(1029) Evaluation of Sugammadex for Reversal of Neuromuscular Blockade in a Multi-Hospital Health System

Introduction: Sugammadex is a selective relaxant binding agent for neuromuscular blockade reversal of rocuronium and vecuronium. The American Society of Anesthesiologists (ASA) Guidelines recommend its use in reversal of deep, moderate and shallow levels of blockade. Many institutions have restricted its use in patients with moderate to deep block with an intent of financial stewardship. Train of four (TOF) is a qualitative monitoring strategy to assess depth of block but cannot assure adequate recovery. TOF ratios have been considered more objective and are used with TOF counts. Neostigmine is an alternative for minimal blockade when the TOF ratio is between 0.4 to < 0.9 and may be used when TOF is 4. This project evaluated sugammadex utilization for neuromuscular blockade reversal after surgery.

Methods: A retrospective chart review was conducted in adult patients across a multi-hospital health system who received at least one dose of sugammadex after surgery during February 2024. The primary outcome was average time from sugammadex administration to extubation. Secondary outcomes were number of patients with TOF documentation, patients that qualified for neostigmine, patients that received neostigmine and percent of patients that received a sugammadex dose greater than 2 mg/kg.

Results: Of the 100 patients reviewed, 56% were outpatient procedures with 28% accounting for robotic cases. The average time from sugammadex to extubation was 9.6 minutes. Documentation of TOF was reported in 29 patients. Of these, 10 patients had a TOF of 4 and could have received neostigmine. In 4 out of 100 patients, neostigmine was used first but required sugammadex due to neostigmine failure. Fifteen percent of patients received doses greater than 2 mg/kg due to obesity or extended surgical times with higher doses of blockade use.

Conclusions: Sugammadex quickly reverses neuromuscular block with an average time of 9.6 minutes from administration to extubation. Use of sugammadex is widespread without adherence to TOF documentation due to provider confidence with drug efficacy. Future efforts will focus on reinforcing sugammadex prescribing guidelines and ensuring TOF documentation. Phase 2 of this study focuses on cases where neostigmine may be considered as an appropriate alternative to sugammadex.