Perioperative Medicine  |   June 2020
Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis
Author Notes
  • From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan (S.K., M.T.V., T.Z.D., N.J.S., D.A.C., A.M.S., M.R.M., L.S.); Center for Observational and Real World Evidence, Merck & Co. Inc, Kenilworth, New Jersey (L.D.B.); Department of Anesthesiology, Beaumont Health, Royal Oak, Michigan (R.G.S.); Department of Anesthesiology, Yale University, New Haven, Connecticut (A.B., R.B.S.); Department of Anesthesiology, University of Colorado, Aurora, Colorado (K.B.); and Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York (P.J.M.). Current position: Department of Anesthesiology, University Medical Center Goettingen, Lower Saxony, Germany (L.S.).
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • This article is accompanied by an editorial on p. 1299.
    This article is accompanied by an editorial on p. 1299.×
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    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
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    This article has a visual abstract available in the online version.×
  • Part of the work presented in this article has been presented at the European Society of Anesthesiology Meeting in Vienna, Austria, June 4, 2019.
    Part of the work presented in this article has been presented at the European Society of Anesthesiology Meeting in Vienna, Austria, June 4, 2019.×
  • Submitted for publication September 20, 2019. Accepted for publication February 19, 2020. Published online first on April 8, 2020.
    Submitted for publication September 20, 2019. Accepted for publication February 19, 2020. Published online first on April 8, 2020.×
  • Address correspondence to Dr. Kheterpal: University of Michigan, Department of Anesthesiology, 1500 East Medical Center Drive, 1H247 University Hospital SPC 5048, Ann Arbor, Michigan 48109-5048. sachinkh@med.umich.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Clinical Science / Neuromuscular Diseases and Drugs / Respiratory System
Perioperative Medicine   |   June 2020
Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis
Anesthesiology 6 2020, Vol.132, 1371-1381. doi:https://doi.org/10.1097/ALN.0000000000003256
Anesthesiology 6 2020, Vol.132, 1371-1381. doi:https://doi.org/10.1097/ALN.0000000000003256
Abstract

Background: Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications.

Methods: Twelve U.S. Multicenter Perioperative Outcomes Group hospitals were included in a multicenter observational matched-cohort study of surgical cases between January 2014 and August 2018. Adult patients undergoing elective inpatient noncardiac surgical procedures with general anesthesia and endotracheal intubation receiving a nondepolarizing neuromuscular blockade agent and reversal were included. Exact matching criteria included institution, sex, age, comorbidities, obesity, surgical procedure type, and neuromuscular blockade agent (rocuronium vs. vecuronium). Other preoperative and intraoperative factors were compared and adjusted in the case of residual imbalance. The composite primary outcome was major postoperative pulmonary complications, defined as pneumonia, respiratory failure, or other pulmonary complications (including pneumonitis; pulmonary congestion; iatrogenic pulmonary embolism, infarction, or pneumothorax). Secondary outcomes focused on the components of pneumonia and respiratory failure.

Results: Of 30,026 patients receiving sugammadex, 22,856 were matched to 22,856 patients receiving neostigmine. Out of 45,712 patients studied, 1,892 (4.1%) were diagnosed with the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine). A total of 796 (1.7%) patients had pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%). In multivariable analysis, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% reduced risk of pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% reduced risk of respiratory failure (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56), compared to neostigmine.

Conclusions: Among a generalizable cohort of adult patients undergoing inpatient surgery at U.S. hospitals, the use of sugammadex was associated with a clinically and statistically significant lower incidence of major pulmonary complications.

Editor’s Perspective:

What We Already Know about This Topic:

  • Approximately 5% of patients experience a major pulmonary complication after noncardiac surgery

  • Inadequate reversal of neuromuscular blockade increases the risk of pulmonary complications

  • In the United States, sugammadex is used with similar frequency as neostigmine at many hospitals

  • Sugammadex provides more rapid and effective restoration of neuromuscular tone without systemic anticholinergic activity; however, neostigmine currently remains the mainstay of practice

What This Article Tells Us That Is New:

  • In a multicenter observational matched cohort study of noncardiac surgery, sugammadex administration was associated with a 30% reduced risk of pulmonary complications, a 47% reduced risk of pneumonia, and a 55% reduced risk of respiratory failure compared to neostigmine