P054: MODULATION OF THE USE OF SUGAMMADEX AT AN AMBULATORY SURGERY CENTER
Stuart Van Der Greeff, MD; Todd J Smaka, MD; Arman Dagal, MD; Richard H Epstein, MD, FASA; University of Miami
Introduction/Background: Sugammadex is a selective, cyclodextrin binding agent that reverses the neuromuscular blocking activity of aminosteroid neuromuscular blocking agents such as rocuronium and vecuronium.1 While sugammadex allows for reliable, rapid reversal from deep levels of blockade, in contrast to neostigmine, the drug is considerably more expensive. At many institutions, hospital administrators have raised concerns about the additional cost. Where quantitative neuromuscular blockade monitoring is employed, more selective use of sugammadex is possible, following the 2023 ASA Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade.2 On June 15, 2021, the anesthesia director (TJS) of the ambulatory surgery center (ASC) sent a message to the ASC anesthesia practitioners with cost information for the alternative reversal agents, and asked that neostigmine and glycopyrrolate be used when clinically appropriate. Acceleromyography is used routinely at the ASC for assessment of the train-of-four ratio to ensure the adequacy of reversal.
Methods: The University of Miami IRB determined that this study represents non-human subjects research. We interrogated the hospital's Epic Clarity database to identify all anesthetics performed at the ASC during which rocuronium was administered. The neuromuscular blockade reversal agent used was determined and the occurrence of prolonged extubation (end of surgery to tracheal extubation ≥15 minutes) was calculated.3 Data were batched by 4-week intervals and analyzed for the percentage of cases in which sugammadex was used and, overall, for the incidence of prolonged extubation.
Results: Following the request to limit the use of sugammadex, there was a steep drop its percentage use from 97.6% (n=31, 99% CI 96.8% to 98.3%) to a nadir of 42.9% (Fig. 1). However, over the next 12 months, sugammadex use returned to the previous value (n=12, 96.5%, 99% CI 95.1% to 99.1%). During this interval, usage was not monitored, and no further reminders were sent. Overall, there was no significant difference (0.93%, 95% CI -0.77% to 2.63%) in the percentage of cases with prolonged extubation with neostigmine (34/679, 5.01%) vs. sugammadex (312/7645, 4.08%).
Discussion/Conclusion: A single reminder use neostigmine plus glycopyrrolate for reversal rather than sugammadex, when clinically appropriate, was insufficient to maintain a sustained decrease in the use of sugammadex. Because quantitative neuromuscular monitoring was employed throughout, with recovery of the train of four ratio to at least 0.9, we think it unlikely that the change had any substantive clinical effect related to residual paralysis. The absence of changes in the incidence of prolonged extubation suggests a lack of impact on OR throughput. Although the reasons are unclear why the anesthesia practitioners reverted to the use of sugammadex, and are currently being studied, continual efforts to mitigate the routine use of sugammadex are likely required.
1. Marour GG et al. Anesthesiology. 2008; 108(5): 956–964.
2. Thilen SR. Anesthesiology. 2023;138:13-41.
3. Epstein RH et al. Can J Anaesth. 2013;60:1070-6.