Neuromuscular Blockade and Antagonism in Patients with Renal Impairment: A Multicenter Retrospective Cross-sectional Study.

Abstract

Background: Current practice guidelines do not address the use of neuromuscular blocking and antagonism agents in patients with renal impairment. The U.S. Food and Drug Administration (Silver Spring, Maryland) label for sugammadex advises against use in patients with severe renal impairment (estimated glomerular filtration rate [eGFR] less than 30 ml/min). Using a multicenter electronic health record registry, the authors sought to understand the modern use of neuromuscular blockade and antagonism agents in patients with significant renal impairment (eGFR less than 60 ml/min).

Methods: Data were obtained from the Multicenter Perioperative Outcomes Group (MPOG) registry for adult patients (older than 18 yr) with an eGFR less than 60 ml/min, based on most recent serum creatinine, receiving general anesthesia for a nonrenal transplant procedure with an endotracheal tube between January 1, 2016, and July 31, 2022. Patients were classified into three mutually exclusive blockade and reversal strategies: rocuronium-sugammadex, cisatracurium-neostigmine, and rocuronium-neostigmine. Adjusted incidence of each blockade reversal strategy was established by a multinomial mixed effects model. The contribution of institution, anesthesiologist, and patient or case factors to variation in strategy choice was assessed by multilevel mixed effects models.

Results: In 243,944 cases across 5,133 anesthesiologists and 48 institutions, adjusted use of rocuronium-sugammadex increased from 4.4 to 95.2%, rocuronium-neostigmine decreased from 84.7 to 4.3%, and cisatracurium-neostigmine decreased from 10.9 to 0.5%. In patients with an eGFR less than 15 ml/min, rocuronium-sugammadex use increased from 0.5 to 86.9%. Of the variation in choice of rocuronium-sugammadex versus cisatracurium-neostigmine, 30.1% was attributed to the institution, 22.7% to the attending anesthesiologist, and 47.2% to patient/case factors or was unexplained. The adjusted median odds ratio for this choice was 2.5 for clinicians and 3.1 for institutions.

Conclusion: Rocuronium-sugammadex is the primary neuromuscular blockade-antagonism strategy for patients with moderate and severe renal impairment. Variation in choice is significantly impacted by the institution and attending anesthesiologist providing care.