Elkhateb Rania, Campbell Davis L, Zhao Xinyi, Mentz Graciela, El Sharawi Nadir, Kumar Sathish, Mhyre Jill M, Kheterpal Sachin, Colquhoun Douglas A
Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Anesthesiology. 2025 Jun 1;142(6):1009-1024. doi: 10.1097/ALN.0000000000005411. Epub 2025 Feb 10.
Current practice guidelines do not address the use of neuromuscular blocking and antagonism agents in patients with renal impairment. The U.S. Food and Drug Administration (Silver Spring, Maryland) label for sugammadex advises against use in patients with severe renal impairment (estimated glomerular filtration rate [eGFR] less than 30 ml/min). Using a multicenter electronic health record registry, the authors sought to understand the modern use of neuromuscular blockade and antagonism agents in patients with significant renal impairment (eGFR less than 60 ml/min).
Data were obtained from the Multicenter Perioperative Outcomes Group (MPOG) registry for adult patients (older than 18 yr) with an eGFR less than 60 ml/min, based on most recent serum creatinine, receiving general anesthesia for a nonrenal transplant procedure with an endotracheal tube between January 1, 2016, and July 31, 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 or case factors to variation in strategy choice was assessed by multilevel mixed effects models.
In 243,944 cases across 5,133 anesthesiologists and 48 institutions, adjusted use of rocuronium-sugammadex increased from 4.4 to 95.2%, rocuronium-neostigmine decreased from 84.7 to 4.3%, and cisatracurium-neostigmine decreased from 10.9 to 0.5%. In patients with an eGFR less than 15 ml/min, rocuronium-sugammadex use increased from 0.5 to 86.9%. Of the variation in choice of rocuronium-sugammadex versus cisatracurium-neostigmine, 30.1% 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.
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.
当前的实践指南未涉及肾功能不全患者使用神经肌肉阻滞和拮抗药物的问题。美国食品药品监督管理局（马里兰州银泉）对舒更葡糖的标签建议，严重肾功能不全（估计肾小球滤过率[eGFR]低于30 ml/min）患者禁用。作者利用多中心电子健康记录登记系统，试图了解在严重肾功能不全（eGFR低于60 ml/min）患者中神经肌肉阻滞和拮抗药物的现代使用情况。
数据来自多中心围手术期结局研究组（MPOG）登记系统，纳入2016年1月1日至2022年7月31日期间，基于最新血清肌酐，eGFR低于60 ml/min、接受非肾移植手术气管插管全身麻醉的成年患者（年龄大于18岁）。患者被分为三种相互排斥的阻滞和逆转策略：罗库溴铵-舒更葡糖、顺式阿曲库铵-新斯的明和罗库溴铵-新斯的明。每种阻滞逆转策略的校正发生率通过多项混合效应模型确定。通过多水平混合效应模型评估机构、麻醉医生以及患者或病例因素对策略选择差异的影响。
在来自5133名麻醉医生和48家机构的243,944例病例中，罗库溴铵-舒更葡糖的校正使用率从4.4%增至95.2%，罗库溴铵-新斯的明从84.7%降至4.3%，顺式阿曲库铵-新斯的明从10.9%降至0.5%。在eGFR低于15 ml/min的患者中，罗库溴铵-舒更葡糖的使用率从0.5%增至86.9%。在罗库溴铵-舒更葡糖与顺式阿曲库铵-新斯的明的选择差异中，30.1%归因于机构，22.7%归因于主治麻醉医生，47.2%归因于患者/病例因素或无法解释。该选择的校正中位优势比，临床医生为2.5，机构为3.1。
罗库溴铵-舒更葡糖是中重度肾功能不全患者的主要神经肌肉阻滞-拮抗策略。选择差异受提供治疗的机构和主治麻醉医生的显著影响。
