Is sugammadex better than neostigmine for preventing postoperative complications?

Treatment with sugammadex for the reversal of neuromuscular blockade falls short of significantly reducing the risk of postoperative pulmonary complications (PPCs) when compared with neostigmine, as shown in a recent study.

A total of 1,786 patients were assessed in this study, of whom 976 (54.6 percent) received neostigmine and 810 (45.4 percent) sugammadex. Overall, 81 patients (4.54 percent) experienced PPCs (7.04 percent sugammadex vs 2.46 percent neostigmine). [Br J Clin Pharmacol 2024;90:1667-1676]

After overlap weighting, both groups showed well-balanced baseline covariates. The risk of PPCs were similar between the sugammadex and the neostigmine arms (overlap weighting odds ratio, 0.75, 95 percent confidence interval, 0.40‒1.41). These results persisted in the sensitivity analysis. In subgroup analysis, these reversal agents stratified by surgery duration had an interaction p-value of 0.011.

“[W]e did not find a significant difference in the rate of PPCs when the neuromuscular blockade was reversed with sugammadex compared to neostigmine,” the researchers said. “Patients undergoing prolonged surgery may benefit from sugammadex, which needs to be further investigated.”

Complications

The 4.54-percent overall PPC incidence in this study was comparable to that observed in previously published retrospective studies. [Anesthesiology 2021;134:862-873; Anesthesiology 2020;132:1371-1381; Br J Anaesth 2020;124:504-507]

In the current study, the most frequent PPC was pneumonia, similar to that found in the literature. Additionally, a 1.01-percent rate of pleural effusion second to pneumonia was observed. Pleural effusions usually occur during abdominal surgery, which accounted for a large part of the cohort, according to the researchers. [J Clin Med 2020;9:1232]

“PPCs have a deleterious environmental effect on patients' postoperative recovery,” the researchers said. “Therefore, it is promising to implement some interventions to reduce the risk of PPCs.”

An earlier study found sugammadex to be more effective than neostigmine in reversing rocuronium-induced neuromuscular block. [Cochrane Database Syst Rev 2017;8:CD012763]

“Despite the controversies, the tide to evaluate the relationship between reversal agents and PPCs will not fade away,” the researchers said.

STRONGER

In a recent retrospective study involving 80,000 adults in the US, treatment with sugammadex did not reduce the occurrence of PPCs. These results were consistent with those of the current study. [Anaesthesia 2023;78:294-302]

On the other hand, the STRONGER study, which also compared sugammadex with neostigmine for the reversal of neuromuscular blockade and PPCs, found a 30-percent lower risk of PPCs with sugammadex relative to neostigmine. [Anesthesiology 2020;132:1371-1381]

A secondary analysis of the previous study, the STIL-STRONGER, revealed similar evidence in high-risk patients. [Br J Anaesth 2023;130:e148-e159]

The current retrospective cohort study, conducted in a tertiary academic medical centre, enrolled patients aged ≥18 years who underwent noncardiac surgical procedures with general anaesthesia and mechanical ventilation between January 2019 and September 2021.

The research team identified patients receiving rocuronium and reversal with neostigmine or sugammadex using electronic medical records. A composite of PPCs (eg, pneumonia, atelectasis, respiratory failure, pulmonary embolism, pleural effusion, or pneumothorax) served as the primary endpoint. Propensity score analysis was carried out to compare the incidence of PPCs.