Trends in the use of neuromuscular blocking agents, reversal agents and neuromuscular transmission monitoring: a single-centre retrospective cohort study

Background: Residual neuromuscular blockade (rNMB) remains a persistent and preventable problem, with serious risks. Methods: Our objective was to describe and assess patterns in the use of neuromuscular blocking agents (NMBAs), neuromuscular transmission (NMT) monitoring, and factors associated with the use of sugammadex. We performed a retrospective, observational cohort study based on electronic medical records in a large teaching hospital in the Netherlands that introduced an integrated NMT monitoring module with automatic recording in 2017. A total of 22,000 cases were randomly selected from all surgeries between January 2015 and December 2019 that required endotracheal intubation with the use of an NMBA. A total of 14,592 cases fulfilled all the inclusion criteria for complete analyses. Results: Relative NMBA usage remained the same over time. For rocuronium, spontaneous reversal decreased from 86 to 81%, sugammadex reversal increased from 12 to 18%. There was a decline in patients extubated in the operating room (OR) with neither documented NMT monitoring nor sugammadex-mediated reversal from 46 to 31%. The percentage of patients extubated in the OR without a documented train-of-four ratio >= 0.9, decreased from 77 to 56%. Several factors were independently associated with the use of sugammadex, including BMI > 30 kg/m(2) (odds ratio: 1.41; 95% CI: 1.24-1.60), ASA class 3 or 4 (1.20; 1.07-1.34), age > 60 years (1.37; 1.23-1.53), duration of surgery < 120 min (3.01; 2.68-3.38), emergency surgery (1.83; 1.60-2.09), laparoscopic surgery (2.01; 1.71-2.36), open abdominal/thoracic surgery (1.56; 1.38-1.78), NMT monitoring used (5.31; 4.63-6.08), total dose of rocuronium (1.99; 1.76-2.25), and (inversely) use of inhalational anaesthetics (0.88; 0.79-0.99). Conclusion: Our data demonstrate that the implementation of NMT monitoring with automatic recording coincides with a gradual increase in the (documented) use of NMT monitoring and an increased use of sugammadex with a more precise dose. Factors associated with sugammadex use include higher age, ASA score, BMI, abdominal and thoracic surgery, higher rocuronium doses, emergency surgery and the use of NMT monitoring.