The Use of Muscle Relaxants and Reversal Agents in a Setting Without Cost Restrictions: Experience from a Tertiary Academic Hospital in the Netherlands

Figures & data

Table 1 NMB Utilization Over Time

	Rocuronium	Atracurium	Succinylcholine	Mivacurium	Total
2016	2279 (90.4%)	42 (1.7%)	195 (7.7%)	6 (0.2%)	2522
2017	3226 (88.1%)	40 (1.1%)	395 (10.8%)	2 (0.1%)	3663
2018	3008 (88.8%)	39 (1.2%)	337 (9.9%)	3 (0.1%)	3387
2019	2891 (87.7%)	25 (0.8%)	380 (11.5%)	2 (0.1%)	3298
2020	2343 (88.0%)	11 (0.4%)	309 (11.6%)	0 (0.0%)	2663
Apr 2016 -Dec 2020	13,747 (88.5%)	157 (1.0%)	1616 (10.4%)	13 (0.1%)	15,533

Notes: There are 15,533 administrations in 15,434 patients. 99 Patients received multiple NMB agents, predominantly succinylcholine + rocuronium.

Figure 1 Flowchart of included cases.

Table 2 Reversal of Rocuronium Induced NMB Over Time

	Sugammadex	Spontaneous Reversal	Total
2016	438 (19.4%)	1817 (80.6%)	2255
2017	629 (19.6%)	2577 (80.4%)	3206
2018	713 (23.9%)	2265 (76.1%)	2978
2019	765 (26.7%)	2105 (73.3%)	2870
2020	606 (26.1%)	1716 (73.9%)	2322
Grand Total	3151 (23.1%)	10,480 (76.9%)	13,631

Table 3 Distribution of Patient Characteristics in Patients Reversed with Sugammadex versus Spontaneous Recovery of Rocuronium Induced Neuromuscular Block

Patient Characteristics	Sugammadex N 3152	(Row) % 23.1	Spontaneous Reversal N 10,479	(Row) % 76.9	Total N 13,631	(Column) 100%
Age N (%)	3152	23.1	10,479	76.9	13,631	100
Mean (SD), (y)	57.1 (17.5)		54.5 (17.5)		55.2 (17.6)
Min, Max, (y)	18, 96		18, 101		18, 101
Age categories (y)	N	%	N	%	N	%
18–29	283	19.5	1170	80.5	1453	10.7
30–39	367	23.4	1199	76.5	1568	11.5
40–49	341	18.5	1502	81.5	1844	13.5
50–59	553	21.7	1997	78.3	2551	18.7
60–69	707	24.1	2230	75.9	2937	21.5
70–79	674	27.4	1786	72.5	2464	18.1
≥ 80	227	27.3	595	71.7	830	6.1
Total	3152	23.1	10,479	76.9	13,631	100
BMI N (%)	2454	23.0	8233	77.0	10,687	100
Mean (SD) (kg.m^−2)	26.5 (5.7)		26.2 (5.2)		26.3 (5.3)
Min, Max (kg.m^−2)	14.9–63.5		14.2–64.1		14.2–64.1
BMI Classes (kg.m^−2)	N	%	N	%	N	%
< 20	218	26.4	607	73.6	825	6.1
20.0–24.9	894	21.9	3190	78.1	4084	30.0
25.0–29.9	801	21.9	2860	78.1	3661	26.9
30–34.9	332	23.2	1098	76.8	1430	10.5
≥ 35	209	30.4	478	69.6	687	5.0
Unknown	697	23.7	2247	76.3	2944	21.6
Total	3151	23.1	10,480	76.9	13,631	100
Gender	N	%	N	%	N	%
Male	1394	22.7	4741	77.3	6135	45.0
Female	1758	23.5	5738	76.5	7496	55.0
Total	3152	23.1	10,479	76.9	13,631	100
Height N (%)	2938	23.0	9853	77.0	12,791	100
Mean (SD) (m)	1.71 (0.10)		1.73 (0.10)		1.73 (0.10)
Min, Max (m)	1.10–2.05		1.10–2.08		1.10–2.08
Weight N (%)	2601	23.0	8689	77.0	11,290	100
Mean (SD), (kg)	78.3 (18.7)		78.1 (17.5)		78.2 (17.8)
Min, Max, (kg)	33–180		29–181		29–181
ASA Class	N	%	N	%	N	%
1	441	18.4	1959	81.6	2400	17.6
2	1350	22.4	4666	77.6	6016	44.1
3	877	30.6	1988	69.4	2865	21.0
4	43	14.8	248	85.2	291	2.1
Unknown	440	21.4	1619	78.6	2059	15.1
Total	3151	23.1	10,480	76.9	13,631	100
Anesthesia type	N	%	N	%	N	%
Volatile	630	19.3	2633	80.7	3263	23.9
TIVA	2410	24.3	7510	75.7	9920	72.8
Unknown	112	25.0	336	75.0	448	3.3
Total	3153	23.1	10,479	76.9	13,631	100
Surgery type	N	%	N	%	N	%
General surgery	1229	28.5	3085	71.5	4314	31.6
ENDOCRINE	17	3.6	458	96.4	475	3.5
GASTROENTEROLOGICAL	369	36.9	630	63.1	999	7.3
GENERAL	634	38.2	1024	61.8	1658	12.2
TRANSPLANTATION	9	34.6	17	65.4	26	0.2
TRAUMA	135	19.5	557	80.5	692	5.1
VASCULAR	65	14.0	399	86.0	464	3.4
Gynecology	244	23.0	815	77.0	1059	7.8
Oral surgery	83	12.0	606	88.0	689	5.1
ENT surgery	717	27.8	1865	72.2	2582	18.9
Neurosurgery	224	10.1	2004	89.9	2228	16.3
Eye surgery	253	35.2	465	64.8	718	5.3
Orthopedics	124	9.2	1218	90.8	1342	9.8
Plastic surgery	73	26.9	198	73.1	271	2.0
Urology	75	30.4	172	69.6	247	1.8
Obstetrics	130	71.8	51	28.2	181	1.3
Total	3152	23.1	10,479	76.9	13,631	100
DoS N (%)	3152	23.1	10,479	76.9	13,631	100
Median, IQR (min)	82 (63–112)		152 (108–219)		134 (90–198)
Min, Max, (min)	15–955		21–1257		15–1257
DoS Classes (min)	N	%	N	%	N	%
< 60	648	71.2	262	28.8	910	6.7
60–120	1834	37.2	3095	62.8	4929	36.2
120–180	497	13.6	3151	86.4	3648	26.8
> 180	173	4.2	3971	95.8	4144	30.4
Total	3152	23.1	10,479	76.9	13,631	100
LoHS N (%)	3132	23.3	10,329	76.7	13,461	100
Median, IQR (days)	1 (0–7)		2 (1–6)		2 (1–6)
Min, Max, (days)	0–171		0–171		0–171
LoHS Classes (days)	N	%	N	%	N	%
0	944	39.7	1435	60.3	2379	17.7
1	654	21.2	2435	78.8	3089	22.9
2–6	747	16.0	3912	84.0	4659	34.6
> 6	787	23.6	2547	76.4	3334	24.8
Total	3132	23.3	10,329	76.7	13,461	100

Abbreviations: BMI, Body Mass Index; ASA, American Society of Anesthesiologists; TIVA, Total Intravenous Anesthesia; ENT, Ear, Nose & Throat; DoS, Duration of Surgery (defined as start incision to closure of skin); LoHS, Length of Hospital Stay (includes PACU and ICU stay).

Table 4 Characteristics of Multivariate Logistical Regression Analysis

Age Category (y)	OR	95% CI Lower	95% CI Upper	p-value
18–29	0.623	0.487	0.797	<0.001
30–39	0.645	0.513	0.811	<0.001
40–49	0.577	0.472	0.705	<0.001
50–59	0.678	0.572	0.805	<0.001
60–69	0.793	0.677	0.929	0.004
70-	1.000	Reference
BMI	OR	95% CI Lower	95% CI Upper	p-value
Underweight (< 20 kg.m^−2)	1.124	0.918	1.375	0.257
Normal – obese (20–34.9 kg.m^−2)	1.000	Reference
Morbidly obese (≥ 35 kg.m^−2)	1.517	1.219	1.888	<0.001
ASA Class	OR	95% CI Lower	95% CI Upper	p-value
1	0.749	0.628	0.894	0.001
2	1.000	Reference
3	1.262	1.102	1.445	0.001
4	0.441	0.293	0.664	<0.001
Anesthesia Type	OR	95% CI Lower	95% CI Upper	p-value
TIVA	0.860	0.741	0.997	0.045
Volatile	1.000	Reference
Specialty	OR	95% CI Lower	95% CI Upper	p-value
General Surgery	1.000	Reference
Gynecology	0.749	0.595	0.942	0.013
Oral surgery	0.407	0.292	0.566	<0.001
ENT surgery	0.761	0.641	0.904	0.002
Neurosurgery	0.422	0.338	0.527	<0.001
Eye surgery	0.715	0.562	0.910	0.007
Orthopedics	0.357	0.277	0.461	<0.001
Urology	0.835	0.566	1.232	0.363
DoS (min)	OR	95% CI Lower	95% CI Upper	p-value
<60	1.000	Reference
60–120	0.233	0.190	0.287	<0.001
120–180	0.066	0.052	0.083	<0.001
>180	0.020	0.016	0.027	<0.001

Abbreviations: BMI, Body Mass Index; ASA, American Society of Anesthesiologists; TIVA, Total Intravenous Anesthesia; ENT, Ear, Nose & Throat; DoS, Duration of Surgery (defined as start incision to closure of skin).

Figure 2 Relative odds ratio of reversal with sugammadex versus spontaneous recovery. (A) Univariate analysis. BMI categories 20–35 were combined to show the contrast with multivariate analysis. (B) Multivariate analysis. Odds ratios shown are adjusted for all other variables listed. Covariates are relative to age > 70 years, BMI 20–35, ASA = 2, anesthesia = volatile, surgery = general surgery, and duration of surgery < 60 min.