perhaps the key finding is that evidence for routinely using sugammadex to prevent postoperative respiratory complications is lacking, including in high-risk patients.While differences were identified between the two health networks, it is hard to know how this information might be investigated further or incorporated into clinical practice.…”