Sugammadex Reduces PACU Recovery Time After Abdominal Surgery Compared With Neostigmine

Jin Deng, MS; Maha Balouch, MA; Michael Albrink, MD; Enrico M. Camporesi, MD

Disclosures

South Med J. 2021;114(10):644-648. 

In This Article

Abstract and Introduction

Abstract

Objective: This study blindly evaluated sugammadex compared with neostigmine on length of stay in the postanesthesia care unit (PACU).

Methods: Fifty patients undergoing elective laparoscopic cholecystectomy or abdominal wall hernia repair consented to receive either sugammadex (2 mg/kg) or neostigmine (0.07 mg/kg) for the reversal of rocuronium neuromuscular blockade. Reversal agents were administered during surgical closing, and the train of four was measured until a twitch ratio of T4:T1 ≥ 0.9 was obtained to signify a robust reversal. Postreversal outcomes also were measured during PACU stay. Aldrete scores, pain visual analog scale score, and nausea were measured during the PACU stay.

Results: Patients receiving sugammadex experienced a shorter PACU stay at the time of discharge than patients receiving neostigmine, by an average of 12 minutes (P < 0.05).

Conclusions: Sugammadex patients had a significantly shorter PACU stay.

Introduction

Patients undergoing elective abdominal surgery such as laparoscopic cholecystectomy or abdominal wall hernia repair require neuromuscular paralysis during the surgical procedure. Ideal clinical management entails neuromuscular blockade (NMB) until completion of the procedure. Afterward, the reversal of NMB at the end of the surgical procedure is vital to ensure optimal clinical management. Reversing muscle paralysis is required to restore spontaneous sustained muscle function needed for appropriate ventilation, swallowing, and various other natural muscular defenses. Incomplete reversal of muscle paralysis can result in suboptimal outcomes for the patient.[1]

Neostigmine is the most commonly used neuromuscular blocking agent antagonist because of its versatility and availability. This cholinesterase inhibitor has a slow onset of action, however, not reaching peak effect until 10 to 15 minutes after administration. Moreover, neostigmine has been associated with bradycardia and increased gastric/tracheal secretions, resulting in postoperative nausea and vomiting (PONV).[2–4] In larger doses, the risk of PONV occurrence rises significantly.[5] To counteract the bradycardia, glycopyrrolate is typically coadministered, but may increase the risk of PONV because of its emetogenic effects.

Sugammadex is a newer NMB reversal agent with a completely different mechanism of action that was originally approved for use in the United States in 2015. As an alternate reversal agent, sugammadex generally lacks parasympathetic activity, but may still have a modest risk of PONV;[6] however, sugammadex has a faster onset of action and reaches a peak effect at 3 to 7 minutes.[7] It has been well established in the literature that sugammadex, compared with neostigmine, significantly decreases NMB reversal times.[4,8–10] It remains unclear, however, whether the shorter reversal time translates into improved downstream efficiency, such as operating room (OR) turnover and shorter length of stay (LOS) in the postanesthesia care unit (PACU).[11–13]

Shortly after introducing sugammadex at our quaternary medical center, a 12-month utilization review completed by our pharmacy analyzed the use of sugammadex in 7443 surgical procedures, compared with neostigmine for 1064 operations. The analysis was completed to compare costs for the two agents. Concomitantly, the results revealed that sugammadex use was associated with a significant (43 min) reduction in PACU LOS (sugammadex: 144 ± 138 min vs neostigmine: 187 ± 357 min; P < 0.0001); however, the retrospective nature of the study and the pooling of data from a wide variety of procedures did not provide a clear conclusion.[14]

Based on the results of the utilization review, we sought to evaluate whether the shorter PACU stays also would be detected in an experimental setting with limited scope of surgery. As such, in a prospective, randomized, investigator-initiated study limited to standardized abdominal surgery, we evaluated whether sugammadex would result in a shorter medically appropriate PACU stay when compared with neostigmine.

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