DOI: 10.1213/ane.0000000000008202 ISSN: 0003-2999

The Impact of Quantitative Neuromuscular Monitoring and Sugammadex Reversal on Postoperative Hypoxemia in Obese Patients

Neal W. Fleming, Bryle Nicole G. Barrameda, David Li, Kenneth T. Furukawa
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BACKGROUND:

Residual neuromuscular blockade is a potential contributor to postoperative pulmonary complications, particularly in obese patients undergoing abdominal surgery. Continued reliance on qualitative neuromuscular monitoring and underutilization of sugammadex highlight a critical gap between evidence and practice. The low incidence of severe complications necessitates large studies to assess the impact of practice changes on clinical outcomes. The incidence and magnitude of postoperative hypoxemia may serve as a marker for other, more severe adverse outcomes. This before/after study evaluated the impact of a structured protocol incorporating quantitative train-of-four monitoring and weight-based sugammadex dosing on postoperative hypoxemia as documented by a continuous monitoring system.

METHODS:

This single-center, prospective before/after study enrolled obese adults (body mass index [BMI] ≥30 kg/m 2 ) undergoing elective intra-abdominal surgery. The intervention was a protocol incorporating quantitative neuromuscular monitoring and standardized sugammadex administration. The primary outcome was postoperative hypoxemic burden, calculated as the area under the curve for peripheral oxygen saturation (SpO 2 ) ≤90% during the first 24 hours after surgery, measured with a wearable continuous pulse oximetry device. Secondary outcomes included intraoperative rocuronium and sugammadex dosing, postanesthesia care unit (PACU) length of stay, postoperative supplemental oxygen use, and feasibility of continuous physiological monitoring. Group analyses were performed using nonparametric statistical tests, with significance set at P < .05.

RESULTS:

A total of 135 patients met the inclusion criteria for final analysis (before: 68; after: 67). Median [interquartile range (IQR)] hypoxemic burden decreased from 123 [58–221] to 74 [27–145] Sp

o
2 %·min after protocol implementation ( P = .004). Rocuronium use increased (0.31 [0.24–0.37] to 0.34 [0.27–0.41] mg·kg −1 ·h − 1 , P = .034), while sugammadex dosing doubled (2.3 [2.1–3.7] to 4.0 [4.0–4.1] mg/kg, P < .0001). PACU length of stay and postoperative supplemental oxygen use were similar. Continuous pulse oximetry identified substantially more hypoxemia than was documented in the electronic medical record, but routine use of continuous monitoring requires improvements in both infrastructure and measurement systems.

CONCLUSIONS:

Implementation of quantitative neuromuscular monitoring with guideline-based sugammadex dosing reduced postoperative hypoxemic burden in obese patients undergoing abdominal surgery. Continuous postoperative pulse oximetry revealed hypoxemia that was frequently missed in routine clinical documentation, underscoring the value of both quantitative neuromuscular management and continuous postoperative monitoring in high-risk patients.

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