A recent study published by Korean scientists compared the effect of sugammadex with that of neostigmine in terms of the occurrence of postoperative nausea and vomiting during the first 24 hours following general anesthesia.
Patients who underwent elective surgery under general anesthesia in 2020, at an academic medical center, in Seoul, South Korea, were included in this retrospective cohort study. The exposure groups were determined according to whether the patient received Sugammadex or neostigmine as a reversal agent of muscle realxant rocuronium. The primary outcome was postoperative nausea and vomiting occurrence during the first 24 hours postoperatively.
Out of the 10,912 patients included in this study, 5,918 (54.2 % of them) received Sugammadex. The clinical study showed that Sugammadex was associated with a significantly lower incidence of overall postoperative nausea and vomiting (15.8% vs. 17.7%; 95% confidence interval.)
From the results of this single-center retrospective study, it was concluded that the use of Sugammadex had a lower risk of postoperative side effects during the first 24 h following general anesthesia, compared with neostigmine. (1)
Another, study published in 2020, demonstrated also significant advantages for patients treated with Sugammadex, as far as their postoperative pulmonary complications are concerned. 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%).
According to the multivariable analysis, Sugammadex administration was associated with a
• 30 % reduced risk of pulmonary complications
• 47 % reduced risk of pneumonia and
• 55 % reduced risk of respiratory failure
as compared to the neostigmine treatment.
This study showed that 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. (2)
Another randomized double-blind controlled trial provided important information on the comparison of incidence of postoperative residual curarization (PORC) may be a potential risk factor of postoperative pulmonary complications (PPCs) between neostigmine and sugammadex through two novel and useful approaches, diaphragm ultrasonography, and lung ultrasound. Sugammadex reversal of neuromuscular blockade was rapid and complete, and there appeared fewer postoperative complications than with neostigmine. 
These results are in aggreement with those published in 2017 in a review including 41 studies. Review results suggest that in comparison with neostigmine, Sugammadex can more rapidly reverse rocuronium-induced neuromuscular block regardless of the depth of the block. Sugammadex 2 mg/kg is 10.22 minutes (˜ 6.6 times) faster in reversing moderate neuromuscular blockade (T2) than neostigmine 0.05 mg/kg , and sugammadex 4 mg/kg is 45.78 minutes (˜ 16.8 times) faster in reversing deep neuromuscular blockade than neostigmine 0.07 mg/kg. Concerning the adverse event, sugammadex appears to have a better safety profile than neostigmine. Patients receiving sugammadex had 40% fewer adverse events compared with those given neostigmine. Specifically, risks of bradycardia, postoperative nausea and vomiting, and overall signs of postoperative residual paralysis were reduced. Both sugammadex and neostigmine were associated with serious adverse events in less than 1% of patients, and data showed no differences in risk of serious adverse events between groups (RR 0.54; GRADE: low quality). (4)
- Ju, JW., Hwang, I.E., Cho, HY. et al. Effects of sugammadex versus neostigmine on postoperative nausea and vomiting after general anesthesia in adult patients:a single-center retrospective study. Sci Rep 13, 5422 (2023). https://doi.org/10.1038/s41598-023-32730-1
- Kheterpal S, Vaughn MT, Dubovoy TZ, et al. Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis. Anesthesiology. 2020 Jun;132(6):1371-1381. https://doi.org/10.1097/ALN.0000000000003256.
- Zhang, Yg., Chen, Y., Zhang, YL. et al. Comparison of the effects of neostigmine and sugammadex on postoperative residual curarization and postoperative pulmonary complications by means of diaphragm and lung ultrasonography: a study protocol for prospective double-blind randomized controlled trial. Trials 23, 376 (2022). https://doi.org/10.1186/s13063-022-06328-3
- Hristovska AM, Duch P, Allingstrup M, Afshari A. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev. 2017 Aug 14;8(8):CD012763. https://doi.org/10.1002/14651858.CD012763.
Picture credit: Wikipedia