Rössler Julian, Abramczyk Emily, Paredes Stephania, Anusic Nikola, Pu Xuan, Maheshwari Kamal, Turan Alparslan, Ruetzler Kurt
From the Departments of Outcomes Research.
General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio.
Anesth Analg. 2025 Jan 1;140(1):110-118. doi: 10.1213/ANE.0000000000006939. Epub 2024 Dec 16.
Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine.
We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery.
Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium ( P = .637) or postoperative early delirium ( P = .904).
Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.
联用胆碱酯酶抑制剂与抗胆碱能药物来逆转神经肌肉阻滞，可能会因中枢胆碱能传递受损而引发谵妄，而使用舒更葡糖可避免这种情况。因此，我们检验了以下主要假设：与新斯的明联合格隆溴铵或阿托品相比，使用舒更葡糖逆转神经肌肉阻滞时，术后谵妄的发生率更低。
我们开展了一项单中心回顾性队列研究，分析了2016年1月至2022年3月期间接受新斯的明或舒更葡糖进行非心脏手术全身麻醉的所有成年患者。采用逆倾向评分加权和倾向评分校准来调整合适的混杂因素。我们的主要结局是术后前4天内出现谵妄，定义为至少1次简易精神状态检查表（bCAM）筛查呈阳性。次要结局是术后24小时内出现早期谵妄。
在我们分析的49468例病例中，6881例接受了舒更葡糖，42587例接受了新斯的明。经过倾向加权后，舒更葡糖组谵妄发生率为1.09%，新斯的明组为0.82%。舒更葡糖组和新斯的明组术后谵妄的几率没有差异，估计优势比（95%置信区间）为1.33（0.91 - 1.95），P = 0.147。一项敏感性分析仅限于纳入术后第1至4天至少有6次bCAM测量的病例，结果一致，因为与新斯的明相比，舒更葡糖与术后谵妄的估计优势比为1.20（0.82 - 1.77），P = 0.346。舒更葡糖与术后早期谵妄发生率增加显著相关，估计优势比为1.71（1.07 - 2.72），P = 0.025。进一步分析显示，术后谵妄（P = 0.637）或术后早期谵妄（P = 0.904）均不存在治疗与年龄的交互作用。
在这项回顾性单中心研究中，与新斯的明相比，使用舒更葡糖逆转神经肌肉阻滞与术后谵妄风险增加无关。虽然舒更葡糖与术后早期谵妄风险在统计学上显著增加相关，但差异很小且无临床相关性，可能反映了存在未知的混杂因素。
