Today’s PAAD by Brown et al.1 and its accompanying editorial by Stein and Cravero2 reviews how the addition of sugammadex substantially changed pediatric (2-17 years of age) anesthetic practice at the University of Michigan. Over the last 20+ years, tracheal intubation facilitated with neuromuscular blockade (NMB) fell out of favor. In its place, to maximize intubation conditions, many anesthesiologists intubated with an IV bolus of propofol or abandoned intubation completely in favor of supraglottic airways like the laryngeal mask airway (LMA). The introduction of sugammadex which is rapidly acting and can antagonize (reverse) even deep rocuronium NMB with minimal side effects essentially changed adult and pediatric practice and has led to a renaissance in the use of NMB agents.3 Myron Yaster MD
Editorial
Stein ML, JP and Cravero J. Unintended Consequences: Is Sugammadex Changing the Way We Deliver Anesthesia? Anesth Analg. 2025 Mar 1;140(3):537-538. doi: 10.1213/ANE.0000000000007116. Epub 2025 Feb 14. PMID: 39976619.
Original article
Brown SES, Cassidy R, Zhao X, Nause-Osthoff R, Wade M, Wagner D, Haydar B, Chimbira W, Kheterpal S, Colquhoun DA. Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study. Anesth Analg. 2025 Mar 1;140(3):539-549. doi: 10.1213/ANE.0000000000007048. Epub 2024 Jul 26. PMID: 39058621; PMCID: PMC11762355.
Brown et al.1 “hypothesized that as sugammadex became available, more children would receive NMB medication and endotracheal intubation. They further hypothesized that these changes would be more pronounced in younger patients because of recommendations encouraging the use of NMB medications for intubation in this population and the lower baseline use of NMB in younger patients.”
This was a retrospective, cross-sectional study examining pediatric patients undergoing general anesthesia with either ETT or LMA in patients 2 to 17 years, between January 1, 2014 through December 31, 2022 at a single tertiary Children’s Hospital (University of Michigan, Ann Arbor, Michigan). Perhaps not surprisingly, the authors found that shortly after sugammadex was introduced into their practice the odds of a patient being paralyzed with rocuronium and reversed with sugammadex increased substantially. Prior to its introduction, when patients were paralyzed during anesthesia in this institution, cisatracurium was the primary NMB. Following the introduction of sugammadex, cisatracurium use plummeted and essentially disappeared and was replaced by rocuronium. The increased use of NMB was most pronounced in children 6-17 years of age. And note that children < 2 years of age were not studied. The authors also found that “NMB medication use was more likely in patients cared for by residents rather than CRNAs, though increases in use occurred among both provider groups during the study period.”1 Finally, the authors found that the use of ETTs relative to LMAs decreased during the study period, contrary to their hypothesis that the availability of sugammadex would result in an increased use of ETT for airway management.1 Overall, while ETTs were used less frequently, when chosen for airway management, their use was more often accompanied by concomitant NMB use.
In the accompanying editorial Stein and Cravero point out how novel therapeutics and technology have the ability to transform and change our practice.2 But, understanding the broader implications of such practice changes, and for me (DF), the unintended consequences that come with the introduction of sugammadex must be considered. An important factor that is mentioned by both Brown et al. and Stein and Cravero is the potential for anesthesiologists to keep patients at deeper levels of neuromuscular block than needed for longer periods of time due to the efficacy of sugammadex to antagonize all levels of block. When patients are paralyzed with NMB agents, it is essential that the adequacy of reversal be established with quantitative assessment of neuromuscular function.4 It has been noted that the use of sugammadex has been associated with decreased monitoring in pediatric anesthesia, even though sugammadex failures have been reported.3 Many questions remain about the risks or benefits resulting from our new practice patterns after the introduction of sugammadex. Are surgical conditions and outcomes improved? Are fewer respiratory adverse events to be seen with adequate neuromuscular recovery, or is risk imposed if sugammadex use leads to increased rates of deep extubations? And what is the impact on the cost of care with possibly increased perioperative efficiency opposed to the cost of medications or unforeseen adverse events resulting from changes in clinical practice.
As discussed in many previous PAADs, quantitative assessment of neuromuscular function with electromyography (EMG), mechanomyography, or acceleromyography at the adductor pollicis is the only way to accurately measure a train of four ratio (TOFr). Current recommendations are not to extubate until the TOFr is >90% as measured quantitatively at the adductor pollicis.4 Over the past 2 years, we’ve reviewed the topic of neuromuscular blockade, monitoring and antagonism in several PAADs. We are including some of our previous PAADs with their hyperlinks for those of you interested in a deeper dive.
PAAD 01/11/2023 Neuromuscular blockade Part https://ronlitman.substack.com/publish/posts/detail/94707173?referrer=%2Fpublish%2Fposts%3Fsearch%3Dneuromuscular
PAAD 01/12/2023 Neuromuscular blockade Part https://ronlitman.substack.com/p/neuromuscular-blockade-part-2
PAAD 07/15/2021 Neuromuscular blockade in pediatrics: some inconvenient truths https://ronlitman.substack.com/p/neuromuscular-blockade-in-pediatrics
PAAD 07/6/2022 “I don’t need no stinkin’ quantitative neuromuscular blockade monitor”…you probably do https://ronlitman.substack.com/publish/posts/detail/61905663?referrer=%2Fpublish%2Fposts%3Fsearch%3Dneuromuscular
PAAD 08/14/2023 Sugammadex reversal of neuromuscular blockade requires quantitative monitoring https://ronlitman.substack.com/p/sugammadex-reversal-of-neuromuscular
An intriguing thought not mentioned in this PAAD’s featured articles is this: when Dr. Ted Eger developed the idea of MAC, he and his colleagues used movement to painful stimulation as the marker of depth of anesthesia. At the time there was simply no way to determine levels of consciousness. We do today and the introduction of continuous EEG monitoring to assess the depth of hypnosis is becoming increasingly common and has also been a frequent area of discussion in the PAADs. We know that the MAC awake (or loss of consciousness depending on your perspective) is at least a third or more less than the traditional MAC values. Why is this important? By providing a depth of anesthesia to prevent movement to pain, such as giving a bolus of propofol prior to intubation in a patient who underwent an inhalational induction, we are probably overdosing them. And in adults overdosing patients with general anesthetics may produce postoperative delirium and long term cognitive defects.5 By using NMB agents, particularly if we are also using continuous EEG monitors, we can produce immobility and hypnosis at much lower and personalized level of anesthesia. We are including some of our previous PAADs on EEG monitoring with their hyperlinks for those of you interested in a deeper dive or review.
PAAD 08/02/2022 EEG part 1 https://ronlitman.substack.com/p/eeg-part-1
PAAD 08/10/2022 EEG part 2 https://ronlitman.substack.com/p/eeg-part-2
PAAD 08/16/2022 EEG part 3 https://ronlitman.substack.com/p/eeg-part-3
PAAD 08/25/2022 EEG part 4 https://ronlitman.substack.com/p/eeg-part-4
PAAD 08/21/2023 Electroencephalogram-Guided Anesthesia Care in Children https://ronlitman.substack.com/p/electroencephalogram-guided-anesthesia
Are you using sugammadex as your primary NMB reversal agent? Have you increased the use of NMB in your practice? Are you routinely using quantitative NMB monitoring when you NMB agents? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Brown SES, Cassidy R, Zhao X, et al. Impact of Sugammadex Introduction on Using Neuromuscular Blockade and Endotracheal Intubation in a Pediatric Hospital: A Retrospective, Observational Cross-Sectional Study. Anesthesia and analgesia 2025;140(3):539-549. (In eng). DOI: 10.1213/ane.0000000000007048.
2. Stein ML, Cravero JP. Unintended Consequences: Is Sugammadex Changing the Way We Deliver Anesthesia? Anesthesia and analgesia 2025;140(3):537-538. (In eng). DOI: 10.1213/ane.0000000000007116.
3. Faulk DJ, Austin TM, Thomas JJ, Strupp K, Macrae AW, Yaster M. A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade. Anesthesia and analgesia 2021;132(6):1518-1526. (In eng). DOI: 10.1213/ane.0000000000005386.
4. Thilen SR, Weigel WA, Todd MM, et al. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023;138(1):13-41. (In eng). DOI: 10.1097/aln.0000000000004379.
5. Fritz BA, Kalarickal PL, Maybrier HR, et al. Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium. Anesthesia and analgesia 2016;122(1):234-42. (In eng). DOI: 10.1213/ane.0000000000000989.