- Design
- pragmatic, international, multicentre, randomised, phase 4 trial with masked outcome assessment and adjudication at 44 hospitals (SNaPP)
- Population
- 3,498 adults aged 40 or over having abdominal or thoracic surgery under general anaesthesia lasting at least 2 hours
- Primary outcome
- postoperative pulmonary complications or death to hospital discharge or postoperative day 7
- Effect
- 19.0% with sugammadex vs 21.5% with neostigmine (RR 0.88; 95% CI 0.77-1.00; p = 0.049); atelectasis 18.4% vs 21.1% (0.86; 0.76-0.99); pneumonia 2.1% vs 2.2%
SNaPP randomised 3,498 adults aged 40 or over having abdominal or thoracic surgery lasting at least two hours, across 44 hospitals in Australia, New Zealand and Hong Kong, to sugammadex or neostigmine for reversal of rocuronium- or vecuronium-induced neuromuscular blockade. Postoperative pulmonary complications or death to discharge occurred in 19.0% with sugammadex and 21.5% with neostigmine.
The investigators are commendably plain about what they found. The risk reduction was small, and almost all of it came from atelectasis — 18.4% against 21.1% — whose clinical significance they describe as uncertain. Pneumonia was identical at about 2%, aspiration was rare in both arms, and deaths numbered one and two.
What makes this worth an edition is scale rather than effect size. Reversal of neuromuscular blockade happens at the end of most general anaesthetics involving an aminosteroid agent, so a 2.5 percentage point absolute difference applied across a hospital's operating lists is a meaningful number of respiratory events, even if no individual patient is transformed.
Cost is the counterweight and it is substantial. Sugammadex is far more expensive than neostigmine, and in a system paying out of pocket the trade — a small reduction in mostly radiological atelectasis against a large per-case cost difference — will land differently than it does in the trial's settings. The trial supports sugammadex as a first-line option; it does not settle whether it should be the default everywhere.
- Consider sugammadex first line for reversal after abdominal or thoracic surgery in patients over 40 lasting two hours or more
- Weigh the cost difference explicitly where the patient or hospital bears it; the benefit is small
- Do not expect a reduction in pneumonia or aspiration; the difference was in atelectasis
- Keep the other reasons for choosing sugammadex in view — deep blockade reversal and rapid recovery — which this trial did not test
- Audit your own postoperative pulmonary complication rate before assuming the 2.5-point difference transfers
The statistics, in plain English
The risk ratio of 0.88 has a 95% confidence interval of 0.77 to 1.00 and p = 0.049 — the upper bound touches 1.0 and the p-value sits just inside the conventional threshold. That is a result at the edge of significance, and it should be read as such rather than as a firm demonstration. The composite outcome is driven by atelectasis, which was the only component to reach significance on its own (0.86; 0.76-0.99); pneumonia, aspiration and death showed nothing. When a composite's effect rests entirely on its softest component, the headline overstates what was achieved.
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