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

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.