Objective:

To evaluate the effect of sugammadex on postoperative pulmonary complications in older adults undergoing major abdominal or thoracic surgery.

Approach:

• Study Design: An international, multicenter phase 4 clinical trial (SNaPP trial) involving 3,498 patients aged 40 years or older.
• Intervention: Patients were randomly assigned to receive either sugammadex or neostigmine at the end of surgery.
• Primary Endpoint: Postoperative pulmonary complications or mortality through hospital discharge or postoperative day 7.
• Secondary Outcomes: Included pulmonary complications, postoperative nausea and vomiting, unplanned intensive care admission, days alive and at home at 30 days, and health-related quality of life at 3 months.

Key Findings:

• Postoperative pulmonary complications or mortality occurred in about 19% of patients receiving sugammadex compared to 22% receiving neostigmine, with the reduction primarily due to fewer cases of atelectasis (18% vs 21%).
• Rates of pneumonia, pulmonary aspiration, and mortality were similar between the two groups.
• Sugammadex resulted in more complete reversal of neuromuscular blockade prior to tracheal extubation.

Interpretation:

The reduction in postoperative pulmonary complications was modest and mainly driven by atelectasis.

Limitations:

• Findings may not be generalizable beyond older adults undergoing major abdominal or thoracic surgery.
• Treating anesthesiologists could not be masked to treatment assignment, potentially influencing management decisions.

Conclusion:

Sugammadex may provide a modest reduction in postoperative pulmonary complications compared to neostigmine in older adults undergoing major surgery.

Sources:

• The Lancet Respiratory Medicine