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Turzhitsky V, Bash LD, Urman RD, Kattan M, Hofer I. Factors Influencing Neuromuscular Blockade Reversal Choice in the United States Before and During the COVID-19 Pandemic: Retrospective Longitudinal Analysis. JMIR Perioper Med 2024; 7:e52278. [PMID: 39038283 DOI: 10.2196/52278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/21/2023] [Accepted: 04/09/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Neuromuscular blockade (NMB) agents are a critical component of balanced anesthesia. NMB reversal methods can include spontaneous reversal, sugammadex, or neostigmine and the choice of reversal strategy can depend on various factors. Unanticipated changes to clinical practice emerged due to the COVID-19 pandemic, and a better understanding of how NMB reversal trends were affected by the pandemic may help provide insight into how providers view the tradeoffs in the choice of NMB reversal agents. OBJECTIVE We aim to analyze NMB reversal agent use patterns for US adult inpatient surgeries before and after the COVID-19 outbreak to determine whether pandemic-related practice changes affected use trends. METHODS A retrospective longitudinal analysis of a large all-payer national electronic US health care database (PINC AI Healthcare Database) was conducted to identify the use patterns of NMB reversal during early, middle, and late COVID-19 (EC, MC, and LC, respectively) time periods. Factors associated with NMB reversal choices in inpatient surgeries were assessed before and after the COVID-19 pandemic reached the United States. Multivariate logistic regression assessed the impact of the pandemic on NMB reversal, accounting for patient, clinical, procedural, and site characteristics. A counterfactual framework was used to understand if patient characteristics affected how COVID-19-era patients would have been treated before the pandemic. RESULTS More than 3.2 million inpatients experiencing over 3.6 million surgical procedures across 931 sites that met all inclusion criteria were identified between March 1, 2017, and December 31, 2021. NMB reversal trends showed a steady increase in reversal with sugammadex over time, with the trend from January 2018 onwards being linear with time (R2>0.99). Multivariate analysis showed that the post-COVID-19 time periods had a small but statistically significant effect on the trend, as measured by the interaction terms of the COVID-19 time periods and the time trend in NMB reversal. A slight increase in the likelihood of sugammadex reversal was observed during EC relative to the pre-COVID-19 trend (odds ratio [OR] 1.008, 95% CI 1.003-1.014; P=.003), followed by negation of that increase during MC (OR 0.992, 95% CI 0.987-0.997; P<.001), and no significant interaction identified during LC (OR 1.001, 95% CI 0.996-1.005; P=.81). Conversely, active reversal (using either sugammadex or neostigmine) did not show a significant association relative to spontaneous reversal, or a change in trend, during EC or MC (P>.05), though a slight decrease in the active reversal trend was observed during LC (OR 0.987, 95% CI 0.983-0.992; P<.001). CONCLUSIONS We observed a steady increase in NMB active reversal overall, and specifically with sugammadex compared to neostigmine, during periods before and after the COVID-19 outbreak. Small, transitory alterations in the NMB reversal trends were observed during the height of the COVID-19 pandemic, though these alterations were independent of the underlying NMB reversal time trends.
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Affiliation(s)
| | | | - Richard D Urman
- College of Medicine, The Ohio State University, Columbus, OH, United States
| | | | - Ira Hofer
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Blum FE, Locke AR, Nathan N, Katz J, Bissing D, Minhaj M, Greenberg SB. Residual Neuromuscular Block Remains a Safety Concern for Perioperative Healthcare Professionals: A Comprehensive Review. J Clin Med 2024; 13:861. [PMID: 38337560 PMCID: PMC10856567 DOI: 10.3390/jcm13030861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/11/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Residual neuromuscular block (RNMB) remains a significant safety concern for patients throughout the perioperative period and is still widely under-recognized by perioperative healthcare professionals. Current literature suggests an association between RNMB and an increased risk of postoperative pulmonary complications, a prolonged length of stay in the post anesthesia care unit (PACU), and decreased patient satisfaction. The 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade provide guidance for the use of quantitative neuromuscular monitoring coupled with neuromuscular reversal to recognize and reduce the incidence of RNMB. Using sugammadex for the reversal of neuromuscular block as well as quantitative neuromuscular monitoring to quantify the degree of neuromuscular block may significantly reduce the risk of RNMB among patients undergoing general anesthesia. Studies are forthcoming to investigate how using neuromuscular blocking agent reversal with quantitative monitoring of the neuromuscular block may further improve perioperative patient safety.
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Affiliation(s)
| | - Andrew R. Locke
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Naveen Nathan
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Jeffrey Katz
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - David Bissing
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Mohammed Minhaj
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
| | - Steven B. Greenberg
- Department of Anesthesiology, Critical Care, and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA
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Brown SES, Mentz G, Cassidy R, Wade M, Liu X, Zhong W, DiBello J, Nause-Osthoff R, Kheterpal S, Colquhoun DA. Factors Associated With Decision to Use and Dosing of Sugammadex in Children: A Retrospective Cross-Sectional Observational Study. Anesth Analg 2024:00000539-990000000-00710. [PMID: 38259183 PMCID: PMC11258207 DOI: 10.1213/ane.0000000000006831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Sugammadex was initially approved for reversal of neuromuscular blockade in adults in the United States in 2015. Limited data suggest sugammadex is widely used in pediatric anesthesia practice however the factors influencing use are not known. We explore patient, surgical, and institutional factors associated with the decision to use sugammadex versus neostigmine or no reversal, and the decision to use 2 mg/kg vs 4 mg/kg dosing. METHODS Using data from the Multicenter Perioperative Outcomes Group (MPOG) database, an EHR-derived registry, we conducted a retrospective cross-sectional study. Eligible cases were performed between January 1, 2016 and December 31, 2020, for children 0 to 17 years at US hospitals. Cases involved general anesthesia with endotracheal intubation and administration of rocuronium or vecuronium. Using generalized linear mixed models with institution and anesthesiologist-specific random intercepts, we measured the importance of a variety of patient, clinician, institution, anesthetic, and surgical risk factors in the decision to use sugammadex versus neostigmine, and the decision to use a 2 mg/kg vs 4 mg/kg dose. We then used intraclass correlation statistics to evaluate the proportion of variance contributed by institution and anesthesiologist specifically. RESULTS There were 97,654 eligible anesthetics across 30 institutions. Of these 47.1% received sugammadex, 43.1% received neostigmine, and 9.8% received no reversal agent. Variability in the choice to use sugammadex was attributable primarily to institution (40.4%) and attending anesthesiologist (27.1%). Factors associated with sugammadex use (compared to neostigmine) include time from first institutional use of sugammadex (odds ratio [OR], 1.08, 95% confidence interval [CI], 1.08-1.09, per month, P < .001), younger patient age groups (0-27 days OR, 2.59 [2.00-3.34], P < .001; 28 days-1 year OR, 2.72 [2.16-3.43], P < .001 vs 12-17 years), increased American Society of Anesthesiologists [ASA] physical status (ASA III: OR, 1.32 [1.23-1.42], P < .001 ASA IV OR, 1.71 [1.46-2.00], P < .001 vs ASA I), neuromuscular disease (OR, 1.14 (1.04-1.26], P = .006), cardiac surgery (OR, 1.76 [1.40-2.22], P < .001), dose of neuromuscular blockade within the hour before reversal (>2 ED95s/kg OR, 4.58 (4.14-5.07], P < .001 vs none), and shorter case duration (case duration <60 minutes OR, 2.06 [1.75-2.43], P < .001 vs >300 minutes). CONCLUSIONS Variation in sugammadex use was primarily explained by institution and attending anesthesiologist. Patient factors associated with the decision to use sugammadex included younger age, higher doses of neuromuscular blocking agents, and increased medical complexity.
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Affiliation(s)
- Sydney E S Brown
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Graciela Mentz
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Ruth Cassidy
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Meridith Wade
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Xinyue Liu
- Division of Epidemiology, Department of Biostatistics and Research Decision Sciences, Merck Sharp & Dohme Corp. (a subsidiary of Merck & Co., Inc.), Rahway, New Jersey
| | - Wenjun Zhong
- Division of Epidemiology, Department of Biostatistics and Research Decision Sciences, Merck Sharp & Dohme Corp. (a subsidiary of Merck & Co., Inc.), Rahway, New Jersey
| | - Julia DiBello
- Division of Epidemiology, Department of Biostatistics and Research Decision Sciences, Merck Sharp & Dohme Corp. (a subsidiary of Merck & Co., Inc.), Rahway, New Jersey
| | - Rebecca Nause-Osthoff
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Sachin Kheterpal
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
| | - Douglas A Colquhoun
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; and
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Chau LC, Jarman A, Prater A, Ferguson R, Soheim R, McFarlin K, Stanton C. Effect of neuromuscular blockade reversal on post-operative urinary retention following inguinal herniorrhaphy. Hernia 2023; 27:1581-1586. [PMID: 37737305 DOI: 10.1007/s10029-023-02857-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/27/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE This study aims to define the risk of post-operative urinary retention (POUR) following inguinal hernia repair in those that received sugammadex compared to anticholinesterase. METHODS Adults undergoing inguinal herniorrhaphy from January 2019 to July 2022 with at least 30-day follow-up receiving rocuronium or edrophonium and reversed with an anticholinesterase or sugammadex were included. 1-to-2 propensity score matched models were fitted to evaluate the treatment of effect of sugammadex vs. anticholinesterase on POUR, adjusting for patient comorbidities, ASA class, wound class, operative laterality, urgency of case, and open versus minimally invasive repair. RESULTS 3345 patients were included in this study with 1101 (32.9%) receiving sugammadex for neuromuscular blockade reversal. The 30-day rate of POUR was 2.8%; 1.4% in the sugammadex and 4.4% in the anticholinesterase group. After propensity score matching, patients receiving sugammadex had significantly lower risk of POUR compared to anticholinesterase overall (OR 0.340, p < 0.001, 95% CI 0.198-0.585), in open (OR 0.296, p = 0.013, 95% CI 0.113-0.775) and minimally invasive cases (OR 0.36, p = 0.002, 95% CI 0.188-0.693), unilateral (OR 0.371, p = 0.001, 95% CI 0.203-0.681) and bilateral repairs (OR 0.25, p = 0.025, 95% CI 0.074-0.838), elective (OR 0.329, p < 0.001, 95% CI 0.185-0.584) and clean cases (OR 0.312, p < 0.001, 95% CI 0.176-0.553). CONCLUSIONS The incidence of 30-day new onset POUR was 2.8%. Sugammadex was associated with significantly lower risk of POUR after inguinal herniorrhaphy compared to anticholinesterase overall and when stratifying by operative modality, laterality, and wound class.
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Affiliation(s)
- Lucy Ching Chau
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA.
| | - Alexa Jarman
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Aaron Prater
- Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Ryan Soheim
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Kellie McFarlin
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Cletus Stanton
- Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
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Hodge C, Myers A, Ceneviva GD, Zhao R, Zhou S, Thomas NJ, Krawiec C. Retrospective Analysis of Sugammadex Use in Adolescent Females on Progestin-Containing Contraceptives. J Pediatr Adolesc Gynecol 2023; 36:459-464. [PMID: 37343781 PMCID: PMC10527360 DOI: 10.1016/j.jpag.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
STUDY OBJECTIVE Sugammadex, a novel neuromuscular blockade reversal agent, functions as a steroid binder postulated to decrease hormone exposure used within progestin-containing contraceptive medications. Thus, alternative non-medication contraceptive methods are recommended to prevent unplanned pregnancies. The study aims were to evaluate sugammadex use in adolescent females prescribed a progestin-containing contraceptive and positive pregnancy screening frequency. We hypothesized that sugammadex use is infrequent in this population and no pregnancy screens would be positive. METHODS This is a retrospective observational cohort study utilizing the TriNetX electronic health record database of female subjects aged 12-21 years reported to be prescribed sugammadex. The data collected were analyzed for demographic characteristics, International Classification of Diseases 9th and 10th edition diagnostics, medication, procedural codes, progestin-containing medication timing, and timing of pregnancy screening. RESULTS We included 18,686 subjects (contraceptive group, 2017 [10.8%], and no contraceptive group, 16,669 [89.2%]). Both groups had similar frequencies of pregnancy screening (contraceptive group, 54 [2.7%], vs no contraceptive group, 366 [2.2%]). Of the contraceptive group, 1 (0.05%) subject, 17 years of age, was confirmed to have a positive pregnancy screen 35 days after surgery. CONCLUSION We found that sugammadex may be administered to adolescent females prescribed progestin-containing contraceptives, but positive pregnancy screens are rare. Effective counseling, use of nonhormonal contraceptives 7 days after sugammadex administration, and the theoretical reproductive risks of this agent may have contributed to these findings. Continued counseling after sugammadex use in the adolescent population is recommended to avoid the occurrence of unplanned pregnancies.
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Affiliation(s)
- Caitlyn Hodge
- Academic Pediatrics, Pediatric, Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Abigail Myers
- Academic Pediatrics, Pediatric, Department of Pediatrics, Penn State Hershey Children's Hospital, Hershey, Pennsylvania
| | - Gasy D Ceneviva
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Rong Zhao
- Division of Biostatistics and Bioinformatics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Shouhao Zhou
- Division of Biostatistics and Bioinformatics, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Neal J Thomas
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania; Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania.
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Carrillo-Torres O, Pliego-Sánchez MG, Pérez-Muñoz VJ, Sánchez-Jurado J, Camacho-Vacherón V, Carrillo-Ruíz JD. Rate of residual neuromuscular block using single-dose rocuronium in general anesthesia for ENT surgery: a retrospective cohort study. BMC Anesthesiol 2023; 23:107. [PMID: 37005560 PMCID: PMC10067182 DOI: 10.1186/s12871-023-02027-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/24/2023] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION NMB facilitates intubating conditions in general anesthesia. However, it is associated with significant residual postoperative paralysis and morbidity. OBJECTIVE To investigate the rate of underdiagnosed residual NMB based on two TOFR criteria (< 0.91 and < 1.00). METHODS We performed a retrospective study adhering to STROBE guidelines. We included patients undergoing ENT surgery using single-dose neuromuscular block for balanced general anesthesia from June to December 2018. We collected demographic and anthropometric data, ASA score, NMBA dose, TOFR recordings at 5, 30 and 60 min and end of the surgery, anesthesia and surgery time, and administration of reversal agent. Statistical analysis included descriptive and dispersion measures statistics, curve and cross tables for residual NMB on different TOFR criteria with sub-analysis for AR, RR, and OR in patients over 65 years old. RESULTS We included 57 patients, mean age 41; 43 females and 14 males. Mean anesthetic and surgical time were 139.4 and 116.1 min, respectively. All the patients received rocuronium under a mean ponderal single-dose of 0.48 mg/kg. Residual NMB rates were 29.9 and 49.1% for a TOFR < 0.91 and < 1.00, respectively. Older adults had an OR of 6.08 for residual NMB. CONCLUSIONS The rate of residual NMB was 29.9 to 49.1%, depending on the criteria used (TOFR < 0.91 and < 1.00, respectively). Patients above 65 years old had an increased risk of residual NMB (6.08 OR) and clinical symptoms related to residual NMB (11.75 OR). We recommend future research aiming to provide a specific surveillance protocol for patients above 65 years old, including shorter-action NMB, early reversal, and prolonged surveillance using the TOFR criteria of < 1.00 to identify patients at risk of residual NMB readily.
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Affiliation(s)
| | | | | | | | | | - José Damián Carrillo-Ruíz
- Research Direction & Neurosurgery Service at Hospital General de México, Mexico City, Mexico.
- Neuroscience Coordination of Psychology Faculty at Mexico Anahuac University, Av. Anahuac 46, Lomas Anahuac, Naucalpan de Juárez, Estado de México, 52786, Mexico.
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Wang M, Li S, Jiang H, Yu W, Hu D, Duan S, Tang J, Li Y. Systematic Evaluation of Neuromuscular Reversal Agents in Obese Patients After General Anesthesia for Bariatric Surgery. Bariatr Surg Pract Patient Care 2023. [DOI: 10.1089/bari.2022.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
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Greco M, Caruso PF, Angelotti G, Aceto R, Coppalini G, Martinetti N, Albini M, Bash LD, Carvello M, Piccioni F, Monzani R, Montorsi M, Cecconi M. REVersal of nEuromusculAr bLocking Agents in Patients Undergoing General Anaesthesia (REVEAL Study). J Clin Med 2023; 12:jcm12020563. [PMID: 36675492 PMCID: PMC9866312 DOI: 10.3390/jcm12020563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Background: Neuromuscular blocking agent (NMBA) monitoring and reversals are key to avoiding residual curarization and improving patient outcomes. Sugammadex is a NMBA reversal with favorable pharmacological properties. There is a lack of real-world data detailing how the diffusion of sugammadex affects anesthetic monitoring and practice. Methods: We conducted an electronic health record analysis study, including all adult surgical patients undergoing general anesthesia with orotracheal intubation, from January 2016 to December 2019, to describe changes and temporal trends of NMBAs and NMBA reversals administration. Results: From an initial population of 115,046 surgeries, we included 37,882 procedures, with 24,583 (64.9%) treated with spontaneous recovery from neuromuscular block and 13,299 (35.1%) with NMBA reversals. NMBA reversals use doubled over 4 years from 25.5% to 42.5%, mainly driven by sugammadex use, which increased from 17.8% to 38.3%. Rocuronium increased from 58.6% (2016) to 94.5% (2019). Factors associated with NMBA reversal use in the multivariable analysis were severe obesity (OR 3.33 for class II and OR 11.4 for class III obesity, p-value < 0.001), and high ASA score (OR 1.47 for ASA III). Among comorbidities, OSAS, asthma, and other respiratory diseases showed the strongest association with NMBA reversal administration. Conclusions: Unrestricted availability of sugammadex led to a considerable increase in pharmacological NMBA reversal, with rocuronium use also rising. More research is needed to determine how unrestricted and safer NMBA reversal affects anesthesia intraoperative monitoring and practice.
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Affiliation(s)
- Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
- Correspondence:
| | - Pier Francesco Caruso
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | | | - Romina Aceto
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giacomo Coppalini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Albini
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | | | - Michele Carvello
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Federico Piccioni
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Roberta Monzani
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marco Montorsi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Surgery, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
- Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
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Togioka BM, Schenning KJ. Optimizing Reversal of Neuromuscular Block in Older Adults: Sugammadex or Neostigmine. Drugs Aging 2022; 39:749-761. [PMID: 35934764 DOI: 10.1007/s40266-022-00969-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 11/03/2022]
Abstract
Residual neuromuscular paralysis, the presence of clinically significant weakness after administration of pharmacologic neuromuscular blockade reversal, is associated with postoperative pulmonary complications and is more common in older patients. In contemporary anesthesia practice, reversal of neuromuscular blockade is accomplished with neostigmine or sugammadex. Neostigmine, an acetylcholinesterase inhibitor, increases the concentration of acetylcholine at the neuromuscular junction, providing competitive antagonism of neuromuscular blocking drug and facilitating muscle contraction. Sugammadex, a modified gamma-cyclodextrin, antagonizes neuromuscular blockade by encapsulating rocuronium and vecuronium in a one-to-one ratio for renal clearance, a pharmacokinetic property that led to the recommendation that sugammadex not be administered to those with end-stage renal disease. While data are limited, reports suggest sugammadex is efficacious and well tolerated in individuals with reduced renal function. Sugammadex provides a more rapid and complete reversal of neuromuscular blockade than neostigmine. There is also accumulating evidence that sugammadex may provide a protective effect against the development of postoperative pulmonary complications, nausea, and vomiting, and that it may have beneficial effects on the rate of bowel and bladder recovery after surgery. Accordingly, sugammadex administration is beneficial for most older patients undergoing surgery.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Mail Code: UHN-2, Portland, OR, 97239-3098, USA.
| | - Katie J Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Martini CH, Honing GHM, Bash LD, Olofsen E, Niesters M, van Velzen M, Dahan A, Boon M. The Use of Muscle Relaxants and Reversal Agents in a Setting Without Cost Restrictions: Experience from a Tertiary Academic Hospital in the Netherlands. Ther Clin Risk Manag 2022; 18:379-390. [PMID: 35422624 PMCID: PMC9005126 DOI: 10.2147/tcrm.s350314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/12/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction Material and Methods Results Conclusion
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Affiliation(s)
- Chris H Martini
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
- Correspondence: Chris H Martini, Department of Anesthesiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333, ZA, the Netherlands, Tel +31 71 526 2301, Email
| | - G H Maarten Honing
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lori D Bash
- Center for Observational and Real- World Evidence (CORE), Merck & Co., Inc, Kenilworth, NJ, USA
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Neuromuscular Blockade and Reversal Agent Practice Variability in the US Inpatient Surgical Settings. Adv Ther 2021; 38:4736-4755. [PMID: 34319550 PMCID: PMC8317140 DOI: 10.1007/s12325-021-01835-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/18/2021] [Indexed: 12/19/2022]
Abstract
Introduction The management of neuromuscular blockade (NMB) has evolved over time and remains a critical component of general anesthesia. However, NMB use varies by patient and procedural characteristics, clinical practices, protocols, and drug access. National utilization patterns are unknown. We describe changes in NMB and NMB reversal agent administration in surgical inpatients since the US introduction of sugammadex in December 2015. Methods In a retrospective observational study of inpatients involving NMB with rocuronium or vecuronium in the Premier Healthcare Database, we estimate associations between factors related to choice of (1) active NMB reversal versus spontaneous recovery and (2) sugammadex versus neostigmine as the reversal agent. Results Among 4.3 million adult inpatient encounters involving rocuronium or vecuronium, the most widely administered NMB agent was rocuronium alone (86%). Over time, gradual declines in both neostigmine use and spontaneous reversal were observed (64% and 36% in 2014 to 38% and 28%, respectively in the first half of 2019). Several factors were independently associated with use of active versus spontaneous NMB recovery including years since 2016, patient (age, race, comorbidities), and procedure (admission and surgery type) characteristics. Among those actively reversed, these and other factors were independently associated with choice of reversal agent administered, including size and teaching affiliation of hospital. While both impacted choices in treatment, the direction and magnitude of effect of patient comorbidities and procedure type varied in their impact on choice of mode (pharmacologic vs. spontaneous) and agent (neostigmine vs. sugammadex) of NMB reversal independent of other factors and each other. Sites which adopted sugammadex earlier were more likely to choose sugammadex over neostigmine compared with later adopters independent of other factors. Conclusions Among US adult inpatients administered NMBs, we observed complex relationships between patient, site, procedural characteristics, and NMB management choices as NMBA choice and active reversal options among inpatient cases changed over time. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01835-2. Neuromuscular blocking agents, medications that temporarily paralyze muscles, are used frequently during surgical procedures to facilitate intubation and patient immobility. Over time, muscle function can return spontaneously or through pharmacological reversal agents. This study looked at how the use of reversal agents in inpatients undergoing surgical procedures changed after a new reversal agent, sugammadex, became available for use in the USA in December 2015. Medical records of 4.3 million adult patients treated with neuromuscular blocking agents (rocuronium or vecuronium) in the USA were studied. In 2014 (before sugammadex was available), one-third of patients (36%) recovered spontaneously from a neuromuscular blocking agent and two-thirds (64%) were treated with the reversal agent neostigmine. The use of both neostigmine and spontaneous recovery reduced gradually after sugammadex became available, so that by the first half of 2019, 38% of patients were treated with neostigmine and 28% of patients recovered spontaneously. Whether or not a patient was treated with a reversal agent and what type of agent was chosen were affected by the length of time since 2016, patient characteristics, the type of surgical procedure that was performed as well as local hospital characteristics and practice differences.
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