Reversal of neuromuscular block with sugammadex compared with neostigmine and postoperative pulmonary complications in obese patients: meta-analysis and trial sequential analysis

Editor—Postoperative pulmonary complications (POPCs) include almost all complications affecting the respiratory system after anaesthesia and surgery. 1 Miskovic A. Lumb A.B. Postoperative pulmonary complications. Br J Anaesth. 2017; 118: 317-334 Abstract Full Text Full Text PDF PubMed Scopus (414) Google Scholar POPCs affect the postoperative course, thus increasing hospital length of stay and costs and rates of short- and long-term mortality. 1 Miskovic A. Lumb A.B. Postoperative pulmonary complications. Br J Anaesth. 2017; 118: 317-334 Abstract Full Text Full Text PDF PubMed Scopus (414) Google Scholar ,2 Colquhoun D.A. Vaughn M.T. Bash L.D. et al. Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee. Association between the choice of reversal agent for neuromuscular block and postoperative pulmonary complications in patients at increased risk undergoing non-emergency surgery: STIL-STRONGER, a multicentre matched cohort study. Br J Anaesth. 2023; 130: e148-e159 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar POPC incidence varies between 2.6% and 7.6% in the general population of patients, 2 Colquhoun D.A. Vaughn M.T. Bash L.D. et al. Multicenter Perioperative Outcomes Group (MPOG) Perioperative Clinical Research Committee. Association between the choice of reversal agent for neuromuscular block and postoperative pulmonary complications in patients at increased risk undergoing non-emergency surgery: STIL-STRONGER, a multicentre matched cohort study. Br J Anaesth. 2023; 130: e148-e159 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar , 3 Kirmeier E. Eriksson L.I. Lewald H. et al. POPULAR ContributorsPost-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study. Lancet Respir Med. 2019; 7: 129-140 Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar , 4 Li G. Freundlich R.E. Gupta R.K. et al. Postoperative pulmonary complications' association with sugammadex versus neostigmine: a retrospective registry analysis. Anesthesiol. 2021; 134: 862-873 Crossref PubMed Scopus (41) Google Scholar , 5 Kheterpal S. Vaughn M.T. Dubovoy T.Z. et al. Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (STRONGER): a multicenter matched cohort analysis. Anesthesiol. 2020; 132: 1371-1381 Crossref PubMed Scopus (152) Google Scholar , 6 Schaefer M.S. Hammer M. Santer P. et al. Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks. Br J Anaesth. 2020; 125: 629-636 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar but it is ∼22% for obese patients (BMI >30 kg m−2) undergoing noncardiac, non-neurological surgery under general anaesthesia. 7 Bluth T. Serpa Neto A. Schultz M.J. et al. Writing Committee for the PROBESE Collaborative Group of the PROtective VEntilation Network (PROVEnet) for the Clinical Trial Network of the European Society of AnaesthesiologyEffect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients: a randomized clinical trial. JAMA. 2019; 321: 2292-2305 Crossref PubMed Scopus (183) Google Scholar Owing to morpho-functional changes, obesity predisposes patients to upper airway obstruction, hypoventilation, atelectasis, and hypoxaemia after receiving general anaesthesia and major surgery that can result in a POPC. 8 Carron M. Safaee Fakhr B. Ieppariello G. Foletto M. Perioperative care of the obese patient. Br J Surg. 2020; 107: e39-e55 Crossref PubMed Scopus (34) Google Scholar