SNaPP: sugammadex modestly reduced pulmonary complications after major surgery

Design

Pragmatic, multicentre, randomised, controlled phase 4 trial (SNaPP)

Population

3,498 adults ≥40 having abdominal or thoracic surgery ≥2 h

Primary outcome

Postoperative pulmonary complications or death to discharge or day 7

Effect

19.0% v 21.5%, RR 0.88 (0.77–1.00); atelectasis RR 0.86 (0.76–0.99)

SNaPP, published in The Lancet Respiratory Medicine on 9 June, was a pragmatic trial in 44 hospitals in Australia, New Zealand and Hong Kong. It randomised 3,498 adults aged 40 or over having abdominal or thoracic surgery of at least two hours to sugammadex or neostigmine to reverse rocuronium or vecuronium.

Postoperative pulmonary complications or death occurred in 19.0% with sugammadex and 21.5% with neostigmine (RR 0.88, 95% CI 0.77 to 1.00; p = 0.049). The difference came mainly from atelectasis (18.4% v 21.1%); pneumonia (2.1% v 2.2%), aspiration and death did not differ. No treatment-related adverse events were reported.

For pulmonologists asked to optimise patients before major surgery, this is a relevant, if modest, lever — about one fewer complication per 40 patients, mostly atelectasis of uncertain importance. The authors suggest sugammadex can be considered first line for aminosteroid reversal. In India the cost difference is substantial, so its use may be best targeted at patients with the highest pulmonary risk, such as those with COPD, obesity or planned upper abdominal and thoracic surgery.

• Sugammadex reduced a composite of pulmonary complications or death compared with neostigmine after major surgery.
• The benefit was mostly less atelectasis; pneumonia and mortality did not differ.
• Where cost limits use, consider prioritising sugammadex for patients at highest pulmonary risk.
• Discuss reversal choice with anaesthesia when optimising high-risk patients before surgery.

Why it matters

It gives randomised evidence that the choice of reversal agent can influence postoperative lung outcomes, if modestly.

Don't overread it

The benefit was driven by atelectasis; pneumonia and mortality were not reduced.

The statistics, in plain English

A risk ratio of 0.88 with an interval reaching 1.00 means the result only just reached significance. The absolute difference was 2.5 percentage points — about 40 patients treated to prevent one complication, mostly atelectasis.

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