Muscle relaxation in pediatric anesthesia has traditionally been achieved using high-dose hypnotics and opioids rather than neuromuscular blocking agents such as rocuronium 1, 2. Reluctance was largely driven by concern for postoperative residual neuromuscular blockade, particularly given the short duration of many pediatric procedures and historical lack of a reliable reversal method 2, 3. Prior to the introduction of sugammadex, many clinicians frequently relied on propofol to optimize intubating conditions, although experimental evidence may link propofol exposure in early childhood to potential neurodevelopmental effects 4-6. While the clinical impact remains uncertain, it reinforces the interest in minimizing deep anesthetic dosing where alternatives exist. Rocuronium provides favorable intubating conditions, avoids hemodynamic changes with larger induction doses, improves surgical conditions, and may reduce airway trauma 3, 7, 8. The advent of sugammadex, capable of rapid and complete reversal, has renewed interest in neuromuscular blockade in children. International data suggest marked increases in neuromuscular blocker use following sugammadex adoption, but the magnitude and reasoning behind practice shifts within Canadian pediatric anesthesia remain understudied 9, 10. The objective of this study was to characterize rocuronium and sugammadex use among Canadian pediatric anesthesiologists, identify perceived barriers and facilitators, and explore decision-making factors through quantitative and qualitative analyses. After obtaining institutional ethics approval, a cross-sectional survey study was conducted among pediatric anesthesiologists listed on the Canadian Pediatric Anesthesia Society (CPAS) mailing list. Our survey was reported according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (Appendix S5, Supporting Information). Eligible participants were consultant pediatric anesthesiologists. The 26-item survey captured demographics, neuromuscular blocker usage patterns, reversal practices, monitoring modalities, and free-text clinical rationale. The survey was administered via REDCap and distributed to the Canadian Pediatric Anesthesia Society online mailing list over 6 weeks with one reminder at week 8. Participation was voluntary and anonymous, with optional separate entry for a prize draw. Descriptive statistics summarized responses. Fisher's exact test was conducted to evaluate associations between facilitators and barriers and rocuronium/sugammadex use. Free-text responses underwent inductive thematic analysis by two reviewers, with codes consolidated into overarching themes. The summary of the relevant quantitative results is presented in Table 1 and the qualitative results in Table 2. Full survey questions, supplemental methods, quantitative results, and summary of analyses are presented in Appendix S1–S4, Supporting Information. “Presence of neuromuscular disease, hypotonia” “Female of childbearing age on birth control” “Difficulty of airway management” “Need for RSI” “Does the surgery require paralysis?” “Surgery finished sooner than expected” “History of anaphylaxis” “Depth of residual block at time of reversal” “I usually intubate with remifentanil and no muscle relaxant (institutional practice)” “When working with trainees” “The necessity to fill out a short form for every use” Sixty pediatric anesthesiologists responded, predominantly practicing in Canada (58/60; 97%) and in academic centers (54/60; 90%). Most had > 10 years of experience (32/56; 57%). Following sugammadex introduction, 15/60 (25%) reported increased rocuronium use, while 42/60 (70%) reported no change. Minimal respondents (2/60; 3%) reported decreased use. Rocuronium use was most frequent in infants/toddlers, with 20/60 (33%) often and 6/60 (10%) always using it for infants, with similar patterns in older children. Better intubating conditions (48/60; 80%) and improved surgical conditions (47/60; 78%) were the most frequently cited advantages, while residual paralysis (35/60; 58%) and anaphylaxis (20/60; 33%) were primary concerns. Endorsing concern for airway trauma was the only variable that correlated with increased rocuronium use, and this was true across age groups (infants, toddlers, and preschool children; Fishers p-value < 0.001, 0.001, and < 0.001, respectively). Sugammadex was commonly valued for complete reversal (53/60; 88%) and rapid airway rescue capability (43/60; 72%). However, cost was identified as a barrier by 40/60 (67%), and neostigmine was the most commonly used reversal agent for 29/60 (48%) of respondents. Notably, 32/60 (53%) reported often or always using sugammadex in infants, despite its off-label status. A striking discrepancy emerged between concern for residual blockade and monitoring practices. Although residual blockade was frequently cited, 25/60 (42%) used qualitative monitoring only and 25/60 (42%) did not monitor neuromuscular function at all. Quantitative monitoring use was limited (15/60; 25%). Response rates to questions which elicited narrative responses describing factors influencing use of rocuronium and sugammadex were 24/60 (40%), and 27/60 (45%), respectively. Survey free-text responses qualitatively condensed into five decision-making themes are presented in Table 2. Our survey demonstrates a measured adoption of rocuronium and sugammadex in Canadian pediatric anesthesia. While sugammadex availability contributed to moderate increases in rocuronium use, widespread practice change has not yet occurred. Findings diverge from international patterns where availability of sugammadex rapidly accelerated neuromuscular blocker use 9, 10. Cost sensitivity and monitoring limitations likely contribute to slower uptake. Although the Health Canada patent for sugammadex expired in November 2020, the first application for a generic sugammadex injection was not approved until August 2024. These cost barriers were reflected in lack of sugammadex availability in certain hospitals and policies restricting its widespread use 11. Multiple generic versions of sugammadex are now available in Canada, and although not widely published, the cost is certainly significantly lower. Indeed, the high use of neuromuscular blockade in Europe, as shown in the APRICOT study (2/3 of cases requiring endotracheal intubation), may reflect greater sugammadex availability; given its regulatory approval ~7.5 years earlier in the EU compared to Canada (July 2008 versus February 2016), similar practice patterns may emerge in Canada as availability expands and cost barriers decline 12. Recently updated recommendations from the Canadian Anesthesiologists' Society which mandate immediate availability of a selective relaxant-binding reversal agent (sugammadex) may also accelerate its use 13. The most influential clinical motivator toward rocuronium use was airway protection, consistent with evidence supporting improved intubating conditions and reduced laryngeal trauma 3, 7, 14. However, the gap between concerns for residual paralysis and the low use of quantitative neuromuscular monitoring indicates a practice-safety misalignment. Improving access to monitors and implementing departmental standards may meaningfully reduce post-operative risk. Sugammadex use in infants was unexpectedly high, signifying strong clinician comfort despite off-label status. A previous survey of Society for Pediatric Anesthesia (SPA) members found similarly low use of quantitative monitoring for neuromuscular blockade (40% consistent use), alongside relatively high use of sugammadex 15. Current practices differ from CAS guidelines, which mandate neuromuscular monitoring whenever neuromuscular blocking agents are administered, with a strong recommendation for quantitative monitoring 13. This study has several limitations. The response rate was low (60 of 290 anesthesiologists on the mailing list), introducing potential non-response bias, as those with stronger views may have been more likely to participate. As with any self-reported survey, responses may reflect recall bias, social desirability bias, attribution bias, and non-response bias. The cross-sectional design captures practice patterns at a single time point and cannot determine causation or evolving trends. Self-reported or perceived changes in practice may not reflect actual practice. Future observational studies using a point prevalence methodology measuring baseline and longitudinal practice patterns would address this concern. Our qualitative findings did not reach thematic saturation given the quantity of narrative responses available for analysis. A dedicated qualitative study would be better suited to comprehensively characterize perceived barriers and facilitators to practice change and clinical decision-making processes. Finally, the use of a convenience sample through the CPAS mailing list may limit generalizability to all Canadian pediatric anesthesia providers. Overall, practice patterns reflect cautious clinical reasoning rather than resistance, shaped by physiology, procedure type, monitoring availability, and system-level economics. These findings support targeted educational interventions, improved quantitative monitoring access, and policy evaluation around sugammadex cost containment as potential strategies to optimize pediatric neuromuscular blockade practice in Canada. Funding was provided by the Anesthesia Research Fund (Department of Anesthesiology, Pain Management, & Perioperative Medicine, Dalhousie University). Research ethics board approval was obtained through the IWK Research Ethics Board. The authors declare no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Appendix S1: Full Survey. Appendix S2: Supplementary Methods. Appendix S3: Quantitative Results. Appendix S4: Summary Table of Data Analyses. Appendix S5: Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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