Sugammadex, neostigmine and postoperative pulmonary complications: an international randomised feasibility and pilot trial

Background Sugammadex reduces residual neuromuscular blockade after anaesthesia, potentially preventing postoperative pulmonary complications. However, definitive evidence is lacking. We therefore conducted a feasibility and pilot trial for a large randomised controlled trial of sugammadex, neostigmine, and postoperative pulmonary complications. Methods Patients aged ≥40 years having elective or expedited abdominal or intrathoracic surgery were recruited in Australia and Hong Kong. Perioperative care was at the discretion of clinicians, except for the use of rocuronium and/or vecuronium for neuromuscular blockade and the randomised intervention (sugammadex or neostigmine) for reversal. Feasibility measurements included recruitment, crossover, acceptability, completeness, and workload. Trial coordinator feedback was systematically sought. Patient-reported quality of life was measured using the EQ-5D-5L score. The primary pilot outcome was the incidence of new pulmonary complications up to hospital discharge (or postoperative day 7 if still in hospital). Results Among 150 eligible patients, 120 consented to participate (recruitment rate 80%, 95% confidence interval [CI] 73 to 86%). The randomised intervention was administered without crossover to 115 of 117 patients who received reversal (98%, 95% CI 94 to 100%). The protocol was acceptable or highly acceptable to the anaesthetist in 108 of 116 cases (93%, 95% CI 87 to 97%; missing = 4). Four patients of the 120 patients were lost to follow-up at 3 months (3.3%, 95% CI 0.9 to 8.3%). Case report forms were complete at 3 months for all remaining patients. The median time to complete trial processes was 3.5 h (range 2.5–4.5 h). Trial coordinators reported no barriers to trial processes. Patients were aged 64 (standard deviation 11) years, 70 (58%) were male and 50 (42%) were female, and planned surgeries were thoracic (23 [19%]), upper abdominal (41 [34%]), and lower abdominal (56 [47%]). The primary outcome was observed in 5 (8.5%) of the 59 sugammadex patients and 5 (8.2%) of the 61 neostigmine patients (odds ratio 1.02, 95% CI 0.28 to 3.67). Conclusions A large international randomised controlled trial of sugammadex, neostigmine and postoperative pulmonary complications in adult patients having abdominal and intrathoracic surgery, including collection of cost-effectiveness evidence for Health Technology Appraisal, is feasible. Trial registration Prospectively registered at the Australian and New Zealand Clinical Trials Registry (ACTRN12620001313921) on December 7, 2020. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380645&isReview=true.

Staphylococcal Pericarditis Causing Pericardial Tamponade and Concurrent Empyema

Bacterial pericarditis is a rare presentation and is usually due to secondary infection from a hematogenous cause or can occur secondary to trauma, intrathoracic surgery, or due to spread of infection from a contiguous focus via ligaments that anchor the pericardium to its surrounding structures. Its course is fulminant characterized by a high mortality rate from sepsis, tamponade, and constriction. We describe a rare case of Staphylococcus aureus pericarditis with concurrent unilateral empyema. The patient rapidly developed tamponade and was successfully treated with antibiotics and urgent percutaneous pericardial drainage with placement of a temporary catheter. Treatment for bacterial pericarditis typically is 4–6 weeks long. Thoracic surgery should be consulted as soon as possible to determine need for surgical intervention, as fibrin deposition may occur, making percutaneous drainage incomplete and leading to complications of persistent purulent pericarditis or constrictive pericarditis.

Chylothorax Complicating Closure of the Ductus Arteriosus: The Second Case

Chylothorax is a possible complication of intrathoracic surgery. The diagnosis of postoperative chylothorax is easy; however, the treatment can cause problems of management because of the lack of consensus. In children, the most common causes of postoperative chylothorax are the cures for congenital heart diseases. We report the case of a two-year-old child, presenting with a chylothorax following surgery of the ductus arteriosus. Our case illustrates the treatment that must first include medical measures without delaying the surgery. The risk is the installation of nutritional and immune deficiency.

Type I Thyroplasty for Acute Unilateral Vocal Fold Paralysis following Intrathoracic Surgery

Patients who undergo intrathoracic operative procedures for malignancy may require sacrifice of a recurrent laryngeal nerve. Postoperative vocal fold paralysis may lead to diminished cough with secretion retention, aspiration, and life-endangering pneumonia. This study retrospectively reviews our institution's experience of 23 patients who underwent type I thyroplasty within the 2-week (acute) period after thoracic surgery. Primary lung cancer (n = 16) was the most common disease. Upper lobectomy (n = 9) and pneumonectomy (n = 7) were the most frequent surgical procedures. Silicone medialization alone (n = 11) or with arytenoid adduction (n = 12) was performed. There were no significant postoperative complications. Improvements in hoarseness (86%), dyspnea (72%), dysphagia (50%), and aspiration (79%) were noted. Pulmonary status improved after vocal fold medialization, as reflected by decreased need for therapeutic bronchoscopy in the majority of patients in the postoperative period. Type I thyroplasty for vocal fold paralysis in the acute phase following thoracic surgery is well tolerated and is associated with improved patient outcome with no postoperative deaths in this high-risk patient population.