Risk factors for administration of additional reversal following neuromuscular blockade with rocuronium in children: A retrospective case-control study.

BACKGROUND: The prevalence and risk factors for residual neuromuscular blockade in children remain poorly characterized. We hypothesize that specific patient and anesthetic risk factors may be associated with the administration of additional reversal in children following initial reversal of rocuronium with neostigmine. METHODS: Our electronic health record was queried for patients <18 years of age who received rocuronium and reversal with neostigmine from 2017 through 2020. Patients receiving other nondepolarizing neuromuscular blocking drugs were excluded. The outcome of interest was defined as the administration of additional neostigmine or sugammadex following primary reversal with neostigmine. Time between the last dose of rocuronium and initial dose of neostigmine, and the cumulative dose of rocuronium were dichotomized. These were combined with other covariates including age, weight, sex, racial group, procedure type, ASA physical status, >1 rocuronium dose administered during the procedure, initial neostigmine dose <0.05 mg kg-1 , use of train-of-four monitoring, duration of anesthesia, inpatient or outpatient, emergency case, neuromuscular disease, and extremes of weight, to assess possible associations with the primary outcome. RESULTS: During the study period, 101/6373 (1.58%) patients received rocuronium and additional reversal. Dichotomization of time between last dose of rocuronium and neostigmine yielded <28 min since the last dose of rocuronium and cumulative dose of rocuronium >0.45 mg kg-1 hr-1 . These were associated with the administration of additional reversal with an OR 1.52 (95% CI, 1.08-2.35) and OR 1.71 (95% CI, 1.10-2.67), respectively. Other risk factors included an initial neostigmine dose <0.05 mg kg-1 , OR 4.98 (95% CI, 2.84-6.49), and African American race, OR 1.78 (95% CI, 1.07-2.87). CONCLUSION: Risk factors associated with the administration of additional reversal included time <28 min from the last dose of rocuronium to initial dose of neostigmine, cumulative dose of rocuronium >0.45 mg kg-1 hr-1 , initial neostigmine dose <0.05 mg kg-1 , and African American race.

A comparison of the breathing apparatus deadspace associated with a supraglottic airway and endotracheal tube using volumetric capnography in young children.

BACKGROUND: Supraglottic airway (SGA) devices including the air-Q® are being used with increasing frequency for anesthesia in infants and younger pediatric patients. To date, there is minimal research documenting the potentially significant airway deadspace these devices may contribute to the ventilation circuit when compared to an endotracheal tube (ETT). The aim of this study was to evaluate the airway apparatus deadspace associated with an air-Q® versus an ETT in young children. METHODS: In a prospective cohort study, 59 patients between 3 months and 6 years of age, weighing between 5 and 20 kg, scheduled for outpatient urologic or general surgery procedures were recruited. An air-Q® or ETT was inserted at the discretion of the attending anesthesiologist, and tidal volume, positive end expiratory pressure, respiratory rate, and end-tidal CO2 were controlled according to protocol. Airway deadspace was recorded using volumetric capnography every 2 min for 10 min. RESULTS: Groups were similar in demographics. There was a significant difference in weight-adjusted deadspace volume between the air-Q® and ETT groups, 4.1 ± 0.8 ml/kg versus 3.0 ± 0.7 ml/kg, respectively (P < 0.001). Weight-adjusted deadspace volume (ml/kg) increased significantly with decreasing weight for both the air-Q® and ETT groups. CONCLUSIONS: In healthy children undergoing positive pressure ventilation for elective surgery, the air-Q® SGA introduces significantly greater airway deadspace than an ETT. Additionally, airway deadspace, and minute ventilation required to maintain normocarbia, appear to increase with decreasing patient weight irrespective of whether a SGA or ETT is used.