Factors Associated With Decision to Use and Dosing of Sugammadex in Children: A Retrospective Cross-Sectional Observational Study

Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study

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.

Sugammadex for our little ones: a brief narrative review

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.

Weight-Based Standardized Sugammadex Dosing in Pediatrics: A Quality Improvement Initiative to Improve Compliance with Dosing Guidelines and Reduce Waste and Cost

Methods

Sugammadex vials were fractionated into 25, 50, or 100 mg aliquots, which would be distributed to anesthesia staff by pharmacy staff in approximate 2 mg/kg of actual body weight doses (±10%). We analyzed changes in sugammadex waste and dosing practices 1/1/2019 to 3/15/2023 pre/postintervention (4/1/2021). We gauged dose appropriateness using last train of four (TOF) prior to sugammadex administration.

Results

7,889 patients 2-17 years (4,771 with documented TOF), ASA 1-4 receiving general anesthesia with a steroidal NMB medication and sugammadex reversal. Pre- and postintervention mean doses were 2.5 mg/kg (SD: 1.2) and 2.4 mg/kg (SD: 0.96), respectively. A smaller proportion of cases received standard 2 or 4 mg/kg doses (pre: 77.6 vs. post: 66.7%). Mean waste per case declined from 4.2 mg/kg (SD: 4.1) to 0.22 mg/kg (SD: 0.38). Among cases with 0 or 1 measured twitches on TOF that should receive at least 4 mg/kg, fewer received at least 3.6 mg/kg (post: 56.7% vs. pre: 66.8%), and a greater proportion received less than 2.2 mg/kg (post: 27.4% vs. pre: 20.7%). Among cases that should have received at least 2 mg/kg by TOF, the proportion of patients receiving more than 3.6 mg/kg declined from 9.5% to 5.2%. Discussion. Fractionating sugammadex vials was associated with decreases in waste, but not dose, and significant underdosing was more likely to occur. While vial fractionation could enable increased access to sugammadex and other costly medications, it may introduce unintended consequences.