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Effect of Sugammadex on Postoperative Myasthenic Crisis in Myasthenia Gravis Patients

Propensity Score Analysis of a Japanese Nationwide Database

Mouri, Hideyuki MD*; Jo, Taisuke MD, PhD; Matsui, Hiroki MPH*; Fushimi, Kiyohide MD, PhD; Yasunaga, Hideo MD, PhD*

doi: 10.1213/ANE.0000000000004239
Anesthetic Clinical Pharmacology: PDF Only

BACKGROUND: In myasthenia gravis (MG) patients, postoperative myasthenic crisis, and residual neuromuscular blocking agent (NMBA) can cause respiratory failure that requires mechanical ventilation. However, it remains unclear whether the use of sugammadex for NMBA reversal reduces postoperative myasthenic crisis in MG patients undergoing surgery. We analyzed the association between use of sugammadex and postoperative myasthenic crisis in patients with MG using a national inpatient database.

METHODS: Adult patients with MG who received thymectomy under general anesthesia were identified in the Japanese Diagnosis Procedure Combination database from July 1, 2010 to March 31, 2016. Patients who received sugammadex (sugammadex group) were compared with those who did not receive sugammadex (control group). The primary outcome was postoperative myasthenic crisis, and the secondary outcomes were postoperative pneumonia, tracheostomy, 28-day mortality, total hospitalization costs, and length of stay after surgery. Propensity scores were estimated by logistic regression based on the following variables: age; sex; body mass index (BMI); smoking index; history of cancer; Charlson comorbidity index (CCI); type of thymectomy; time from hospital admission to surgery; use of plasma exchange, immunosuppressants, corticosteroids, anticholinesterase, and oral benzodiazepine before surgery; type of hospital; and treatment year. The outcomes were compared using stabilized inverse probability of treatment weighting (IPTW) analyses to obtain good between-group balance.

RESULTS: Of 795 patients identified, 506 patients received sugammadex and 289 patients did not. After stabilized IPTW, the sugammadex group was associated with a decrease in postoperative myasthenic crisis (22/507 [4.3%] vs 25/288 [8.7%]; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.25–0.91), but not associated with a decrease in postoperative pneumonia (5/507 [1.0%] vs 7/288 [2.4%]; OR, 0.44; 95% CI, 0.17–1.14) or tracheostomy (7/507 [1.4%] vs 10/288 [3.5%]; OR, 0.38; 95% CI, 0.12–1.22) compared with the control group. The sugammadex group had significantly lower median (interquartile range) total hospitalization costs ($13,186 [$11,250–$16,988] vs $14,119 [$11,713–$20,207]; P < .001) and median length of stay after surgery (10 [8–15] vs 11 [8–18] days; P < .001), compared with the control group.

CONCLUSIONS: In this retrospective observational study, sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs in adult patients with MG who received thymectomy. Given the present findings, sugammadex should be routinely administered for MG patients undergoing thymectomy.

From the *Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan

Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan.

Accepted for publication April 13, 2019.

Funding: This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (H30-Policy-Designated-004 and H29-ICT-General-004) and the Ministry of Education, Culture, Sports, Science and Technology, Japan (17H04141).

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Hideyuki Mouri, MD, Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan. Address e-mail to

© 2019 International Anesthesia Research Society
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