Introduction

The management of neuromuscular blockade (NMB) has evolved over time and remains a critical component of general anesthesia. However, NMB use varies by patient and procedural characteristics, clinical practices, protocols, and drug access. National utilization patterns are unknown. We describe changes in NMB and NMB reversal agent administration in surgical inpatients since the US introduction of sugammadex in December 2015.

Methods

In a retrospective observational study of inpatients involving NMB with rocuronium or vecuronium in the Premier Healthcare Database, we estimate associations between factors related to choice of (1) active NMB reversal versus spontaneous recovery and (2) sugammadex versus neostigmine as the reversal agent.

Results

Among 4.3 million adult inpatient encounters involving rocuronium or vecuronium, the most widely administered NMB agent was rocuronium alone (86%). Over time, gradual declines in both neostigmine use and spontaneous reversal were observed (64% and 36% in 2014 to 38% and 28%, respectively in the first half of 2019). Several factors were independently associated with use of active versus spontaneous NMB recovery including years since 2016, patient (age, race, comorbidities), and procedure (admission and surgery type) characteristics. Among those actively reversed, these and other factors were independently associated with choice of reversal agent administered, including size and teaching affiliation of hospital. While both impacted choices in treatment, the direction and magnitude of effect of patient comorbidities and procedure type varied in their impact on choice of mode (pharmacologic vs. spontaneous) and agent (neostigmine vs. sugammadex) of NMB reversal independent of other factors and each other. Sites which adopted sugammadex earlier were more likely to choose sugammadex over neostigmine compared with later adopters independent of other factors.

Conclusions

Among US adult inpatients administered NMBs, we observed complex relationships between patient, site, procedural characteristics, and NMB management choices as NMBA choice and active reversal options among inpatient cases changed over time.

中文翻译：

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美国住院手术环境中的神经肌肉阻滞和逆转剂实践差异

介绍

神经肌肉阻滞 (NMB) 的管理随着时间的推移而发展，并且仍然是全身麻醉的关键组成部分。然而，NMB 的使用因患者和程序特征、临床实践、方案和药物获取而异。国家使用模式未知。我们描述了自 2015 年 12 月美国引入舒更葡糖以来，外科住院患者 NMB 和 NMB 逆转剂给药的变化。

方法

在 Premier Healthcare 数据库中对住院患者使用罗库溴铵或维库溴铵进行的一项回顾性观察研究中，我们估计了与选择 (1) 主动 NMB 逆转与自发恢复和 (2) 舒更葡糖与新斯的明作为逆转剂的选择相关的因素之间的关联。

结果

在涉及罗库溴铵或维库溴铵的 430 万成人住院患者中，使用最广泛的 NMB 药物是单独使用罗库溴铵 (86%)。随着时间的推移，观察到新斯的明使用和自发逆转逐渐下降（2014 年分别为 64% 和 36% 至 2019 年上半年分别为 38% 和 28%）。有几个因素与主动或自发 NMB 恢复的使用独立相关，包括自 2016 年以来的年份、患者（年龄、种族、合并症）和手术（入院和手术类型）特征。在那些积极逆转的人中，这些和其他因素与逆转剂的选择独立相关，包括医院的规模和教学机构。虽然两者都影响了治疗选择，患者合并症和手术类型的影响方向和程度不同，它们对 NMB 逆转模式（药物与自发）和药剂（新斯的明与舒更葡糖）选择的影响各不相同，与其他因素和彼此无关。与独立于其他因素的后来采用者相比，较早采用舒更葡糖的站点更有可能选择舒更葡糖而不是新斯的明。

结论

在接受 NMB 的美国成年住院患者中，我们观察到患者、部位、程序特征和 NMB 管理选择之间的复杂关系，因为住院病例中的 NMBA 选择和主动逆转选择随着时间而变化。