Reversal of rocuronium with neostigmine or sugammadex in high risk elderly patients: prospective randomized investigation of postoperative outcome

Though neuromuscular paralysis with e.g. rocuronium is a frequent requirement to facilitate airway manipulation and surgery, there is a well known danger arising from the unpredictably duration of effect of these drugs (neuromuscular blocking agents, NMBA): residual neuromuscular blockade (RNMB). The incidence of RNMB is very high and ranges from 3.5-83%. RNMB affects patients’ postoperative wellbeing, but even more importantly respiratory function and hypoxic ventilator response. Patients with RNMB have been shown to suffer more adverse respiratory effects in the recovery room and during their stay in hospital with the obvious burden of disease to the individual but also a significant financial burden to the healthcare system. To avoid the above, patients in whom NMBA have been used are frequently “reversed” at the end of surgery. This means that the effects of the NMBA are antagonized with the cholinesterase-inhibitor neostigmine. A more recent method of reversal with significantly less side effects is the reversal of NMBA with sugammadex, a modified gamma-cyclodextrin which encapsulates the NMBA molecule prior to its renal excretion. Though sugammadex reversal is known to be faster and produce fewer side effects than neostigmine, no prospective investigation has so far shown different effects on postoperative outcome. However, a recent retrospective investigation involving 1444 patients showed a significant benefit for pulmonary outcome in high risk elderly patients when reversed with sugammadex vs neostigmine. Aim of this trial is to investigate the postoperative outcome of 180 high risk patients after reversal with either neostigmine or sugammadex.