Sugammadex Versus Neostigmine for Reversal of Residual Neuromuscular Blocks After Surgery: A Retrospective Cohort Analysis of Postoperative Side Effects

Abstract

BACKGROUND: Sugammadex and neostigmine given to reverse residual neuromuscular blockade can cause side effects including bradycardia, anaphylaxis, bronchospasm, and even cardiac arrest. We tested the hypothesis that sugammadex is noninferior to neostigmine on a composite of clinically meaningful side effects, or vice versa. METHODS: We analyzed medical records of patients who had general, cardiothoracic, or pediatric surgery and were given neostigmine or sugammadex from June 2016 to December 2019. Our primary outcome was a collapsed composite of bradycardia, anaphylaxis, bronchospasm, and cardiac arrest occurring between administration of the reversal agent and departure from the operation room. We a priori restricted our analysis to side effects requiring pharmacologic treatment that were therefore presumably clinically meaningful. Sugammadex would be considered noninferior to neostigmine (or vice versa) if the odds ratio for composite of side effects did not exceed 1.2. RESULTS: Among 89,753 surgeries in 70,690 patients, 16,480 (18%) were given sugammadex and 73,273 (82%) were given neostigmine. The incidence of composite outcome was 3.4% in patients given sugammadex and 3.0% in patients given neostigmine. The most common individual side effect was bradycardia (2.4% in the sugammadex group versus 2.2% neostigmine). Noninferiority was not found, with an estimated odds ratio of 1.21 (sugammadex versus neostigmine; 95% confidence interval [CI], 1.09–1.34; noninferiority P = .57), and neostigmine was superior to sugammadex with an estimated odds ratio of 0.83 (0.74–0.92), 1-side superiority P < .001. CONCLUSIONS: The composite incidence was less with neostigmine than with sugammadex, but only by 0.4% (a negligible clinical effect). Since 250 patients would need to be given neostigmine rather than sugammadex to avoid 1 episode of a minor complication such as bradycardia or bronchospasm, we conclude that sugammadex and neostigmine are comparably safe.

Postoperative Risk of Transfusion After Reversal of Residual Neuromuscular Block With Sugammadex Versus Neostigmine: A Retrospective Cohort Study

“…7,17 However, it remains unclear whether these mechanisms translate into a significant clinical benefit and warrant its higher cost. 8 Our results are consistent with the results of a previous clinical trial randomizing patients to receive either sugammadex or spontaneous recovery. 12 Sugammadex did not increase the postoperative risk of bleeding and transfusion events, although this trial was limited to patients having major orthopedic surgeries and at high risk of postoperative bleeding.…”

“…7,17 However, it remains unclear whether these mechanisms translate into a significant clinical benefit and warrant its higher cost. 8…”

“…3–6 Therefore, it is the clinical routine to monitor neuromuscular function and if necessary reverse neuromuscular block at the end of surgery by giving either neostigmine or more recently sugammadex. 7,8…”

“…[3][4][5][6] Therefore, it is the clinical routine to monitor neuromuscular function and if necessary reverse neuromuscular block at the end of surgery by giving either neostigmine or more recently sugammadex. 7,8 Both neostigmine and sugammadex are comparably safe medications. 8 However, it remains controversial whether sugammadex increases the risk of postoperative bleeding.…”

2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade

“…Adverse Events. Anaphylaxis was reported with neostigmine in one study 91 of five (supplemental table S21; http:// links.lww.com/ALN/C928). [91][92][93][94][95] Among patients receiving sugammadex, the pooled incidence rate of anaphylaxis was 1.6 per 10,000 (low strength of evidence).…”