Sugammadex for reversal of neuromuscular blockade: a retrospective analysis of clinical outcomes and cost-effectiveness in a single center

Abstract

ObjectiveThe aim of the study is to evaluate the clinical and economic impact of introducing a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen for neuromuscular block (NMB) management.MethodsWe conducted a retrospective analysis of clinical outcomes and cost-effectiveness in five operating rooms at University Hospital of Padova. A clinical outcome evaluation after sugammadex administration as first-choice reversal drug in selected patients (rocuronium–sugammadex) and as rescue therapy after neostigmine reversal (rocuronium–neostigmine–sugammadex) compared to control was performed. A cost-analysis of NMB management accompanying the introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen was carried out. To such purpose, two periods were compared: 2011–2012, without sugammadex available; 2013–2014, with sugammadex available. A subsequent analysis was performed to evaluate if sugammadex replacing neostigmine as first choice reversal drug is cost-effective.ResultsThe introduction of a rocuronium–neostigmine–sugammadex strategy into a cisatracurium–neostigmine regimen reduced the average cost of NMB management by 36%, from €20.8/case to €13.3/case. Patients receiving sugammadex as a first-choice reversal drug (3%) exhibited significantly better train-of-four ratios at extubation (P<0.001) and were discharged to the surgical ward (P<0.001) more rapidly than controls. The cost-saving of sugammadex as first-choice reversal drug has been estimated to be €2.9/case. Patients receiving sugammadex as rescue therapy after neostigmine reversal (3.2%) showed no difference in time to discharge to the surgical ward (P=0.44) compared to controls. No unplanned intensive care unit (ICU) admissions with rocuronium–neostigmine–sugammadex strategy were observed. The potential economic benefit in avoiding postoperative residual curarization (PORC)-related ICU admission in the 2013–2014 period was estimated at an average value of €13,548 (€9,316–€23,845).ConclusionSugammadex eliminated PORC and associated morbidities. In our center, sugammadex reduced the costs of NMB management and promoted rapid turnover of patients in operating rooms, with total cost-effectiveness that counteracts the disadvantages of its high cost.

A Short Update on Sugammadex with a Special Focus on Economic Assessment of its Use in North America

“…In the United States, sugammadex could also lower the OR cost for surgeries requiring moderate NMB. Several european cost-effectiveness investigations are in-line with our estimation [95][96][97]. A recent Canadian investigation also confirmed our analysis using a discrete event simulation model specifically developed to explore the effect of sugammadex versus neostigmine on the OR efficiency and postoperative patients' outcome.…”

“…The second concept is that time saving could be converted into valuable activities. Rapid NMB reversal can lower the operating room (OR) occupancy with the consequential potential to increase the OR workflow especially for short cases [96,97]. Also, by eliminating postoperative residual curarization and related pulmonary complications, sugammadex might reduce the costs related to the time necessary to discharge the patients from the PACU, which would result in a more rapid turnover between surgeries [42,[98][99][100][101].…”

Residual Neuromuscular Blockade in the Critical Care Setting

“…23 An international, single-center retrospective analysis from 2016 contrasted the use of sugammadex against a control group (rocuronium-induced paralysis reversed using only neostigmine) under 2 circumstances. 24 In the first arm of the study, sugammadex was administered as a preventive medication to avert undesirable outcomes in patients who had multiple comorbidities, were expected to be at an increased risk for complications, and were paralyzed with rocuronium-representing 3% of the population sample (128 of 4282). 24 Patients who received sugammadex as a preventive medication recovered sooner than patients who received neostigmine.…”

Sugammadex as rescue therapy for residual neuromuscular blockade in the intensive care unit

“…1 However, quantitative neuromuscular function monitoring does not entirely abolish the risk of postoperative residual NMB. 2 In some situations (e.g., malfunction, absence of calibration and normalization, peripheral neuropathy, hypothermia), monitoring may be not able to predict accurately an adequate recovery from NMB. 2 Furthermore, it is not always used in clinical practice.…”

“…Compared to neostigmine, sugammadex can reverse NMB more rapidly and allows prompt treatment of CRE associated with postoperative residual NMB, avoiding the need for prolonged sedation or reintubation. 2,4 Furthermore, sugammadex reverses NMB with a lower likelihood of postoperative weakness (OR, 0.45; 95% CI, 0.21 to 0.97) or adverse respiratory (OR, 0.36; 95% CI, 0.14 to 0.95) and cardiovascular (OR, 0.23; 95% CI, 0.08 to 0.61) events. 4 On the contrary, reversal of NMB with neostigmine, particularly if administered in an inadequate dose or without appropriate guidance from neuromuscular function monitoring, has been associated with an increased risk of postoperative desaturation \ 90% (OR, 1.32, 95% CI, 1.20 to 1.46) and reintubation (OR, 1.76; 95% CI, 1.38 to 2.3).…”