The comparative efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. A Cochrane systematic review with meta‐analysis and trial sequential analysis

Abstract

We compared the efficacy and safety of sugammadex and neostigmine in reversing neuromuscular blockade in adults. Our outcomes were: recovery time from second twitch to train-of-four ratio > 0.9; recovery time from post-tetanic count 1-5 to train-of-four ratio > 0.9; and risk of composite adverse and serious adverse events. We searched for randomised clinical trials irrespective of publication status and date, blinding status, outcomes reported or language. We included 41 studies with 4206 participants. Time to reversal of neuromuscular blockade from second twitch to a train-of-four ratio > 0.9 was 2.0 min with sugammadex 2 mg.kg and 12.9 min with neostigmine 0.05 mg.kg , with a mean difference (MD) (95%CI)) of 10.2 (8.5-12.0) (I = 84%, 10 studies, n = 835, Grades of Recommendation, Assessment, Development and Evaluation (GRADE): moderate quality). Time to reversal of neuromuscular blockade from a post-tetanic count of 1-5 to a train-of-four ratio > 0.9 was 2.9 min with sugammadex 4 mg.kg and 48.8 min with neostigmine 0.07 mg.kg , with a MD (95%CI) of 45.8 (39.4-52.2) (I = 0%, 2 studies, n = 114, GRADE: low quality). There were significantly fewer composite adverse events in the sugammadex group compared with neostigmine, with a risk ratio (95%CI) of 0.60 (0.49-0.74) (I = 40%, 28 studies, n = 2298, number needed to treat (NNT): 8, GRADE: moderate quality). Specifically, the risk of bradycardia (RR (95%CI) 0.16 (0.07-0.34), n = 1218, NNT: 14, GRADE: moderate quality), postoperative nausea and vomiting (RR (95%CI) 0.52 (0.28-0.97), n = 389, NNT: 16, GRADE: low quality) and overall signs of postoperative residual paralysis (RR (95%CI) 0.40 (0.28-0.57), n = 1474, NNT: 13, GRADE: moderate quality) were all reduced. There was no significant difference regarding the risk of serious adverse events (RR 0.54, 95%CI 0.13-2.25, I = 0%, n = 959, GRADE: low quality). Sugammadex reverses neuromuscular blockade more rapidly than neostigmine and is associated with fewer adverse events.

Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study

“…2e5 A meta-analysis found the advantages of sugammadex vs neostigmine in terms of recovery time from both moderate and deep neuromuscular block. 4 Moreover, there were significantly fewer composite adverse events with sugammadex compared with neostigmine, including bradycardia, postoperative nausea and vomiting, and overall signs of postoperative residual paralysis. 4 Although this meta-analysis was based on large-scale data involving 4206 subjects from 41 studies, hypersensitivity reactions were not adequately evaluated.…”

“…4 Moreover, there were significantly fewer composite adverse events with sugammadex compared with neostigmine, including bradycardia, postoperative nausea and vomiting, and overall signs of postoperative residual paralysis. 4 Although this meta-analysis was based on large-scale data involving 4206 subjects from 41 studies, hypersensitivity reactions were not adequately evaluated. As the incidence of perioperative hypersensitivity is very low, at one case per thousand to tens of thousands, 6,7 more extensive studies are needed to estimate the incidence of hypersensitivity to individual drugs, including sugammadex and neostigmine.…”

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

“…This implies that NMB has a sedative effect by decreasing afferent input and subsequent stimulation of brain arousal centers [19][20]. Tracheal extubation time was de ned as the time between study drug administration to extubation, which was much shorter in the sugammadex group, as shown in a previous study [21], including in the elderly or pediatric population [22][23], because of a different mechanism than neostigmine by directly binding and rapidly inactivating steroidal neuromuscular blockers [24].…”

Neuromuscular Block and Blocking Agents in 2018

“…Geometric mean times of recovery were less variable with sugammadex (2.0 min; range: 1.0-8.3 min) than with neostigmine (12.9 min; range: 3.7-106 min). Just 11% of neostigmine recipients reached a TOFR of 0.9 within 5 min in contrast to 98% of sugammadex recipients (55)(56)(57). Surprisingly sugammadex reversing a vecuronium-induced moderate neuromuscular blockade had a wider range of neuromuscular recovery from 1.2 to 64.2 min (32).…”