Influence of sugammadex versus neostigmine for neuromuscular block reversal on the incidence of postoperative pulmonary complications: a meta-analysis of randomized controlled trials

Jia-Feng Wang, Zhen-Zhen Zhao, Zheng-Yu Jiang, Hui-Xing Liu, Xiao-Ming Deng, Jia-Feng Wang, Zhen-Zhen Zhao, Zheng-Yu Jiang, Hui-Xing Liu, Xiao-Ming Deng

Abstract

Background: The influence of sugammadex for reversal of neuromuscular block (NMB) on postoperative pulmonary complications (PPCs), compared with neostigmine, remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) to compare the incidence of PPCs between patients who received sugammadex versus neostigmine.

Methods: Relevant studies were obtained by searching the PubMed, Embase, and Cochrane Library databases. A random effects model incorporating the potential heterogeneity was used to pool the results.

Results: Fourteen RCTs including 1478 adult patients who underwent surgeries with general anesthesia were included, and of these, 753 received sugammadex and 725 received neostigmine for reversal of NMB. The pooled results showed that sugammadex was associated with a lower risk of overall PPCs compared to neostigmine (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.43-0.89, p = 0.01; I2 = 0%). This finding remained consistent after exclusion of two studies with potential overlapping events (OR: 0.58, 95% CI: 0.36-0.96, p = 0.03; I2=9%). Stratified analyses according to the categories of PPCs showed that sugammadex was associated with a significantly lower risk of postoperative respiratory failure (OR: 0.60, 95% CI: 0.38-0.97, p = 0.04; I2 = 0%) but not of postoperative pulmonary infection (OR: 0.79, p = 0.71), atelectasis (OR: 0.78, p = 0.33), or pneumothorax (OR: 0.87, p = 0.79).

Conclusions: Compared with neostigmine, the use of sugammadex for reversal of NMB was associated with a lower risk of PPCs, mainly due to a lower incidence of postoperative respiratory failure with the use of sugammadex.

Keywords: Meta-analysis; Neostigmine; Neuromuscular block; Postoperative pulmonary complications; Sugammadex.

Conflict of interest statement

The authors report no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Flow chart of literature search
Fig. 2
Fig. 2
Summary of study quality evaluation using Cochrane’s risk of bias tool
Fig. 3
Fig. 3
Forest plots for the meta-analysis comparing sugammadex and neostigmine for the incidence of PPCs. A Main meta-analysis and B sensitivity analysis based on exclusion of two studies with patients who potentially had overlapping PPCs
Fig. 4
Fig. 4
Stratified analyses according to the individual categories of PPCs
Fig. 5
Fig. 5
Funnel plots for the meta-analysis comparing the incidence of PPCs after the use of sugammadex and neostigmine for NMB reversal. Each square represents one of the included studies, and the plots were formed based on the data of OR (x-axis) and standard error of lg(OR) (y-axis). A symmetrical of the plots could be indicated if the distributions of the squares were symmetrical according to the vertical line as the axis

References

    1. Agha RA, Borrelli MR, Vella-Baldacchino M, Thavayogan R, Orgill DP. The STROCSS statement: strengthening the reporting of cohort studies in surgery. Int J Surg. 2017;46:198–202. doi: 10.1016/j.ijsu.2017.08.586.
    1. Alday E, Munoz M, Planas A, Mata E, Alvarez C. Effects of neuromuscular block reversal with sugammadex versus neostigmine on postoperative respiratory outcomes after major abdominal surgery: a randomized-controlled trial. Can J Anaesth. 2019;66(11):1328–1337. doi: 10.1007/s12630-019-01419-3.
    1. Amao R, Zornow MH, Cowan RM, Cheng DC, Morte JB, Allard MW. Use of sugammadex in patients with a history of pulmonary disease. J Clin Anesth. 2012;24(4):289–297. doi: 10.1016/j.jclinane.2011.09.006.
    1. Ba YF, Liu YN, He SH, Li HM, Wang HR, Zhu JP, Xing WQ, Li CS. Analysis of sugammadex for antagonistic neuromuscular block in patients with radical resection of lung cancer under thoracoscope. Zhonghua Yi Xue Za Zhi. 2020;100(3):213–219. doi: 10.3760/cma.j.issn.0376-2491.2020.03.011.
    1. Brueckmann B, Sasaki N, Grobara P, Li MK, Woo T, de Bie J, Maktabi M, Lee J, Kwo J, Pino R, Sabouri AS, McGovern F, Staehr-Rye AK, Eikermann M. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth. 2015;115(5):743–751. doi: 10.1093/bja/aev104.
    1. Bulka CM, Terekhov MA, Martin BJ, Dmochowski RR, Hayes RM, Ehrenfeld JM. Nondepolarizing neuromuscular blocking agents, reversal, and risk of postoperative pneumonia. Anesthesiology. 2016;125(4):647–655. doi: 10.1097/ALN.0000000000001279.
    1. Cammu G. Residual neuromuscular blockade and postoperative pulmonary complications: what does the recent evidence demonstrate? Curr Anesthesiol Rep. 2020;1–6. 10.1007/s40140-020-00388-4.
    1. Carron M, Baratto F, Zarantonello F, Ori C. Sugammadex for reversal of neuromuscular blockade: a retrospective analysis of clinical outcomes and cost-effectiveness in a single center. Clinicoecon Outcomes Res. 2016;8:43–52. doi: 10.2147/CEOR.S100921.
    1. Carron M, Linassi F, De Cassai A. Role of sugammadex in accelerating postoperative discharge: an updated meta-analysis. J Clin Anesth. 2020;65:109895. doi: 10.1016/j.jclinane.2020.109895.
    1. Carron M, Veronese S, Foletto M, Ori C. Sugammadex allows fast-track bariatric surgery. Obes Surg. 2013;23(10):1558–1563. doi: 10.1007/s11695-013-0926-y.
    1. Carron M, Zarantonello F, Lazzarotto N, Tellaroli P, Ori C. Role of sugammadex in accelerating postoperative discharge: a meta-analysis. J Clin Anesth. 2017;39:38–44. doi: 10.1016/j.jclinane.2017.03.004.
    1. Carron M, Zarantonello F, Tellaroli P, Ori C. Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials. J Clin Anesth. 2016;35:1–12. doi: 10.1016/j.jclinane.2016.06.018.
    1. Cedborg AI, Sundman E, Boden K, Hedstrom HW, Kuylenstierna R, Ekberg O, et al. Pharyngeal function and breathing pattern during partial neuromuscular block in the elderly: effects on airway protection. Anesthesiology. 2014;120(2):312–325. doi: 10.1097/ALN.0000000000000043.
    1. Claroni C, Covotta M, Torregiani G, Marcelli ME, Tuderti G, Simone G, et al. Recovery from anesthesia after robotic-assisted radical cystectomy: two different reversals of neuromuscular blockade. J Clin Med. 2019;8(11). 10.3390/jcm8111774.
    1. De Troyer A, Bastenier-Geens J. Effects of neuromuscular blockade on respiratory mechanics in conscious man. J Appl Physiol Respir Environ Exerc Physiol. 1979;47(6):1162–1168. doi: 10.1152/jappl.1979.47.6.1162.
    1. Dubois PE, Mulier JP. A review of the interest of sugammadex for deep neuromuscular blockade management in Belgium. Acta Anaesthesiol Belg. 2013;64(2):49–60.
    1. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634. doi: 10.1136/bmj.315.7109.629.
    1. Eikermann M, Zaremba S, Malhotra A, Jordan AS, Rosow C, Chamberlin NL. Neostigmine but not sugammadex impairs upper airway dilator muscle activity and breathing. Br J Anaesth. 2008;101(3):344–349. doi: 10.1093/bja/aen176.
    1. Fuchs-Buder T, Nemes R, Schmartz D. Residual neuromuscular blockade: management and impact on postoperative pulmonary outcome. Curr Opin Anaesthesiol. 2016;29(6):662–667. doi: 10.1097/ACO.0000000000000395.
    1. Geldner G, Niskanen M, Laurila P, Mizikov V, Hubler M, Beck G, et al. A randomised controlled trial comparing sugammadex and neostigmine at different depths of neuromuscular blockade in patients undergoing laparoscopic surgery. Anaesthesia. 2012;67(9):991–998. doi: 10.1111/j.1365-2044.2012.07197.x.
    1. Haerter F, Eikermann M. Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion. Expert Opin Pharmacother. 2016;17(6):819–833. doi: 10.1517/14656566.2016.1145667.
    1. Hakimoglu S, Tuzcu K, Davarci I, Karcioglu M, Ayhan Tuzcu E, Hanci V, et al. Comparison of sugammadex and neostigmine-atropine on intraocular pressure and postoperative effects. Kaohsiung J Med Sci. 2016;32(2):80–85. doi: 10.1016/j.kjms.2016.01.009.
    1. Hazizaj A, Hatija A. Bronchospasm caused by neostigmine. Eur J Anaesthesiol. 2006;23(1):85–86. doi: 10.1017/S0265021505241820.
    1. Herbstreit F, Zigrahn D, Ochterbeck C, Peters J, Eikermann M. Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure. Anesthesiology. 2010;113(6):1280–1288. doi: 10.1097/ALN.0b013e3181f70f3d.
    1. Higgins J, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0: The Cochrane Collaboration; 2011. . Accessed 20 Sept 2020.
    1. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–1558. doi: 10.1002/sim.1186.
    1. Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017;8:CD012763.
    1. Hristovska AM, Duch P, Allingstrup M, Afshari A. 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. Anaesthesia. 2018;73(5):631–641. doi: 10.1111/anae.14160.
    1. Ishii K, Shibata O, Nishioka K, Tsuda A, Makita T, Sumikawa K. Effects of neostigmine on bronchoconstriction with continuous electrical stimulation in rats. J Anesth. 2012;26(1):80–84. doi: 10.1007/s00540-011-1258-5.
    1. Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, Leva B, Rhodes A, Hoeft A, Walder B, Chew MS, Pearse RM, European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) European Society of Anaesthesiology. European Society of Intensive Care Medicine Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol. 2015;32(2):88–105. doi: 10.1097/EJA.0000000000000118.
    1. Koyuncu O, Turhanoglu S, Ozbakis Akkurt C, Karcioglu M, Ozkan M, Ozer C, et al. Comparison of sugammadex and conventional reversal on postoperative nausea and vomiting: a randomized, blinded trial. J Clin Anesth. 2015;27(1):51–56. doi: 10.1016/j.jclinane.2014.08.010.
    1. Lee YJ, Oh AY, Koo BW, Han JW, Park JH, Hong JP, Seo KS. Postoperative residual neuromuscular blockade after reversal based on a qualitative peripheral nerve stimulator response: a randomised controlled trial. Eur J Anaesthesiol. 2020;37(3):196–202. doi: 10.1097/EJA.0000000000001157.
    1. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317–334. doi: 10.1093/bja/aex002.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(jul21 1):b2535. doi: 10.1136/bmj.b2535.
    1. Murphy GS, Szokol JW, Franklin M, Marymont JH, Avram MJ, Vender JS. Postanesthesia care unit recovery times and neuromuscular blocking drugs: a prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium. Anesth Analg. 2004;98:193–200. doi: 10.1213/01.ANE.0000095040.36648.F7.
    1. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg. 2008;107(1):130–137. doi: 10.1213/ane.0b013e31816d1268.
    1. Park S, Oh EJ, Han S, Shin B, Shin SH, Im Y, et al. Intraoperative anesthetic management of patients with chronic obstructive pulmonary disease to decrease the risk of postoperative pulmonary complications after abdominal surgery. J Clin Med. 2020;9(1):150. 10.3390/jcm9010150.
    1. Raval AD, Anupindi VR, Ferrufino CP, Arper DL, Bash LD, Brull SJ. Epidemiology and outcomes of residual neuromuscular blockade: a systematic review of observational studies. J Clin Anesth. 2020;66:109962. doi: 10.1016/j.jclinane.2020.109962.
    1. Ren M, Wang Y, Luo Y, Fang J, Lu Y, Xuan J. Economic analysis of sugammadex versus neostigmine for reversal of neuromuscular blockade for laparoscopic surgery in China. Health Econ Rev. 2020;10(1):35. doi: 10.1186/s13561-020-00292-x.
    1. Schaller SJ, Fink H, Ulm K, Blobner M. Sugammadex and neostigmine dose-finding study for reversal of shallow residual neuromuscular block. Anesthesiology. 2010;113(5):1054–1060. doi: 10.1097/ALN.0b013e3181f4182a.
    1. Stauble CG, Blobner M. The future of neuromuscular blocking agents. Curr Opin Anaesthesiol. 2020;33(4):490–498. doi: 10.1097/ACO.0000000000000891.
    1. Stawicki N, Gessner P. Residual neuromuscular blockade in the critical care setting. AACN Adv Crit Care. 2018;29(1):15–24. doi: 10.4037/aacnacc2018384.
    1. Tao T, Bo L, Chen F, Xie Q, Zou Y, Hu B, Li J, Deng X. Effect of protective ventilation on postoperative pulmonary complications in patients undergoing general anaesthesia: a meta-analysis of randomised controlled trials. BMJ Open. 2014;4(6):e005208. doi: 10.1136/bmjopen-2014-005208.
    1. Togioka BM, Yanez D, Aziz MF, Higgins JR, Tekkali P, Treggiari MM. Randomised controlled trial of sugammadex or neostigmine for reversal of neuromuscular block on the incidence of pulmonary complications in older adults undergoing prolonged surgery. Br J Anaesth. 2020;124(5):553–561. doi: 10.1016/j.bja.2020.01.016.
    1. Unal DY, Baran I, Mutlu M, Ural G, Akkaya T, Ozlu O. Comparison of sugammadex versus neostigmine costs and respiratory complications in patients with obstructive sleep apnoea. Turk J Anaesthesiol Reanim. 2015;43(6):387–395. doi: 10.5152/TJAR.2015.35682.
    1. Won YJ, Lim BG, Lee DK, Kim H, Kong MH, Lee IO. Sugammadex for reversal of rocuronium-induced neuromuscular blockade in pediatric patients: a systematic review and meta-analysis. Medicine (Baltimore) 2016;95:e4678. doi: 10.1097/MD.0000000000004678.
    1. Yagan O, Tas N, Mutlu T, Hanci V. Comparison of the effects of sugammadex and neostigmine on postoperative nausea and vomiting. Braz J Anesthesiol. 2017;67(2):147–152. doi: 10.1016/j.bjane.2015.08.003.
    1. Zafirova Z, Dalton A. Neuromuscular blockers and reversal agents and their impact on anesthesia practice. Best Pract Res Clin Anaesthesiol. 2018;32(2):203–211. doi: 10.1016/j.bpa.2018.06.004.

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