Anesth Pain Med Search

CLOSE


Anesth Pain Med > Epub ahead of print
Jong and Jung: Analysis of characteristics of patients whose sugammadex claims were denied by the Auto Insurance Claims Review Department of Korean Health Insurance Review & Assessment Service: a retrospective single-center review

Abstract

Background

Recently, there have been many cases where sugammadex used in traffic accident patients has been deducted from auto insurance claims. This study aims to investigate the characteristics of sugammadex deductions through retrospective analysis.

Methods

We included patients who underwent general anesthesia after traffic accidents at our institution between January 2019 and December 2023. Data for patients for whom sugammadex payments were deducted from the Auto Insurance Claims Review Department of the Korean Health Insurance Review and Assessment Service were obtained from the hospital's insurance department, and electronic medical records were analyzed. The characteristics of neuromuscular blockade (NMB) and its reversal, including administration time and dosage of neuromuscular blockading agent (NMBA) and reversal agent, intraoperative neuromuscular transmission (NMT) monitoring results, and reasons for sugammadex use, were assessed and analyzed.

Results

A total of 251 patients deducted sugammadex payments during the study period. The deduction rate significantly decreased from 88-100% in previous years to 43.4% in 2023. Sugammadex was used to reverse deep NMB (55.1%) and in high-risk patients (23.1%). Sugammadex was mostly used to reverse deep NMB (55.1%) and in high-risk patients (23.1%). NMT monitoring was documented in 81.3% of cases, with 38.9% showing deep NMB and 33.3% showing moderate NMB. Despite improved NMT documentation after 2021, sugammadex payment deductions persisted.

Conclusions

Sugammadex payment deductions occur despite clinical necessity, particularly in deep and moderate NMB cases. Thorough documentation may help reduce these deductions. Collaboration between healthcare providers and policymakers is required to use reversal agents guided by clinical evidence.

INTRODUCTION

Recovery from muscle relaxation after the use of neuromuscular blocking agents (NMBA) during surgery is crucial for patient safety [1]. Specifically, the importance of complete recovery from muscle relaxation has been emphasized owing to the occurrence of various complications resulting from residual muscle relaxation after surgery [2,3]. Compared to traditional reversal agents, sugammadex causes rapid recovery from muscle relaxation regardless of age or patient condition, garnering attention for its advantages such as reducing urinary or respiratory complications and enabling a quick return to daily activities [4]. In traffic accident patients who often present with severe conditions, such as multiple fractures or intra-abdominal bleeding, the appropriate use of NMBAs is necessary for surgery. Furthermore, adequate recovery from muscle relaxation is required to reduce postoperative complications, suggesting that sugammadex has several benefits. However, recently, there have been many cases in which sugammadex used for patients in traffic accidents has been deducted from claims in auto insurance evaluations, necessitating an analysis of this trend.
This study analyzed the characteristics of patients whose compensation claims were denied by the Auto Insurance Claims Review Department of the Korean Health Insurance Review and Assessment Service (HIRA). By conducting a retrospective single-center review, we aimed to identify common factors for claim denials among these patients and contribute to reducing the deduction rate of sugammadex claims.

MATERIALS AND METHODS

Data sources

This single-center, retrospective, observational study was approved by the Institutional Review Board (CHOSUN 2022-08-037). This study included patients who underwent surgery and anesthesia after traffic accidents at our institution between January 2019 and December 2023. The list of patients for whom sugammadex payments were deducted from the Auto Insurance Claims Review Department of the HIRA was obtained from the hospital's review team, and electronic medical records, including preoperative evaluation, anesthesia records, and other mandatory documentation, were analyzed. If the medical records of a patient were found to be incomplete, they were categorized as incomplete and excluded from further analysis. Only complete records were included in additional analyses.

Outcomes

The primary outcome of this study was the sugammadex payment deduction rate from the Auto Insurance Claims Review Department of the HIRA over the study period. This outcome measures the proportion of sugammadex claims deducted each year, providing insights into trends and potential improvements in insurance policies.
Secondary outcomes involved analyzing the characteristics of patients whose claims were denied. This included evaluating patient demographics, comorbidities, American Society of Anesthesiologists physical status class, surgical and anesthetic factors, neuromuscular blockade (NMB) and reversal, and the fidelity of anesthesia records.

Description of the variables

The number of cases with deductions and patient characteristics were analyzed annually. Patient characteristics such as sex, age, American Society of Anesthesiologists physical status class, and underlying comorbidities were investigated and recorded. Elderly patients were defined as those aged ≥ 70, as per the criteria for sugammadex claims provided by HIRA. The presence of comorbidities such as hypertension, electrocardiogram abnormalities, cardiovascular disease, diabetes, chest X-ray abnormalities, pulmonary disease, cerebrovascular disease, mental status change, liver disease, renal dysfunction, and coagulation abnormalities was confirmed through preoperative assessment records.
Surgical or anesthetic characteristics such as the department of surgery, emergency surgery status, presence of massive bleeding [5], extubation status after surgery, postoperative conditions, duration of surgery, and anesthesia were obtained.
The main reasons for using sugammadex were classified and analyzed as follows: deep NMB, respiratory failure or desaturation, high risk and comorbidities, morbid obesity, poor vital signs, short-duration surgeries, etc.
The characteristics of NMB and its reversal, including the administration time and dosage of NMBAs and reversal agents, intraoperative neuromuscular transmission (NMT) monitoring results, and reasons for sugammadex use, were assessed and analyzed. According to anesthetic records, rocuronium was the only NMBA used during anesthesia. The following profiles of NMB and its reversal were analyzed: time to administration of the reversal agent after the last NMBA injection; NMT profile such as post-tetanic count (PTC), train-of-four (TOF) count (TOFc), and TOF ratio (TOFr, %) before the first reversal agent administration; and the types of the first reversal agent (pyridostigmine or sugammadex). If the secondary reversal agent was used after the first reversal agent administration, profiles of NMB and its reversal, such as the time to administration of the secondary reversal agent after the first reversal agent injection and NMT profile before the secondary reversal agent administration, were analyzed: Also, the final NMT profiles during emergence were assessed. The depth of NMB was classified according to the 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade as follows: Deep blockade, PTC ≤ 1 or TOFc 0; Moderate blockade, TOFc 1-3; Shallow blockade, TOFc equal to 4 and TOFr < 0.4; minimal blockade, TOFr greater ≥ 0.4 and < 0.9 [6]. TOFc and TOFr prior to the administration of the reversal agent were analyzed based on the time since the last use of NMBA.
The fidelity of anesthesia records regarding the necessity for sugammadex usage was evaluated based on the following criteria, with each criterion assigned one point, for a total score of four points: specific risk assessment and documentation based on patient history and pre-anesthetic evaluation, documentation of TOF, documentation of PTC, and assessment and documentation of specific patient status during emergence or recovery from anesthesia. Fidelity was graded as follows: 0 = very poor, 1 = poor, 2 = average, 3 = good, and 4 = excellent.

Statistical analysis

Microsoft Excel (Microsoft) and IBM Statistical Package for the Social Sciences (SPSS) (version 22.0, SPSS Inc.) were used for the statistical analysis. Categorical variables of patient characteristics, NMB profiles, and their reversals were presented as numbers (%). Continuous variables, including age, time to administration of the reversal agent, PTC, and TOFr, are expressed as mean ± standard deviation. The depth of NMB, main reason for using sugammadex, and fidelity of the anesthesia records were analyzed using percentages in a stacked graph.

RESULTS

Overall, 251 patients had deducted sugammadex payments from the Auto Insurance Claims Review Department of the study period (January 2019 and December 2023).
We observed a significant reduction in the sugammadex deduction rate in 2023, dropping from an average of 88-100% in previous years to 43.4% (Table 1). However, despite these improvements, deductions persist (Fig. 1).
Table 2 displays the patient demographic data. The American Society of Anesthesiologists physical status class distribution indicated that ~40% of the patients were American Society of Anesthesiologists class 3 or higher. There were 80 patients aged ≥ 70, accounting for 31.9% of the total. Approximately 80% of the patients had various comorbidities. Emergency surgery accounted for 53 cases (21.1%), and 15 cases (6.0%) involved massive bleeding. Extubation was not performed after surgery in 24 cases (9.7%).
Orthopedic surgery accounted for the highest number of cases (57.8%), followed by neurosurgery, plastic surgery, and other specialties, as detailed in Fig. 1. As shown in Fig. 2, sugammadex was primarily used for deep blockade (55.1%), high-risk assessments (23.1%), and respiratory failure or desaturation (12.2%) during emergence for other reasons, including morbid obesity, poor vital signs, and short duration of surgery.

Analysis of the patterns of NMB and its reversal

The analysis of the patterns of NMB and its reversal is shown in Table 3. The average time required to administer the reversal agent after the last NMBA injection was approximately 68 min. However, when additional NMBA was administered after anesthesia induction, this time was shorter at 51.5 min on average.
NMT monitoring was recorded in 81.3% of cases, with 38.9% showing deep blockade and 33.3% showing moderate blockade (Table 3 and Fig. 3). The average TOFr in cases with TOFc 4 was 36.7%. Pyridostigmine and sugammadex were used almost equally as the first reversal agents (49.0% and 51.0%, respectively). In 50 cases, secondary reversal agents were required because of insufficient NMB recovery, indicating a shallow blockade. Pyridostigmine was the first agent in 82% of these cases, and sugammadex in 18%. The time to administer a secondary agent was 11.1 ± 6.6 min with pyridostigmine and 5.0 ± 4.3 min with sugammadex.
When comparing the NMT profiles based on the time since the last NMBA usage (Table 4), 91.9% of cases exhibited a deep blockade state within 30 min. Meanwhile, 92.1% had deep to moderate blockade between 30-60 min, and 54.8% showed shallow blockade between 60-120 min. After 120 min, 61.1% exhibited minimal blockade.

Analysis of the fidelity of anesthesia record

By 2020, over half of the patients had poor or very poor NMT documentation (Fig. 4). The percentage of cases without NMT records decreased from 32.6% in 2019 to 0% after 2022. After 2021, NMT results and reasons for sugammadex use are well-documented (75.5-97.2%), yet deductions for sugammadex payments persist despite these improvements.

DISCUSSION

In this study, we evaluated the characteristics of patients whose sugammadex claims were denied by the Auto Insurance Claims Review Department of the HIRA. The results of this study highlight the discordance between modern clinical guidelines and the policies of the Auto Insurance Claims Review Department of the HIRA. This discordance underscores the need for policy revisions to align insurance practices with the current clinical guidelines to ensure patient safety and optimal outcomes.
According to the drug approval conditions for sugammadex by the Korean Ministry of Food and Drug Safety (MFDS), it can be used for the reversal of NMB induced by rocuronium or vecuronium, with no particular contraindications aside from precautions [7]. Sugammadex is not used when the conventional reversal agent fails to restore recovery of NMB but is used for the reversal of NMB induced by rocuronium or vecuronium in itself [4,7]. Therefore, the administration of sugammadex for the recovery of NMB in traffic accident patients is an appropriate use of the proper drug approved by the Korean MFDS based on standard indications.
However, the findings of this study reveal that the Auto Insurance Claims Review Department of HIRA has substantiated deductions for sugammadex payments despite adequate usage based on clinical indications. Persistent deductions may discourage physicians from using sugammadex, thereby restricting their autonomy in prescribing the necessary medications and their ability to provide optimal care, which may be an ethical issue. Hopefully, the percentage of deducted claims has dropped significantly to 43.4% by 2023. We believe that this change indicates improved documentation practices or policy shifts. Initially, 58.2% of cases had poor or very poor documentation of NMT results before administration reversal agents until 2020, likely contributed to the high rate of claim deductions, especially in 2019. However, from 2021 onwards, all anesthesia records consistently included NMT results before administration reversal agents, with documentation quality improving to between 75.5% and 97.2%.
Nevertheless, despite improvements in record accuracy and detailed justifications for sugammadex use, sugammadex payment deductions persist, indicating that better documentation alone does not resolve the underlying issue of claim denial. According to the informally known criteria for the use of sugammadex in traffic accident patients by the Auto Insurance Claims Review Department of HIRA, sugammadex payments are not deducted in high-risk patients aged ≥ 70 years, with an American Society of Anesthesiologists physical status class of 3 or higher, or the status of a deep NMB of PTC 1-2, with mandatory documentation of NMT monitoring. However, payments for the use of sugammadex in high-risk elderly patients who were evaluated as American Society of Anesthesiologists physical status class 3 and had a high risk of postoperative pulmonary complications, such as atelectasis and pneumonia, have been deducted in quite a few cases. According to Table 2, 80 elderly patients (31.9%) have had deducted sugammadex payments in auto insurance evaluations, despite intraoperative NMT monitoring in all patients. Moreover, out of 251 patients, 90 (35.9%) were classified as American Society of Anesthesiologists physical status class 3, indicating a high-risk status with significant comorbidities; these patients are more likely to experience complications and require precise management of MNB and its reversal. Despite the high clinical need, many sugammadex payment claims have been deducted. The persistently high deduction rates, especially in patients with American Society of Anesthesiologists physical status class 3 or higher, suggest a misalignment between the clinical guidelines and the Auto Insurance Claims Review Department of the HIRA's deduction policies.
The new 2023 guidelines for the antagonism of NMB emphasize the critical importance of selecting an appropriate reversal agent based on the NMB level at the end of surgery [6,8]. These updated guidelines from both the American Society of Anesthesiologists and European Society of Anesthesiology and Intensive Care (ESAIC) provide clear recommendations to ensure patient safety and optimal recovery. The guidelines strongly recommend sugammadex for patients in a deep NMB (TOFc of 0 or PTC ≤ 1) due to its rapid and reliable reversal of profound NMB for ensuring patient safety and preventing complications such as respiratory depression or arrest. In cases of moderate NMB (TOFc 1-3) cases, sugammadex remains the preferred agent, providing quicker and more complete recovery than conventional agents. For shallow blockade (TOFc 4 and TOF ratio < 0.4), sugammadex is recommended because of its efficacy in achieving complete recovery. When minimal blockade is present (TOF ratio ≥ 0.4), sugammadex is preferred, but neostigmine can be a reasonable alternative if quantitative monitoring confirms adequate spontaneous recovery. However, the choice should be guided by the patient's risk factors and overall clinical condition. The guidelines highlight that inappropriate use of neostigmine in deep blockade states can lead to incomplete reversal and residual neuromuscular blockade, increasing the risk of postoperative complications. Conversely, sugammadex is recommended owing to its ability to safely and effectively reverse deep NMB, particularly in high-risk patients and those with significant comorbidities.
In the analysis of the patterns of NMB in this study, 67.1% of deducted cases exhibited deep and moderate NMB, which required sugammadex, according to the recent NMT monitoring guidelines. Moreover, the average TOFr in cases showing TOFc 4 was 36.7%, representing shallow NMB requires sugammadex for the reversal from NMB. In addition, insufficient recovery from NMB after administration the first reversal agent was seen as shallow blockade status, with a mean TOFr of 37.6%. According to recent guidelines, all cases require the use of sugammadex for NMB reversal. Despite the clear clinical indications for sugammadex, the Auto Insurance Claims Review Department of the HIRA deducted these claims, which contradict established guidelines and may compromise patient safety and quality of care.
Patients undergoing short surgery or additional NMB encounter deep NMB at the end of surgery. In short surgeries, such as closed reduction of nasal bone fractures, it generally takes approximately an hour after administering rocuronium for intubation for sufficient recovery to use conventional reversal agents such as neostigmine or pyridostigmine [9]. Similarly, additional administration of NMBA before the end of surgery may cause a deep NMB state at the end of surgery. As inadequate recovery from NMB due to the inappropriate use of conventional reversal agents in deep or moderate NMB increases the risk of respiratory depression and respiratory arrest, it is necessary to wait until the patient reaches a minimal block state for the use of conventional reversal agents. In such cases, conventional neuromuscular reversal agents should not be used and sugammadex should be administered instead [10]. The NMT profile analysis in the present study supports these findings. Most patients exhibited deep NMB within 30 min of NMBA administration, which transitioned to deep or moderate blockade within 30-60 min, shallow blockade within 60-120 min, or minimal blockade beyond 120 min. These results emphasize the importance of selecting an appropriate reversal agent based on the NMB state at the end of surgery, considering the time since the last NMBA administration.
The 2023 American Society of Anesthesiologists and ESAIC guidelines advise that neostigmine or pyridostigmine should only be used once the TOF ratio exceeds 0.2-0.4 [6,8]. Waiting for the minimal block state requires the maintenance of unnecessary anesthesia and endotracheal tube intubation, even if the patient regains consciousness, leading to extended anesthesia time, increased patient discomfort, and potential additional complications, posing significant risks to patient safety. As both recent guidelines recommend using sugammadex if the TOF ratio has not reached 0.2-0.4, it is crucial to ensure that recent recommendations are followed and not to restrict the use of sugammadex.
This study had some limitations. First, the study was conducted at a single center, which may have limited the generalizability of the findings. These results may not fully represent the status of sugammadex payment deductions at other institutions with different patient populations, clinical practices, and administrative policies. Replicating this study in multiple centers with diverse patient populations is necessary to confirm our findings and enhance their applicability. Second, although there were improvements in documentation quality over the study period, poor documentation of the NMT results could have influenced them. Third, this study did not provide long-term follow-up data on patient outcomes after administration of reversal agents. Consequently, the effects of sugammadex versus those of conventional agents on long-term patient safety and recovery remain unclear. Fourth, although this study highlights the issue of sugammadex payment deductions, it does not extensively explore their economic implications on overall healthcare costs, patient outcomes, and institutional practices.
In conclusion, this study analyzed the status of sugammadex payment deductions in patients with traffic accidents. However, insurance deductions by the Auto Insurance Claims Review Department of the HIRA remain high, despite the clinical necessity of sugammadex, especially in cases of deep and moderate NMB. Ensuring thorough documentation, particularly NMT monitoring, may help to reduce these deductions. The choice of reversal agent should be guided by the best clinical evidence rather than economic considerations to ensure optimal patient outcomes. Ensuring adherence to these guidelines helps to protect patient safety, optimize recovery, and maintain the highest standards of medical care. Continued collaboration between health care providers and policymakers can help achieve more consistent practices. Further research and discussion are needed to refine these policies and ensure that they provide the best care for patients.

Notes

FUNDING

This study was supported by research fund from Chosun University, 2023.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

DATA AVAILABILITY STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

AUTHOR CONTRIBUTIONS

Writing - original draft: Ki Tae Jung. Writing - review & editing: Hwa Song Jong, Ki Tae Jung. Conceptualization: Ki Tae Jung. Data curation: Hwa Song Jong, Ki Tae Jung. Formal analysis: Hwa Song Jong, Ki Tae Jung. Methodology: Ki Tae Jung. Project administration: Ki Tae Jung. Funding acquisition: Ki Tae Jung. Visualization: Ki Tae Jung. Investigation: Hwa Song Jong, Ki Tae Jung. Resources: Ki Tae Jung. Software: Ki Tae Jung. Supervision: Ki Tae Jung. Validation: Ki Tae Jung.

Fig. 1.
Analysis of deducted sugammadex payments from the Auto Insurance Claims Review Department of Korean Health Insurance Review & Assessment Service in the study period (January 2019 to December 2023). The numbers represent the cases for each year. OS: orthopedic surgery, NS: neurosurgery, PS: plastic surgery, GS: general surgery, CS: thoracic & cardiovascular surgery, others include ophthalmology, urology, and oral & maxillofacial surgery.
apm-24095f1.jpg
Fig. 2.
Analysis of 162 cases where the primary reasons for using sugammadex. Numbers represent the percentage for each year (others: postoperative pneumonthorax).
apm-24095f2.jpg
Fig. 3.
Analysis of neuromuscular blockade status before the administration of reversal agents. Numbers represent the percentage for each year. Deep blockade: post-tetanic count ≤ 1 or TOFc (train-of-four count) 0, moderate blockade: TOFc 1-3, shallow blockade: TOFc equal to 4 and TOFr (train-of-four ratio) < 0.4, minimal blockade: TOFr ≥ 0.4 and < 0.9. TOF: train-of-four, TOFc: count TOF, TOFr: ratio (TOFr, %).
apm-24095f3.jpg
Fig. 4.
Analysis of anesthesia record fidelity across all cases. Numbers represent the percentage for each year.
apm-24095f4.jpg
Table 1.
Number of Sugammadex Claims by Year
Variable/year 2019 (n = 86) 2020 (n = 54) 2021 (n = 45) 2022 (n = 30) 2023 (n = 36) Overall (n = 251)
Number of general anesthesia cases for automobile insurance patients 370 304 149 242 245 1,310
Number of sugammadex claims (% of total cases) 86 (23.2) 61 (20.1) 52 (34.9) 34 (14.0) 83 (33.9) 316 (24.1)
Number of deducted sugammadex payments (% of sugammadex cases) 86 (100.0) 54 (88.5) 45 (86.5) 30 (88.2) 36 (43.4) 251 (79.4)

Values are presented as number (%).

Table 2.
Characteristics of Traffic Accident Patients Whose Sugammadex Payment Was Deducted
Variable/year 2019 (n = 86) 2020 (n = 54) 2021 (n = 45) 2022 (n = 30) 2023 (n = 36) Overall (n = 251)
Sex (M/F) 51/35 27/27 32/13 14/16 19/17 143/108
ASA-PS class
 1 10 (11.6) 7 (13.0) 5 (11.1) 2 (6.7) 5 (13.9) 29 (11.6)
 2 40 (46.5) 25 (46.3) 25 (55.6) 17 (56.7) 14 (38.9) 121 (48.2)
 3 30 (33.3) 22 (40.7) 12 (26.7) 9 (30.0) 17 (47.2) 90 (35.9)
 4 6 (7.0) 0 (0.0) 3 (6.7) 2 (6.7) 0 (0.0) 11 (4.4)
Age 59.1 ± 19.9 56.8 ± 20.7 59.8 ± 18.9 56.8 ± 22.0 59.6 ± 19.9 58.5 ± 20.0
 Elderly (> 70 yr) 28 (32.6) 16 (29.6) 14 (31.1) 9 (30.0) 13 (36.1) 80 (31.9)
Comorbidity
 Hypertension 31 (36.0) 18 (33.3) 17 (37.8) 9 (30.0) 9 (25.0) 84 (33.5)
 ECG abnormality 50 (58.1) 31 (57.4) 26 (57.8) 17 (56.7) 23 (63.9) 147 (58.6)
 Cardiovascular disease 18 (20.9) 11 (20.4) 12 (26.7) 5 (16.7) 2 (5.6) 48 (19.1)
 Diabetes 25 (29.1) 13 (24.1) 12 (26.7) 7 (23.3) 10 (27.8) 67 (26.7)
 CXR abnormality 36 (41.9) 23 (42.6) 20 (44.4) 10 (33.3) 14 (38.9) 103 (41.0)
 Pulmonary disease 21 (24.4) 7 (13.0) 8 (17.8) 6 (20.0) 1 (2.8) 43 (17.1)
 Cerebrovascular disease 12 (14.0) 5 (9.3) 6 (13.3) 4 (13.3) 4 (11.1) 31 (12.4)
 Mental status change 11 (12.8) 6 (11.1) 3 (6.7) 2 (6.7) 2 (5.6) 24 (9.6)
 Liver disease 7 (8.1) 3 (5.6) 4 (8.9) 2 (6.7) 2 (5.6) 18 (7.2)
 Renal dysfunction 5 (5.9) 1 (1.9) 4 (8.9) 0 (0.0) 0 (0.0) 10 (4.0)
 Coagulation abnormality 3 (3.5) 3 (5.6) 0 (0.0) 2 (6.7) 3 (8.3) 11 (4.4)
Emergency operation 21 (24.4) 8 (14.8) 11 (24.4) 5 (9.4) 8 (22.2) 53 (21.1)
Massive bleeding 7 (8.1) 1 (1.9) 4 (8.9) 2 (6.7) 1 (2.8) 15 (6.0)
Failed extubation 11 (12.9) 4 (7.5) 3 (6.7) 2 (6.7) 4 (11.4) 24 (9.7)

Values are presented as number only, number (%) or mean ± SD. ASA-PS: American Society of Anesthesiologists physical status, ECG: electrocardiogram, CXR: chest radiography.

Table 3.
Profiles of Neuromuscular Blockade and Its Reversal of Cases
Variable Overall (n = 251)
First reversal
 Time to administration of reversal agent after the last NMBA injection (min) 68.1 ± 44.1
 Reversal agent (Pyridostigmine/sugammadex) 123 (49.0)/128 (51.0)
 NMT profile before first reversal agent administration Recorded n = 204 (81.3) Incomplete record n = 47 (18.7)
  PTC 5.3 ± 6.4
  TOFc 0 69 (33.8) -
   1 13 (6.4)
   2 17 (8.3)
   3 48 (23.5)
   4 57 (27.9)
  TOFr at TOFc 4 36.7 ± 20.9 -
Secondary reversal
 Time to administration of secondary reversal agent after first reversal agent injection (min) Pyridostigmine as first reversal agent (n=41): 11.1 ± 6.6
Sugammadex as first reversal agent (n=9): 5.0 ± 4.3
 Reversal agent (first - secondary)
  Pyridostigmine - Sugammadex 41 (82.0)
  Sugammadex - Pyridostigmine 6 (12.0)
  Sugammadex - Sugammadex 3 (6.0)
  Pyridostigmine - Pyridostigmine 0 (0.0)
 NMT profile before second reversal agent administration Recorded n = 47 (94.0) Incomplete record n = 3 (6.0)
  TOFc 0 0 (0.0) -
   1 3 (6.4)
   2 2 (4.3)
   3 3 (6.4)
   4 39 (83.0)
  TOFr at TOFc 4 37.6 ± 22.3 -
Final
 NMT profile Recorded n = 177 (30.5) Incomplete record n = 74 (29.5)
  TOFr at TOFc 4 95.4 ± 12.7 -

Values are presented as mean ± SD or number (%). NMBA: neuromuscular blocking agent, NMT: neuromuscular transmission, PTC: post-tetanic count, TOF: train-of-four, TOFc: TOF count, TOFr: TOF ratio (TOFr, %).

Table 4.
Profiles of Neuromuscular Blockade Based on the Time Since the Last NMBA Usage
NMT Time since last NMBA usage (min)
Overall
< 30 30-60 60-120 > 120
TOFc 0 34 (91.9) 29 (38.2) 6 (8.2) 0 (0.0) 69 (33.8)
 1 3 (8.1) 10 (13.2) 0 (0.0) 0 (0.0) 13 (6.4)
 2 0 (0.0) 10 (132.) 6 (8.2) 1 (5.6) 17 (8.3)
 3 0 (0.0) 21 (27.6) 21 (28.8) 6 (33.3) 48 (23.5)
 4 0 (0.0) 6 (7.9) 40 (54.8) 11 (61.1) 57 (27.9)
TOFr at TOFc 4 - 33.3 ± 18.0 31.0 ± 18.7 57.5 ± 17.2 36.7 ± 20.9

Values are presented as number (%) or mean ± SD. NMBA: neuromuscular blocking agent, NMT: neuromuscular transmission, PTC: post-tetanic count, TOF: train-of-four, TOFc: TOF count, TOFr: TOF ratio (TOFr, %).

REFERENCES

1. Blum FE, Locke AR, Nathan N, Katz J, Bissing D, Minhaj M. Residual neuromuscular block remains a safety concern for perioperative healthcare professionals: a comprehensive review. J Clin Med 2024; 13: 861.
crossref pmid pmc
2. Plaud B, Debaene B, Donati F, Marty J. Residual paralysis after emergence from anesthesia. Anesthesiology 2010; 112: 1013-22.
crossref pmid pdf
3. Shin YS. Postoperative residual neuromuscular blockade. Anesth Pain Med 2015; 10: 1-5.
crossref
4. Fuchs-Buder T, Meistelman C, Raft J. Sugammadex: clinical development and practical use. Korean J Anesthesiol 2013; 65: 495-500.
crossref pmid pmc
5. Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton PJ.; British Committee for Standards in Haematology. Guidelines on the management of massive blood loss. Br J Haematol 2006; 135: 634-41.
crossref pmid
6. Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, et al. 2023 American Society of Anesthesiologists practice guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists task force on neuromuscular blockade. Anesthesiology 2023; 138: 13-41.
crossref pmid pdf
7. Details of medicines. Korean Ministry of Food and Drug Safety. Ministry of Food and Drug Safety [Internet]. 2012 Oct date [cited 2024 Jul date]. Available from https://nedrug.mfds.go.kr/pbp/CCBBB01/getItemDetailCache?cacheSeq=201207240aupdateTs2024-05-23%2011:40:38.0b.

8. Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, et al. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol 2023; 40: 82-94.
crossref pmid
9. Unterbuchner C. Neuromuscular Block and Blocking Agents in 2018. Turk J Anaesthesiol Reanim 2018; 46: 75-80.
crossref pmid pmc
10. Brull SJ, Kopman AF. Current status of neuromuscular reversal and monitoring: challenges and opportunities. Anesthesiology 2017; 126: 173-90.
crossref pmid
TOOLS
Share :
Facebook Twitter Linked In Google+ Line it
METRICS Graph View
  • 0 Crossref
  •   Scopus 
  • 137 View
  • 5 Download
Related articles in Anesth Pain Med


ABOUT
ARTICLE & TOPICS
Article category

Browse all articles >

Topics

Browse all articles >

BROWSE ARTICLES
AUTHOR INFORMATION
Editorial Office
101-3503, Lotte Castle President, 109 Mapo-daero, Mapo-gu, Seoul 04146, Korea
Tel: +82-2-792-5128    Fax: +82-2-792-4089    E-mail: apm@anesthesia.or.kr                

Copyright © 2024 by Korean Society of Anesthesiologists.

Developed in M2PI

Close layer
prev next