From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
Anesth Analg. 2021 Oct 1;133(4):958-966. doi: 10.1213/ANE.0000000000005465.
Sugammadex binds progesterone with high affinity and may interfere with hormonal contraceptive effectiveness. The clinical, economical, and ethical implications of unintended pregnancy should prompt anesthesiologists to actively consider and manage this pharmacologic interaction. We surveyed anesthesiology providers at our institution about knowledge of this potential adverse drug interaction, how they manage it clinically, and the extent to which they involve patients in shared decision-making regarding choice of neuromuscular blocker antagonist.
A survey instrument was distributed to anesthesiology providers at a large, tertiary-care medical center. The survey explored prior experience using neostigmine and sugammadex, knowledge about potential sugammadex interference with hormonal contraception, pre-/postoperative counseling practices, clinical management, and shared decision-making regarding potential use of neostigmine in lieu of sugammadex to avoid this drug-drug interaction.
Of 259 surveys distributed, 155 were fully completed, and 10 were partially completed. Overall response rate was 60% (residents 85%, student nurse anesthetists 53%, certified registered nurse anesthetists 58%, attendings 48%). All but 1 respondent recognized the potential for sugammadex interference with oral hormonal contraception. Far fewer accurately identified potential interference with hormonal intrauterine devices (44%) and hormonal contraceptive implants (55%). The manufacturer's recommended 7-day duration of alternative contraception was correctly identified by 72% of respondents; others (22%) reported longer durations (range 10-30 days). Most (78% overall) agreed/strongly agreed that potential interference with contraceptive effectiveness should be discussed with patients preoperatively. Despite the majority (86% overall) that endorsed shared decision-making and inviting patient input regarding choice between sugammadex and neostigmine, many respondents reported "rarely/never" having discussed this drug interaction with patients in actual clinical practice, either preoperatively (67%) or postoperatively (80%). Furthermore, most respondents (79%) reported "rarely/never" administering neostigmine to intentionally avoid this drug interaction.
Two years after designating sugammadex as antagonist of choice, physician and nurse anesthesia providers reported seldom inquiring about contraceptive use among women of childbearing potential and rarely discussing potential risk of contraceptive failure from sugammadex exposure. Most lack accurate knowledge of sugammadex interference with hormonal intrauterine and subcutaneous contraceptive devices. Although most endorse preoperative counseling and support patient autonomy or shared decision-making regarding choice of reversal agent, the same respondents report rarely, if ever, actualizing these positions in clinical practice. These conflicting findings highlight the need for education regarding residual neuromuscular block versus adverse drug interactions, collaboration among providers involved in patient counseling, and intentional mindfulness of reproductive justice when caring for women of childbearing potential.
舒更葡糖钠与孕激素具有高亲和力，可能会干扰激素避孕的效果。意外怀孕的临床、经济和伦理影响应该促使麻醉医生积极考虑并管理这种药物相互作用。我们调查了我们机构的麻醉医生对这种潜在药物不良反应的认识，他们如何在临床上进行管理，以及他们在多大程度上让患者参与关于选择神经肌肉阻滞剂拮抗剂的共同决策。
向一家大型三级医疗中心的麻醉医生提供了一份调查问卷。该调查探讨了使用新斯的明和舒更葡糖钠的既往经验、对舒更葡糖钠可能干扰激素避孕的认识、术前/术后咨询实践、临床管理以及关于替代新斯的明以避免这种药物相互作用以避免这种药物相互作用的潜在用途的共同决策。
在分发的 259 份调查中，有 155 份完整填写，10 份部分填写。总回复率为 60%（住院医师 85%，学生护士麻醉师 53%，注册护士麻醉师 58%，主治医生 48%）。除 1 人外，所有受访者均认识到舒更葡糖钠可能干扰口服激素避孕药。只有 44%的人准确识别出对宫内节育器（IUD）和激素避孕埋植剂（HIC）的潜在干扰（55%）。受访者中有 72%正确识别出制造商建议的 7 天替代避孕时间；其他人（22%）报告了更长的时间（范围为 10-30 天）。大多数（总体 78%）同意/强烈同意应在术前与患者讨论潜在的避孕效果干扰。尽管大多数人（总体 86%）赞成共同决策并邀请患者在舒更葡糖钠和新斯的明之间做出选择，但许多受访者报告说，在实际临床实践中，他们“很少/从未”与患者讨论过这种药物相互作用，无论是术前（67%）还是术后（80%）。此外，大多数受访者（79%）报告说，他们“很少/从未”使用新斯的明来故意避免这种药物相互作用。
在指定舒更葡糖钠为首选拮抗剂两年后，医生和护士麻醉师报告说，他们很少询问有生育能力的女性的避孕使用情况，也很少讨论舒更葡糖钠暴露导致避孕失败的潜在风险。大多数人对舒更葡糖钠与宫内节育器和皮下避孕装置的干扰缺乏准确的认识。尽管大多数人赞成术前咨询并支持患者自主权或共同决策选择逆转剂，但同样的受访者报告说，在临床实践中，他们很少（如果有的话）真正实施这些立场。这些相互矛盾的发现强调了需要教育残留的神经肌肉阻滞与不良药物相互作用，参与患者咨询的提供者之间的协作，以及在为有生育能力的女性提供护理时有意关注生殖正义。
