Background
Methods
Search strategy and study selection
Data extraction
Study quality assessment
Results
Study selection
Study characteristics
Author (year)/ Country | Study design | Age (years) mean ± SDM | Gender (male/female) n | Body mass index (kg/m2) mean ± SDM | Total number of subjects | OSA status (n) | Purpose of study | Surgery | Comparators | Oxford LOE |
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Q 1. OSA vs. non-OSA | ||||||||||
Sudre [32] 2015 Brazil | RCT | IPG 37 ± 11 CG 36 ± 11 | IPG 49/151 CG 36/116 | IPG 46 ± 6 CG 44 ± 6 | 352 | Already diagnosed OSA (Interventional = 89, Control = 79) | Compared the effects of 2 protocols, Interventional (Remif, Roc, Sevo) vs. Control (Suf, Atracurium, Iso) on immediate recovery time and PPCs after bariatric surgery. | Laparotomy for gastric bypass | Interventional group vs. Control group | 2 |
Ahmad [30] 2009 US | Prospective Cohort | OSA 43 ± 10 Non-OSA 42 ± 12 | OSA 8/23 Non-OSA 0/9 | OSA 50 ± 9 Non-OSA 48 ± 6 | 40 | Diagnosed OSA (31) by PSG and Berlin questionnaire | To determine whether obese patients with OSA vs. non-OSA were at greater risk for postoperative hypoxemic episodes after bariatric surgery | Laparoscopic bariatric | OSA vs. non-OSA | 3 |
Pereira [31] 2013 Portugal | Prospective Observational | HR-OSA 63 ± 12 LR-OSA 48 ± 18 | HR-OSA 113/66 LR-OSA 33/128 | HR-OSA 28 ± 5 LR-OSA 24 ± 5 | 340 | STOP-Bang {If ≥3, HR-OSA (179) If 0–2, LR-OSA (161)} | To evaluate the STOP-Bang score in surgical patients in PACU. | Intra-abdominal/bariatric, musculoskeletal, Otolaryngologic | HR-OSA vs. LR-OSA | 3 |
Q 2. Sugammadex vs. Neostigmine | ||||||||||
Unal [33] 2015 Turkey | RCT | Group S (44 ± 9), Group N (46 ± 11) | Not mentioned | Group S 28 ± 3 Group N 28 ± 3 | 74 | Already diagnosed OSA (74) | To compare sugammadex and neostigmine for reversing rocuronium-induced NMB, PPCs s and costs in patients undergoing surgery for treatment of OSA. | Anterior palatoplasty; UPP; tonsillectomy+ UPP, septoplasty; tonsillectomy+ Lateral pharyngoplasty | Sugammadex vs neostigmine | 2 |
Llaurado [34] 2014 Spain | Cohort - Observational | SG 45 ± 35 HG 44 ± 31 | SG 32/68 HG 27/73 | SG 49 ± 27 HG 46 ± 24 | 320 | Already diagnosed OSA (SG = 74, HG = 61) | To determine whether sugammadex vs. neostigmine to reverse NMB could decrease adverse postoperative respiratory outcomes. | Laparoscopic bariatric | Sugammadex group vs. historical group (neostigmine) | 3 |
Studies | PPCs | Definitions |
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Sudre [32] (2015) | Atelectasis, pleural effusion, acute pulmonary edema | Chest radiograph findings. |
Respiratory failure | Not defined | |
Ahmed [30] (2009) | Hypoxemia | SpO2 > 4% below preoperative baseline values for > 10 s in duration. |
Pereira [31] (2013) | Hypoxemia | Mild-moderate hypoxia (SpO2 of 93–90%) on 3 L nasal cannula O2, not improved after active interventions (increasing O2 flows to > 3 L/min, application of high-flow face mask O2, verbal requests to breathe deeply and tactile stimulation); Severe hypoxia (SpO2 < 90%) on 3 L nasal cannula O2 not improved after active interventions (increasing O2 flows to > 3 L/min, application of high-flow facemask O2, verbal requests to breathe deeply, and tactile stimulation). |
Respiratory failure | Signs of respiratory distress or impending ventilatory failure (respiratory rate > 20 breaths per minute, accessory muscle use, and tracheal tug). | |
Airway obstruction | Patient complaining of symptoms of respiratory or upper airway muscle weakness (difficulty breathing, swallowing, or speaking), requiring reintubation in the PACU. | |
Residual NMB | TOFR < 0.9 and was quantified at PACU admission using acceleromyography of the adductor pollicis muscle (TOF-Watch®). | |
Others (airway obstruction, muscle weakness, decreased inspiratory capacity, bronchospasm) | Not defined. | |
Unal [33] (2015) | Hypoxemia | SpO2 ≤ 90% in PACU. |
Airway obstruction | Requiring an intervention (jaw thrust, oral or nasal airway, intubation). | |
Apnea | Not defined. | |
Re-intubation & invasive postoperative mechanical ventilation. | Patient whose hypoxemia and airway obstruction did not improve despite the application of oxygen through a mask and airway maneuvers. | |
Llaurado [34] (2014) | Atelectasis, pleural effusion | Chest radiograph finding. |
Study | NMBD used | NMBD dose | Reversal Used | Reversal Dose | NMBD monitoring (TOFR) | Postoperative complications | Conclusion |
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Q 1. OSA vs. non-OSA | |||||||
Sudre [32] 2015 | Succinylcholine + Rocuronium or Atracurium | Induction: succinylcholine 1 mg.kg− 1 TBW & interventional group (rocuronium 0.1 mg.kg− 1.hr.− 1 IBW) Control group (atracurium 0.4 mg.kg− 1) Maintenance: IPG (rocuronium 0.1 mg.kg-1.hr.− 1IBW) CG (atracurium 0.04 mg.kg− 1) | Not specified | Not specified | Yes | OSA was associated with a higher risk of postoperative respiratory failure. (OR 6.88) No difference in atelectasis, bronchospasm, pleural effusion, pulmonary edema | Higher risk of postoperative respiratory failure in OSA vs. non-OSA patients receiving NMBA. |
Ahmad [30] 2008 | Succinycholine + rocuronium | Succinylcholine (0.5 mg/kg), rocuronium (0.5 mg/kg) | Neostigmine + glycopyrrolate | Neostigmine 0.05 mg.kg− 1 (IBW) + Glycopyrolate 0.005 mg.kg− 1 (IBW) | Yes | No difference in median SpO2 in OSA vs. non-OSA patients given supplemental oxygen in first 24 h after surgery, P = 0.97 | OSA did not increase the risk for postoperative hypoxemia |
Pereira [31] 2013 | NMB - drug not specified | Not specified | Neostigmine - where required | Not specified | Yes | Postoperative mild/moderate hypoxia was higher in HR-OSA vs. LR-OSA patients (n = 15 vs.4, P = 0.012). Significantly higher residual NMB was found in HR-OSA vs. LR-OSA patients (n = 35 vs.25, P = 0.035). | Mild/moderate hypoxemia (P = 0.012) and residual neuromuscular blockade are more frequent in HR-OSA patients vs. LR-OSA patients (P = 0.035). |
Q 2. Sugammadex vs. Neostigmine | |||||||
Unal [33] 2015 | Rocuronium | Total rocuronium dose group S = 2.6 + − 16.7 mg, group N = 85.0 + − 14.7 mg. | Sugammadex / neostigmine | SG: 2 mg.kg− 1 sugammadex, n = 37 and 0.04 mg.kg− 1 N: neostigmine+ 0.02 mg.kg− 1 atropine. n = 37. | Yes | PPCs (desaturation, hypoxemia, apnea, airway manipulation, airway usage, re-intubation, CPAP, invasive mechanical ventilation) were lower in OSA patients reversed with sugammadex vs neostigmine, P = 0.048. Cardiovascular complications (bradycardia) lower with sugammadex vs. neostigmine, P = 0.04. | Postoperative pulmonary complications and bradycardia occurred less frequently in OSA patients who received sugammadex vs. neostigmine (P < 0.05). |
Llaurado [34] 2014 | Succinycholine/ Rocuronium/ Cis-atracurium | SG: succinylcholine 1 mg.kg− 1 RBW or rocuronium 1 mg.kg− 1 IBW + rocuronium 0.15 mg.kg− 1 at T2. HG: succinylcholine 1 mg.kg− 1 RBW or rocuronium1 mg.kg− 1 IBW or cis-atracurium 0.2 mg/ kg IBW + cis-atracurium 0.03 mg.kg− 1 | Sugammadex / neostigmine | SG: sugammadex 4 mg.kg− 1 + 2 mg.kg− 1 (TOFR< 0.9, 3 min apart); HG: neostigmine 0.04 mg.kg− 1 + 0.02 mg.kg− 1 | Yes | Significantly less postoperative abnormalities on chest radiograph (atelectasis, pleural effusions) were observed in the SG: 6.9% (n = 11) vs. HG 16.3% (n = 26). P = 0.015 No difference in need for mechanical ventilation in SG vs. HG (2 vs.5), P = 0.38 or hospital stay (3 vs.4, P = 0.3). | Significantly less postoperative chest radiograph changes in the OSA patients receiving sugammadex vs. neostigmine. No difference in postoperative mechanical ventilation, and hospital stay. |
Risk of Bias
First author (yr) | Adequate sequence generation | Allocation concealment | Blinding | Blinding of outcome assessment | Incomplete outcome data assessed | Free of selective outcome reporting | Free of other biases |
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Unal (2015) [33] | Unclear | Unclear | Unclear | Unclear | Yes | Yes | Yes |
Sudre (2015) [32] | Unclear | Unclear | Unclear | Yes | Yes | Yes | Unclear |
Quality of Included Studies Assessed by Using the Newcastle-Ottawa Quality Scale for Comparative Studies | |||||||||||||||||||||||||||
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Study | Study design | Selection (Max = 4 stars) | Comparability (Max = 2Stars) | Outcome (Max = 3Stars) | Total | ||||||||||||||||||||||
1 | 2 | 3 | 4 | 1 | 1 | 2 | 3 | ||||||||||||||||||||
A* | B* | C | D | A* | B | C | A* | B* | C | D | A* | B | A* | B* | A* | B* | C | D | A* | B | A* | B* | C | D | |||
Ahmed [30] 2009 | Prospective Cohort |
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Pereira [31] 2013 | Prospective Cohort |
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Llaurado [34] 2014 | Prospective Cohort |
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