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 Table of Contents  
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 52-57

Comparison between sugammadex and neostigmine–atropine in morbidly obese patients during anesthesia in ophthalmic surgery

Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Web Publication24-Jan-2018

Correspondence Address:
Heba M Fathi
Department of Anesthesia and Surgical Intensive Care, Zagazig University Hospitals, Zagazig, 44519
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_26_17

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Background Sugammadex provides fast and complete recovery from rocuronium-induced neuromuscular blockade. The objective of this study was to compare between the effect of sugammadex and neostigmine on intraocular pressure (IOP), hemodynamics, and postoperative complications in morbidly obese patients.
Patients and methods A prospective randomized study was done to study the effect of sugammadex and neostigmine on IOP in morbidly obese patients during elective eye surgery. A total of 60 morbidly obese patients (BMI >35 kg/m2) American Society of Anesthesiologists I–II, aged between 35 and 55 years, requiring general anesthesia and who received rocuronium for muscle relaxation were randomly assigned into two groups: group I (n=30) (Sug) received sugammadex 2 mg/kg and group II (n=30) (Neo) received neostigmine of 0.05 mg/kg at the end of surgery when response of train-of-four reached T2 by using peripheral nerve stimulator. The neuromuscular function was recorded and time to achieve 90% of train-of-four (safe extubation) was measured. After extubation was done, the IOP was measured 1, 2, 5, 10, and 20 min for all patients (those with baseline IOP of >30 mmHg were excluded). Tono-Pen XL applanation tonometer was used to measure IOP. Heart rate and blood pressure were measured and compared in both groups. Patients were examined directly after arrival to the recovery room for observation of complications.
Results Sugammadex give safe, fast, and complete recovery in morbidly obese patients, lower values of IOP and minimal effect on hemodynamics during ophthalmic operations.
Conclusion Sugammadex provided a more rapid reversal of neuromuscular functions in morbidly obese patients, lower IOP and hemodynamic stability during ophthalmic operations.

Keywords: intraocular pressure, morbidly obese, neostigmine, sugammadex

How to cite this article:
Fathi HM, Ezz GF. Comparison between sugammadex and neostigmine–atropine in morbidly obese patients during anesthesia in ophthalmic surgery. Res Opin Anesth Intensive Care 2018;5:52-7

How to cite this URL:
Fathi HM, Ezz GF. Comparison between sugammadex and neostigmine–atropine in morbidly obese patients during anesthesia in ophthalmic surgery. Res Opin Anesth Intensive Care [serial online] 2018 [cited 2019 Mar 18];5:52-7. Available from: http://www.roaic.eg.net/text.asp?2018/5/1/52/223831

  Introduction Top

The morbidly obese patient is especially susceptible for critical respiratory events, including airway obstruction, hypoventilation, hypercapnia, hypoxia and acute respiratory failure in the postoperative period [1].

Postoperative respiratory complications (PORC) is also associated with an increased risk of pulmonary complications such as lung inflammation caused by ineffective swallowing and coughing and inaccurate protective reflexes from the larynx and pharynx resulting in the aspiration of secretions [2].

Increase in intraocular pressure (IOP) is a serious problem during intraocular surgery. Management of anesthesia requires the control of IOP in the perioperative period since the IOP rises during open globe conditions like traumatic injury or cataract surgery may cause permanent loss of vision [3].

IOP may increase due to airway manipulations, rise in blood pressure (BP), and ocular blood flow during general anesthesia process. It is highlighted that these changes in IOP can be faced during the recovery period of anesthesia and tracheal extubation as well as during the course of tracheal intubation [4].

Sugammadex is a 9-cyclodextrin agent that selectively binds steroidal neuromuscular blockers such as rocuronium. By making complexes with rocuronium in circulation and at neuromuscular junction, it enables the excretion of drug in the urine output without metabolism. Sugammadex gives rise to safe and rapid reversal of deep neuromuscular blockade induced by rocuronium [5].

Lower end-extubation IOP levels were obtained when sugammadex was used as a neuromuscular block reversal agent in comparison with neostigmine–atropine combination [6].

Objectives of this work are the use of sugammadex for fast, complete recovery of neuromuscular function in morbidly obese patients and comparison between sugammadex and neostigmine in those patients on IOP, hemodynamics, and postoperative complications during opthalmic operations.

  Patients and methods Top

A prospective randomized double-blind study was done after ethics committee approval and written informed consent. The study included 60 morbidly obese patients with BMI more than or equal to 35 kg/m2, American Society of Anesthesiologists I–II, aged 35–55 years, male or female patients, height ranged between 155 and 175 cm and who were undergoing elective ophthalmic surgery under general anesthesia.

The exclusion criteria were lack of consent, coexisting muscular disease, severe cardiovascular disease (New York Heart Association >2), history of allergic reaction to neuromuscular blocking agents, and history of difficult intubation.

The included patients were randomly assigned into two equal groups. Randomization was done using computer random numbers. Allocation was done by opening a sealed opaque envelope immediately before surgery by the anesthetist not involved in further data handling:
  1. Group I (n=30): sugammadex group.
  2. Group II (n=30): neostigmine group.

General anesthesia was induced in both groups using propofol and fentanyl in doses according to total body weight; sevoflurane [ideal body weight (IBW)] was used for maintenance of anesthesia.

The patients’ lungs were ventilated with a mixture of oxygen and air, and ventilation parameters were adjusted to maintain normocarpia. Muscle relaxation was done by using rocuronium (Esmeron; Esmeron® N.V. Organon, Oss, The Netherlands) 0.6 mg/kg single intubating dose on IBW. During surgery, 0.1–0.15 mg/kg (CBW) of rocuronium was administered when the TOF count exceeded 1.

Monitoring was done by using ECG, noninvasive BP, pulse oximetry, monitoring of neuromuscular junction by peripheral nerve stimulator in both groups.

At the end of the surgery and at reappearance of T2 in adductor pollicis, in group I (Sug), sugammadex of 2 mg/kg of total body weight was given. In group II (Neo), neostigmine of 0.05 mg/kg (IBW) together with atropine 0.02 mg/kg were given. Ventilatory support was maintained until recovery of neuromuscular function to train-of-four ratio (TOFR) more than or equal to 0.9 and when the anesthesiologist judged the patient as ready for tracheal extubation. After tracheal extubation, patients were placed in 60° upright position and transferred to the postanesthesia care unit for continued monitoring.

The primary outcome was the time in minutes from administration of sugammadex or neostigmine at reappearance of T2 after rocuronium till recovery of T4/T1 ratio to 0.9.

The secondary outcomes were the following:
  1. IOP measured preoperatively (baseline) and at 1, 2, 5, 10, and 20 min after extubation.
  2. Heart rate (HR) and main arterial BP recorded preoperatively (baseline) and at 1, 2, 5, 10, and 20 min after extubation.
  3. Any complications such as laryngospasm, bronchospasm, hypoxia, need for postoperative ventilatory support, bradycardia, nausea, and vomiting that were managed in both groups.
  4. Criteria of recovery from neuromuscular blocker recorded in both groups as the ability to swallow after extubation, the ability to sustain head lift for 5 s, the ability to get into bed independently, and postanesthesia care unit time.

Statistical analysis

Data were tabulated and subjected to computer-assisted statistical analysis using the statistical package for social science version 18.0 (SPSS Inc., Chicago, Illinois, USA). Continuous data was expressed by mean±SD, whereas categorical data was expressed as frequency and percentage. Student’s t-test was used for comparing the mean of continuous data. Categorical data was compared using χ2. A P value of less than 0.05 was considered statistically significant.

The sample size was calculated, using open Epi version 3 (Open Source Epidemiologic Statistics for Public Health, Version 3 available at www.OpenEpi.com), to be at least 24 patients per group at an α error of 0.05, power of 90%, and confidence interval of 95%, to detect a 15% decrease in IOP, depending on the previous study of Igboko et al. [7] that reported IOP values after endotracheal tube extubation (17.1±3.3 mmHg). We assumed ∼25% dropout rate and so 30 patients in each group were included in this study.

  Results Top

No significant differences were detected between two groups when demographic data and surgery time were compared ([Table 1]).
Table 1 Patient’s criteria

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IOP was significantly elevated in both groups after extubation (P<0.0001) as compared with baseline. In sugammadex (S group), the IOP was significantly lower (P<0.0001) at 1, 2, and 5 min after extubation as compared with Neostigmine–atropine (N group). After 10 min and 20 min after extubation in both groups, IOP was nearly returned to baseline ([Table 2]).
Table 2 Changes in intraocular pressure

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As regards criteria of recovery from muscle relaxant, there was significant shortening in all times (P<0.0001) in the sugammadex group as compared with neostigmine–atropine group ([Table 3]).
Table 3 Criteria of patient’s recovery from neuromuscular blockers

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HR and main BP were compared in both groups. Regarding HR, there was significant elevation in the neostigmine–atropine group (P<0.0001) at 1 and 2 min after extubation as compared with the sugammadex group. At 5, 10, and 20 min, the HR has showed nonsignificant changes in both groups ([Table 4]).
Table 4 Hemodynamics

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Main BP was significantly elevated in the neostigmine–atropine group at 1 min (P<0.0001), 2 min (P=0.0068), and 5 min (P<0.0088) after extubation than the sugammadex group. At 10 and 20 min, MBP showed nonsignificant changes in both groups ([Table 4]).

When complications were assessed, it was found that nausea showed significant elevation in the neostigmine–atropine group (P=0.024) compared with the sugammadex group. Other complications showed a nonsignificant difference in both groups ([Table 5]).
Table 5 Complications

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  Discussion Top

This study was done on morbidly obese patients undergoing ophthalmic surgery. The prevalence of obesity is increasing worldwide. The prevalence of obesity varies with the socioeconomic status. In developing countries, poverty is associated with greater prevalence of obesity whereas in developed areas, it is affluence that carries the higher risk [8].

Sugammadex was used in this study as a reversal agent of rocuronium rather than neostigmine–atropine. It is a cyclodextrin permanently binding with rocuronium and vecuronium hereby blocking the neuromuscular polarization. It is action different from the commonly used acetylcholine–esterase blocking agents such as neostigmine which are not binding directly on the neuromuscular blocking agent molecule. Sugammadex is able to remove the relaxant molecule from the synaptic gap, so it can be administered at every stage of neuromuscular block, including deep block [9].

In consistent with a study done by Madan et al. [10], IOP in our study was significantly elevated when compared with baseline in both groups after extubation but IOP showed significant lower values with sugammadex rather than with neostigmine–atropine.

Hakimoglu et al. [11] have shown that sugammadex used in the reversal of nondepolarizing neuromuscular blockade did not affect IOP such as neostigmine–atropine.

Together with our study, Yagan et al. [6] have demonstrated that neostigmine–atropine combination leads to significantly higher levels of IOP in the measurements after administration of the reversal agent and after the extubation when compared with sugammadex for the antagonism of neuromuscular blockade with rocuronium.

In our study, there was significant shortening in all times related to recovery from muscular relaxant in those patients reversed by sugammadex as compared with those patients given neostigmine–atropine, we observed that the time to 0.9 TOF was shorter in the sugammadex group and this leads to rapid recovery in those morbidly obese patients.

Together with our study, Flackton et al. [12] reported that sugammadex reverses rocuronium-induced neuromuscular block significantly faster than neostigmine reverses a block of similar depth induced by cisatracurium. The time to recovery of the TOFR to 0.9 was almost five times faster with sugammadex than with neostigmine.

Blobner et al. [13] in their study compared 2 mg/kg sugammadex with 50 µg/kg neostigmine which were the same doses used in our study and found that recovery of the TOF T4/T1 ratio to 0.9 was achieved more rapidly with sugammadex than neostigmine which is consistent with our results.

Flackton et al. [12] reported that the combination of rocuronium and sugammadex provide clinicians with a rapid onset, rapid reversal combination which is potentially advantageous in a busy operating list.

As regards the effect on HR, there was significant elevation in HR with neostigmine at 1 and 2 min after extubation. Then, HR showed a nonsignificant difference in both groups. A similar greater change in HR was observed for neostigmine–glycopyrrolate compared with sugammadex in the study by Sacan et al. [14].

Mirakhur et al. [15] reported that considerable fluctuations in HR are often observed with neostigmine, particularly when atropine is the anticholinergic agent used.

Sparr et al. [16] showed that lack of a need to use a muscarinic antagonist with sugammadex should also result in fewer side effects.

In the study of Sorgenfrei et al. [5], both sugammadex and neostigmine were safe and well tolerated.

Mean arterial pressure (MAP) in our study showed the same significance as the HR; there was significant elevation with neostigmine–atropine at 1, 2, and 5 min than with sugammadex. Then, both groups showed the same significance in MAP after that. In the study by Jones et al. [17], it was reported that the HR and MAP were higher at 2, 5, and 10 min after neostigmine administration but not after sugammadex administration when compared with baseline values.

In our study, there was no significant difference in complications between two groups but postoperative nausea was more common in the neostigmine–atropine group.

Hakimoglu et al. [11] found that the incidence of postoperative nausea and vomiting was higher in patients who received neostigmine.

In consistence with previous studies, other complications such bradycardia, bronchial spasm, and laryngeal spasm have occurred but with no significant difference between two groups. Besides, hypoxia has occurred but it was transient and did not need postoperative reintubation [18].

  Conclusion Top

Sugammadex provided more rapid reversal of neuromuscular functions in morbidly obese patients, lower values of IOP postextubation than neostigmine–atropine, together with more hemodynamic stability and no significant difference in complications between the groups but nausea was higher in the neostigmine–atropine group.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Gaszynski T, Jakubiak J, Szlachcinski L, Gaszynski W. Administration of neostigmine does not prevent from postoperative residual curarization in morbidly obese patients. Eur J Anaesthesiol 2008; 25(Suppl 44):137.  Back to cited text no. 1
Sundman E, Witt H, Olsson R, Ekberg O, Kuylenstierna R, Eriksson L. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videodiography and simultaneous manometry after atracurium. Anesthesiology 2000; 92:977–984.  Back to cited text no. 2
Akhavanakbari G, Entezariasl M, Ojagi H, Isazadehfar K. Comparison of the effects of remifentanil and alfentanil on intraocular pressure in cataract surgery. Saudi J Anaesth 2013; 7:160–164.  Back to cited text no. 3
[PUBMED]  [Full text]  
Lamb K, James MFM, Janicki PK. The laryngeal mask airway for intraocular surgery: effects on intraocular pressure and stress response. Br J Anaesthesia 1992; 69:143–147.  Back to cited text no. 4
Sorgenfrei IF, Morrild K, Larsen PB, Stensballe J, Ostergaard D, Prins ME et al. Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study. Anesthesiology 2006; 104:667–674.  Back to cited text no. 5
Yagan O, Karakahya RH, Tas N, Cunakci E, Hanci V, Yurtlu BS. Intraocular pressure changes associated with tracheal extubation: comparison of sugammadex with conventional reversal of neuromuscular blockade. J Pak Med Assoc 2015; 65:1219–1225.  Back to cited text no. 6
Igboko JO, Desalu I, Akinsola FB, Kushimo OT. Intraocular pressure changes in Nigerian population-effects of tracheal tube and laryngeal mask airway insertion and removal. Niger Postgrad Med J 2009; 16:99–104.  Back to cited text no. 7
Sobal J, Stunkard A. Socioeconomic status of obesity: a review of the literature. Psychol Bull 1989; 105:260–275.  Back to cited text no. 8
Jones PM, Turkstra TP. Urgent usage of sugammadex to treat residual neuromuscular blockade in the PACU. Anesth Analg 2007; 105:877.  Back to cited text no. 9
Madan R, Tamilselvan P, Shende D, Gupta VJ. Intraocular pressure and haemodynamic changes after tracheal intubation and extubation: a comparative study in glaucomatous and non-glaucomatous children. Anaesthesia 2000; 55:367–390.  Back to cited text no. 10
Hakimoglu S, Tuzcu K, Davarci I, Karcioglu M, Ayhan Tuzcu E, Hancı V et al. Comparison of sugammadex and neostigmine-atropine on intraocular pressure and postoperative effects. Kaohsiung J Med Sci 2016; 32:80–85.  Back to cited text no. 11
Flackton EA, Mastronardi P, Hunter JM, Gomar C, Mirakhur RK, Aguilera L et al. Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine. Br J Anaesth 2008; 100:622–630.  Back to cited text no. 12
Blobner M, Eriksson L, Scholz J, Hillebrand H, Pompei L et al. Sugammadex (2 mg/kg) significantly faster reverses shallow rocurinium-induced neuromuscular blockade compared with neostgimine (50 μg/kg). Eur J Anaesth 2007; 24:125.  Back to cited text no. 13
Sacan O, White PF, Tufanogullar B, Klein K et al. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg 2007; 104:569–574.  Back to cited text no. 14
Mirakhur RK, Durdee JW, Jones CJ, Coppel DL, Clarke RS et al. Reversal of neuromuscular blockade: dose determination studies with atropine and glycopyrrolate given before or in a mixture with neostigmine. Anesth Analg 1981; 60:557–562.  Back to cited text no. 15
Sparr H, Vermenyen KM, Beaufort AM, Rietbergen H, Proost JH, Saldien V et al. Early reversal of profound rocuronium-induced neuromuscular blockade by sugammadex in a randomized multicenter study. Anesthesiology 2007; 106:935–943.  Back to cited text no. 16
Jones RK, Caldwell JE, Brull SJ, Soto RG. Reversal of profound rocuronium-induced blockade with sugammadex: a randomized comparison with neostigmine. Anesthesiology 2008; 109:816–824.  Back to cited text no. 17
Eikermann M, Vogt FM, Herbstein F, Vahid-Dastgerdi M, Zenge MO et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med 2007; 179:9–15.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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