Survey of attitudes towards a randomised trial about sugammadex, neostigmine and pulmonary complications

Abstract

A recent retrospective observational study found that reversing neuromuscular blockade with sugammadex was associated with fewer postoperative pulmonary complications than reversing with neostigmine. However, this is only an association, and causation has not been confirmed with a randomised controlled trial. We are proposing a large pragmatic trial across Australia and New Zealand—the SNaPP study—to answer the question: compared to neostigmine, does reversing neuromuscular blockade with sugammadex reduce the incidence of new pulmonary complications? As part of preparing for the SNaPP study, we conducted a survey (following previously published survey research recommendations) of the related practices and attitudes of anaesthetists (e-appendix) affiliated with the Clinical Trials Network of the Australian and New Zealand College of Anaesthetists who would be likely investigators and site leaders for the study. Following ethics committee approval (Melbourne Health Office for Research; QA2020139 approved 18 September 2020), we piloted the survey and then sent 646 emails during September 2020 containing a link to the online survey. We received 167 (28%) responses. With 646 surveys, the 95% confidence interval for the percentage estimates was 7%. The respondents were from all Australian states, New Zealand and a few international sites, with 72% in predominantly metropolitan practice and 28% in predominantly regional or rural practice. Fiftyseven percent of respondents were in both public and private practice, 40% were in public practice alone and 3% were in private practice alone. Eighty-nine percent of respondents agreed or strongly agreed that postoperative pulmonary complications are important, and 62% agreed or strongly agreed that a trial comparing the effects of sugammadex and neostigmine on postoperative pulmonary complication is worthwhile (19% were neutral and 18% disagreed or strongly disagreed). Most respondents (79%) had rocuronium (57%) or vecuronium (22%) as their preferred non-depolarising muscle relaxant. Most had used sugammadex with both rocuronium (81%) and vecuronium (61%), and few always used sugammadex (12%) or never used sugammadex (7%). Furthermore, 72% agreed or strongly agreed about including their patients in such a trial (17% were neutral and 11% disagreed or strongly disagreed). Free-text answers did not have clear themes, but a few respondents expressed a strong bias for or against sugammadex, while others were uncertain about the value proposition for sugammadex. This survey is limited by a typically low response rate, but has the strengths of reasonable precision to draw conclusions and respondent diversity in geography and practice. We conclude that many respondents who would be site leaders for the SNaPP study agree that postoperative pulmonary complications are important and have sufficient equipoise to conduct the SNaPP study at their sites across Australia, New Zealand and beyond to determine if sugammadex reduces postoperative pulmonary complications compared to neostigmine.