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Each year, more than 230 million major surgical procedures worldwide involve the administration of neuromuscular blocking drugs.1 Neuromuscular blocking agents (NMBAs) were introduced into clinical anesthesiology in the form of intocostrin (curare) by Harold Randall Griffith in 1942.2 These drugs can be classified as nondepolarizing and depolarizing NMBAs, with succinylcholine (relaxin) being the sole clinically used depolarizing agent. To reverse the neuromuscular blockade induced by nondepolarizing NMBAs, neostigmine, a clinical acetylcholinesterase inhibitor, increases the acetylcholine concentration at the neuromuscular junction.2–4
Sugammadex, approved in the European Union in 2008,5 is a selective relaxant-binding drug that rapidly and directly reverses nondepolarizing NMBAs in the vascular system. It offers advantages over traditional acetylcholinesterase inhibitors, such as neostigmine, as it avoids cholinergic side effects and prevents arrhythmias, respiratory muscle weakness, and hypersalivation.6 This facilitates the quick restoration of muscle tension, allows smooth endotracheal tube removal, and ensures seamless transfer to the postanesthesia care unit (PACU).7,8
In this study, we hypothesize that sugammadex can shorten operation time and improve operation room turnover efficiency in VATS. The primary outcome indicated that sugammadex shorten operation time and improve operation turnover efficiency, as observed through arterial blood gas (ABG) analysis, the secondary outcomes suggested favorable vital signs, particularly those associated with sugammadex administration, compared with neostigmine.
2. METHODSThis cohort study was conducted at Taipei Veterans General Hospital, Taiwan, from July 2022 to March 2023, enrolling lung cancer patients scheduled for wedge resection who met the specific inclusion criteria. Was performed at Taipei Veterans General Hospital, Taiwan, which is registered with the Institutional Review Board (IRB) with reference number 2022-06-014 BC. The patients were randomly assigned to the sugammadex or neostigmine groups, with 30 patients in each group. Perioperative data, including anesthesia duration, surgery type, and vital signs, were collected from 60 participants with the American Society of Anesthesiologists physical status grades I-III, who underwent video-assisted thoracoscopic surgery (VATS) for lung cancer with wedge resection under general anesthesia using double-lumen tubes. Factors such as operation time, blood loss, renal function, and liver function were also assessed to determine overall health status. The anesthesiologist discreetly managed general anesthesia during VATS, employing double-lumen tubes for one-lung ventilation confirmed by bronchoscopy and exclusively administering rocuronium as a nondepolarizing neuromuscular drug (Fig. 1).
Fig. 1: Flowchart of patient selection.
The choice of reversal agent, either sugammadex (2 mg/kg) or neostigmine with atropine (0.04 + 0.02 mg/kg), was based on body weight after the last dose of rocuronium. Extubation followed specific criteria for awakening, responsiveness, stable hemodynamics, muscle strength, and satisfactory oxygenation and ventilation (≥8 breaths/min). An ABG analysis was conducted at multiple time points during the study, including after anesthesia induction, 15 minutes after unilateral lung inflation, and 5 minutes after restoring bilateral lung inflation postsurgery. In the PACU, ABG analysis was performed on arrival, and vital signs and blood oxygen levels were regularly monitored while the patients’ respiratory condition was closely observed, with another ABG analysis performed before PACU discharge. Vital signs and blood oxygen levels were continuously monitored for 8, 16, and 24 hours after returning to the thoracic surgery ward.
2.1. Statistical analysisIn this study, data analysis was performed using IBM® SPSS® Statistics software version 24, encompassing various data, including demographic information, medical history, perioperative details, vital signs, anesthesia duration, surgical specifics, medication usage, physiological measurements, and underlying medical conditions, to gain a comprehensive understanding of the patient population and their specific characteristics relevant to the study.
3. RESULTS 3.1. Clinical characteristics of the study populationThis study, conducted at Taipei Veterans General Hospital in Taiwan from July 2022 to March 2023, included patients who underwent wedge resection for lung cancer. The sugammadex group (mean age, 59 years) included 16 male cases (53%) and 14 female cases (47%; p = 0.035), while the neostigmine group (mean age, 54 years) included 16 male cases (53%) and 14 female cases (47%; Table 1). Significant differences in ABG analysis were observed between the two groups following bilateral ventilation reversal, from maintenance of anesthesia until leaving the PACU, with the sugammadex group showing a pH value of 7.36 ± 0.01 (p = 0.039) and an arterial partial pressure of oxygen (PaO2) of 285 ± 28 mmHg (p = 0.012); the neostigmine group had a pH value of 7.38 ± 0.01 and a PaO2 of 385 ± 27 mmHg (Table 2).
Table 1 - Baseline characteristics Variables TotalBMI = body mass index.
*p < 0.05.
Data are means ± SD or median (interquartile range).
PACU = postanesthesia care unit; PaO2 = arterial partial pressure of oxygen.
*p < 0.05.
During the preinduction phase and maintenance of anesthesia, no significant differences in the average arterial blood pressure and heart rate were observed between the sugammadex and neostigmine groups. However, on leaving the operating room, the neostigmine group exhibited a significantly higher heart rate (85 ± 3/min; p = 0.002) than the sugammadex group (73 ± 3 beats/min). In the PACU at 120 minutes, the neostigmine group had a higher heart rate (76 ± 2 beats/min; p = 0.016) than the sugammadex group (68 ± 2 beats/min). Additionally, the sugammadex group had significantly shorter total operation time (130 ± 7 min vs 157 ± 7 min, p = 0.009), anesthesia induction to operation, completion time (90 ± 4 vs 126 ± 6 min; p = 0.041), and last rocuronium administration to leaving the operating room (55 ± 5 vs 125 ± 23 min; p = 0.005) compared with the neostigmine group (Tables 3 and 4).
Table 3 - Patient’s vital sign in PACU and thoracic surgery ward Variables Sugammadex groupData are means ± SD or median (interquartile range).
PACU = postanesthesia care unit; MAP = mean arterial pressure.
*p < 0.05,
**p < 0.01.
In this prospective study conducted from July 2022 to March 2023, we observed a significant difference in operation time and turnover efficiency in VATS when using sugammadex compared with neostigmine.
The gas data and heart rate also showed notable differences after the administration of sugammadex and on leaving the operating room. Interestingly, another study reported no difference in gas data after administering sugammadex to pediatric patients with congenital heart disease upon entering the cardiac intensive care unit.9 However, no other articles have discussed this.
Several articles have mentioned the association of sugammadex with shorter extubation times, albeit with a difference of less than 1 minutes. Patients receiving sugammadex also have a shorter duration of surgery and anesthesia.5,10,11 However, the high cost of sugammadex may limit its widespread use owing to economic constraints. However, the use of sugammadex has facilitated the implementation of protocols to increase operating room efficiency.
This study aimed to compare the effects of sugammadex and neostigmine for anesthesia reversal in patients undergoing thoracoscopic surgery, with a focus on operating room efficiency and the rapid and effective restoration of neuromuscular function associated with sugammadex, despite its higher cost,12 and the potential for slower recovery and more side effects associated with neostigmine when used for deep neuromuscular blockade reversal. Data were collected by observing the operating room and employing different reversal strategies, with administration at the end of steady-state anesthesia.
This single-center study conducted in Taiwan had limited generalizability because it focused solely on thoracoscopic surgery and excluded other critical outcomes. The lack of long-term follow-up hindered a comprehensive evaluation of safety and efficacy, necessitating larger sample sizes and diverse populations in future research to validate and extend these findings. This clinical trial aimed to compare the safety and efficacy of sugammadex and neostigmine as reversal agents for respiratory recovery after neuromuscular blockade in VATS, and the findings support the use of sugammadex due to its stable heart rate profile, fewer side effects, and shorter overall surgery duration compared with neostigmine.
This highlights the significance of sugammadex in patient care and anesthesia management during VATS.
ACKNOWLEDGMENTSThis study was supported in part by Taipei Veterans General Hospital, Taiwan (Grant No. V112C-042).
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