Residual neuromuscular blockade after surgery is a plausible cause of postoperative pulmonary complications, and sugammadex reverses it more completely than neostigmine. SNaPP tested whether that translates into fewer complications.
This pragmatic phase 4 trial at 44 hospitals in Australia, New Zealand and Hong Kong randomised 3,498 adults aged 40 or over undergoing abdominal or thoracic surgery lasting at least two hours, with an expected stay of at least one night, to sugammadex or neostigmine for reversal of rocuronium or vecuronium blockade. Doses were left to the attending anaesthetist. Patients, outcome assessors and the adjudication committee were masked.
The primary outcome of postoperative pulmonary complications or death occurred in 331 of 1,743 (19.0%) with sugammadex and 377 of 1,752 (21.5%) with neostigmine, risk ratio 0.88 (95% CI 0.77 to 1.00, p=0.049).
The components explain what that means. Atelectasis accounted for almost all of it — 18.4% versus 21.1% (risk ratio 0.86). Pneumonia was identical at 2.1% versus 2.2%. Deaths were one and two. So the composite moved because radiological atelectasis moved, and the authors say plainly that its clinical significance is uncertain.
The honest reading is a small, real, statistically marginal benefit driven by the softest component. Sugammadex is reasonable as a first-line reversal agent on this evidence, and in a system where it costs many times more than neostigmine, this trial does not make the case that it must be. Where cost is the constraint — as it is across most of Indian practice — neostigmine with proper quantitative monitoring remains defensible.
- Sugammadex reduced postoperative pulmonary complications from 21.5% to 19.0%, driven almost entirely by atelectasis
- Pneumonia rates were identical at about 2% in both arms, and deaths were one versus two
- The p value of 0.049 is marginal — treat this as a small effect, not a decisive one
- Where cost limits sugammadex use, neostigmine with quantitative neuromuscular monitoring remains reasonable
- The trial enrolled abdominal and thoracic surgery over two hours in patients aged 40 and above; do not extrapolate beyond that
The statistics, in plain English
A risk ratio of 0.88 with an upper confidence bound of exactly 1.00 and a p value of 0.049 is about as marginal as a positive result gets. Had one or two events fallen differently, the trial would have been reported as negative. That does not make it wrong, but it does mean the finding needs replication before it becomes a standard. The more informative analysis is the components: when a composite is positive and the only moving part is the mildest and most frequent one, while the serious components are flat, the clinical value of the composite is much smaller than the headline suggests.
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