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

December 19, 2022

BACKGROUND:
Sugammadex and neostigmine given to reverse residual neuromuscular block- ade can cause side effects including bradycardia, anaphylaxis, bronchospasm, and even cardiac arrest. We tested the hypothesis that sugammadex is noninferior to neostigmine on a compos- ite of clinically meaningful side effects, or vice versa
METHODS:
We analyzed medical records of patients who had general, cardiothoracic, or pedi- atric 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 consid- ered 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 indi- vidual 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 neo- stigmine; 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 neo- stigmine rather than sugammadex to avoid 1 episode of a minor complication such as bra- dycardia or bronchospasm, we conclude that sugammadex and neostigmine are comparably safe. (Anesth Analg 2022;134:1043–53)