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Brown SES, Cassidy R, Zhao X, Nause-Osthoff R, Wade M, Wagner D, Haydar B, Chimbira W, Kheterpal S, Colquhoun DA. Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study. Anesth Analg 2024:00000539-990000000-00883. [PMID: 39058621 DOI: 10.1213/ane.0000000000007048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
BACKGROUND Sugammadex is a neuromuscular blockade (NMB) reversal agent introduced in the United States in 2016, which allows the reversal of deep NMB, not possible with neostigmine. Few data describe associated practice changes, if any, in NMB medication use that may have resulted from its availability. We hypothesized that after institutional introduction, use of NMB agents increased. Furthermore, as NMB medication is typically used when the airway has been secured with an endotracheal tube (ETT), we speculated that ETT use may have also increased over the same time period as a result of sugammadex availability. METHODS This was a single-center cross-sectional study of patients ages 2 to 17 years undergoing general anesthesia for surgical cases where anesthesia providers often have discretion over NMB medication use or whether to use an ETT versus a laryngeal mask airway (LMA), comparing the time periods 2014 to 2016 (presugammadex) to 2017 to 2019 (early sugammadex) and 2020 to 2022 (established sugammadex). Outcomes included use of (1) any nondepolarizing NMB medication during the case and (2) an ETT versus LMA. We used generalized linear mixed models to examine changes in practice patterns over time. We also examined whether patient age group and in-room provider (resident versus certified registered nurse anesthetist [CRNA]) were associated with increased NMB medication or ETT use. RESULTS There were 25,638 eligible anesthetics. Patient and surgical characteristics were similar across time periods. In adjusted analyses, the odds of NMB medication use increased from 2017 to 2019 (odds ratio [OR], 1.55, 95% confidence interval [CI], 1.38-1.75) and 2020 to 2022 (OR, 5.62, 95% CI, 4.96-6.37) relative to 2014 to 2016, and were higher in older children (age 6-11 years vs 2-5 years OR, 1.81, 95% CI, 1.63-2.01; age 12-17 years vs 2-5 years OR, 7.01, 95% CI, 6.19-7.92) and when the primary in-room provider was a resident rather than a CRNA (OR, 1.24, 95% CI, 1.12-1.37). The odds of ETT use declined 2017 to 2019 (OR, 0.69, 95% CI, 0.63-0.75) and 2020 to 2022 (OR, 0.71, 95% CI, 0.65-0.78), more so in older children (age 6-11 years vs 2-5 years OR, 0.45, 95% CI, 0.42-0.49; age 12-17 years vs 2-5 years OR, 0.28, 95% CI, 0.25-0.31). Resident presence at induction was associated with increased odds of ETT use (OR, 1.50, 95% CI, 1.38-1.62). CONCLUSIONS The decision to use NMB medication as part of an anesthetic plan increased substantially after sugammadex became available, particularly in older children and cases staffed by residents. ETT use declined over the study period.
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Affiliation(s)
- Sydney E S Brown
- From the Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
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Willer BL, Mpody C, Nafiu OO. Trends in Adolescent Comorbid Cannabis Use Disorder and Postoperative Complications. Pediatrics 2024; 153:e2024065757. [PMID: 38708543 DOI: 10.1542/peds.2024-065757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Increasing legalization and widespread misinformation about the dangers of cannabis use have contributed to the rising prevalence of cannabis use disorder (CUD) among adolescents. Our objective was to determine the prevalence of CUD in adolescent surgical patients and evaluate its association with postoperative complications. METHODS We performed a retrospective, 1:1 propensity-matched cohort study of adolescents (aged 10-17 years) with and without CUD who underwent inpatient operations at US hospitals participating in the Pediatric Health Information System from 2009 to 2022. The primary outcome was the trend in prevalence of CUD. Secondary outcomes included postoperative complications. Using a Bonferroni correction, we considered a P value < .008 to be significant. RESULTS Of 558 721 adolescents undergoing inpatient surgery from 2009 to 2022, 2604 (0.5%) were diagnosed with CUD (2483 were propensity matched). The prevalence of CUD increased from 0.4% in 2009 to 0.6% in 2022 (P < .001). The adjusted odds of respiratory complications, ICU admission, mechanical ventilation, and extended hospital stay were significantly higher in adolescents with CUD (respiratory complications: odds ratio [OR], 1.52; 95% confidence interval [CI], 1.16-2.00; P = .002; ICU admission: OR, 1.78; 95% CI, 1.61-1.98; P < .001; mechanical ventilation: OR, 2.41; 95% CI, 2.10-2.77; P < .001; extended hospital stay: OR, 1.96; 95% CI, 1.74-2.20; P < .001). The propensity score-adjusted odds of postoperative mortality or stroke for adolescents with CUD were not significantly increased (mortality: OR, 1.40; 95% CI, 0.87-2.25; P = .168; stroke: OR, 2.46; 95% CI, 1.13-5.36; P = .024). CONCLUSIONS CUD is increasing among adolescents scheduled for surgery. Given its association with postoperative complications, it is crucial to screen adolescents for cannabis use to allow timely counseling and perioperative risk mitigation.
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Affiliation(s)
- Brittany L Willer
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio
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Faulk DJ, Karlik JB, Strupp KM, Tran SM, Twite M, Brull SJ, Yaster M, Austin TM. The Incidence of Residual Neuromuscular Block in Pediatrics: A Prospective, Pragmatic, Multi-institutional Cohort Study. Cureus 2024; 16:e56408. [PMID: 38638790 PMCID: PMC11024486 DOI: 10.7759/cureus.56408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Introduction Residual neuromuscular block, defined as a quantitatively measured train-of-four ratio (TOFr) <0.9, is common postoperatively. Using a pragmatic trial design, we hypothesized that qualitative and/or clinical assessment of neuromuscular block would inadequately detect residual block following antagonism with neostigmine or sugammadex. Method After IRB approval and written informed consent, 74 children (aged 2-17 years), undergoing elective surgery and receiving rocuronium, were prospectively enrolled in the study at Children's Hospital Colorado and Children's Healthcare of Atlanta. Routine clinical practice at both institutions consisted of clinical signs and/or qualitative assessment with peripheral nerve stimulators. Children at the Colorado hospital routinely received sugammadex antagonism; whereas children at the Atlanta hospital received neostigmine. Residual neuromuscular block was assessed postoperatively using quantitative electromyography. If TOFr was <0.9, patients received sugammadex until TOFr ≥0.9. Result Qualitative and clinical assessment failed to detect residual block in 29.7% of patients in the neostigmine reversal cohort (adjusted odds ratio (aOR) 29.8, 95% confidence interval (CI): 2.7 to 5,559.5, p-value = 0.002). No residual block was detected in the sugammadex reversal cohort. A correlation between increasing patient weight and incidence of postoperative residual block was observed in the neostigmine cohort (aOR 1.05, 95% CI: 1.02 to 1.10, p-value = 0.002). Conclusion Qualitative and/or clinical assessment of neuromuscular block inadequately detects residual block following neostigmine antagonism.
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Affiliation(s)
- Debra J Faulk
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Joelle B Karlik
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Kim M Strupp
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Stephanie M Tran
- Anesthesiology, Emory University School of Medicine, Atlanta, USA
| | - Mark Twite
- Anesthesiology, Children's Hospital Colorado, Denver, USA
| | - Sorin J Brull
- Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, USA
| | - Myron Yaster
- Anesthesiology, Children's Hospital Colorado, Denver, 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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Brown SES, Spellman K, Cassidy R, Nause-Osthoff R, Bailey M, Mentz G, Wagner D, Haydar B, Chimbira W, Kheterpal S, Colquhoun D. A retrospective observational cross-sectional study of intraoperative neuromuscular blocking agent choice and dosing in a US paediatric referral hospital before and after introduction of sugammadex ☆. Br J Anaesth 2023; 131:e117-e120. [PMID: 37574423 PMCID: PMC10624852 DOI: 10.1016/j.bja.2023.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/30/2023] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Affiliation(s)
- Sydney E S Brown
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
| | - Kevin Spellman
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ruth Cassidy
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | | | - Meridith Bailey
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Deborah Wagner
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Bishr Haydar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Wilson Chimbira
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Douglas Colquhoun
- Department of Anesthesiology, University of Michigan, Ann Arbor, 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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Cha YM, Faulk DJ. Management of Neuromuscular Block in Pediatric Patients — Safety Implications. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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