Comparison of postoperative coagulation profiles and outcome for sugammadex versus pyridostigmine in 992 living donors after living-donor hepatectomy

Abstract

Donor safety is the major concern in living donor liver transplantation, although hepatic resection may be associated with postoperative coagulopathy. Recently, the use of sugammadex has been gradually increased, but sugammadex is known to prolong prothrombin time (PT) and activated partial thromboplastin time (aPTT). We compared the postoperative coagulation profiles and outcomes of sugammadex versus pyridostigmine group in donors receiving living donor hepatectomy.Consecutive donor hepatectomy performed between September 2013 and August 2016 was retrospectively analyzed. For reversal of rocuronium-induced neuromuscular blockade, donors received sugammadex 4 mg/kg or pyridostigmine 0.25 mg/kg. The primary end-points were laboratory findings (PT, aPTT, hemoglobin, platelet count) and clinically evaluated postoperative bleeding (relaparotomy for bleeding, cumulative volume collected in drains). Secondary outcomes were anesthesia time, postoperative hospital day.Of 992 donors, 383 treated with sugammadex and 609 treated with pyridostigmine for the reversal of neuromuscular blockade. There were no significant differences between both groups for drop in hemoglobin and platelet, prolongation in PT, aPTT, and the amount of 24-h drain volume. Bleeding events within 24 h were reported in 2 (0.3%) for pyridostigmine group and 0 (0%) for sugammadex group (P = .262). Anesthesia time was significantly longer in pyridostigmine group than that in sugammadex group (438.8 ± 71.4 vs. 421.3 ± 62.3, P < .001). Postoperative hospital stay was significantly longer in pyridostigmine group than that in sugammadex group (P = .002).Sugammadex 4 mg/kg was not associated with increased bleeding tendency, but associated with reduced anesthesia time and hospital stay. Therefore, sugammadex may be safely used and will decrease morbidity in donor undergoing living-donor hepatectomy.

The Effect of Sugammadex on Prothrombin and Activated Partial Thromboplastin Time

“…Moon et al compared postoperative coagulation profiles in living donors undergoing hepatectomy [ 18 ]. The two patient groups received either sugammadex 4 mg/kg or pyridostigmine 0.25 mg/.kg to reverse rocuronium-induced neuromuscular blockade.…”

“…According to Table 1 , three out of nine studies were randomized crossover trials [ 8 - 9 , 20 ], two were randomized controlled trials [ 19 , 21 ], one was a randomized trial without a control group [ 23 ], two were prospective observational studies [ 17 , 22 ], and one was a retrospective observational study [ 18 ]. In three out of nine trials, sugammadex was used in the dosage of 4 mg/kg [ 9 , 18 , 21 ], in three out of nine trials the sugammadex dosage was 2 mg/kg and 4 mg/kg [ 17 , 22 - 23 ], in two out of nine trials, sugammadex 4 mg/kg and 16 mg/kg were used [ 8 , 20 ], and finally, in one out of nine, the dosage for sugammadex was 2 mg/kg [ 19 ].…”

“…In one trial, the control groups received a placebo, a placebo with enoxaparin, or a placebo with heparin [ 20 ]. In one out of nine, the control group received pyridostigmine [ 18 ]. In two out of nine trials, the control group received neostigmine [ 19 ] or either neostigmine or a placebo [ 21 ], whereas two trials did not include a control group [ 22 - 23 ].…”

“…PT and/or aPTT were found to increase after sugammadex administration in seven out of the nine studies [ 8 - 9 , 18 , 20 - 23 ]. However, the increase seemed to be transient and dose-dependent.…”

Effects of rocuronium, sugammadex and rocuronium-sugammadex complex on coagulation in rats

“…It was first introduced by the scientific community in 2002; since then, both animal and human studies have demonstrated the efficacy and tolerability of this drug [5, 6]. Additionally, from the time that this drug was introduced, several adverse events that are related to the use of sugammadex, including coagulation disorders, have been reported [7–9]. In vitro experiments have demonstrated that sugammadex influences the effects of factor Xa in the coagulation pathway, which then leads to the inhibition of the prothrombine-to-thrombin conversion [10].…”