A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade

Debra J. Faulk, MD; Thomas M. Austin, MD, MS; James J. Thomas, MD; Kim Strupp, MD; Andrew W. Macrae, BS; Myron Yaster, MD

Disclosures

Anesth Analg. 2021;132(6):1518-1526. 

In This Article

Abstract and Introduction

Abstract

Background: Although the package insert clearly states that "the safety and efficacy of sugammadex in pediatric patients have not been established," we hypothesized that sugammadex is used widely in pediatric anesthetic practice supplanting neostigmine as the primary drug for antagonizing neuromuscular blockade (NMB). Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex's effects on hormonal contraception, we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period.

Methods:We e-mailed a questionnaire to all 3245 members of the Society of Pediatric Anesthesia (SPA) requesting demographic data and attitudes regarding use of NMB agents, monitoring, and antagonism practices. To address low initial response rates and quantify nonresponse bias, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not initially respond. Response differences between the 2 cohorts were determined.

Results:Initial questionnaire response rate was 13% (419 of 3245). Overall, 163 respondents (38.9%; 95% confidence interval [CI], 34.2–43.8) used sugammadex as their primary reversal agent, and 106 (25.2%; 95% CI, 21.2–30.0) used it exclusively. Respondents with ≤5 years of practice used sugammadex as their primary reversal agent more often than those with ≥6 years of practice (odds ratio [OR]: 2.08; 95% CI, 1.31–3.31; P = .001). This increased utilization remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38–3.54; P = .001). Only 40% of practitioners always assess NMB (train-of-four), and use was inversely correlated with years of practice (Spearman ρ = −0.11, P = .04). Anesthesiologists who primarily used sugammadex assess NMB less routinely (OR: 0.56; 95% CI, 0.34–0.90; P = .01). A slim majority (52.8%) used sugammadex for pediatric postmenarchal girls; those with less experience used it more commonly (P < .001). Thirty-eight percent did not discuss its effects on hormonal contraception with the patient and/or family, independent of anesthesiologist experience (P = .33) and practice location (P = .38). No significant differences were seen in demographics or practice responses between initial and follow-up survey respondents.

Conclusions: Sugammadex is commonly used in pediatric anesthesia, particularly among anesthesiologists with fewer years of practice. Failure to warn postmenarchal adolescents of its consequences may result in unintended pregnancies. Finally, pediatric anesthesia training programs should emphasize objective monitoring of NMB, particularly with sugammadex use.

Introduction

Neuromuscular blocking agents (NMBAs) suppress voluntary or reflex skeletal muscle movements to pain.[1,2] Since their introduction they have revolutionized anesthetic practice by facilitating tracheal intubation, ensuring patient immobility, and improving surgical operating conditions.[1,2] Before extubation, it is standard clinical practice to pharmacologically antagonize these agents with either neostigmine or sugammadex in a process known as "reversal."[1] Residual blockade, defined as a train-of-four (TOF) ratio of <0.9, during the early recovery period from anesthesia is common in both adult and pediatric populations.[1,2] However, small degrees of muscle weakness can have important clinical consequences, including pharyngeal dysfunction, airway obstruction, aspiration, hypoxemic episodes, critical respiratory events, prolonged postanesthesia care unit length of stay, and unpleasant symptoms of muscle weakness.[2–5] Indeed, impaired upper airway integrity may persist in some subjects even after the TOF ratio has returned to unity.[6]

The introduction of sugammadex has revolutionized anesthetic practice and has replaced neostigmine as the drug of choice to antagonize the effects of rocuronium and vecuronium in adult patients, but still requires assessment of NMB.[7–9] Sugammadex has displaced neostigmine because it produces fast and predictable reversal of any degree of neuromuscular blockade (NMB), increases patient safety, and reduces the incidence of residual block on recovery. As a result, sugammadex is a more efficient use of health care resources and leads to fewer postoperative complications.[4,5,10,11] We hypothesized that the use of sugammadex in pediatric anesthetic practice is widespread and has supplanted neostigmine as the primary drug for antagonizing NMB despite its package insert clearly stating that "the safety and efficacy of sugammadex in pediatric patients have not been established."[12] Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex's effects on hormonal contraception,[13] we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period.

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