STRONGER Trial

Summary by Ian Paterson MD, 07.18.22
https://pubmed.ncbi.nlm.nih.gov/32282427/

Take Home Point:

  • NMB reversal with Sugammadex is associated with a lower risk of pulmonary complications.

  • As such, the increased cost of Sugammadex may be justified by the prevention of major postoperative pulmonary complications and their associated costs. It is important to think of cost of stay (~$100,000 per occurrence of major pulmonary complication) when we criticize the cost of sugammadex.


Summary:

Background:

  • Approximately 5% of patients have pulmonary complications after noncardiac surgery (pneumonia, respiratory failure, other complications)

  • Post-op pulmonary complications result in increased morbidity, mortality, length of stay, cost of stay (estimated at $100,000 per occurrence of major pulmonary complication)

  • Inadequate NMB reversal is a risk factor for these complications

Study Design:

  • Retrospective observational matched cohort study

  • Compared outcomes in patients receiving Sugammadex versus Neostigmine

  • The authors hypothesized that superior NMB reversal with Sugammadex would result in fewer post-op pulmonary complications

  • 22,856 patients who received Sugammadex were matched with 22,856 patients who received Neostigmine

  • Matching criteria included age, sex, BMI, ASA score, comorbidities, type of surgery, etc

  • Primary outcome: Major Pulmonary Complication (composite of pneumonia, respiratory failure, and/or other major complications). Secondary outcomes: Pneumonia, Respiratory Failure

Results:

  • 3.5% of Sugammadex patients vs 4.8% of Neostigmine patients experienced the composite primary outcome (30% risk reduction)

  • 1.3% Sugammadex vs 2.2% Neostigmine experienced pneumonia (47% risk reduction)

  • 0.8% Sugammadex vs 1.7% Neostigmine experienced respiratory failure (55% risk reduction)

Discussion:

  • Residual neuromuscular blockade can result in pulmonary complications such as pneumonia and respiratory failure by impairing the ability to cough, clear secretions, and breathe deeply.

This study provides evidence that NMB reversal with Sugammadex is associated with a statistically lower risk of these complications.

As such, the increased cost of Sugammadex may be justified by the prevention of post-op pulmonary complications and their associated costs.