Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (SNaPP): an international, randomised, controlled, phase 4 trial.

Summary

A large, masked, multicentre RCT (n=3498) showed sugammadex modestly reduced the composite of postoperative pulmonary complications or death compared with neostigmine (19.0% vs 21.5%; RR 0.88; p=0.049), primarily driven by a reduction in atelectasis. No increase in treatment-related adverse events was observed.

Key Findings

• Sugammadex reduced postoperative pulmonary complications or death (19.0% vs 21.5%; RR 0.88; p=0.049).
• Reduction was mainly in atelectasis (18.4% vs 21.1%; RR 0.86; p=0.030).
• No significant differences observed in pneumonia, aspiration, or mortality; no treatment-related adverse events identified.

Clinical Implications

Consider using sugammadex as first-line reversal for aminosteroid neuromuscular blockade in adults undergoing major abdominal or thoracic surgery to modestly reduce postoperative pulmonary complications, particularly atelectasis; cost and availability should be balanced against small absolute risk reduction.

Limitations

• Absolute risk reduction was small; clinical significance of reduced atelectasis is uncertain.
• Dosing was at clinicians' discretion, introducing heterogeneity in administered doses.

Future Directions

Cost-effectiveness analyses, subgroup assessments (e.g., high-risk pulmonary patients), and real-world implementation studies to inform guideline updates.