Blockade-Reversal Choice Shifts to Sugammadex in Renal Issue

TOPLINE:

The use of rocuronium and sugammadex for reversing neuromuscular blockade increased dramatically over 6 years in patients with moderate and severe renal impairment. The variation in strategy selection was influenced by institutions and attending anesthesiologists.

METHODOLOGY:

• Researchers conducted a retrospective observational study using data from a multicenter electronic health record–derived registry spanning institutions in the United States, Europe, and the Middle East to examine the selection of neuromuscular blockade and reversal agents in patients with significant renal impairment.
• They included 243,944 adults (mean age, 68.5 years; 50.1% women) who underwent noncardiac surgery under general anesthesia with neuromuscular blockade and endotracheal intubation between 2016 and 2022 and were cared for by 5133 attending anesthesiologists across 48 institutions.
• The estimated glomerular filtration rate (eGFR) was calculated using creatinine values recorded within 60 days prior to the start of anesthesia care, with an eGFR threshold of below 60 mL/min classified as moderate renal impairment and below 30 mL/min classified as severe renal impairment.
• Patients were divided into three mutually exclusive blockade and reversal categories: Those receiving a combination of rocuronium and sugammadex, those receiving cisatracurium and neostigmine, and those receiving rocuronium and neostigmine.
• The primary outcome was the use of the neuromuscular blocking and reversal strategies in each case. The contributions of institutions, anesthesiologists, and patient factors on the choice of the blockade-reversal strategy were also assessed.

TAKEAWAY:

• Adjusted analysis revealed that the use of the rocuronium-sugammadex combination increased from 4.4% to 95.2% between 2016 and 2022 across all cases (P P
• Between 2016 and 2022, the use of rocuronium-sugammadex increased from 4.9% to 96.3% among patients with an eGFR of ≥ 45 and less than 60 mL/min and from 0.5% to 86.9% among those with an eGFR below 15 mL/min.
• Institutions accounted for 30.1% of the variation in the choice of rocuronium-sugammadex vs cisatracurium plus neostigmine, and attending anesthesiologists accounted for 22.7% of the variation, with an adjusted median odds ratio of 3.1 for institutions and 2.5 for attending anesthesiologists.
• For rocuronium-sugammadex vs rocuronium-neostigmine, 41.7% of the total variability was attributable to institutions and 16.6% was attributable to the attending anesthesiologists.

IN PRACTICE:

“In recent years, rocuronium-sugammadex has become the strategy most commonly used for patients with renal impairment, including in those patients with severe renal impairment,” the authors of the study wrote. “While our study documents a significant practice change, we do not describe the clinical or safety outcomes experienced by these patients.”

SOURCE:

This study was led by Rania Elkhateb, MD, MS-CTS, of the University of Arkansas for Medical Sciences in Little Rock, Arkansas. It was published online on February 10, 2025, in Anesthesiology.

LIMITATIONS:

This retrospective observational study relied on electronic data collected routinely, which limited the ability to describe institutional policies on the utilization of neuromuscular blockade and reversal. The sample might not have fully represented US practice. The eGFR calculations were based on a single creatinine value recorded closest to the start of the case, and other methods of estimating eGFR may perform differently in various clinical settings.

DISCLOSURES:

This study was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Partial funding was provided by the Blue Cross Blue Shield of Michigan/Blue Care Network. Several authors reported receiving financial support from various agencies unrelated to the study. One author reported receiving an honorarium from Medscape, Inc.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.