Efficacy and Safety of Sugammadex versus Neostigmine in Reversing Neuromuscular Blockade in Morbidly Obese Adult Patients: A Systematic Review and Meta-Analysis

The Dosage of Muscle Relaxants in Morbidly Obese Patients in Daily Practice - A Narrative Review

The prevalence of morbid obesity in today's population around the world is alarming. Morbid obesity involves substantial changes in body composition and function, which can affect the pharmacodynamics and pharmacokinetics of many drugs. This paper aims to discuss the application of muscle relaxants and their reversing agents in patients with morbid obesity. This work is based both on the available literature and the author's personal experience. Dosage recommendations for muscle relaxants in morbidly obese patients are as follows: non-depolarizing relaxants like rocuronium, vecuronium, atracurium, and cisatracurium should be based on ideal body weight. Succinylcholine dosage should be adjusted to total body weight with a 200 mg maximum, while mivacurium should also be based on total body weight. Pancuronium is not used due to its long duration. Neostigmine dosing remains uncertain, but some suggest using total body weight. When it comes to Sugammadex opinions of the authors are divided, some indicate that it should be dosed based on ideal body weight, but more recent studies show that it should be based on 40% of corrected body weight.

Perioperative efficiency of sugammadex following minimally invasive gastric sleeve surgery: A superiority trial

BACKGROUND

Studies have proposed that the routine use of sugammadex could provide perioperative time savings and a reduction in the incidence of postoperative nausea and vomiting. The purpose of this study was to test the effectiveness of sugammadex on perioperative times and on the incidences of adverse events when compared with the active control, neostigmine, for minimally invasive gastric sleeve surgery.

METHODS

Following institutional review board approval, patient characteristics, type of primary neuromuscular blocking reversal agents, operating room discharge times, post-anaesthesia care unit recovery times, and incidences of and treatment for postoperative nausea and vomiting and orotracheal reintubation were the measures of interest. Superiority testing determined the between-group means differences of the reversal agents on the two perioperative time periods of interest.

RESULTS

Superiority testing demonstrated no improvement of the two perioperative times with sugammadex. There was no clinical difference in the incidence of postoperative nausea and vomiting or in the number of antiemetic doses received in the post-anaesthesia care unit between the two groups. Finally, the two orotracheal reintubations in the post-anaesthesia care unit were in the sugammadex administered group.

CONCLUSION

These results with sugammadex provide no perioperative time savings or reduce the incidence and treatment for postoperative nausea and vomiting in the post-anaesthesia care unit when compared with neostigmine.

Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center

BACKGROUND

Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described.

METHODS

A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes.

RESULTS

Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization.

CONCLUSIONS

Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Impact of Sugammadex Versus Neostigmine Reversal on Postoperative Recovery Time in Patients With Obstructive Sleep Apnea Undergoing Bariatric Surgery: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Residual neuromuscular blockade can be associated with serious postoperative complications. Sugammadex is a newer neuromuscular blocking drug (NMBD) reversal agent that rapidly and completely reverses rocuronium. Whether sugammadex has any advantages over neostigmine in morbidly obese patients with obstructive sleep apnea (OSA) is unclear. We investigated whether sugammadex would reduce discharge time from the operating room (OR) compared with neostigmine in morbidly obese patients with OSA undergoing bariatric surgery.

METHODS

This was a prospective, double-blinded randomized controlled superiority trial with 2 parallel groups. Patients were randomized 1:1 into reversal of NMBD with sugammadex or neostigmine. Our inclusion criteria were morbidly obese adult patients with OSA undergoing elective bariatric surgery under general anesthesia. Our exclusion criteria were allergy to rocuronium, sugammadex or neostigmine, malignant hyperthermia, hepatic or renal insufficiency, neuromuscular diseases, and an inability to give consent. The primary outcome was the time from administration of the NMBD reversal agent to discharge from the OR. Secondary outcomes included the time from administration of the NMBD reversal agent to the time the patient opened eyes to command, and the time to extubation. The Mann-Whitney test was used to compare the outcomes between treatment groups.

RESULTS

We randomized 120 patients into 2 groups of 60 patients. Overall median body mass index (BMI) was 48.1 kg/m2 ([interquartile range, IQR]) [43.0-53.5]. The time from drug administration to discharge from OR was 13.0 minutes [10.0-17.0] in the sugammadex group and 13.5 minutes [11.0-18.3] in the neostigmine group (P = .27). The treatment effect estimate with a bootstrapped 95% confidence interval [CI] for time from admission to discharge from OR was -0.5 [-2.5 to 3]. No differences were observed in postoperative complications and other secondary outcomes.

CONCLUSIONS

No difference was observed in OR discharge time in morbidly obese patients with OSA when sugammadex was administered instead of neostigmine.

General Anesthetic Care of Obese Patients Undergoing Surgery: A Review of Current Anesthetic Considerations and Recent Advances

Obesity has long been linked to adverse health effects over time. As the prevalence of obesity continues to rise, it is important to anticipate and minimize the complications that obesity brings in the anesthesia setting during surgery. Anesthetic departments must recognize the innumerable risks when managing patients with obesity undergoing surgery, including anatomical and physiological changes as well as comorbidities such as diabetes, cardiovascular diseases, and malignancies. Therefore, the purpose of this review is to analyze the current literature and evaluate the current and recent advances in anesthetic care of obese patients undergoing surgery, to better understand the specific challenges this patient population faces. A greater understanding of the differences between anesthetic care for obese patients can help to improve patient care and the specificity of treatment. The examination of the literature will focus on differing patient outcomes and safety precautions in obese patients as compared to the general population. Specifically highlighting the differences in pre-operative, intra-operative, and post-operative care, with the aim to identify issues and present possible solutions.

Use of sugammadex is associated with reduced incidence and severity of postoperative nausea and vomiting in adult patients with obesity undergoing laparoscopic bariatric surgery: a post-hoc analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common but troublesome complication in patients who undergo laparoscopic bariatric surgery (LBS). Whether sugammadex use is related to the persistent decrease in the occurrence of PONV during postoperative inpatient hospitalization, which is critical for the rehabilitation of patients after LBS, remains unknown.

METHODS

The study was based on a randomized controlled trial conducted in an accredited bariatric centre. A total of 205 patients who underwent LBS were included in the analysis. Univariate analysis and multivariable logistic regression model were used to identify the significant variables related to PONV. Then propensity score matching and inverse probability of treatment weighting (IPTW) were employed to compare outcomes between the sugammadex and neostigmine groups. The primary outcome was the incidence of PONV within 48 h after LBS. The secondary endpoints included the severity of PONV, time to first flatus, need for rescue antiemetic therapy, and water intake.

RESULTS

The incidence of PONV was 43.4% (89/205) within the first 48 h after LBS. In multivariable analysis, sugammadex use (OR 0.03, 95% CI 0.01-0.09, P < 0.001) was an independent protective factor of PONV. After IPTW adjustment, sugammadex use was associated with lower incidence of PONV (OR 0.54, 95% CI 0.48-0.61, P < 0.001), postoperative nausea (PON) (OR 0.77, 95% CI 0.67-0.88, P < 0.001), and postoperative vomiting (POV) (OR 0.60, 95% CI 0.53-0.68, P < 0.001) within postoperative 48 h. The severity of PON as well as the incidence and severity of POV within the first 24 h were also lower in the sugammadex group (all P < 0.05). Reduced need for rescue antiemetic therapy within the first 24 h, increased water intake for both periods, and earlier first passage of flatus were observed in the sugammadex group (all P < 0.05).

CONCLUSIONS

Compared with neostigmine, sugammadex can reduce the incidence and severity of PONV, increase postoperative water intake, and shorten the time to first flatus in bariatric patients during postoperative inpatient hospitalization, which may play a pivotal role in enhanced recovery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100052418, http://www.chictr.org.cn/showprojen.aspx?proj=134893 , date of registration: October 25, 2021).

Appropriate dosing of sugammadex for reversal of rocuronium-/vecuronium-induced muscle relaxation in morbidly obese patients: a meta-analysis of randomized controlled trials

Objective

To conduct a meta-analysis to compare different dosing scalars of sugammadex in a morbidly obese population for reversal of neuromuscular blockade (NMB).

Methods

PubMed®, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were searched for relevant randomized controlled trials (RCTs) comparing lower-dose sugammadex using ideal body weight (IBW) or corrected body weight (CBW) as dosing scalars with standard-dose sugammadex based on total body weight (TBW) among morbidly obese people after NMB. Mean difference with SD was used to estimate the results.

Results

The analysis included five RCT with a total of 444 morbidly obese patients. The reversal time was significantly longer in patients receiving sugammadex with dosing scalar based on IBW than in patients receiving sugammadex with dosing scalar based on TBW (mean difference 55.77 s, 95% confidence interval [CI] 32.01, 79.53 s), but it was not significantly different between patients receiving sugammadex with dosing scalars based on CBW versus TBW (mean difference 2.28 s, 95% CI –10.34, 14.89 s).

Conclusion

Compared with standard-dose sugammadex based on TBW, lower-dose sugammadex based on IBW had 56 s longer reversal time whereas lower-dose sugammadex based on CBW had a comparable reversal time.