Factors Associated With Decision to Use and Dosing of Sugammadex in Children

BACKGROUND:

Sugammadex was initially approved for reversal of neuromuscular blockade in adults in the United States in 2015. Limited data suggest sugammadex is widely used in pediatric anesthesia practice however the factors influencing use are not known. We explore patient, surgical, and institutional factors associated with the decision to use sugammadex versus neostigmine or no reversal, and the decision to use 2 mg/kg vs 4 mg/kg dosing.

METHODS:

Using data from the Multicenter Perioperative Outcomes Group (MPOG) database, an EHR-derived registry, we conducted a retrospective cross-sectional study. Eligible cases were performed between January 1, 2016 and December 31, 2020, for children 0 to 17 years at US hospitals. Cases involved general anesthesia with endotracheal intubation and administration of rocuronium or vecuronium. Using generalized linear mixed models with institution and anesthesiologist-specific random intercepts, we measured the importance of a variety of patient, clinician, institution, anesthetic, and surgical risk factors in the decision to use sugammadex versus neostigmine, and the decision to use a 2 mg/kg vs 4 mg/kg dose. We then used intraclass correlation statistics to evaluate the proportion of variance contributed by institution and anesthesiologist specifically.

RESULTS:

There were 97,654 eligible anesthetics across 30 institutions. Of these 47.1% received sugammadex, 43.1% received neostigmine, and 9.8% received no reversal agent. Variability in the choice to use sugammadex was attributable primarily to institution (40.4%) and attending anesthesiologist (27.1%). Factors associated with sugammadex use (compared to neostigmine) include time from first institutional use of sugammadex (odds ratio [OR], 1.08, 95% confidence interval [CI], 1.08–1.09, per month, P < .001), younger patient age groups (0–27 days OR, 2.59 [2.00–3.34], P < .001; 28 days–1 year OR, 2.72 [2.16–3.43], P < .001 vs 12–17 years), increased American Society of Anesthesiologists [ASA] physical status (ASA III: OR, 1.32 [1.23–1.42], P < .001 ASA IV OR, 1.71 [1.46–2.00], P < .001 vs ASA I), neuromuscular disease (OR, 1.14 (1.04–1.26], P = .006), cardiac surgery (OR, 1.76 [1.40–2.22], P < .001), dose of neuromuscular blockade within the hour before reversal (>2 ED95s/kg OR, 4.58 (4.14–5.07], P < .001 vs none), and shorter case duration (case duration <60 minutes OR, 2.06 [1.75–2.43], P < .001 vs >300 minutes).

CONCLUSIONS:

Variation in sugammadex use was primarily explained by institution and attending anesthesiologist. Patient factors associated with the decision to use sugammadex included younger age, higher doses of neuromuscular blocking agents, and increased medical complexity.