In this episode, I’ll discuss an article comparing respiratory events with sugammadex vs neostigmine.
Article
Neostigmine Versus Sugammadex for Reversal of Neuromuscular Blockade and Effects on Reintubation for Respiratory Failure or Newly Initiated Noninvasive Ventilation
Lead author: Martin Krause
Published in Anesthesia & Analgesia November 2019
Background
Occasionally, after surgery where a patient received a neuromuscular blocker, the patient may have residual blockade that results in re-intubation and an unexpected night spent in the ICU. Neostigmine has been the standard treatment to prevent this from occurring, and it is significantly less expensive than using sugammadex. Using an interrupted time series design, the authors of this study tested whether proportions of reintubation for respiratory failure or new noninvasive ventilation were changed after a system-wide transition of the standard reversal agent from neostigmine to sugammadex.
Methods
Adult patients undergoing a procedure with general anesthesia that included pharmacologic reversal of neuromuscular blockade and admission ≥1 night were eligible. The primary outcome was defined as a composite of reintubation for respiratory failure or new noninvasive ventilation. Segmented logistic regression models appropriate for an interrupted time series design and adjusting for potential confounders were utilized to evaluate the immediate effect of the implementation of sugammadex and on the difference between preintervention and postintervention slopes of the outcomes. Models containing all parameters (full) and only significant parameters (parsimonious) were fitted and are reported.
Results
Over 7000 patients were included. The composite respiratory outcome occurred in 6.1% of the pre-sugammadex group and 4.2% of the post-sugammadex group. This resulted in non-significant decreases in odds ratios for all groups except the parsimonious model, which had a significantly lower adjusted odds ratio of 0.66.
Conclusion
The authors concluded:
The system-wide transition of the standard pharmacologic reversal agent from neostigmine to sugammadex was associated with a reduction in the odds of the composite respiratory outcome. This observation is supported by nonsignificant within-group time trends and a significant reduction in intercept/level from pre-sugammadex to post-sugammadex in a parsimonious logistic regression model adjusting for covariates.
Discussion
I have been skeptical of sugammadex in the past because I do not believe it can be relied upon to reverse a “can’t intubate, can’t oxygenate” scenario and because a reduction in OR turn around time of a few minutes is not a significant finding. This study is encouraging news for sugammadex because the endpoint of reduced respiratory events is clinically meaningful. Using sugammadex to reverse rocuronium and avoid reintubation and the resulting ICU admission was the logic used to obtain formulary status for sugammadex at my institution, and this study does support that argument. As the study authors identified a large number of potential confounders, it would be nice to see this study replicated at another institution or a prospective investigation be completed to give further confidence to the results.
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