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Choice of agent to reverse postoperative neuromuscular blockade (June 2021)

The most common cause of upper airway obstruction in the post-anesthesia care unit is the residual effect of longer-acting neuromuscular blocking agents. The administration of a reversal agent diminishes this effect, but the optimal agent has not been established. In a recent study that included >10,000 patients, institutional change of the reversal agent from neostigmine to sugammadex did not affect the incidence of unplanned reintubation, prolonged mechanical ventilation, or pneumonia [1]. However, in a previous larger study (>45,000 patients), sugammadex recipients had a lower incidence of pneumonia and respiratory failure compared with neostigmine recipients. Given these and other data, it remains unclear whether the choice of reversal agent affects risk for postoperative pulmonary complications.

Effects of weight-based dexamethasone administration on complications after major noncardiac surgery (June 2021)

Protocols for enhanced recovery after surgery typically include administering a prophylactic anti-emetic regimen of intravenous (IV) dexamethasone 8 to 10 mg after induction of anesthesia and ondansetron 4 mg at the end of the surgical procedure. Evidence is lacking regarding a beneficial effect of dexamethasone on other outcomes. In a randomized trial of patients undergoing major noncardiac surgery, postoperative administration of dexamethasone 0.2 mg/kg IV did not reduce a composite of serious complications (eg, organ failure) compared with placebo, but increased the risk for hyperglycemia requiring insulin therapy [2]. These data suggest that using higher doses of dexamethasone would not reduce postoperative organ failure of inflammatory origin and could have adverse side effects.

1
Li
G
,
Freundlich
RE
,
Gupta
RK
, et al
.
Postoperative Pulmonary Complications' Association with Sugammadex versus Neostigmine: A Retrospective Registry Analysis
.
Anesthesiology
2021
;
134
:
862
.
2
Asehnoune
K
,
Le Moal
C
,
Lebuffe
G
, et al
.
Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial
.
BMJ
2021
;
373
:
n1162
.

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