Sugammadex versus Neostigmine for Reversal of Neuromuscular Blockade and Postoperative Pulmonary Complications (STRONGER): A Multicenter Matched Cohort Analysis

Major postoperative pulmonary complications after inpatient noncardiac surgery are common, costly, and deadly. Approximately 5% of patients experience a major pulmonary complication, resulting in increased mortality and U.S. $100,000 in additional costs per occurrence.^1–3  With more than 300 million surgical procedures performed each year worldwide, the public health impact is significant.^4,5  Decreasing pulmonary complications after surgery will be of interest to many different healthcare provider specialties, patients, and their families. While there have been advances in the areas of surgical technique, perioperative processes, and patient selection, residual neuromuscular blockade after surgery remains a common modifiable risk factor for major postoperative pulmonary complications.⁶ 

Most adult patients undergoing general anesthesia with endotracheal intubation receive a nondepolarizing neuromuscular blockade agent such as rocuronium or vecuronium.^1,7  The rise of minimally invasive and laparoscopic techniques has increased the use of deep neuromuscular blockade.^8,9  Before extubation, standard clinical practice involves pharmacologic “reversal” of these agents using either neostigmine or sugammadex.^10,11  Despite this, more than 60% of patients still demonstrate objective evidence of residual neuromuscular blockade due to provider variation in care and patient-to-patient pharmacologic response variability.^12–15  Recent multicenter European data have called into question whether the routine use of either neuromuscular blockade reversal agent, neostigmine or sugammadex, is associated with improvements in pulmonary complications.¹  Unfortunately, wide variation in practice across countries and centers demonstrated that contrary to the preponderance of evidence, less than half of patients were reversed using either agent, and only 12% received sugammadex despite a decade of availability in Europe.^1,11,12,16  In the United States, single center data have demonstrated that routine reversal may improve postoperative outcomes.^16,17  In addition, clinical equipoise has been established—approximately half of all surgical patients requiring a neuromuscular blockade agent receive sugammadex and half receive neostigmine.¹⁸  Despite the millions of doses of neostigmine and sugammadex administered annually, robust multicenter prospective randomized or retrospective observational data regarding their relative impact on postoperative clinical outcomes beyond the recovery room are lacking.

Using a prospectively validated national registry of preoperative, intraoperative, and postoperative data across academic and private hospitals, we evaluated the clinical impact of sugammadex compared to neostigmine. The recent U.S. regulatory approval of sugammadex, combined with granular intraoperative medication dosing, timing, and other surgical details not available in current literature, offered a unique experimental model to provide generalizable and reproducible real-world evidence to the many specialties that manage major pulmonary complications. We hypothesized that patients receiving sugammadex were at lower risk of postoperative pulmonary complications compared to similar patients receiving neostigmine.

The Multicenter Perioperative Outcomes Group (Ann Arbor, Michigan)¹⁹  is a consortium of more than 50 hospitals across the United States. Patient clinical and administrative data are collected from each facility monthly. For each anesthetic case, the following data are extracted and mapped to a common lexicon allowing integration across centers: preoperative, intraoperative, and postoperative laboratory values; outcome codes using International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology charge capture codes; clinical problem summary list International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes; intraoperative medications, fluids, vital signs, procedures, notes, and events. Standardized data validation efforts are undertaken at each center before data submission, including over 80 automated data quality checks and manual clinician case audit of 5 to 20 cases per month. This registry has been used previously for numerous perioperative peer-reviewed studies.^20–23  The current study protocol, including primary and secondary outcomes, patient inclusions and exclusions, and statistical analysis, was reviewed and approved by the Multicenter Perioperative Outcomes Group publication committee a priori. Individual site Institutional Review Board approval including a waiver of informed consent for data collection was obtained by each contributing hospital before submitting an anonymized dataset to the data coordinating center. Project-specific Institutional Review Board exemption was also obtained (HUM150403, University of Michigan Medical School Institutional Review Board, Ann Arbor, Michigan). This study was designed and reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

This retrospective observational matched cohort study includes two distinct time periods that define the matched exposure groups. Hospital policies often restrict use of sugammadex to patients with morbid obesity, significant respiratory disease, sleep apnea, coronary artery disease, cardiac arrhythmias, or major abdominal/thoracic surgery due to the higher cost of sugammadex compared to neostigmine.²⁴  A comparison of contemporaneous patients receiving neostigmine and sugammadex would be biased via unmeasured covariates or severity of disease due to the indication bias explicitly embodied in such clinical policy and practice. Its recent U.S. Food and Drug Administration approval in December 2015 allows the use of an experimental model to compare similar patients before and after sugammadex availability. The pre-sugammadex period (from which neostigmine treated patients were identified) includes patients from January 1, 2014, to the first documented sugammadex use, specific to each Multicenter Perioperative Outcomes Group hospital. The post-sugammadex period (from which sugammadex treated patients were identified) includes patients after sugammadex was first used at each hospital until August 31, 2018. A 6-month transition period after sugammadex introduction at each hospital was excluded to account for clinical practice pattern evolution with new medication availability. Patients receiving sugammadex were matched to patients receiving neostigmine using criteria described below. Multicenter Perioperative Outcomes Group contributing hospitals include tertiary care university hospitals and private community hospitals throughout the United States.

Adult patients aged 18 yr or older undergoing general anesthesia with an endotracheal tube and receiving a modern steroidal neuromuscular blockade agent (vecuronium or rocuronium) by bolus or infusion with administration of neostigmine or sugammadex were eligible for matching. Sugammadex dosing within 10% of Food and Drug Administration–approved indicated dosing range was required (1.8 to 4.4 mg/kg). Exclusion criteria included age younger than 18 yr; outpatient procedure; emergency, cardiac, liver, or lung transplantation surgery; intubation before operating room arrival; American Society of Anesthesiologists (ASA; Schaumburg, Illinois) Physical Status V or VI, denoting a moribund patient or a brain-dead patient undergoing organ procurement;²⁵  renal failure documented in International Classification of Diseases, Ninth Revision/Tenth Revision codes or estimated glomerular filtration rate less than 30 ml/min; sugammadex used in combination with neostigmine; sugammadex or neostigmine use with subsequent redosing of neuromuscular blockade agent, suggestive of temporary neuromuscular blockade reversal for intraoperative neuromonitoring; median intraoperative positive end-expiratory pressure greater than 10 cm H₂O; and institutional use of sugammadex for less than 10% of neuromuscular blockade patients. For patients with multiple procedures in a 30-day period, only the index case was included. In order to maintain a limited data set per U.S. privacy regulations, age for all participants over 90 yr is censored at 90 yr in the Multicenter Perioperative Outcomes Group dataset.

The primary outcome was a composite of postoperative pulmonary complications plausibly related to residual neuromuscular blockade and endorsed by international consensus guidelines^26,27 : (1) pneumonia, (2) respiratory failure, or (3) other major pulmonary complications. Consistent with previous literature,^6,28  these outcomes were defined using International Classification of Diseases, Ninth Revision/Tenth Revision codes (Supplemental Digital Content 1, https://links.lww.com/ALN/C335) and derived from hospital discharge diagnoses and complications data. Pulmonary complications previously used in the literature, but with unclear clinical significance or relationship to neuromuscular blockade (atelectasis, pulmonary edema, etc.), were not included in the primary outcome. The secondary outcomes were the individual component complications of (1) pneumonia and (2) respiratory failure.

The primary exposure studied was sugammadex administration before extubation. The control exposure was neostigmine administration before extubation.

To minimize known institutional guideline driven bias of allowing sugammadex administration to higher-risk patients or those having higher-risk procedures, a matched-cohort design was implemented. Exact matching criteria were Multicenter Perioperative Outcomes Group institution identification, sex, age (matched within 5 yr), ASA Physical Status (I, II, III, or IV), World Health Organization body mass index classifications; procedures at intrinsic risk of pulmonary complications (major thoracic and major abdominal, defined using primary anesthesiology Current Procedural Terminology charge capture code), specific Elixhauser comorbidities associated with increased pulmonary complication risk or indication bias (chronic pulmonary disease, congestive heart failure, paralysis, liver disease, and cardiac arrhythmia)²⁹ ; and neuromuscular blockade agent used intraoperatively (rocuronium alone vs. vecuronium with or without rocuronium). Detailed definitions and clinical foundation for matching criterion are available in Supplemental Digital Content 2 (https://links.lww.com/ALN/C335). Each sugammadex case was matched to exactly one neostigmine case without replacement. A database programmer used Structured Query Language Server Management Studio 2017 (Microsoft Corporation, USA) to perform the exact match.

Many other preoperative and intraoperative covariates were used to adjust for any residual confounding or indication bias: Elixhauser-defined comorbidities not used for exact matching, primary in-room provider type, general anesthesia technique, intraoperative factors associated with pulmonary complications (fluid balance in ml/kg · h, estimated blood loss in three categories of 0 to 500 ml, 501 to 1,000 ml, and 1,000 ml or over, intraoperative opioid administration in morphine equivalents/kg · h, median ventilator driving pressure), or neuromuscular blockade management (intraoperative neuromuscular blockade bolus and infusion total dose in ED95 equivalents/kg · h, last train-of-four documented within 30 min before extubation, time from last neuromuscular blockade dose to reversal in 15-min increments, and time from last neuromuscular blockade dose to extubation in 15-min increments; Supplemental Digital Content 3, https://links.lww.com/ALN/C335).²⁸ 

Continuous data were presented as medians and interquartile ranges due to skew; binary primary and secondary outcomes were summarized by frequencies and percentages for each matched group. Some continuous variables were transformed consistent with published clinical standards (body mass index) or clinically meaningful categories that incorporate realities of clinical documentation accuracy (estimated blood loss, time from last dose to reversal of extubation) as described in Supplemental Digital Content 2 and 3 (https://links.lww.com/ALN/C335). Unadjusted differences between patients receiving sugammadex versus neostigmine were assessed using conditional logistic regression to account for the matching.

To assess the independent association between administration of sugammadex versus neostigmine reversal and the primary composite pulmonary complication, separate multivariable conditional logistic regression models were developed. Additional variables not used in matching were assessed for residual confounding using absolute standardized differences. Any covariate with a standardized difference greater than 0.10 was included in the multivariable analysis. In addition, surgical body region/invasiveness (16 distinct categorical variables) and neuromuscular blockade agent (rocuronium alone, vecuronium alone, or both) were included. Adjusted odds ratios with 95% CI were reported for all models. Model discrimination and calibration were assessed using standard logistic regression methods, since current statistical software is unable to calculate diagnostic measures that account for the matched design.^30,31  All statistical analyses were performed using SAS version 9.4 (SAS Institute, USA), and hypothesis testing was two-sided.

Using an approximated formula and assuming a conservative estimate for the sample proportions and 95% confidence, to achieve a margin of error of ±1%, we would need a study sample size of approximately 9,600. For the defined study period, we expected to observe greater than 30,000 patients receiving sugammadex.

Several sensitivity analyses were prespecified. First, we evaluated the potential impact of changes in coding due to the International Classification of Diseases, Ninth Revision/Tenth Revision transition and restricted analyses to patients undergoing care after October 1, 2015, when International Classification of Diseases, Tenth Revision, codes were required by major U.S. payers. Next, to assess resiliency of the observed relationships to coding error, multivariable models focused on a primary outcome of diagnosis codes that clearly denote postsurgical pulmonary complications (518.51, J95.821 or J96.00, 518.52, J95.1 or J95.2) were assessed. Third, a sensitivity analysis including the administration of intraoperative blood products (packed red blood cells, fresh frozen plasma, or platelets) as a distinct covariate was performed. Finally, given concerns regarding severe hypersensitivity reactions associated with sugammadex administration, we identified all cases of hemodynamically significant anaphylaxis.^32,33 

A data analysis and statistical plan was written and filed with a private entity (Multicenter Perioperative Outcomes Group publications committee) before data were accessed.

Twenty-two Multicenter Perioperative Outcomes Group hospitals with sugammadex available on formulary as of August 31, 2018, and submitting discharge International Classification of Diseases, Ninth Revision/Tenth Revision outcome data as part of their monthly contribution met inclusion criteria. Of 563,456 eligible cases, 228,946 were excluded as outpatient cases, 35,501 emergency, 143 liver or lung transplantation, 3 ASA V or VI, 18,623 renal failure, 667 combined sugammadex and neostigmine use or neuromonitoring, 283 high median positive end-expiratory pressure, and 68,709 institutional low use of sugammadex. Of the remaining cases, 67,640 lacked intraoperative surgical start and end times, and 21,418 lacked outcomes data; these patients were similar to cases with available outcome data (Supplemental Digital Content 4, https://links.lww.com/ALN/C335). There were 119,611 patients with complete outcomes and intraoperative data who were eligible for matching; 30,026 patients received sugammadex and 89,585 received neostigmine. Before matching, patients receiving sugammadex demonstrated a much higher preoperative comorbidity burden (table 1). After matching 22,856 sugammadex patients to 22,856 neostigmine patients, only 12 hospitals were represented; excellent preoperative and intraoperative covariate balance was achieved (tables 1 and 2); out of 80 covariates, eight demonstrated a standardized difference greater than 0.10 and one greater than 0.20 (tables 1 and 2, and Supplemental Digital Content 5, https://links.lww.com/ALN/C335). Missing data rates for the studied population were small, with all intraoperative and preoperative elements other than body mass index (13.4% missing) demonstrating completeness greater than 98%.

Among the 45,712 patients in the matched analytic dataset, the median age was 58 yr, median body mass index was 28.5 kg/m²; 55% were female, and 55% were ASA III. The most common surgical procedures were major abdominal (30.4%), major urologic/gynecologic (13.6%), and major head and neck (11.9%). A total of 1,892 patients (4.1%) experienced the composite primary outcome (3.5% sugammadex vs. 4.8% neostigmine), 796 (1.7%) pneumonia (1.3% vs. 2.2%), and 582 (1.3%) respiratory failure (0.8% vs. 1.7%; fig. 1).

In multivariable conditional logistic regression analyses incorporating all covariates with an absolute standard difference greater than 0.10 and each surgical procedure category, sugammadex administration was associated with a 30% reduced risk of pulmonary complications (adjusted odds ratio, 0.70; 95% CI, 0.63 to 0.77), 47% for pneumonia (adjusted odds ratio, 0.53; 95% CI, 0.44 to 0.62), and 55% (adjusted odds ratio, 0.45; 95% CI, 0.37 to 0.56) for respiratory failure (fig. 2; Supplemental Digital Content 6, 7, and 8 for full model results and diagnostics, https://links.lww.com/ALN/C335). Prespecified sensitivity analyses demonstrated similar effect sizes and statistical significance: (Supplemental Digital Content 9, https://links.lww.com/ALN/C335) patients after the International Classification of Diseases, Tenth Revision, transition (primary outcome adjusted odds ratio, 0.79; 95% CI, 0.66 to 0.94); International Classification of Diseases, Ninth Revision/Tenth Revision outcome codes specific to postsurgical pulmonary complications (adjusted odds ratio, 0.68; 95% CI, 0.52 to 0.88); adjustment for blood product administration (adjusted odds ratio, 0.71; 95% CI, 0.63 to 0.78). No patients demonstrated hemodynamically significant anaphylaxis after administration of neostigmine or sugammadex.

Several post hoc sensitivity analyses were also performed. First, to evaluate whether any specific hospital with outlier observations may be driving the overall results, we compared each center’s unadjusted primary outcome rate between matched patients administered sugammadex and neostigmine; six out of seven hospitals with matched patient volume of 1,000 or more patients had point estimates less than 1.0, consistent with the primary analysis, while one had a point estimate of 1.02 (Supplemental Digital Content 10, https://links.lww.com/ALN/C335). As expected given the range of academic and private hospitals included in the analysis, 10-fold variation in clinical volume and 8-fold variation in recorded pulmonary complications was noted. Next, to minimize the potential impact of temporal changes in practice, we restricted the matched cohort analysis to sugammadex–neostigmine patient pairs undergoing surgery within 24 months of each other and observed a consistent primary outcome adjusted odds ratio 0.76 (95% CI, 0.62 to 0.92). Finally, to identify the resiliency of the observations to unmeasured confounders, we calculated the E value associated with the adjusted odds ratios of the primary analysis,³⁴  demonstrating unmeasured confounders with effect sizes of 2.21, 3.26, or 3.77 would be required to explain the observed association between sugammadex administration and composite pulmonary complications, pneumonia, and respiratory failure, respectively.

In a retrospective matched-cohort analysis across 12 U.S. hospitals for 45,712 adult patients undergoing inpatient surgery requiring general anesthesia with endotracheal intubation, administration of sugammadex to restore neuromuscular function before operative extubation was associated with a 30 to 50% lower risk of pulmonary complications including pneumonia and respiratory failure. The matching algorithm resulted in excellent balance across the studied groups in patient, procedure, and intraoperative care factors (table 1). The findings are resilient to several sensitivity analyses and are generalizable given the number of centers and variety of surgical cases included. Our studied outcomes, pneumonia and respiratory failure, represent reliable and impactful pulmonary complications, unlike less severe yet more frequent events such as pulmonary edema, atelectasis, and need for postoperative supplemental oxygen.^26,27 

These data provide evidence that known effects of sugammadex on intermediate biologic outcomes such as neuromuscular recovery may extend to clinically related downstream postoperative outcomes such as pneumonia and respiratory failure. A recent Cochrane review of 41 randomized trials spanning 4,206 patients showed improvements in bradycardia, postoperative nausea and vomiting, and postoperative residual neuromuscular blockade in patients receiving sugammadex compared to neostigmine.¹¹  However, no data on outcomes beyond the recovery room were available. Improved muscle tone affects diaphragmatic, upper airway, and chest wall strength, potentially improving a patient’s ability to cough, clear secretions, decrease alveolar collapse enabling pneumonia, and prevent microaspiration.^16,35  The primary outcome is directly related to neuromuscular tone. We observed a 30% reduction in the overall composite primary outcome, driven largely by reductions in the component outcomes of pneumonia (47% relative reduction, absolute reduction from 2.2 to 1.3%) and respiratory failure (55% relative reduction, absolute reduction from 1.7 to 0.8%; figs. 1 and 2), similar to a recently published single-center before–after analysis.¹⁷  We did not observe a reduction in the “other pulmonary complication” component of the primary outcome (adjusted odds ratio, 0.99; 95% CI, 0.85 to 1.15), which included International Classification of Diseases codes for conditions less likely related to neuromuscular blockade, such as pneumonitis, pulmonary congestion, iatrogenic pulmonary embolism and infarction, iatrogenic pneumothorax, and other pulmonary complications (Supplemental Digital Content 1, https://links.lww.com/ALN/C335).

Our observed improvement in pulmonary outcomes should be placed in the context of recent observations from POPULAR (post-anaesthesia pulmonary complications after use of muscle relaxants), a prospective observational study across 28 European countries that analyzed data for 22,803 patients receiving general anesthesia and did not observe an association between neuromuscular blockade reversal and improved outcomes.¹  First, POPULAR’s most common “pulmonary complication” was “mild respiratory failure,” defined as the need for supplementary oxygen to maintain oxygen saturation measured by pulse oximetry 90% or greater postoperatively, occurring in 5.2% of patients. The clinical impact and reproducibility of this definition are questionable given provider variations in the decision to administer supplemental oxygen. Our primary outcome that focuses on reintubation and pneumonia is more reliable and clinically meaningful. Next, contrary to evidence-based guidelines, less than half of the patients in the POPULAR study were actually reversed with any agent. Less than 2,000 patients received sugammadex, and only 10% of patients had complete data needed for appropriate patient matching and comparison across therapeutic groups. Our data across 12 hospitals included more than 20,000 patients receiving sugammadex, allowing for a more precise matching of patient and surgical factors across treatment choices. More importantly, our data included detailed intraoperative pharmacologic, physiologic, and hemodynamic information necessary for meaningful indication bias adjustment.

Despite these strengths, this study does include several limitations. First, the marked reduction in pulmonary complications associated with sugammadex may be due to temporal factors. Although the 4-yr study period did not include any other major changes in pulmonary care clinical protocols, natural improvement in clinical practice may account for some of the reduction in complications. However, given the median time difference between neostigmine and sugammadex cases of only 29 months, it is unlikely that a 50% reduction in pneumonia is explained entirely by other improvements in practice over time. Table 2 demonstrates the measured intraoperative processes of care were statistically indistinguishable between the two groups, although other unmeasured covariates may or may not be balanced. The post hoc sensitivity analysis focused on matched patients within 24 months provides additional support. In addition, discharge coding errors or misclassification may have also contributed to the observed change in outcome. However, the sensitivity analysis focused on patients after October 2015, when the International Classification of Diseases, Tenth Revision, transition occurred, and the sensitivity analysis using only explicit postsurgical complication International Classification of Diseases codes both revealed similar effect sizes and statistically significant results as seen in the primary analysis. There are inherent limitations due to the observational nature of the study, which may warrant a prospective, pragmatic controlled trial. Residual confounding and selection bias are likely present; however, given the indication bias for higher-risk patients to receive sugammadex, this issue would bias toward the null hypothesis. E value analysis demonstrated that an extremely strong unmeasured confounder with an effect size greater than 3 would be required to refute the improved outcomes associated with sugammadex use. Next, due to missing outcome data, approximately 14% of patients meeting clinical inclusion criteria were excluded. These patients were demographically and clinically similar to the studied patients. Next, the comorbidity definitions are based upon discharge diagnoses codes and algorithms that may not adequately address specific pulmonary diseases or severity of disease (such as home oxygen use, restrictive lung disease). Finally, the study population excluded emergency surgery, patients receiving sugammadex outside normal dosing guidelines, outpatients, and centers not contributing outcome data, leaving unclear the effect of sugammadex in these populations.

Given the tens of millions of patients undergoing general endotracheal anesthesia each year worldwide, these data inform efforts to decrease pulmonary complications after inpatient surgery and the choice between neostigmine and sugammadex use. While sugammadex provides rapid and effective restoration of neuromuscular tone without systemic anticholinergic activity, neostigmine currently remains the mainstay of practice worldwide given decades of experience and the higher price of sugammadex.^1,24  The current analysis provides generalizable, real-world observations given the multicenter data collection methodology during routine care, and should encourage clinicians and policymakers to reevaluate current practice patterns. The observed use of sugammadex in patients with a range of underlying risks and depths of neuromuscular blockade reflects an evolving pattern of use that may be discordant with some institutional policies intending to strictly limit its use. Future research should evaluate the reproducibility of these findings in specific patient subgroups, consider prospective effectiveness controlled trials, and establish the cost/benefit ratio of the different reversal strategies.

The authors gratefully acknowledge the valuable contributions to protocol and final manuscript review by the Multicenter Perioperative Outcomes Group Perioperative Clinical Research Committee, including Michael F. Aziz, M.D., Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon; William Hightower, M.D., Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health System, West Bloomfield Township, Michigan; Robert M. Craft, M.D., Department of Anesthesiology, University of Tennessee Medical Center, Knoxville, Tennessee; Zachary A. Turnbull, M.D., Department of Anesthesiology, New York Presbyterian–Weill Cornell, New York, New York; Adit A. Ginde, M.D., M.P.H., Department of Anesthesiology, University of Colorado, Aurora, Colorado.

Funding was provided by departmental and institutional resources at each contributing site. In addition, partial funding to support underlying electronic health record data collection into the Multicenter Perioperative Outcomes Group registry was provided by Blue Cross Blue Shield of Michigan/Blue Care Network as part of the Blue Cross Blue Shield of Michigan/Blue Care Network Value Partnerships program. Although Blue Cross Blue Shield of Michigan/Blue Care Network and Multicenter Perioperative Outcomes Group work collaboratively, the opinions, beliefs and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of Blue Cross Blue Shield of Michigan/Blue Care Network or any of its employees. Partial funding for data extraction and analysis was provided by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., (Kenilworth, New Jersey) to the University of Michigan. This work was funded in part through the National Cancer Institute Cancer Center support grant No. P30 CA008748 (Bethesda, Maryland; to Dr. McCormick); National Institute of Drug Abuse grant No. K23DA040923-04 (Bethesda, Maryland; to Dr. Bartels); National Institute of General Medical Sciences grant No. T32GM103730-05 (Bethesda, Maryland; to Dr. Colquhoun); and National Heart, Lung, and Blood Institute grant No. K01HL141701-02 (Bethesda, Maryland; to Dr. Mathis).

The study protocol and statistical analysis plan were reviewed and approved a priori by the Multicenter Perioperative Outcomes Group publications committee, an academic entity independent of funding sources and free from industry and funder involvement. All authors had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

All authors have completed the International Committee of Medical Journal Editors uniform disclosure form at www.icmje.org/coi_disclosure.pdf. Dr. Bash is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. (Kenilworth, New Jersey), which manufactures and distributes sugammadex. Drs. Kheterpal, Vaughn, Dubovoy, Shanks, and Saager declare indirect support from Merck & Co., Inc., to their organization (University of Michigan) to support aspects of the submitted work. Drs. Bardia and Schonberger declare indirect support from Merck & Co., Inc., to their organization (Yale University, New Haven, Connecticut) for other research. Drs. Soto and Saager declare receiving consulting fees from Merck & Co., Inc. Other relationships unrelated to the current work include the following: Drs. Kheterpal and Shah declare indirect support from Apple, Inc. (Cupertino, California), to their organization (University of Michigan, Ann Arbor, Michigan). Dr. Dubovoy declares serving on an expert panel for Fresenius Kabi (East Schaumburg, Illinois). Dr. McCormick is a board member of the Society for Technology in Anesthesia (Milwaukee, Wisconsin), and his spouse owns stock in Johnson & Johnson (New Brunswick, New Jersey). Dr. Schonberger owns stock in Johnson & Johnson. Dr. Saager declares consulting fees or serving on an expert panel for Medtronic (Covidien; Minneapolis, Minnesota) and the The37Company. Dr. Soto declares serving on an expert panel for Mallinckrodt LLC and consulting fees from Heron Therapeutics, Inc.