Neuromuscular blockade in pediatrics: some inconvenient truths

Myron Yaster

Original article

Debra J Faulk, Thomas M Austin, James J Thomas, Kim Strupp, Andrew W Macrae, Myron Yaster. A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade. Anesth Analg.  2021 Jun 1;132(6):1518-1526. PMID: 33543867

Editorial

J Ross Renew, Joseph D Tobias, Sorin J Brull. The Time to Seriously Reassess the Use and Misuse of Neuromuscular Blockade in Children Is Now. Anesth Analg  2021 Jun 1;132(6):1514-1517. PMID: 34032656

Before reading today’s PAAD, an important disclaimer.  I am the senior author of this paper and as the senior author and mentor to its authors, I obviously have a conflict of interest.

Based on a survey of the members of the Society for Pediatric Anesthesia, Faulk et al. found some very important and at times disturbing findings concerning the use, monitoring, and antagonism of neuromuscular blockade in pediatric anesthesia practice.  First and not surprisingly, sugammadex, despite its lack of US FDA approval for use in pediatrics, is used either primarily or exclusively by nearly two-thirds of pediatric anesthesiologists, particularly by those clinicians with ≤5 years of practice. Second, because of sugammadex’s presumed effectiveness, fewer and fewer people are monitoring neuromuscular blockade.  Again, failure to monitor blockade was more common in clinicians who came of age in the sugammadex era, that is, clinicians with ≤5 years of practice.  Third, even when respondents do monitor neuromuscular blockade, they are primarily using qualitative and not quantitative monitors. The implications are enormous; without quantitative guidance, residual neuromuscular block and its attendant complications are to be expected.  Fourth, quantitative monitoring devices are now commercially available.  Why are qualitative monitors, which are very inaccurate, still the norm?  My bet is that you, the reader, do not have quantitative monitors in your ORs.  Why not?  Finally, these results point to a terrible failure in our training programs which to me are incomprehensible.  Trainees are taught or observe that monitoring of neuromuscular blockade is unnecessary.  As the accompanying editorial points out “training programs must start emphasizing the need for objective (quantitative) neuromuscular monitoring during anesthesia training; residents who understand and embrace safety principles during their critical formative years are much more likely to incorporate these principles in their routine lifelong practice”.

Another interesting finding in the survey involved sugammadex administration and female pediatric patients of child-bearing age. Faulk et al. raise an important potential concern with sugammadex: its potential to reduce the effectiveness of hormonal contraceptives. Thirty-eight percent of survey respondents reported not discussing the interaction between sugammadex and hormonal contraceptives with their patients. The package insert clearly suggests that if sugammadex is administered, the patient must use an additional, nonhormonal method of contraception for the following 7 days. I know I didn’t do this or avoided the whole issue by switching to “old reliable” neostigmine. What do you do?

Finally, this study underlines the power and limitations of on-line surveys.  A low response rate (only 13% of SPA members in this study, 16% of ASA members in Amy Vinson’s recent burn out study, which will be highlighted in the PAAD next week) is a potential source of bias and only representative of those who replied. In this study, and others performed by this research group, a subset of non-responders were contacted by telephone or email to compare their responses to those who responded to the original survey. Because the results were essentially the same, the authors concluded that the results are representative of the entire Society.  Obviously, there are many other problems with all surveys as well, not the least of which is that we don’t know if respondents are 100% truthful in their responses.  Nevertheless, (and here is where my bias comes into play), I think surveys with all of their shortcomings provide a powerful window into how we practice.  Soooooo, I would urge all of you, when you get these SPA or ASA surveys in your inbox, take a couple of minutes and fill them out!

Myron Yaster MD