Introduction
Liver transplantation is the second common transplant surgery in the
United States1, and it remains the first-line
treatment for patients with end-stage liver disease. With advances in
surgical technique, anesthetic management, multidisciplinary patient
care, and immunosuppression, the procedure has a greater than 90%
1-year survival and greater than 75% 5-year
survival.1 Due to this multidisciplinary approach,
numerous centers have been able to perform the procedure with fewer
perioperative complications allowing for extubation in the operating
room and transfer to the floor, bypassing the intensive care unit (ICU),
a process known as ”fast-tracking.”
Traditionally, anticholinesterase inhibitors have been used as a
neuromuscular blockade antagonist (NMBA) prior to extubation for
patients undergoing procedures requiring neuromuscular blockade. Over
the last decade, a novel neuromuscular blockade antagonist, sugammadex,
has become available as an alternative for reversing aminosteroidal
neuromuscular blocking agents.2Sugammadex is a modified
cyclodextrin that selectively encapsulates and reverses the effects of
steroidal neuromuscular relaxants.
Compared to neostigmine,
sugammadex has a lower risk of adverse events such as bradycardia and a
lower incidence of postoperative nausea and vomiting
(PONV).3 However,
sugammadex is known to prolong
prothrombin time (PT) and activated thromboplastin time
(aPTT).4 This
characteristic is of particular concern during liver transplantation as
coagulopathy is common, and postoperative hemorrhage requiring
re-operation can occur in approximately 10-15% of
patients.5
Compared to the general population, liver transplant recipients often
present with abnormal coagulation profiles and other comorbidities prior
to liver transplantation and have a higher risk of postoperative
bleeding.
Data
on the impact of sugammadex on coagulation in orthotopic liver
transplantation surgery patients is limited. The primary goal of this
study was to compare the bleeding risk of sugammadex versus neostigmine,
with secondary outcomes focused on
the incidence of organ rejection, PONV, and length of hospital stay
(LOS) in liver transplant recipients. We hypothesize that the use of
sugammadex has no impact on postoperative bleeding, organ rejection, and
LOS, and may reduce the incidence of PONV when compared to neostigmine.