We are grateful to both Nhan et al and Faulk et al for taking the time to review and comment upon our recent article “Analysis of the Factors Contributing to Residual Weakness After Sugammadex Administration in Pediatric Patients Under 2 Years of Age.”1–3 We intended to ignite further discussion and investigation into the way in which pediatric anesthesiologists manage paralytic administration, neuromuscular blockade monitoring, and neuromuscular blockade reversal in this unique patient population. We believe that these letters to the editor highlight that we have been successful. Thank you.
As both authors aptly note, one of the greatest flaws with our existing practice involves the inconsistent use of neuromuscular blockade monitoring. Without such monitoring, the appropriate depth of neuromuscular blockade, dose of reversal agent, and adequacy of blockade reversal are left to clinical judgment—flying blind, so to speak. We need to improve upon our use of neuromuscular blockade monitoring, ensuring adequate standardization. In addition to implementing appropriate monitoring in routine clinical practice, we must recognize that the unique pharmacokinetic and pharmacodynamic profile of the neonatal population means that significant uncertainty still exists around optimal management of neuromuscular blockade in this complex population. We agree that future studies should be performed to understand the optimal approach to neuromuscular blockade and reversal in pediatric patients under 2 years of age. While univariate, stepwise, and other variable selection methods are known to be flawed, we agree that a propensity score matched case–control study design would be one of several appropriate analytical techniques for future studies, and worth considering in future studies.4
We are encouraged to see that we have successfully sparked discussion around existing practice and look forward to continued investigation into the appropriate approach to neuromuscular blockade management in this unique patient population.
FUNDING INFORMATION
ACC, ANL, and JCC received no specific external funding. REF receives funding from the following grants: K23HL148640 and UL1TR002243.
Footnotes
CONFLICT OF INTEREST STATEMENT
The authors report no conflict of interest relevant to this submission.
DATA AVAILBILITY STATEMENT
The data that support the findings of our original study are available from the corresponding author upon reasonable request.
REFERENCES
- 1.Nhan HN, Terada R, Butt AL, de Armendi A. Sugammadex dosing challenges in pediatric neuromuscular reversal—comments on Cates et al. Paediatr Anaesth. 2023. Online ahead of print. doi: 10.1111/pan.14821 [DOI] [PubMed] [Google Scholar]
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of our original study are available from the corresponding author upon reasonable request.