Association of sugammadex, neostigmine, or pyridostigmine for reversal of neuromuscular block with postoperative bradycardia: a multicentre, retrospective observational study.

Background: The aim of this study was to evaluate the risk of bradycardia after sugammadex administration for reversal of neuromuscular block compared with neostigmine and pyridostigmine.

Methods: This multicentre retrospective observational study included adult patients who underwent surgery under general anaesthesia between 2011 and 2021 in three university hospitals in Korea. The risk of bradycardia, defined as relative (≥10%, ≥20%, ≥30%, or ≥40%) or absolute (≥5, ≥10, ≥15, or ≥20 beats min^-1) decreases in heart rate (HR) from baseline within 30 min after the administration of sugammadex, neostigmine, or pyridostigmine was compared using logistic regression with stabilised inverse probability of treatment weighting.

Results: A total of 359 414 patients were analysed; sugammadex, neostigmine, and pyridostigmine were administered in 107 018, 97 754, and 154 642 patients, respectively. The overall incidence of bradycardia in the sugammadex group was similar to that of the neostigmine group. Specifically, the risk of a ≥20% decrease in HR was not significantly different between the sugammadex and neostigmine groups (9.8% vs 10.2%; odds ratio [95% confidence interval]: 1.00 [0.97-1.03]), though it was significantly higher in the sugammadex group than in the pyridostigmine group (9.8% vs 5.8%; 1.93 [1.87-1.98]). Restricted cubic spline curves suggested a linear increase in the risk of a ≥20% decrease in HR as the dose of sugammadex increased.

Conclusions: The incidence of bradycardia after sugammadex administration was low, and its adjusted risk was not significantly different from that of neostigmine, the most commonly used acetylcholinesterase inhibitor for reversal of neuromuscular block.