Respiratory events with sugammadex vs. neostigmine following laparoscopic sleeve gastrectomy: a prospective pilot study assessing neuromuscular reversal strategies

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DOI: http://dx.doi.org/10.21454/rjaic.7518.242.evr

Shmuel Evron1, Yuri Abelansky1, Tiberiu Ezri1, Alexander Izakson2

1 Department of Anesthesia, Edith Wolfson Medical Center, Holon, Affiliated with Sackler Medical School, Tel Aviv University, Israel
2 Department of Anesthesia, Sieff Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed Israel

Abdominal surgery in obese patients may be associated with pulmonary morbidity, and mortality. Some patients may arrive in the PACU with residual paralysis.
The purpose of this study was to find out if there was an association between the type of muscle relaxant reversal agent and the development of postoperative respiratory events in patients undergoing laparoscopic sleeve gastrectomy surgery.
Methods: From September 2012 to February 2013, in a prospective randomized pilot study, two different muscle relaxant reversal agents were administered at the end of surgery in 57 patients undergoing laparoscopic sleeve gastrectomy: sugammadex 2 mg/kg (32 patients) vs. neostigmine 2.5 mg (25 patients).
We compared the occurrence of early and late respiratory events/complications by the type of reversal agent. Postoperative respiratory rate, oxyhemoglobin saturation (SpO2), number of patients with SpO2 lower than 95% in PACU, the minimum value of SpO2 in PACU, train-of four counts (TOF) before reversal, unexpected ICU admissions, duration of hospitalization and incidence of reintubation were recorded.
Results: SpO2 in the PACU was significantly lower in the neostigmine group – 95.80 (± 0.014)) vs. in sugammadex group – 96.72 (± 0.011) (p < 0.01), despite a lower TOF count measured in the sugammadex group before reversal, meaning a deeper level of residual relaxation in this group before the administration of the reversal agent (2.53 ± 0.98 vs. 3.48 ± 0.58 p < 0.01). Also, the minimal SpO2 was significantly lower in the PACU in the neostigmine group: 93% vs. 94% (p = 0.01). Respiratory rates were not different. After the administration of reversal, both groups had TOF counts of 4 with no fade assessed visually. There were no postoperative respiratory events or complications.
Conclusions: The use of sugammadex (as compared to neostigmine) as a reversal agent following laparoscopic sleeve gastrectomy surgery was associated with higher postoperative SpO2 despite the lower TOF count before the administration of reversal agent. Despite the statistical difference in SpO2, its clinical importance seems to be minimal. The lack of difference in the other measured variables may stem from the small number of patients studied (pilot).
Keywords: muscle relaxants, reversal, sugammadex, neostigmine, respiratory events