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


Anesth Analg. 2021;132(6):1518-1526. 

In This Article


Survey Design and Administration

This article was written in accordance with the Strengthening The Reporting of Observational studies in Epidemiology (STROBE) guidelines. After obtaining a waiver from the Colorado Multiple Institutional Review Board and approval from the research and quality and safety committees of the Society for Pediatric Anesthesia (SPA), we sent an e-mail questionnaire to all SPA members (n = 3245) between October and December 2019. The survey was created with input from SPA's research and quality and safety committees and a survey and database specialist. We piloted the survey with attendings and fellows of the Children's Hospital Colorado to assess for language and comprehension. The questionnaire (Supplemental Digital Content 1, Table 1, http://links.lww.com/AA/D364) consisted of 13 questions to identify which antagonist was the respondent's preferred agent to reverse NMB, if this choice was altered in postmenarchal females, and how and if they assess NMB in their practice. We also collected provider demographics including age, sex, fellowship training, type of practice (pediatrics only or mixed adult/pediatric), practice setting (private, academic, military, or other), site of practice (freestanding pediatric hospital, adult hospital, pediatric hospital within an adult hospital, ambulatory surgery center, or other), location of practice by time zone (East, Central, Mountain, Pacific, or outside of North America), and years in practice (Supplemental Digital Content 1, Table [Survey] 1, http://links.lww.com/AA/D364). All responses were deidentified and were collected with Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN; https://redcap.vanderbilt.edu) electronic data capture tools. A reminder e-mail was sent weekly for 1 month to those members who did not complete the survey over the study collection period.

Nonrespondent Survey

Because the initial response rate was low, a method was needed to quantify nonresponse bias. Therefore, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not respond to the initial survey. We used these surveys to determine response differences between the 2 cohorts. Members were selected through the Society's membership directory and were contacted via telephone or e-mail address based on their listed information.

Statistical Analysis

All deidentified REDCap data were exported as an Excel spreadsheet (Microsoft Corporation, Redmond, WA). Data from respondents who did not complete the survey were excluded. Univariate analyses were carried out with the Wilcoxon Rank Sum test for ordinal outcome (eg, TOF monitor use) and categorical exposure (eg, academic center), with the Fisher exact test for categorical outcome (eg, sugammadex preference) and categorical exposure (eg, academic center), with the Spearman test to analyze correlation between an ordinal outcome (eg, TOF monitor use) and an ordinal exposure (eg, years in practice), and with simple logistic regression for a binary outcome (eg, sugammadex preference) and ordinal exposure (eg, years in practice). To limit confounding, we performed multivariable logistic regression with sugammadex preference as the response variable and years in practice (≤5 years vs ≥6 years), institutional restriction, and academic center as the explanatory variables. The R statistical software package (Version 2.15.1) was used for this analysis and 2-sided P values of <.05 were considered statistically significant. We calculated the 95% confidence interval (CI) for proportions using exact Clopper-Pearson intervals.

Power Analysis

In a previous worldwide study from 2017,[14] 28% of anesthesia providers stated that they utilized sugammadex mostly/always for reversal of NMB. Since sugammadex received approval from the US Food and Drug Administration (US FDA) in 2015,[15] we hypothesized that pediatric anesthesiologists who finished their training within the last 5 years (and current trainees) would display a 2-fold increase in the odds of using sugammadex as their primary reversal agent (ie, >50% use) compared to pediatric anesthesiologists 6 or more years out from training (ie, 44% vs 28%). Given the approximate 3:1 predominance of pediatric anesthesia providers in SPA who have been in practice for ≥6 years versus those who have been practicing ≤5 years,[16] a total sample size of 379 (n = 95 in the ≤5-year cohort) was required to exhibit this difference with a type I and II error rate of 5% and 20%, respectively.