Reversal of neuromuscular block by sugammadex is associated with less postoperative respiratory dysfunction in the PACU compared with neostigmine: a retrospective study

Editor—Postoperative respiratory dysfunction, defined by requirements for supplemental oxygen, hypoxaemia, or tracheal reintubation, is a known potential complication of general anaesthesia. 1 International Surgical Outcomes Study groupGlobal patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth. 2016; 117: 601-609 Abstract Full Text Full Text PDF PubMed Scopus (372) Google Scholar ,2 Hafeez K.R. Tuteja A. Singh M. et al. Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnoea patients: a systematic review. BMC Anesthesiol. 2018; 18: 91 Crossref PubMed Scopus (31) Google Scholar Respiratory dysfunction can encompass many respiratory complications occurring after emergence from anaesthesia, such as pneumonia, respiratory failure, atelectasis, and acute respiratory distress syndrome (ARDS). 3 Miskovic A. Lumb A.B. Postoperative pulmonary complications. Br J Anaesth. 2017; 118: 317-334 Abstract Full Text Full Text PDF PubMed Scopus (469) Google Scholar ,4 Jammer I. Wickboldt N. Sander M. et al. 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: 88-105 Crossref PubMed Scopus (526) Google Scholar Risk factors include airway surgery, multiple tracheal intubation attempts, and patient factors such as pre-existing respiratory disease. 5 Nagappa M. Subramani Y. Chung F. Best perioperative practise in management of ambulatory patients with obstructive sleep apnoea. Curr Opin Anaesthesiol. 2018; 31: 700-706 Crossref PubMed Scopus (10) Google Scholar ,6 Gali B. Whalen F.X. Schroeder D.R. Gay P.C. Plevak D.J. Identification of patients at risk for postoperative respiratory complications using a preoperative obstructive sleep apnoea screening tool and postanaesthesia care assessment. Anesthesiology. 2009; 110: 869-877 Crossref PubMed Scopus (219) Google Scholar Although multifactorial, one probable contributor is continued weakness as a result of residual neuromuscular block. 7 Murphy G.S. Szokol J.W. Marymont J.H. Greenberg S.B. Avram M.J. Vender J.S. Residual neuromuscular blockade and critical respiratory events in the postanaesthesia care unit. Anesth Analg. 2008; 107: 130-137 Crossref PubMed Scopus (490) Google Scholar , 8 Patrocinio M.D. Shay D. Rudolph M.I. et al. Residual neuromuscular block prediction score versus train-of-four ratio and respiratory outcomes: a retrospective cohort study. Anesth Analg. 2021; 133: 610-619 Crossref PubMed Scopus (4) Google Scholar , 9 Murphy G.S. Szokol J.W. Avram M.J. et al. Residual neuromuscular block in the elderly: incidence and clinical implications. Anesthesiology. 2015; 123: 1322-1336 Crossref PubMed Scopus (85) Google Scholar Residual neuromuscular block occurs in 20–60% of patients in the PACU and can result from incomplete reversal prior to emergence from anaesthesia. In the immediate postoperative period, residual neuromuscular block is associated with increased postoperative hypoxaemia, atelectasis, and unplanned reintubations. 10 Grosse-Sundrup M. Henneman J.P. Sandberg W.S. et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012; 345: e6329 Crossref PubMed Scopus (213) Google Scholar