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


Of the 3245 SPA members surveyed, 419 (13%) responded to the online questionnaire with most answering all of the questions (response missingness ranged from 0% to 6.4% depending on the question). Respondent demographics, years in practice, and practice setting and type are presented in Table 1. Overall, 163 respondents (38.9%; 95% CI, 34.2–43.8) used sugammadex as their primary reversal agent, and 106 (25.3%; 95% CI, 21.2–30.0) used it exclusively (Table 2). Sugammadex use differed by years in practice, with more seasoned practitioners administering it less often (P = .003). Compared to pediatric anesthesia providers who had been in practice for ≥6 years, respondents with ≤5 years of independent practice used sugammadex as their primary reversal agent more often (odds ratio [OR]: 2.08; 95% CI, 1.31–3.31; P = .001; Figure 1). This increased use of sugammadex remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38–3.54; P = .001). An overwhelming majority (83.4%) of the respondents stated that there was no extrinsic institutional restriction to either sugammadex or neostigmine use (Table 2), and this was not associated with practice setting (P = .14) and site (P = .45). Practitioners were more likely to self-limit the use of sugammadex because of either cost (24.9%) or efficacy (3.3%) rather than institutional mandates (Table 2).

Figure 1.

The percentage of Society for Pediatric Anesthesia members with 5 or fewer years of experience and with 6 or more years of experience who use sugammadex as their primary reversal agent; ≤5 y (38%), >6 y (22%); *P = .001.

Most respondents did not have an age restriction for administering sugammadex to pediatric patients (61.1%, Table 2). In addition, a slim majority of providers would use sugammadex for pediatric postmenarchal girls (52.8%). Less experienced providers were more likely to use sugammadex in this subpopulation than were those with more years of independent practice experience (P < .001; Figure 2). Of the respondents who would use sugammadex in this subpopulation, more than a third (38.2%) did not discuss its effects on hormonal contraception with the patient and/or family (Table 2). However, this practice was not associated with anesthesiologist experience (P = .33) and practice location (P = .38). A large majority of respondents (89.2%) did not believe that there was an US FDA-labeled indication for sugammadex use in pediatric populations and most (85.4%) were unaffected by this labeling (Table 2).

Figure 2.

The percentage of Society for Pediatric Anesthesia members who use sugammadex in postmenarchal adolescents, distributed by years in practice. Currently in training (76%), 0–5 y (68%), 6–10 y (55%), 11–15 y (45%), 16–25 y (41%), and >25 y (47%). P < .001, based on simple logistic regression for the binary outcome sugammadex use and the ordinal exposure years in practice.

Qualitative TOF devices (peripheral nerve stimulators [PNSs]) were the most commonly available devices (57.7%) regardless of practice location (Table 3). Quantitative monitors (acceleromyography-based, kinemyography-based, or electromyography-based monitors) were available in 38% of locations. Many respondents (40.0%) always used some manner of TOF assessment before sugammadex introduction (Table 3), and use was inversely correlated with years of experience (Spearman ρ = −0.11; P = .04). Since the introduction of sugammadex, two-thirds of practitioners still routinely use TOF assessment (Table 3), although anesthesiologists who used sugammadex as their primary reversal agent did not use routine TOF assessment as often (OR: 0.56; 95% CI, 0.34–0.90; P = .01). The most common (47.3%) preferred anatomic site for the TOF assessment was based on surgical positioning, with the exact site being consequential (Table 3). Some respondents (12.8%) reported failure of reversal with sugammadex after normal rocuronium dosing, but a much larger percentage (62.9%) experienced failure with neostigmine (Table 3).

Regarding the secondary survey, 5 surveys were conducted via telephone call while the remainder occurred by e-mail. All but one of the respondents answered all of the questions. The demographics of the nonrespondents were similar to those of SPA members who responded to the primary survey (Supplemental Digital Content 2, Table 2, http://links.lww.com/AA/D365). In addition, the nonrespondents did not differ significantly from initial respondents in their practices with respect to NMB reversal and TOF monitoring (Supplemental Digital Content 3, Table 3, http://links.lww.com/AA/D366).