P1.029: Trends in sugammadex use in critically ill children at academic children’s hospitals using the Pediatric Health Information System database (2016–2023)

Background: Neuromuscular antagonists (NMA) are frequently used for endotracheal intubation and mechanical ventilation (MV) in children with either surgical or medical critical illnesses. Neostigmine has traditionally been used to reverse NMA effects before extubation, especially in surgical patients, but is limited by inconsistent efficacy and muscarinic side effects. sugammadex, a newer agent that encapsulates steroidal NMAs, enables rapid and targeted reversal. While adult use is well described, pediatric utilization patterns remain underreported, particularly across a large number of academic children’s hospitals.

Methods: With IRB approval (STUDY20241179), we performed a database study using the Pediatric Health Information System (PHIS). We collected data on all children < 18 yo admitted to a pediatric intensive care unit (PICU) from 2016–2023. Surgical patients, complex chronic conditions (CCC), and use of MV were defined using the appropriate PHIS “flags” and sugammadex usage was defined using pharmacy billing data. Demographics, clinical characteristics and outcomes (mortality and PICU length of stay [LOS]) were compared between centers grouped by sugammadex usage using t-tests, ANOVA, and chi-squared testing in SigmaPlot, with p< 0.05 defining statistical significance. Only centers contributing data in all study years were included in analyses.

Results: Among 550,877 children at 43 centers, 29.9% were surgical, mean PICU LOS was 11.87 ± 20.46 and 1.9% died. Overall, 12.3% of patients received sugammadex, with a quantitative increase during the study period from 1.1% to 27.4%. Patients who received sugammadex were 83.2% surgical with mean LOS of 13.82 ± 27.57, and 0.8% died. Among surgical patients, 34.3% received sugammadex; centers were classified as low usage ( < 26% of surgical patients receiving sugammadex), medium usage (26–35%), and high usage (>35%). In all three center types, sugammadex was associated with older age, lower use of MV in the PICU, longer PICU LOS, and lower mortality (Table 1). Among non-surgical patients, 2.9% received sugammadex; centers were classified as low usage ( < 2.5%) and high usage (>2.5%). In both center-types, sugammadex was associated with older age, presence of a CCC, and longer PICU LOS (Table 2).

Conclusion: Sugammadex use increased markedly in academic children’s hospitals between 2016 and 2023. Sugammadex is used commonly in surgical patients and is generally associated with favorable clinical outcomes, likely as a marker of peri-operative extubation and lower illness severity. Use is much less common in non-surgical patients, and with less clear associations with illness severity or clinical outcomes. Continued analyses of the dataset will aim to understand if outcomes vary between centers with different usage patterns. Further research is needed to guide utilization and assess impact on clinical outcomes in critically ill children.