JMIR Publications

ABSTRACT

Background:

Neuromuscular blockade (NMB) agents are a critical component of balanced anesthesia. NMB reversal methods can include spontaneous reversal, sugammadex, or neostigmine and the choice of reversal strategy can depend on various factors. Unanticipated changes emerged due to the COVID-19 pandemic, and a better understanding of how NMB reversal trends were affected by the pandemic may help provide insight into how providers view the tradeoffs in choice of NMB reversal agents.

Objective:

To analyze NMB reversal agent utilization patterns for US adult inpatient surgeries before and after the COVID-19 outbreak to determine whether pandemic-related practice changes affected utilization trends.

Methods:

A retrospective longitudinal analysis of a large all-payer national electronic US healthcare database (PINC AI™ Healthcare Database, PHD) was conducted to identify the utilization patterns of NMB reversal during early, mid, and late-COVID-19 (EC, MC, and LC, respectively) time-periods. Factors associated with NMB reversal choices in inpatient surgeries were assessed before and after the COVID-19 pandemic reached the US. Multivariate logistic regression assessed the impact of the pandemic on NMB reversal, accounting for patient, clinical, procedure, and site characteristics. A counterfactual framework was used to understand if patient characteristics affected how COVID-era patients would have been treated prior to the pandemic.

Results:

More than 3.2 million inpatients experiencing over 3.5 million surgical procedures across 931 sites that met all inclusion criteria were identified between January 1, 2017, and December 31, 2021. NMB reversal trends showed a steady increase in reversal with sugammadex over time, with the trend from January 2018 onwards being linear with time (R2>0.99). Multivariate analysis showed that the post-COVID-19 time-periods had a small but statistically significant effect on the trend, as measured by the interaction terms of the COVID-19 time periods and the time-trend in NMB reversal. A slight increase in the likelihood of sugammadex reversal was observed during EC relative to the pre-COVID trend (Odds ratio [OR], 1.008; p=0.003), followed by negation of that increase during MC (OR, 0.992; p<0.001), and no significant interaction identified during LC (OR, 1.001, p=0.811). Conversely, active reversal (using either sugammadex or neostigmine) did not show a significant association relative to spontaneous reversal, or a change in trend, during EC or MC (p>0.05), though a slight decrease in the active reversal trend was observed during LC (OR, 0.987; p<0.001).

Conclusions:

We observed a steady increase in NMB active reversal overall, and specifically with sugammadex compared to neostigmine, during periods before and after the COVID-19 outbreak. Small, transitory alterations in the NMB reversal trends were observed during the height of the COVID-19 pandemic, though these alterations were independent of the underlying NMB reversal time-trends. Clinical Trial: Not applicable