MPOG Pediatric
Subcommittee Meeting
August 18, 2021
Agenda
Announcements
Measure Updates
TOF Monitoring (NMB-01)
Measure Review and Discussion
Reversal Administered (NMB-02)
Measure Review and Discussion
Proposed Measure: NMB Dosing
Open Discussion
Announcements
• Remaining 2021 Meeting Dates
– MPOG pediatric subcommittee update
at SPA Q&S (virtual)
– Next Subcommittee meeting:
– December 15
th
, 1pm EST via Zoom
Coming Soon! Pediatric Subcommittee Website
• New! Local anesthetic administered at surgical site added as passing criteria
• Currently, this measure is informational only, with no attribution to individual
providers. As a result, individual providers are unable review their cases on the
QI Reporting Tool.
• MPOG Quality Committee voting in progress to help decide if we should attribute
this measure to Individual Provider(s) signed into case. Options include:
– Providers signed into case at Induction
– For longest duration
– For any duration and at any time during the case (all providers who signed into
case)
– At Emergence
– No attribution. Keep at departmental level
PAIN 01 - Multimodal Pain Management
Is there interest in development of an informational measure for # of
tonsil bleed cases?
TRAN-01 and TRAN-02
Plan is to build separate TRAN 01/02 measures specific to pediatric patients in
2022
• Include patients ≥ 6 months old (previous inclusion ≥ 2yo)
• Exclusion Updates
– Cardiac bypass cases and all obstetric procedures
– Patients on ECMO
– Massive Transfusion/blood loss: Change definition from Total transfused volume (or EBL)
of 30cc/kg → 40cc/kg
• TRAN 02 Revision: If No Hb/Ht checked within 18 hours of Anesthesia End, the case should be
flagged for systematic review
MPOG Pediatric Data Review
• MPOG enables participants to view institutional comparison data on
select measures at collaborative meetings
• Facilitates further discussion and provides additional context to the
comparison scores on the dashboard
• Would the Peds Subcommittee be interested in a performance review
once per year?
• We would encourage low/high performers on the pediatric measures to
speak to the care they provide and current barriers they face
Measure Review
Train of Four Monitoring
NMB-01
NMB-01 - TOF Monitoring
Description
Percentage of cases with a documented Train of Four (TOF)
after last dose of nondepolarizing neuromuscular blocker
Measure Time Period
Anesthesia Start → Earliest Extubation
Responsible Provider
The provider signed in at time of earliest extubation
Inclusion/Exclusion Criteria
Inclusions
All patients that have received either by
bolus or infusion a non-depolarizing
neuromuscular blocker (NMB) AND
were
extubated postoperatively or in the PACU.
The following NMBs are included:
• Atracurium
• Cisatracurium
• Pancuronium
• Rocuronium
• Vecuronium
Exclusions
• ASA 5 and 6 cases.
• Patients that were not extubated in the
immediate postoperative period.
• Patients not given NMBs.
• Cardiac surgery with or without pump
(CPT: 00560, 00561, 00562, 00563,
00567, 00580)
• Cases performed by cardiac surgical
service: MPOG concept 80005.
Success Criteria
• Documentation of a Train of Four count (1, 2, 3, or
4), sustained tetany, or TOF ratio provided by
acceleromyography AFTER
last dose or stopping of
infusion of neuromuscular blocker and before
earliest extubation.
• A Train of Four value of ‘0’ is accepted for cases in
which Sugammadex is administered for reversal.
Reversal Administered
NMB-02
NMB 02
Description - Administration of Neostigmine, Sugammadex, and/or
Edrophonium before extubation for cases with non-depolarizing
neuromuscular blockade.
Exclusions
• ASA 5&6
• Patients who remain intubated in the immediate postop period
• Patients who do not receive NMBs
• Cardiac Surgery
• Cases where patient (age > 12) receive defasciculating doses of
– Vecuronium ≤ 1mg
– Cisatracurium ≤ 2mg
– Rocuronium ≤ 10 mg
NMB 02 - Success Criteria
EXISTING
• Documentation of Neostigmine or
Sugammadex before earliest
extubation OR
• For patients < 12yo, At least two
hours exists between last dose of
NMB and extubation
(three hours for
Patients ≥ 12yo)
OR
• An acceleromyography ratio of ≥
0.9 documented after last dose of
NMB and before earliest
extubation.
PROPOSED
Documentation of reversal before
earliest extubation
OR
An acceleromyography ratio of ≥
0.9 documented after last dose of
NMB and before earliest
extubation.
Sugammadex or Neostigmine across MPOG?
NMB-02 cases, Patients <18y
Sugammadex or Neostigmine across MPOG?
New Proposed Measure
NMB-03
Background
• The effective dose of rocuronium is reduced
in infants compared to children
– TAIVAINEN, T., MERETOJA, O.A., ERKOLA, O.,
RAUTOMA, P. and JUVAKOSKI, M. (1996),
Rocuronium in infants, children and adults
during balanced anaesthesia. Pediatric
Anesthesia, 6: 271-275.
Background
• High dose rocuronium (1.5 mg/kg) may
have markedly prolonged duration
– Soffer OD, Kim A, Underwood E, Hansen
A, Cornelissen L, Berde C.
Neurophysiological Assessment of
Prolonged Recovery From Neuromuscular
Blockade in the Neonatal Intensive Care
Unit. Front Pediatr 2020;8:580.
Background
• High rocuronium dosing in
infants has been associated with
prolonged anesthesia time
– Gilbertson LE, Fiedorek MC,
Fiedorek CS, Trinh TA, Lam H,
Austin TM. Prolonged
neuromuscular block after
rocuronium administration in
laparoscopic pyloromyotomy
patients: A retrospective bayesian
regression analysis. Paediatr
Anaesth 2021;31:290–7.
Background
• High rocuronium dosing in infants has
been associated with postoperative
respiratory complications
– Scheffenbichler FT, Rudolph MI, Friedrich
S, Althoff FC, Xu X, Spicer AC, Patrocínio
M, Ng PY, Deng H, Anderson TA,
Eikermann M. Effects of high
neuromuscular blocking agent dose on
post-operative respiratory complications
in infants and children. Acta Anaesthesiol
Scand 2020;64:156–67.
• Sugammadex is not a panacea
– Renew JR, Tobias JD, Brull SJ. The Time to Seriously Reassess the Use and Misuse of Neuromuscular
Blockade in Children Is Now. Anesth Analg 2021;132:1514–7.
– Lorinc AN, Lawson KC, Niconchuk JA, Modes KB, Moore JD, Brenn BR. Residual Weakness and
Recurarization After Sugammadex Administration in Pediatric Patients: A Case Series. A A Pract
2020;14:e01225.
– Carollo DS, White WM. Postoperative Recurarization in a Pediatric Patient After Sugammadex
Reversal of Rocuronium-Induced Neuromuscular Blockade: A Case Report. A A Pract 2019;13:204–
5.
– APSF Postoperative recurarization after sugammadex administration due to the lack of appropriate
neuromuscular monitoring: https://www.apsf.org/article/postoperative-recurarization-after-
sugammadex-administration-due-to-the-lack-of-appropriate-neuromuscular-monitoring-the-
japanese-experience/
Background
Existing dosing recommendations - Smith’s 9th edition
Proposed measure: NMB-03-peds
• Description: Percentage of infant cases that receive appropriate initial dosing of non-
depolarizing neuromuscular blocking drugs (NMB) intraoperatively.
• Measure Type: Process (informational)
• Measure Time Period: Anesthesia Start → Earliest Extubation
• Success Criteria: The first dose of neuromuscular blocker is less than the thresholds
below, during the measure time period:
– Cisatracurium: dose ≤ 0.2 mg/kg
– Atracurium: dose ≤ 0.5 mg/kg
– Rocuronium: dose ≤ 1 mg/kg
– Pancuronium: dose ≤ 0.1 mg/kg
– Vecuronium: dose ≤ 0.1 mg/kg
Open Discussion
Next Steps...
• We will incorporate your feedback and update the NMB metrics as
needed
• Next Subcommittee meeting: December 15th @ 1p EST
– Discussion: TEMP-03 (Postoperative Hypothermia)
