Postoperative residual neuromuscular blockade after reversal based on a qualitative peripheral nerve stimulator response

Abstract

BACKGROUND Incomplete recovery of neuromuscular blockade is a common postoperative adverse event in the postanaesthesia care unit. OBJECTIVE We examined and compared the incidence of residual neuromuscular blockade when the recommended dose of neostigmine or sugammadex was administered according to a qualitative nerve stimulator response. DESIGN A randomised controlled trial. SETTING A tertiary care hospital in South Korea from September 2017 to November 2017. PATIENTS Eighty patients aged between 18 and 69 years were included in this study. All were patients scheduled to undergo elective laparoscopic cholecystectomy and who had an American Society of Anaesthesiologists physical status of one or two were eligible. INTERVENTIONS Patients were allocated randomly to receive neostigmine or sugammadex at the end of surgery. The doses of the reversal agents were based on the response to peripheral nerve stimulation, which was discontinued after administration of the reversal agent. MAIN OUTCOME MEASURES The primary outcome was the incidence of postoperative residual neuromuscular blockade. The secondary outcomes were the incidences of symptoms or signs of residual neuromuscular blockade such as hypoxaemia, inability to maintain head-lift for 5 s and diplopia. RESULTS The incidence of residual neuromuscular blockade on arrival in the recovery room was 44.4% in the neostigmine group and 0% in the sugammadex group (P < 0.0001, relative risk = 1.80, 95% confidence interval 1.36 to 2.41). The incidences of adverse events in the recovery room were low and comparable between the groups. CONCLUSION The incidence of residual neuromuscular blockade on arrival in the recovery room was significantly higher in the neostigmine group than that in the sugammadex group. However, the incidence of adverse events was similar in the neostigmine and sugammadex groups. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03292965.

Effect of sugammadex on postoperative pulmonary complications in patients with respiratory dysfunction after laparoscopic gastric or intestinal surgery: A retrospective study

“…However, the relationship between administration of NMB and postoperative complications remains controversial [28][29][30]. This study showed that sugammadex administration lowered the rate of transfer to ICU in patients with pulmonary dysfunction, which was related to a lower incidence of residual NMB, which was in agreement with the ndings of Yea-Ji Lee [31].…”

Quality of Recovery after Laparoscopic Cholecystectomy Following Neuromuscular Blockade Reversal with Neostigmine or Sugammadex: A Prospective, Randomized, Controlled Trial

“…We previously showed that, when reversal agents were administered in accordance with NMB status confirmed by a qualitative nerve stimulator response, but without confirming TOF ratio ≥ 0.9 before tracheal extubation, the incidence of residual NMB upon arrival in the PACU was 44% after neostigmine, whereas it was 0% after sugammadex. However, all patients who showed residual NMB recovered to TOF ratio ≥ 0.9 within 15 min [21]. Additionally, electromyographic activity of the diaphragm and intercostal muscles, PaO 2 , and tidal volume increased after sugammadex, compared with neostigmine, even though the TOF ratios were comparable between groups [22,23].…”

Influence of sugammadex versus neostigmine for neuromuscular block reversal on the incidence of postoperative pulmonary complications: a meta-analysis of randomized controlled trials

“…1 . Finally, 14 RCTs were included (Schaller et al, 2010 ; Geldner et al, 2012 ; Carron et al, 2013 ; Brueckmann et al, 2015 ; Koyuncu et al, 2015 ; Unal et al, 2015 ; Hakimoglu et al, 2016 ; Agha et al, 2017 ; Yagan et al, 2017 ; Alday et al, 2019 ; Claroni et al, 2019 ; Ba et al, 2020 ; Lee et al, 2020 ; Togioka et al, 2020 ).

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“…Additionally, the use of sugammadex is suggested to be associated with fewer overall postoperative adverse events compared with neostigmine (Hristovska et al, 2017 ), leading to accelerated postoperative discharge of patients after general anesthesia (Carron et al, 2020 ; Carron et al, 2017 ). However, clinical studies comparing the incidence of PPCs after NMB reversal with sugammadex versus neostigmine have provided inconsistent results (Schaller et al, 2010 ; Geldner et al, 2012 ; Carron et al, 2013 ; Brueckmann et al, 2015 ; Koyuncu et al, 2015 ; Unal et al, 2015 ; Hakimoglu et al, 2016 ; Agha et al, 2017 ; Yagan et al, 2017 ; Alday et al, 2019 ; Claroni et al, 2019 ; Ba et al, 2020 ; Lee et al, 2020 ; Togioka et al, 2020 ). For example, some previous randomized controlled trials (RCTs) showed that sugammadex is associated with a reduced risk of PPCs as compared with neostigmine (Carron et al, 2013 ; Unal et al, 2015 ), while other studies did not show a significant difference regarding the incidence of PPCs among patients allocated to the two drugs (Schaller et al, 2010 ; Geldner et al, 2012 ; Brueckmann et al, 2015 ; Koyuncu et al, 2015 ; Hakimoglu et al, 2016 ; Agha et al, 2017 ; Yagan et al, 2017 ; Alday et al, 2019 ; Claroni et al, 2019 ; Ba et al, 2020 ; Lee et al, 2020 ; Togioka et al, 2020 ).…”

“…However, clinical studies comparing the incidence of PPCs after NMB reversal with sugammadex versus neostigmine have provided inconsistent results (Schaller et al, 2010 ; Geldner et al, 2012 ; Carron et al, 2013 ; Brueckmann et al, 2015 ; Koyuncu et al, 2015 ; Unal et al, 2015 ; Hakimoglu et al, 2016 ; Agha et al, 2017 ; Yagan et al, 2017 ; Alday et al, 2019 ; Claroni et al, 2019 ; Ba et al, 2020 ; Lee et al, 2020 ; Togioka et al, 2020 ). For example, some previous randomized controlled trials (RCTs) showed that sugammadex is associated with a reduced risk of PPCs as compared with neostigmine (Carron et al, 2013 ; Unal et al, 2015 ), while other studies did not show a significant difference regarding the incidence of PPCs among patients allocated to the two drugs (Schaller et al, 2010 ; Geldner et al, 2012 ; Brueckmann et al, 2015 ; Koyuncu et al, 2015 ; Hakimoglu et al, 2016 ; Agha et al, 2017 ; Yagan et al, 2017 ; Alday et al, 2019 ; Claroni et al, 2019 ; Ba et al, 2020 ; Lee et al, 2020 ; Togioka et al, 2020 ). Moreover, the outcome of PPCs was rarely observed in previous meta-analyses comparing the efficacy and safety between sugammadex and neostigmine for reversal of NMB (Carron et al, 2016a ; Hristovska et al, 2017 ; Hristovska et al, 2018 ).…”