- Neuromuscular blocking agents, (NMBAs) are typically pharmacologically reversed in order to minimize the risk of post-operative pulmonary complications secondary to residual weakness of the respiratory muscles.
- Traditionally, anticholinesterase agents, such as neostigmine, were used to reverse NMBAs; however, these drugs have undesirable muscarinic effects such as bradycardia. To mitigate muscarinic activity, anticholinesterase agents are co-administered with an anticholinergic agent such as glycopyrrolate or atropine. However, anticholinergic agents are associated with other post-operative adverse effects such as urinary retention.
- Sugammadex is a neuromuscular block (NMB) reversal agent that directly binds to aminosteroid NMBAs (i.e., rocuronium, vecuronium) and is devoid of muscarinic activity, thus does not require co-administration of an anticholinergic agent.
- Evidence from small, single institution studies have found decreased incidence of post-operative urinary retention (POUR) associated with sugammadex reversal. POUR is distressing for patients, decreases healthcare efficiency, and increases length of stay. Additionally, treatment of POUR with bladder catheterization can result in additional complications such as urinary tract infection and bladder mucosal trauma.
- In this retrospective cohort study, the authors utilized the PINC-AI™ Healthcare Database (PHD) including 61,898 matched adult inpatients and 95,500 matched adult outpatients to determine if the association between POUR and NMB reversal with neostigmine with glycopyrrolate compared to sugammadex could be replicated.
- The PHD was used to identify surgical cases that occurred between February 1, 2017, and November 30, 2021. Inclusion criteria were patients ≥18 years of age undergoing elective surgery, requiring NMB with rocuronium or vecuronium and reversed with either neostigmine with glycopyrrolate or sugammadex.
- When comparing rates of POUR by NMB reversal method, there was an approximately two-fold higher rate for inpatients reversed with neostigmine (5.0% [n=9447]) compared to sugammadex (2.3% [n = 3089]) (p < 0.0001). Outpatient rates of POUR were 0.8% (n = 1915) and 0.4% (n = 720) for neostigmine and sugammadex reversal, respectively (p < 0.0001). POUR-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 =018) and outpatients (0.5% vs. 0.1%; p <0.0001).
- The authors concluded that while these results need to be confirmed by large prospective studies, the consistency of these findings suggest that the use of sugammadex for NMB reversal could have a clinically relevant reduction in the rate of POUR and might be relevant to the choice of NMB reversal agent in patients at higher risk of POUR.
Summary of "Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting"
Summary published August 8, 2024