Reversal of neuromuscular blockade after coronary artery bypass grafting: a randomized control trial

Early extubation in cardiac surgery improves recovery and outcomes. Extubation of the airway after cardiac surgery in the operating room or in the immediate postoperative period is a key component of the optimization of outcomes in cardiac surgical patients. Specific objectives of this study included measuring time to extubation with secondary outcomes of post-extubation vital signs, lung function, and esophageal motility. Exploratory parameters included ICU stay and re-intubation in 24 h.

In this study, we compare two groups of patients undergoing coronary bypass grafting surgery (CABG) under general anesthesia with muscle relaxation. Reversal of neuromuscular blockade randomized to group 1: neostigmine and group 2: sugammadex. A standard anesthetic protocol was followed throughout the perioperative period in each of these patients with the goal of in-operating room extubation. A two-sample t-test and/or linear model was used in the data analysis.

4 subjects were not extubated in the neostigmine group versus 1 subject in the sugammadex group. The average time to extubation in the neostigmine group was 10.4 min, (STDEV: 5.9 min) and sugammadex was 6 min, (STDEV: 4.7 min). p = 0.001 (ANOVA). Significant secondary outcome measures included patients who received sugammadex had higher heart rates at the second measurement (85.0) vs. neostigmine (79.5) p = 0.047 and higher systolic blood pressures at the second measurement point for sugammadex (111.7) vs. neostigmine (103.9) p = 0.023. 11/36 (30%) failed the Functional Dysphasia Screen in the neostigmine group versus 5/35 (14%) in the sugammadex. Subjects in the neostigmine group had an average ICU stay of 40.1 +/- 32.4 h versus 35.6 +/- 15.8 in the sugammadex group. 2 patients in the neostigmine group were re-intubated and 1 patient was placed on non-invasive positive pressure ventilation vs. no airway interventions in the sugammadex group.

Based on the results of this study, utilizing sugammadex for reversal of neuromuscular blockade after CABG may increase early extubation in the operating room, decrease the re-intubation rates, provide a very consistent level of muscle strength for lung function, and may improve postoperative esophageal dysmotility.

ClinicalTrials.gov NCT03939923, Registration date of Feb 2, 2019.