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Wang W, Marks-Anglin A, Turzhitsky V, Mark RJ, Otero Rosales A, Bailey NW, Jiang Y, Abueg J, Hofer IS, Weingarten TN. Economic Impact of Postoperative Urinary Retention in the US Hospital Setting. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2024; 11:29-34. [PMID: 39267889 PMCID: PMC11392480 DOI: 10.36469/001c.121641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/15/2024] [Indexed: 09/15/2024]
Abstract
Background: Postoperative urinary retention (POUR) is a common and distressing surgical complication that may be associated with the pharmacological reversal technique of neuromuscular blockade (NMB). Objective: This study aimed to investigate the impact that POUR has on medical charges. Methods: This was a retrospective observational study of adult patients undergoing select surgeries who were administered neuromuscular blockade agent (NMBA), which was pharmacologically reversed between February 2017 and November 2021 using data from the PINC-AI™ Healthcare Database. Patients were divided into 2 groups: those experiencing POUR (composite of retention of urine, insertion of temporary indwelling bladder catheter, insertion of non-indwelling bladder catheter) during index hospitalization following surgery and those without POUR. Surgeries in inpatient and outpatient settings were analyzed separately. A cross-sectional comparison was performed to report total hospital charges for the 2 groups. Furthermore, patients experiencing subsequent POUR events within three days after discharge from index hospitalization were studied. Results: A total of 330 838 inpatients and 437 063 outpatients were included. POUR developed in 13 020 inpatients and 2756 outpatients. Unadjusted results showed that POUR was associated with greater charges in both inpatient ( 92 529 w i t h P O U R v s 78 556 without POUR, p < .001) and outpatient ( 48 996 w i t h P O U R v s 35 433 without POUR, p < .001) settings. After adjusting for confounders, POUR was found to be associated with greater charges with an overall mean adjusted difference of 10 668 ( 95 95 760- 11 760 , p < .001 ) i n i n p a t i e n t a n d 13 160 (95% CI 11 750 - 14 571, p < .001) in outpatient settings. Charges associated with subsequent POUR events following discharge ranged from 9418 i n p a t i e n t c h a r g e s t o 1694 outpatient charges. Conclusions: Surgical patients who were pharmacologically reversed for NMB and developed a POUR event incurred greater charges than patients without POUR. These findings support the use of NMB reversal agents associated with a lower incidence of POUR.
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Affiliation(s)
- Weijia Wang
- Outcomes Research, Merck & Co., Inc., Rahway, New Jersey, USA
| | | | | | - Robert J Mark
- Global Medical Affairs, Merck & Co., Inc., Rahway, New Jersey, USA
| | | | | | - Yiling Jiang
- Biostatistics and Research Decision Sciences Health Economics and Decision Science, Merck Sharp & Dohme (UK) Ltd., London, UK
| | - Joseph Abueg
- Global Medical Affairs, Merck & Co., Inc., Rahway, New Jersey, USA
| | - Ira S Hofer
- Department of Anesthesiology, Pain, and Perioperative Medicine; Department of Medicine, Division of Data Driven Medicine Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Sharma S, McKechnie T, Talwar G, Patel J, Heimann L, Doumouras A, Hong D, Eskicioglu C. Postoperative Gastrointestinal Dysfunction After Neuromuscular Blockade Reversal With Sugammadex Versus Cholinesterase Inhibitors in Patients Undergoing Gastrointestinal Surgery: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:1618-1629. [PMID: 38199669 DOI: 10.1177/00031348241227200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Postoperative gastrointestinal dysfunction (POGD) commonly occurs following gastrointestinal (GI) surgery and is associated with specific anesthetic agents. Cholinesterase inhibitors employed for reversing neuromuscular blockade have been implicated in development of POGD. Sugammadex, a novel reversal agent, is linked with reduced POGD. However, there is a lack of comprehensive comparative review between these agents regarding their impact on POGD following GI surgery. This study aims to systematically review the effects of sugammadex on POGD compared to cholinesterase inhibitors following GI surgery. METHODS MEDLINE, EMBASE, and CENTRAL were searched as of July 2022 to identify articles comparing sugammadex with cholinesterase inhibitors in patients undergoing gastrointestinal surgery, specifically in relation to POGD. Secondary endpoints included length of hospital stay, readmission rates, pulmonary complications, and postoperative morbidity. RESULTS From 198 citations, 2 randomized controlled trials (RCTs) and 3 retrospective cohorts with 717 patients receiving sugammadex and 812 patients receiving cholinesterase inhibitors were included. Significantly lower rates of prolonged postoperative ileus (OR .44, 95% CI .25-.77, P < .05, I2 = 56%, low certainty evidence) was observed with sugammadex. No significant difference in any other outcome was observed. Narrative review of readmission data demonstrated no significant difference. CONCLUSION The use of sugammadex following gastrointestinal surgery is associated with significantly lower rates of prolonged postoperative ileus compared to cholinesterase inhibitors. However, these do not translate into a significant reduction in length of stay, morbidity, or postoperative nausea and vomiting. Results are limited by the numer of studies included and missing data, more robust RCTs are needed before recommendations can be made.
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Affiliation(s)
- Sahil Sharma
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Gaurav Talwar
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Janhavi Patel
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Luke Heimann
- Division of General Surgery, Department of Surgery, Liberty University, Lynchburg, VA, USA
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Bash LD, Turzhitsky V, Mark RJ, Hofer IS, Weingarten TN. Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting. J Clin Anesth 2024; 93:111344. [PMID: 38007845 DOI: 10.1016/j.jclinane.2023.111344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 11/28/2023]
Abstract
STUDY OBJECTIVE Perioperative neuromuscular blocking agents are pharmacologically reversed to minimize complications associated with residual neuromuscular block. Neuromuscular block reversal with anticholinesterases (e.g., neostigmine) require coadministration of an anticholinergic agent (e.g., glycopyrrolate) to mitigate muscarinic activity; however, sugammadex, devoid of cholinergic activity, does not require anticholinergic coadministration. Single-institution studies have found decreased incidence of post-operative urinary retention associated with sugammadex reversal. This study used a multicenter database to better understand the association between neuromuscular block reversal technique and post-operative urinary retention. DESIGN Retrospective cohort study utilizing large healthcare database. SETTING Non-profit, non-governmental and community and teaching hospitals and health systems from rural and urban areas. PATIENTS 61,898 matched adult inpatients and 95,500 matched adult outpatients. INTERVENTIONS Neuromuscular block reversal with sugammadex or neostigmine plus glycopyrrolate. MEASUREMENTS Incidence of post-operative urinary retention by neuromuscular block reversal agent and the independent association of neuromuscular block reversal technique and risk of post-operative urinary retention. MAIN RESULTS The incidence of post-operative urinary retention was 2-fold greater among neostigmine with glycopyrrolate compared to sugammadex patients (5.0% vs 2.4% inpatients; 0.9% vs 0.4% outpatients; both p < 0.0001). Multivariable logistic regression identified reversal with neostigmine to be independently associated with greater risk of post-operative urinary retention (inpatients: odds ratio, 2.20; 95% confidence interval, 2.00 to 2.41; p < 0.001; outpatients: odds ratio, 2.57; 95% confidence interval, 2.13 to 3.10; p < 0.001). Post-operative urinary retention-related visits within 2 days following discharge were five-fold higher among those reversed with neostigmine than sugammadex among inpatients (0.05% vs. 0.01%, respectively; p = 0.018) and outpatients (0.5% vs. 0.1%; p < 0.0001). CONCLUSION Though this study suggests that neuromuscular block reversal with neostigmine can increase post-operative urinary retention risk, additional studies are needed to fully understand the association.
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Affiliation(s)
- Lori D Bash
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Vladimir Turzhitsky
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Robert J Mark
- Center for Observational and Real-World Evidence (CORE), Merck & Co., Inc., Rahway, NJ, United States
| | - Ira S Hofer
- Department of Anesthesiology, Pain and Perioperative Medicine; Department of Medicine, Division of Data Driven Medicine; Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Toby N Weingarten
- Mayo Clinic College of Medicine, Department of Anesthesiology and Perioperative Medicine, Rochester, MN, United States.
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De Lima Laporta Miranda ML, Ochs Kinney MA, Bakkum-Gamez JN, Schroeder DR, Sprung J, Weingarten TN. Sugammadex and urinary retention after hysterectomy: A propensity-matched cohort study. BIOMOLECULES & BIOMEDICINE 2024; 24:395-400. [PMID: 37715536 PMCID: PMC10950351 DOI: 10.17305/bb.2023.9569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 09/17/2023]
Abstract
Postoperative urinary retention (POUR) is a well-known complication after gynecologic surgery. Our objective was to investigate whether the choice of pharmacologic agent for reversing neuromuscular blockade at the end of a hysterectomy is a risk factor for POUR. Among adult patients undergoing hysterectomy with general anesthesia from 2012 to 2017, those who received aminosteroid nondepolarizing neuromuscular agents followed by pharmacologic reversal were identified, and electronic health records were reviewed. The cohort was dichotomized into two groups by reversal agent: 1) sugammadex and 2) neostigmine with glycopyrrolate. The primary outcome, POUR, was defined as unplanned postoperative bladder recatheterization. A propensity-adjusted analysis was performed to investigate the association between POUR and reversal agent by using inverse probability of treatment weighting to adjust for potential confounders. We identified 1,974 patients, of whom 1,586 (80.3%) received neostigmine-glycopyrrolate and 388 (19.7%) received sugammadex for reversal of neuromuscular blockade. The frequency of POUR was 24.8% (393/1,586) after reversal with neostigmine-glycopyrrolate and 18.3% (71/388) with sugammadex. Results from the propensity-adjusted analysis showed that sugammadex was associated with a lower POUR risk than neostigmine-glycopyrrolate (odds ratio 0.53, 95% confidence interval [CI] 0.37 - 0.76, P < 0.001). A post hoc analysis of sugammadex recipients who received glycopyrrolate for another indication showed a higher POUR risk than among those who did not receive glycopyrrolate (odds ratio 1.86, 95% CI 1.07 - 3.22, P = 0.03). Use of sugammadex to reverse aminosteroid neuromuscular blocking agents is associated with decreased risk of POUR after hysterectomy. A potential mechanism is the omission of glycopyrrolate, which is coadministered with neostigmine to mitigate unwanted cholinergic effects.
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Affiliation(s)
- Mariana L De Lima Laporta Miranda
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Michelle A Ochs Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Darrell R Schroeder
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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