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.