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Featured Articles: Original Clinical Research Report

A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade

Faulk, Debra J. MD*; Austin, Thomas M. MD, MS; Thomas, James J. MD*; Strupp, Kim MD*; Macrae, Andrew W. BS; Yaster, Myron MD*

Author Information
doi: 10.1213/ANE.0000000000005386

Abstract

KEY POINTS

  • Question: Has sugammadex supplanted neostigmine as the primary drug for antagonizing neuromuscular blockade (NMB) in pediatrics and has this affected practice?
  • Findings: In pediatric anesthetic practice, sugammadex is commonly used despite its lack of US Food and Drug Administration (US FDA) approval and routine monitoring of NMB is becoming uncommon, particularly among physicians with <5 years of experience.
  • Meaning: How pediatric anesthesiologists block, assess, and antagonize the NMB is very dependent on years of practice, with younger anesthesiologists using primarily sugammadex and rarely assessing NMB, creating concern that we may be training a generation of pediatric anesthesiologists who will not know how to use neostigmine or appropriately assess NMB.

See Article, p 1514

Neuromuscular blocking agents (NMBAs) suppress voluntary or reflex skeletal muscle movements to pain.1,2 Since their introduction they have revolutionized anesthetic practice by facilitating tracheal intubation, ensuring patient immobility, and improving surgical operating conditions.1,2 Before extubation, it is standard clinical practice to pharmacologically antagonize these agents with either neostigmine or sugammadex in a process known as “reversal.”1 Residual blockade, defined as a train-of-four (TOF) ratio of <0.9, during the early recovery period from anesthesia is common in both adult and pediatric populations.1,2 However, small degrees of muscle weakness can have important clinical consequences, including pharyngeal dysfunction, airway obstruction, aspiration, hypoxemic episodes, critical respiratory events, prolonged postanesthesia care unit length of stay, and unpleasant symptoms of muscle weakness.2–5 Indeed, impaired upper airway integrity may persist in some subjects even after the TOF ratio has returned to unity.6

The introduction of sugammadex has revolutionized anesthetic practice and has replaced neostigmine as the drug of choice to antagonize the effects of rocuronium and vecuronium in adult patients, but still requires assessment of NMB.7–9 Sugammadex has displaced neostigmine because it produces fast and predictable reversal of any degree of neuromuscular blockade (NMB), increases patient safety, and reduces the incidence of residual block on recovery. As a result, sugammadex is a more efficient use of health care resources and leads to fewer postoperative complications.4,5,10,11 We hypothesized that the use of sugammadex in pediatric anesthetic practice is widespread and has supplanted neostigmine as the primary drug for antagonizing NMB despite its package insert clearly stating that “the safety and efficacy of sugammadex in pediatric patients have not been established.”12 Additionally, we sought to identify the determinants by which pediatric anesthesiologists choose reversal agents and if and how they assess NMB in their practice. Finally, because of sugammadex’s effects on hormonal contraception,13 we sought to determine whether pediatric anesthesiologists counseled postmenarchal patients on the need for additional or alternative forms of contraception and the risk of unintended pregnancy in the perioperative period.

METHODS

Survey Design and Administration

This article was written in accordance with the Strengthening The Reporting of Observational studies in Epidemiology (STROBE) guidelines. After obtaining a waiver from the Colorado Multiple Institutional Review Board and approval from the research and quality and safety committees of the Society for Pediatric Anesthesia (SPA), we sent an e-mail questionnaire to all SPA members (n = 3245) between October and December 2019. The survey was created with input from SPA’s research and quality and safety committees and a survey and database specialist. We piloted the survey with attendings and fellows of the Children’s Hospital Colorado to assess for language and comprehension. The questionnaire (Supplemental Digital Content 1, Table 1, https://links.lww.com/AA/D364) consisted of 13 questions to identify which antagonist was the respondent’s preferred agent to reverse NMB, if this choice was altered in postmenarchal females, and how and if they assess NMB in their practice. We also collected provider demographics including age, sex, fellowship training, type of practice (pediatrics only or mixed adult/pediatric), practice setting (private, academic, military, or other), site of practice (freestanding pediatric hospital, adult hospital, pediatric hospital within an adult hospital, ambulatory surgery center, or other), location of practice by time zone (East, Central, Mountain, Pacific, or outside of North America), and years in practice (Supplemental Digital Content 1, Table [Survey] 1, https://links.lww.com/AA/D364). All responses were deidentified and were collected with Research Electronic Data Capture (REDCap; Vanderbilt University, Nashville, TN; https://redcap.vanderbilt.edu) electronic data capture tools. A reminder e-mail was sent weekly for 1 month to those members who did not complete the survey over the study collection period.

Nonrespondent Survey

Because the initial response rate was low, a method was needed to quantify nonresponse bias. Therefore, we sent a shortened follow-up survey to a randomly selected subsample (n = 75) of SPA members who did not respond to the initial survey. We used these surveys to determine response differences between the 2 cohorts. Members were selected through the Society’s membership directory and were contacted via telephone or e-mail address based on their listed information.

Statistical Analysis

All deidentified REDCap data were exported as an Excel spreadsheet (Microsoft Corporation, Redmond, WA). Data from respondents who did not complete the survey were excluded. Univariate analyses were carried out with the Wilcoxon Rank Sum test for ordinal outcome (eg, TOF monitor use) and categorical exposure (eg, academic center), with the Fisher exact test for categorical outcome (eg, sugammadex preference) and categorical exposure (eg, academic center), with the Spearman test to analyze correlation between an ordinal outcome (eg, TOF monitor use) and an ordinal exposure (eg, years in practice), and with simple logistic regression for a binary outcome (eg, sugammadex preference) and ordinal exposure (eg, years in practice). To limit confounding, we performed multivariable logistic regression with sugammadex preference as the response variable and years in practice (≤5 years vs ≥6 years), institutional restriction, and academic center as the explanatory variables. The R statistical software package (Version 2.15.1) was used for this analysis and 2-sided P values of <.05 were considered statistically significant. We calculated the 95% confidence interval (CI) for proportions using exact Clopper-Pearson intervals.

Power Analysis

In a previous worldwide study from 2017,14 28% of anesthesia providers stated that they utilized sugammadex mostly/always for reversal of NMB. Since sugammadex received approval from the US Food and Drug Administration (US FDA) in 2015,15 we hypothesized that pediatric anesthesiologists who finished their training within the last 5 years (and current trainees) would display a 2-fold increase in the odds of using sugammadex as their primary reversal agent (ie, >50% use) compared to pediatric anesthesiologists 6 or more years out from training (ie, 44% vs 28%). Given the approximate 3:1 predominance of pediatric anesthesia providers in SPA who have been in practice for ≥6 years versus those who have been practicing ≤5 years,16 a total sample size of 379 (n = 95 in the ≤5-year cohort) was required to exhibit this difference with a type I and II error rate of 5% and 20%, respectively.

RESULTS

Of the 3245 SPA members surveyed, 419 (13%) responded to the online questionnaire with most answering all of the questions (response missingness ranged from 0% to 6.4% depending on the question). Respondent demographics, years in practice, and practice setting and type are presented in Table 1. Overall, 163 respondents (38.9%; 95% CI, 34.2-43.8) used sugammadex as their primary reversal agent, and 106 (25.3%; 95% CI, 21.2-30.0) used it exclusively (Table 2). Sugammadex use differed by years in practice, with more seasoned practitioners administering it less often (P = .003). Compared to pediatric anesthesia providers who had been in practice for ≥6 years, respondents with ≤5 years of independent practice used sugammadex as their primary reversal agent more often (odds ratio [OR]: 2.08; 95% CI, 1.31-3.31; P = .001; Figure 1). This increased use of sugammadex remained after controlling for institutional restriction and practice type (adjusted OR [aOR]: 2.20; 95% CI, 1.38-3.54; P = .001). An overwhelming majority (83.4%) of the respondents stated that there was no extrinsic institutional restriction to either sugammadex or neostigmine use (Table 2), and this was not associated with practice setting (P = .14) and site (P = .45). Practitioners were more likely to self-limit the use of sugammadex because of either cost (24.9%) or efficacy (3.3%) rather than institutional mandates (Table 2).

Table 1. - Respondent Demographics
Response rate 419/3245 (12.9%)
Parameter N (%)
Age (y) 20–30 6 (1.5)
31–40 144 (35.7)
41–50 99 (24.6)
51–60 87 (21.6)
>60 67 (16.6)
Sex Male 175 (43.4)
Female 222 (55.1)
Transgender female 0 (0.0)
Transgender male 1 (0.2)
Gender nonconforming 0 (0.0)
Different identity 0 (0.0)
Decline to state 5 (1.2)
Years in practice Currently in training 17 (4.2)
0–5 98 (24.3)
6–10 70 (17.4)
11–15 53 (13.2)
16–25 65 (16.1)
>25 98 (24.3)
Retired 2 (0.5)
Region of United States Pacific time zone 182 (45.2)
Mountain time zone 99 (24.6)
Central time zone 30 (7.4)
Eastern time zone 65 (16.1)
Hawaii/Alaska 1 (0.2)
Outside the United States 26 (6.5)
Practice type Academic 273 (67.7)
Private 115 (28.5)
Military 0 (0.0)
Other 15 (3.7)
Pediatric fellowship training Yes 348 (86.4)
No 42 (10.4)
Currently 13 (3.2)
Practice type All pediatric 249 (61.8)
Mixed 154 (38.2)
Primary site of practice Freestanding pediatric hospital 223 (5.3)
Adult hospital 23 (5.7)
Pediatric hospital in adult hospital 140 (34.7)
Ambulatory surgical center 10 (2.5)
Clinical setting 1 (0.2)
Other 6 (1.5)
Data are presented as count (percentage).

Table 2. - Neuromuscular Blockade Reversal Utilization
Parameter N (%)
Reversal agent(s) used in pediatric practice Sugam 106 (25.3)
Neostigmine 181 (43.2)
Both Sugam and neostigmine 111 (26.5)
No reversal used 21 (5.0)
If both utilized Mostly (50%–100%) 57 (51.4)
Frequency Sometimes (25%–50%) 46 (41.4)
Sugam used Rarely (>0%–25%) 8 (7.2)
Institutional restriction on reversal agent(s) Sugam only 19 (4.8)
Neostigmine only 0 (0.0)
Both 47 (11.8)
None 332 (83.4)
Voluntary personal Sugam—too costly 99 (24.9)a
Restriction of reversal Neostigmine—too costly 5 (1.3)a
Agent(s) due to cost or efficacy Sugam—less effective 13 (3.3)a
Neostigmine—less effective 108 (27.1)a
None 199 (50.0)a
Patient age restrictions for Sugam administration No age restriction 243 (61.1)a
<1-mo old 36 (9.0)a
<2-mo old 37 (9.3)a
<2-y old 41 (10.3)a
<12-y old 21 (5.3)a
12-y old to <18-y old 46 (11.6)a
Reversal agent preference for postmenarchal females Neostigmine 178 (47.2)
Sugam routinely—prior discussion with patient/family 40 (10.6)
Sugam routinely—no prior discussion with patient/family 26 (6.9)
Sugam situationally—prior discussion with patient/family 83 (22.0)
Sugam situationally—no prior discussion with patient/family 50 (13.3)
FDA indication for pediatric Sugam Yes 43 (10.8)
No 354 (89.2)
Sugam use affected by US FDA labeling Yes 55 (14.6)
No 321 (85.4)
Data are presented as count (percentage).
Abbreviations: FDA, Food and Drug Administration; Sugam, sugammadex.
aBecause multiple answers were accepted, percentages do not equal 100%.

F1
Figure 1.:
The percentage of Society for Pediatric Anesthesia members with 5 or fewer years of experience and with 6 or more years of experience who use sugammadex as their primary reversal agent; ≤5 y (38%), >6 y (22%); *P = .001.

Most respondents did not have an age restriction for administering sugammadex to pediatric patients (61.1%, Table 2). In addition, a slim majority of providers would use sugammadex for pediatric postmenarchal girls (52.8%). Less experienced providers were more likely to use sugammadex in this subpopulation than were those with more years of independent practice experience (P < .001; Figure 2). Of the respondents who would use sugammadex in this subpopulation, more than a third (38.2%) did not discuss its effects on hormonal contraception with the patient and/or family (Table 2). However, this practice was not associated with anesthesiologist experience (P = .33) and practice location (P = .38). A large majority of respondents (89.2%) did not believe that there was an US FDA-labeled indication for sugammadex use in pediatric populations and most (85.4%) were unaffected by this labeling (Table 2).

F2
Figure 2.:
The percentage of Society for Pediatric Anesthesia members who use sugammadex in postmenarchal adolescents, distributed by years in practice. Currently in training (76%), 0–5 y (68%), 6–10 y (55%), 11–15 y (45%), 16–25 y (41%), and >25 y (47%). P < .001, based on simple logistic regression for the binary outcome sugammadex use and the ordinal exposure years in practice.

Qualitative TOF devices (peripheral nerve stimulators [PNSs]) were the most commonly available devices (57.7%) regardless of practice location (Table 3). Quantitative monitors (acceleromyography-based, kinemyography-based, or electromyography-based monitors) were available in 38% of locations. Many respondents (40.0%) always used some manner of TOF assessment before sugammadex introduction (Table 3), and use was inversely correlated with years of experience (Spearman ρ = −0.11; P = .04). Since the introduction of sugammadex, two-thirds of practitioners still routinely use TOF assessment (Table 3), although anesthesiologists who used sugammadex as their primary reversal agent did not use routine TOF assessment as often (OR: 0.56; 95% CI, 0.34-0.90; P = .01). The most common (47.3%) preferred anatomic site for the TOF assessment was based on surgical positioning, with the exact site being consequential (Table 3). Some respondents (12.8%) reported failure of reversal with sugammadex after normal rocuronium dosing, but a much larger percentage (62.9%) experienced failure with neostigmine (Table 3).

Table 3. - Neuromuscular Blockade Monitoring
Parameter N (%)
Type of TOF monitor available Qualitative only 226 (57.7)
Quantitative only 60 (15.3)
Both qualitative and quantitative 91 (23.2)
Unsure 8 (2.0)
No monitors available 7 (1.8)
TOF monitor use Always (100%) 154 (40.0)
Before Sugam Mostly (50%–100%) 141 (36.6)
Introduction Sometimes (25%–50%) 47 (12.2)
Rarely (>0%–25%) 37 (9.6)
Never (0%) 6 (1.6)
TOF monitor use since Sugam introduction No longer a need 6 (1.7)
Still routinely use 231 (67.0)
Case-by-case basis 103 (29.9)
Never monitored before 5 (1.4)
Preferred anatomic site for TOF monitor Adductor pollicis 126 (32.7)
Orbicularis oculi 33 (8.6)
Posterior tibialis 2 (0.5)
Does not matter—use whatever site available based on position 42 (10.9)
Does matter—use whatever site available based on position 182 (47.3)
Encountered Sugam Yes 44 (12.8)
Failure No 301 (87.2)
Encountered neostigmine Yes 242 (62.9)
Failure No 143 (37.1)
Data are presented as count (percentage).
Abbreviations: Sugam, sugammadex, TOF, train-of-four.

Regarding the secondary survey, 5 surveys were conducted via telephone call while the remainder occurred by e-mail. All but one of the respondents answered all of the questions. The demographics of the nonrespondents were similar to those of SPA members who responded to the primary survey (Supplemental Digital Content 2, Table 2, https://links.lww.com/AA/D365). In addition, the nonrespondents did not differ significantly from initial respondents in their practices with respect to NMB reversal and TOF monitoring (Supplemental Digital Content 3, Table 3, https://links.lww.com/AA/D366).

DISCUSSION

Our survey of SPA members revealed that, despite sugammadex not being labeled for use in pediatrics, it is commonly used among all pediatric anesthesiologists and is rapidly replacing neostigmine as the drug of choice to antagonize the effects of rocuronium and vecuronium. Furthermore, we found that sugammadex’s more rapid effectiveness and better safety profile compared to neostigmine outweigh its higher cost.1,11 The survey data revealed that how pediatric anesthesiologists block, assess, and antagonize the NMB is very dependent on years of practice. Indeed, we found that anesthesiologists who trained after the introduction of sugammadex into the American marketplace in 2015 have been profoundly impacted with respect to the use and assessment of NMBAs. These younger anesthesiologists use sugammadex as their primary NMBA reversal agent and rarely assess NMB. More experienced anesthesiologists also do not universally assess NMB. This represents a training and practice failure in the profession of pediatric anesthesiology. Finally, the common use of sugammadex in postmenarchal females and the failure to warn young women of its hormonal contraception consequences may result in unintended pregnancy.13,17

The appeal of sugammadex is not surprising. Unlike the cholinesterase inhibitors neostigmine and edrophonium, which inhibit the breakdown of acetylcholine in the neuromuscular junction (NMJ), sugammadex does not interfere with acetylcholinesterase receptor systems. Therefore, it does not produce the muscarinic side effects associated with other reversal medications for NMBAs, such as bradycardia, hypotension, bronchospasm, and postoperative nausea and vomiting. Sugammadex is a synthetically modified gamma-cyclodextrin, a chemical structure with a hydrophilic exterior and a hydrophobic core.1 It was designed specifically to reverse rocuronium-induced paralysis by encapsulating rocuronium; however, its inner cavity is large enough to encapsulate other aminosteroidal NMBAs such as vecuronium, pipecuronium and, to a much lesser degree, pancuronium.1,18,19 Its potential clinical benefits include fast and predictable reversal of any degree of block, increased patient safety, reduced incidence of residual block on recovery, and more efficient use of health care resources.1,6,11,20

Postoperative residual paralysis after the intraoperative use of NMBAs remains a problem and can be difficult to assess.2,5,11 Furthermore, the extent of residual paralysis and respiratory complications in pediatrics has only recently been studied. Indeed, several investigators have reported that residual NMB in children is common and can lead to postoperative pulmonary complications, especially when high doses of NMBA are utilized.21–23 Infants and children have also been seen to have wide variations and prolonged duration of action following administration of NMBA.21,23 The practice of using time from last administration of NMBA or clinical signs to determine return of neuromuscular function and readiness for extubation is inadequate. Objective assessment of neuromuscular function with quantitative monitoring and appropriate reversal of NMB should be used.

In adults, the application of qualitative and quantitative neuromuscular monitoring in the operating room has been demonstrated to reduce the risk of postoperative NMB (“recurarization”).8,9 Quantitative devices, which are preferred, evaluate muscle relaxation objectively by mechanomyography, accelerometry, or electromyography in conjunction with electrical nerve stimulation and display the results as a TOF ratio on a screen.2,9 Unfortunately, our results confirm other studies that reveal that these monitors are rarely available.2 Furthermore, quantitative monitors are difficult to use and may be inaccurate in neonates and small infants.24 Even in older patients, electrode placement and polarity, and stimulus intensity affect NMB assessment.1,8,20,25 Electrode placement is particularly important. Several different muscle groups can be assessed (adductor pollicis, laryngeal, orbicularis oculi, and diaphragm), with the most clinically relevant results obtained with the adductor pollicis.2 “Monitoring of adductor pollicis muscle, which lags the recovery of the diaphragm, will ensure that if recovery is sufficient at the thumb, the diaphragm and upper airway muscles will function normally. Monitoring TOF recovery in response to facial nerve stimulation can lead to erroneous decisions: the eyebrow muscle, the corrugator supercilii, recovers faster than the upper airway or the adductor pollicis muscles.”8 Unfortunately, we found that more than half of the respondents chose a site of convenience or believed that the preferred anatomic site for NMB assessment using TOF did not matter (Table 3).

On the contrary, 80% of respondents have access to qualitative devices. These devices are the most commonly used but are also the most prone to error.2,9 Qualitative devices deliver a stimulus to a peripheral nerve, and the anesthesia practitioner must visually or tactilely judge the muscle’s response.2,9 Hence, it is a subjective and inaccurate method of assessment.26 Our survey results, similar to those of others, suggest that despite their availability, these monitors are increasingly being disregarded when sugammadex is the reversal agent.7,27 Subjective clinical signs (such as the 5-second head lift or sustained handgrip) and clinical tests (such as tidal volume and vital capacity) are ineffective at assessing the incidence of residual NMB and should be discouraged. They do not guarantee complete resolution of NMB and no longer have a place as the sole determinant of adequate recovery of neuromuscular function.9,27 Finally, the failure to assess NMB with either a qualitative or quantitative device has important implications in terms of sugammadex dosing. In adults, 4 mg/kg is the recommended dose for reversal of deep NMB (no twitch response to TOF and recovery of twitch response to 1–2 posttetanic counts), while 2 mg/kg is the recommended dose for a “shallow block” (reappearance of the second twitch to TOF stimulation).12 Although there are no US FDA dosing guidelines for pediatrics, there are European guidelines that require an assessment of NMB.28

Thus, our data suggest that pediatric anesthesiologists are “flying blind” and that use of neuromuscular monitoring devices is becoming increasingly rare, particularly by practitioners with <5 years of experience who received training after sugammadex’s introduction. Furthermore, many practitioners are not routinely using the adductor pollicis when they are assessing NMB. These findings have enormous training and patient safety implications going forward.

Finally, although sugammadex has fewer side effects than cholinesterase inhibitors, it is not devoid of problems. The most serious are anaphylactic reactions, including bronchospasm, bradycardia, and asystole, and its potential to reduce the effectiveness of hormonal contraceptives and increase the risk of unintended pregnancy.13,17,29,30 Our survey results reveal that more than half of respondents use sugammadex in postmenarchal patients and that those who trained after its introduction are more likely to do so. Additionally, almost 40% of the pediatric anesthesiologists in our survey who use sugammadex in this patient population stated that they do not discuss its potential interference with hormonal contraception preoperatively.

This risk in the adolescent female population cannot be overstated. Even with appropriate counseling, and assuming that hormonal contraceptives are taken reliably by these patients, a 4 mg/kg dose of sugammadex may be equivalent to a 12-hour delay in contraceptive dosing.31 According to the Centers for Disease Control and Prevention, 2018 saw an encouraging decline in numbers of sexually active teens and the lowest reported teen birth rates on record.32 However, the 2018 Youth Risk Behavior Survey33 also revealed a trend toward increasing utilization of hormonal contraception and decreasing use of barrier methods among sexually active teens between the ages of 15 and 19 years . Ultimately, we cannot ignore the possibility that adolescent girls using hormonal contraceptives may face significant barriers to finding alternative means of contraception. Therefore, we should consider whether the use of neostigmine is more appropriate in these patients. As such, the concern for anesthesiologists entering practice without the appropriate knowledge of how to assess NMB appropriately may have huge implications for the future of public health.

Interestingly, in a letter to the editor, Corda and Robards34 point out that other commonly administered perioperative drugs such as antibiotics also interfere with oral contraceptives (and cause anaphylaxis) and suggest that a more general statement about oral contraception should be provided to patients when obtaining consent. They suggest stating “You may receive medications during your anesthetic that could interfere with the effectiveness of oral contraceptives. If you are using oral contraceptives, consider alternative methods of birth control for 7 days following your anesthetic.”34 Thus, we recommend development of a robust system of education and counseling in all perioperative postmenarchal pediatric patients to explain the risk of medication interactions with hormonal contraception and the need for alternative methods of contraception. We also suggest that this information be documented in the medical record for medical-legal purposes.

Sugammadex is hardly the only drug used in pediatric practice “off label.”35,36 Off label use is defined as “the unauthorized use of a drug for a purpose other than that approved by the US Food and Drug Administration (US FDA).” In 1979, the US FDA began requiring that specific precautions with regard to usage in pediatric patients be included on product package inserts. That same year, regulations were enacted that required any statement on pediatric use of drugs to be based on substantial evidence unless a waiver was granted by the US FDA. Subsequently, the percentage of medications listed in the Physician’s Desk Reference that had either no indication for pediatric use or age-specific limitations actually increased from 78% in 1971 to 81% in 1991.35 To remedy this situation, the US FDA has instituted multiple initiatives and regulations since 1994, including the Pediatric Rule for Labeling, the US FDA Modernization Act of 1997, the Best Pharmaceuticals for Children Act, the Pediatric Research in Equity Act, and the 2007 US FDA Amendments Act.37–39 As a result of these initiatives, many drug labels have been revised to include new pediatric information.35 We are aware of several clinical trials to relabel sugammadex for pediatric use and hope that these changes will occur in the near future.

This study has many of the limitations associated with online surveys. Although 419 pediatric anesthesiologists responded to the questionnaire, this number represents only 13% of potential respondents, a response rate that is consistent with survey research.40 A low response rate is a potential source of bias and is only representative of those who replied. In addition, because the physician anesthesiologists surveyed practice primarily at American medical institutions and belong to SPA, our results may not be reflective of physicians in training, nurse anesthetists, or practices in other countries, thereby limiting the generalizability of our findings. On the contrary, the large survey sample size ensured that the demographic profile of survey respondents reflected the survey population and provided a sufficiently large data set for analysis. Additionally, as with all survey studies, respondents may not be 100% truthful in their responses and may not have carefully read the questions or thought through their responses before answering. Lastly, trainees were not separated between fellows and residents in the survey and this differentiation would influence their knowledge of sugammadex and NMB monitoring in the pediatric population.

In conclusion, we found that even though sugammadex is not labeled for use in pediatrics, its use is common among SPA members and rapidly replacing neostigmine as the drug of choice to antagonize the effects of rocuronium and vecuronium. Furthermore, we found that how the NMJ is blocked and antagonized, and how NMB is assessed is very dependent on years of practice and that anesthesiologists who primarily use sugammadex rarely assess NMB. Finally, the common use of sugammadex in postmenarchal females and the failure to warn young women of its hormonal contraception consequences may risk unintended pregnancies. This trend in preference for sugammadex, indifference toward monitoring of NMB, and disregard for potential drug-drug interactions with hormonal contraceptives may create a generation of anesthesiologists who are ill-prepared to utilize neostigmine when it may be more appropriate, increasing risks to patient safety and public health.

ACKNOWLEDGMENTS

The authors thank Claire Levine, MS, ELS, for her editorial assistance, Kim Battle of the Society for Pediatric Anesthesia for her assistance in the electronic distribution of the survey, and the Society for Pediatric Anesthesia’s research and quality and safety committees for their assistance in survey design. The authors also thank the Colorado Clinical and Translational Sciences Institute (CCTSI) and the Development and Informatics Services Center (DISC) grant support (NIH/NCRR Colorado CTSI Grant number UL1 RR025780) for their assistance with this project.

DISCLOSURES

Name: Debra J. Faulk, MD.

Contribution: This author helped conceptualize and design the study and data collection instruments; acquire, analyze, and interpret the data; draft the initial manuscript; review and approve the final manuscript.

Conflicts of Interest: None.

Name: Thomas M. Austin, MD, MS.

Contribution: This author helped conceptualize and design the study and data collection instruments; acquire, analyze, and interpret the data; draft the initial manuscript; review and approve the final manuscript.

Conflicts of Interest: None.

Name: James J. Thomas, MD.

Contribution: This author helped conceptualize and design the study and data collection instruments; acquire, analyze, and interpret the data; review and approve the final manuscript.

Conflicts of Interest: None.

Name: Kim Strupp, MD.

Contribution: This author helped conceptualize and design the study and data collection instruments; acquire, analyze, and interpret the data; review and approve the final manuscript.

Conflicts of Interest: None.

Name: Andrew W. Macrae, BS.

Contribution: This author helped acquire data; review and approve the final manuscript.

Conflicts of Interest: None.

Name: Myron Yaster, MD.

Contribution: This author helped conceptualize and design the study and data collection instrument; acquire, analyze, and interpret the data; draft the initial manuscript; review and approve the final manuscript.

Conflicts of Interest: M. Yaster was, within the last 3 years, on the Data Safety Monitoring Board for Endo Pharmaceuticals (oxymorphone).

This manuscript was handled by: James A. DiNardo, MD, FAAP.

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