Author: Erika Powers
The time between the last dose of rocuronium and neostigmine, and a cumulative dose of rocuronium >0.505 mg/kg/hr appear to be associated with incomplete neuromuscular blockade reversal in children and adolescents aged younger than 18 years, according to a study presented at Anesthesiology 2021, the Annual Meeting of the American Society of Anesthesiologists (ASA).
“Although incomplete neuromuscular blockade reversal has been shown to be fairly common in adult patients, it is rarely reported in children,” stated Madeline Fram, Wake Forest University School of Medicine, Winston Salem, North Carolina.
The researchers evaluated risk factors for incomplete neuromuscular blockade reversal following administration of rocuronium in 6,415 paediatric patients who received neostigmine for reversal following administration of rocuronium. Of these, 105 patients were found to have incomplete reversal, with 38 receiving sugammadex following initial neuromuscular blockade reversal and 67 receiving a second dose of neostigmine following initial neuromuscular blockade reversal.
Time less than 35 minutes between the last dose of rocuronium and neostigmine (odds ratio [OR], 1.655; 95% confidence interval [CI], 1.014-2.698]), and a cumulative dose of rocuronium more than 0.505 mg/kg/hr (OR, 4.421; 95% CI, 2.647-7.510) were significantly associated with the need for additional reversal.
The researchers also found that an initial reversal dose of <0.05 mg/kg of neostigmine (OR, 2.674; 95% CI, 1.721-4.152) and African American race (OR, 2.151; 95% CI, 1.286-3.529) were also associated with the need for additional reversal.
“At this point, it is not immediately obvious why children of African American descent would be at greater risk for additional reversal,” noted Fram.
The researchers queried electronic medical records for paediatric patients who underwent anaesthesia from January 1, 2017 to December 31, 2020 and received rocuronium and additional reversal with sugammadex, or a second dose of neostigmine following initial reversal with neostigmine. Patients were matched to controls by age and sex.
Limitations of the study include its retrospective nature and the exclusion of patients who received other non-depolarising neuromuscular blocking drugs.
“These findings should be confirmed in a larger multicentre cohort of patients,” said Fram.