Sugammadex or neostigmine for reversal of neuromuscular block on the quality of postoperative recovery in older adults undergoing video-assisted thoracoscopic lobectomy: a randomised controlled trial

Background Pulmonary nodules, especially prevalent in older adults, are increasingly diagnosed due to improved imaging technologies. Video-assisted thoracoscopic surgery (VATS) is the preferred treatment due to its minimal invasiveness and quicker recovery compared to open thoracotomy. However, the prolonged use of muscle relaxants during VATS can result in postoperative residual neuromuscular block (PRNB), particularly in older adults, leading to pulmonary complications. While neostigmine has been traditionally used for neuromuscular block reversal, sugammadex offers a faster, more complete reversal with fewer side effects. This study compares the efficacy of sugammadex versus neostigmine in enhancing postoperative recovery. Methods This prospective, randomized, double-blind trial included 80 patients aged ≥ 65 undergoing video-assisted thoracoscopic lobectomy. Patients were randomly assigned to receive either sugammadex (2 mg/kg) or neostigmine (0.04 mg/kg) with atropine for neuromuscular block reversal. The primary outcome was the quality of recovery at postoperative day 1, assessed by the QoR-15 questionnaire. Secondary outcomes included extubation time, PACU stay, incidence of hypoxaemia, PRNB, and postoperative pulmonary complications (PPCs). Statistical analysis was performed using t-tests, chi-square tests, and Mann-Whitney U tests. Results Eighty patients were randomized (39 sugammadex, 38 neostigmine). Sugammadex significantly reduced extubation time (18 vs. 27.5 minutes, P  = 0.001) and PACU stay (52 vs. 62 minutes, P  = 0.001). Hypoxaemia (28% vs. 53%, P  = 0.029) and PRNB (5% vs. 24%, P  = 0.020) were less frequent in the sugammadex group. The QoR-15 scores were significantly higher in the sugammadex group at day 1 (125 vs. 122, P  < 0.001). Although the sugammadex group had fewer PPCs, the difference was not statistically significant (26% vs. 45%, P  = 0.079). Conclusions Sugammadex demonstrated superior efficacy in reducing extubation and PACU times, minimizing hypoxaemia and PRNB, and improving early postoperative recovery in older adults undergoing video-assisted thoracoscopic lobectomy compared to neostigmine. These findings suggest that sugammadex may offer enhanced recovery benefits, particularly for elderly patients. Trial registration: Retrospectively registered, Chinese Clinical Trial Registry, ChiCTR2400089863(Date:18/09/2024).