Neuromuscular Blockade and Antagonism in Patients with Renal Impairment: A Multicenter Retrospective Cross Sectional Study

Background: Current practice guidelines do not address the use of neuromuscular blocking and antagonism agents in patients with renal impairment. The FDA label for sugammadex advises against use in patients with severe renal impairment (eGFR < 30 ml/min). Using a multicenter electronic health record registry, we sought to understand the modern use of neuromuscular blockade and antagonism agents in patients with significant renal impairment (eGFR < 60 ml/min). Methods: Data was obtained from the Multicenter Perioperative Outcomes Group (MPOG) registry, for adult patients (>18yrs) with an estimated glomerular filtration rate (eGFR) < 60ml/min, based on most recent serum creatinine, receiving general anesthesia for a non-renal transplant procedure with an endotracheal tube between January 1st 2016 and July 31st 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/case factors to variation to 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% and rocuronium-neostigmine decreased from 84.7% to 4.3% and cisatracurium-neostigmine decreased from 10.9% to 0.5%. In patients with an eGFR <15ml/min, rocuronium-sugammadex use increased from 0.5% to 86.9%. 30.1% of the variation in choice of rocuronium-sugammadex vs cisatracurium-neostigmine, 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.