Sugammadex may reduce postoperative pulmonary complications in older adults undergoing major abdominal or thoracic surgery, according to findings from a clinical trial. Researchers reported a modest reduction in the composite outcome of postoperative pulmonary complications or death, with the benefit largely attributable to fewer cases of atelectasis rather than differences in other pulmonary events or mortality.

In the international, multicenter phase 4 SNaPP trial, researchers enrolled 3,498 patients aged 40 years or older undergoing abdominal or thoracic surgery expected to last at least 2 hours at 44 hospitals across Australia, Aotearoa New Zealand, and Hong Kong and requiring reversal of rocuronium- or vecuronium-induced neuromuscular blockade. They randomly assigned the patients to receive sugammadex or neostigmine at the end of surgery. The primary endpoint was postoperative pulmonary complications or mortality through hospital discharge or postoperative day 7; while secondary outcomes included pulmonary complications, postoperative nausea and vomiting, unplanned intensive care or high-dependency unit admission, days alive and at home at 30 days, and health-related quality of life at 3 months.

Postoperative pulmonary complications or mortality occurred in about 19% of the patients who received sugammadex compared with 22% of those who received neostigmine, a modest reduction in the primary endpoint. Atelectasis, the most common pulmonary complication, occurred in 18% and 21% of the patients, respectively, accounting for most of the observed difference. Rates of pneumonia, pulmonary aspiration, and mortality remained similar between the two groups. No cases of acute respiratory distress syndrome were reported.

Sugammadex also resulted in more complete reversal of neuromuscular blockade prior to tracheal extubation and reduced the need for rescue reversal compared with neostigmine. However, the researchers observed no statistically significant differences in postoperative nausea and vomiting, unplanned intensive care or high-dependency unit admission, days alive and at home at 30 days, or health-related quality of life at 3 months. Prespecified subgroup analyses likewise showed no evidence that the treatment effect differed across patient or procedural characteristics.

The researchers noted that the reduction in the primary outcome was modest and driven primarily by fewer cases of atelectasis, whose long-term clinical significance remained uncertain. They also cautioned that the findings may not be generalizable beyond older adults undergoing major abdominal or thoracic surgery. Because treating anesthesiologists could not be masked to treatment assignment, management decisions during reversal may have been influenced by knowledge of the allocated intervention.

The findings suggested that sugammadex may offer a modest advantage over neostigmine for reducing postoperative pulmonary complications in this higher-risk surgical population.

"The risk reduction was small with atelectasis of uncertain clinical significance being the most common complication," wrote lead study author Kate Leslie, MD, of the University of Melbourne in Australia, and colleagues.

The study authors reported no conflicts of interest.

Source: The Lancet Respiratory Medicine