Reversing neuromuscular blockade with
sugammadex can eliminate residual
paralysis, which has been associated with postoperative respiratory complications. There are equivocal data on whether
sugammadex reduces these when compared with
neostigmine. We investigated the association of the choice of reversal
drug with postoperative respiratory complications and advanced healthcare utilisation. We included adult patients who underwent surgery and received general anaesthesia with
sugammadex or
neostigmine reversal at two academic healthcare networks between January 2016 and June 2021. The primary outcome was postoperative respiratory complications, defined as post-extubation oxygen saturation < 90%,
respiratory failure requiring
non-invasive ventilation, or tracheal re-intubation within 7 days. Our main secondary outcome was advanced healthcare utilisation, a composite outcome including: 7-day unplanned intensive care unit admission; 30-day
hospital readmission; or non-home discharge. In total, 5746 (6.9%) of 83,250 included patients experienced postoperative respiratory complications. This was not associated with the reversal
drug (adjusted OR (95%CI) 1.01 (0.94-1.08); p = 0.76). After excluding patients admitted from skilled nursing facilities, 8372 (10.5%) patients required advanced healthcare utilisation, which was not associated with the choice of reversal (adjusted OR (95%CI) 0.95 (0.89-1.01); p = 0.11). Equivalence testing supported an equivalent effect size of
sugammadex and
neostigmine on both outcomes, and
neostigmine was non-inferior to
sugammadex with regard to postoperative respiratory complications or advanced healthcare utilisation. Finally, there was no association between the reversal
drug and major adverse cardiovascular events (adjusted OR 1.07 (0.94-1.21); p = 0.32). Compared with
neostigmine, reversal of neuromuscular blockade with
sugammadex was not associated with a reduction in postoperative respiratory complications or post-procedural advanced healthcare utilisation.