TOPLINE

Among adults who underwent major abdominal or thoracic surgery with rocuronium- or vecuronium-induced neuromuscular block, reversal with sugammadex reduced the risk for postoperative pulmonary complications or death compared with neostigmine. The risk reduction was small, and atelectasis of uncertain clinical significance was the most common complication.

METHODOLOGY

• Researchers conducted a phase 4 randomized trial to compare postoperative pulmonary outcomes of sugammadex vs neostigmine for reversal of neuromuscular block induced by rocuronium or vecuronium in patients having abdominal or thoracic surgery between July 2023 and July 2025.
• A total of 3498 patients aged at least 40 years (mean age, 62.6 years; 54% men) who were undergoing surgery under general anesthesia lasting at least 2 hours and had an expected postoperative stay of one night or longer were randomly assigned 1:1 to receive either sugammadex or neostigmine.
• The primary outcome was a composite of new pulmonary complications (atelectasis, pneumonia, acute respiratory distress syndrome, and aspiration pneumonitis) or death, assessed up to hospital discharge or postoperative day 7 for patients still in hospital.
• Secondary outcomes included the individual components of the primary outcome, postoperative nausea and vomiting through postoperative day 1, and unplanned admission to the ICU or a high-dependency unit.

TAKEAWAY

• Pulmonary complications or death occurred in 19.0% of patients receiving sugammadex vs 21.5% receiving neostigmine, corresponding to a risk ratio (RR) of 0.88 (P = .049).
• Atelectasis was the most common complication, occurring in 18.4% of patients in the sugammadex group vs 21.1% in the neostigmine group (RR, 0.86; P = .030); the rates of pneumonia, aspiration pneumonitis, and acute respiratory distress syndrome did not differ significantly.
• Among patients with quantitative neuromuscular monitoring, 87.4% of patients receiving sugammadex and 64.3% of patients receiving neostigmine achieved adequate reversal of neuromuscular block (train-of-four ratio ≥ 0.9) before tracheal extubation.
• Rates of postoperative nausea and vomiting and unplanned ICU or high-dependency admissions were similar between the groups. No adverse events were judged to be treatment-related; no mild or moderate allergic reactions were attributed to either study drug.

IN PRACTICE

“In conclusion, in a large, international, randomized controlled trial involving older adults having major abdominal or thoracic surgery under general anesthesia, in which compliance with neuromuscular monitoring guidelines was incomplete, sugammadex reduced the incidence of postoperative pulmonary complications or death compared with neostigmine,” the authors wrote.

SOURCE

The study was led by Kate Leslie, MD, University of Melbourne, Melbourne, Australia. It was published online on June 09, 2026, in The Lancet Respiratory Medicine.

LIMITATIONS

The generalizability of the findings was limited to patients aged at least 40 years who had major abdominal or thoracic surgery in settings where neostigmine could be used for reversal. Anesthesiologists were not blinded, which may have influenced their decisions during reversal. Moreover, nonadherence to the assigned interventions differed between groups.

DISCLOSURES

This study was supported by the Australian Medical Research Future Fund and the Hong Kong Health and Medical Research Fund. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.