Neuromuscular and Clinical Recovery in Thoracic Surgical Patients Reversed With Neostigmine or Sugammadex

Abstract

BACKGROUND: Patients undergoing thoracoscopic procedures may be at high-risk for incomplete neuromuscular recovery and associated complications. The aim of this clinical investigation was to assess the incidence of postoperative residual neuromuscular blockade in adult thoracic surgical patients administered neostigmine or sugammadex when optimal dosing and reversal strategies for these agents were used. The effect of choice of reversal agent on hypoxemic events and signs and symptoms of muscle weakness were also determined. Additionally, operative conditions in each group were graded by surgeons performing the procedures. METHODS: Two hundred patients undergoing thoracoscopic surgical procedures were enrolled in this nonrandomized controlled trial. One hundred consecutive patients maintained at moderate levels of neuromuscular blockade were reversed with neostigmine (neostigmine group) followed by 100 consecutive patients given sugammadex to antagonize deeper levels of neuromuscular blockade (sugammadex group). Anesthetic and neuromuscular management were standardized. Surgeons rated operative conditions at the conclusion of the procedure on a 4-point scale (grade 1 = excellent to grade 4 = poor). Train-of-four ratios were measured immediately before extubation and at PACU admission (primary outcomes). Postoperatively, patients were assessed for adverse respiratory events and 11 signs and 16 symptoms of muscle weakness. RESULTS: The 2 groups were similar in intraoperative management characteristics. The percentage of patients with residual neuromuscular blockade, defined as a normalized train-of-four ratio <0.9, was significantly greater in the neostigmine group than the sugammadex group at both tracheal extubation (80% vs 6%, respectively, P < .0001) and PACU admission (61% vs 1%, respectively, P < .0001). Patients in the neostigmine group had less optimal operative conditions (median score 2 [good] versus 1 [excellent] in the sugammadex group; P < .0001), and more symptoms of muscle weakness were present in these subjects (median number [interquartile range] 4 [1–8] vs 1 [0–2] in the sugammadex group, P < .0001). No differences between groups in adverse airway events were observed. CONCLUSIONS: Despite the application of strategies documented to reduce the risk of residual neuromuscular blockade, a high percentage of thoracoscopic patients whose neuromuscular blockade was reversed with neostigmine were admitted to the PACU with clinical evidence of residual paralysis. In contrast, muscle weakness was rarely observed in patients whose neuromuscular blockade was antagonized with sugammadex.

Sugammadex Versus Neostigmine for Recovery of Respiratory Muscle Strength Measured by Ultrasonography in the Postextubation Period: A Randomized Controlled Trial

“…Patients 18 to 65 years of age scheduled for ambulatory microlaryngeal surgery were included. Exclusion criteria were as follows: (1) American Society of Anesthesiology (ASA) physical status III-V; (2) significant kidney disease (stage 4 kidney disease or higher); (3) significant liver disease (Child-Pugh B or C class); (4) history of chronic obstructive pulmonary disease; (5)…”

“…1,2 Compared with neostigmine, sugammadex reduces the incidence of residual NMB. [3][4][5] However, the association between PPCs and sugammadex remains unclear. [6][7][8][9][10] The return of muscle function to its preoperative level is responsible for protecting patients from PPCs.…”

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

“…128 Intraoperative methadone, with or without ketamine, for some inpatient and outpatient procedures, can result in less postoperative pain and opioid use, with benefits that last for weeks to months. [185][186][187][188][189]…”

Sugammadex for reversing neuromuscular blockages after lung surgery: A systematic review and meta-analysis

“…[9,10] Specifically, however, patients undergoing thoracic surgery may be at a higher risk of incomplete neuromuscular recovery. [11,12] Hence, a residual block is proposed to increase the incidence of prolonged lung atelectasis and PPCs. In these surgeries, even mild PPCs were associated with increased early postoperative mortality, ICU admissions and length of stay (ICU & hospital).…”