Sugammadex or neostigmine are given at the end of the surgery to reverse neuro muscular blocking drugs (NMBD). This study will evaluate whether reversal of NMBD with sugammadex is associated with faster recovery than neostigmine resulting in faster discharge from the operating room (OR) in obese patients with OSA undergoing bariatric surgery. Half of the patients in the study will receive sugammadex and the other half of the patients will receive neostigmine.

Sugammadex and neostigmine are NMBD reversal agents. Neostigmine - an anticholinesterase is given to reverse NMBD; however reversal of NMBD with neostigmine may be associated with residual neuromuscular blockade in up to 64% patients postoperatively in the post anesthesia care unit. Even mild degrees of residual neuromuscular blockade can have serious clinical consequences in the postoperative period. The severity of OSA often worsens after surgery and patients with OSA are at increased risk for early respiratory complications after extubating and in the PACU. Morbid obesity is associated with critical respiratory complications in patients with OSA.

Sugammadex is a newer NMBD reversal agent that rapidly and completely reverses rocuronium. It is a modified gamma cyclodextrin that forms a complex with the neuromuscular blocking agent rocuronium. It reduces the amount of neuromuscular blocking agent available to bind to nicotinic cholinergic receptors in the neuromuscular junction. It has been shown to more rapidly reverse residual neuromuscular blockade than neostigmine in obese patients without obstructive sleep apnea (OSA).

This study will evaluate whether reversal of NMBD with sugammadex is associated with faster recovery than neostigmine resulting in faster discharge from the operating room (OR) in obese patients with OSA undergoing bariatric surgery. Half of the patients in the study will receive sugammadex and other half of the patients will receive neostigmine

Inclusion Criteria:

• Age ≥ 18 years old
• Diagnosed Obstructive Sleep Apnea patients by polysomnography
• Scheduled elective bariatric surgery

Exclusion Criteria:

• Age<18 years old
• Allergy to rocuronium
• Allergy to sugammadex
• Allergy to neostigmine
• Malignant hyperthermia
• Hepatic insufficiency
• Renal insufficiency
• Neuromuscular Disease
• Pregnancy

Research study results will be presented for publication in peer reviewed journals by the protocol.

Study population were morbidly obese adult (≥18 years) patients with OSA diagnosed by polysomnography for elective bariatric surgery under general anesthesia at Toronto Western Hospital- University Health Network, who were able to give consent. They were randomized 1:1 for reversal of NMBDs with sugammadex or neostigmine.

Adverse event data was collected when available through the course of study completion for each participant, an average of 1 day.

Standard definitions were used by the study for adverse events.

1. . USFDA recommends neostigmine 0.03 mg/kg to 0.07 mg/kg. We used 2.5 mg for NMBD reversal. A less-than-recommended dose being used in our patients. However, providers had the option of giving a supplemental dose of neostigmine or sugammadex if they felt it was clinically indicated, with a very low rate of redosing
2. . Lack of continuous quantitative neuromuscular monitoring and ability to detect residual NMBD at the time of extubating
3. . Conservative use of muscle relaxants by our providers

All study investigators, research coordinator, patients, surgeons, anesthesiologists, health care personnel will be blinded to the treatment arm allocation in the study.