Sugammadex and Postoperative Respiratory Failure in Head and Neck Surgery: A Cohort Study

Purpose: This study investigated whether sugammadex use reduces postoperative acute respiratory failure compared with neostigmine use in patients undergoing head and neck free flap reconstruction, a population at high risk for pulmonary complications. Patients and methods: We conducted a retrospective cohort study using the TriNetX Research Network database to identify adult patients with head and neck cancer who underwent flap reconstruction surgery between January 2016 and December 2024. The patients received either sugammadex or neostigmine for rocuronium reversal. The primary outcome was acute respiratory failure within 30 days of the surgery. The secondary outcomes included composite pulmonary complications, intensive care unit (ICU) admission, major adverse cardiovascular events (MACEs), and flap failure. Results: After propensity score matching, the analysis included 2576 patients, with 1288 patients in each group. Sugammadex use was associated with significantly lower acute respiratory failure at 30 days compared with neostigmine (hazard ratio [HR] 0.67, 95% confidence interval [CI] 0.50– 0.88, p=0.004), with persistent benefit at 90 days (HR 0.76, 95% CI 0.59– 0.99, p=0.042). Multivariate analysis confirmed that sugammadex was an independent protective factor (HR 0.61, p< 0.001). Independent risk factors included ischemic heart disease, anemia, nicotine dependence, and advanced age. No differences were observed in the other outcomes. Conclusion: Sugammadex is the preferred neuromuscular blockade reversal strategy in head and neck flap reconstruction, offering improved respiratory safety without compromising surgical outcomes. Future prospective studies are warranted to confirm these findings and clarify their implications for perioperative management. Keywords: sugammadex, neuromuscular blockade reversal, head and neck surgery, respiratory failure, free flap reconstruction, neostigmine