Succinylcholine use in Patients 8 Years and Younger is NOT Zero While Midazolam use in Patients 65 Years and Older is NOT Decreasing Anymore: A 14-Year Census Report from a Tertiary Care Medical Center in the United States
Year: 2024
Type: article
Study design: Observational Study
Abstract: As an anesthesia provider for over 14 years at a medical center in the United States, it has been anecdotally observed that succinylcholine use among pediatric patients may be zero and midazolam use among geriatric patients may be declining. This is in the line of boxed warning for succinylcholine, precluding its use, especially among pediatric patients aged 8 years or less due to the risk of cardiac dysrhythmias and arrest secondary to hyperkalemic rhabdomyolysis in patients with undiagnosed skeletal myopathies and boxed warning for midazolam, reducing its use, especially among geriatric patients aged 65 years or more due to the risk of cognitive dysfunction with postoperative delirium, delayed neurocognition recovery, potential for dependence, and worsening of premorbid neurocognition.[1-8] For tracheal intubation, rocuronium has been available as an alternative neuromuscular blocking agent with sugammadex as its specific antidote becoming recently and increasingly available to maybe make succinylcholine use redundant. For perioperative sedation, dexmedetomidine has been available to maybe make midazolam use redundant. However, the clinical conditions of perioperative patients may allow exceptions from these boxed warnings when perioperative clinicians may make judgment calls for their perioperative patients to use these medications under caution but with hypervigilant cardiac and neurologic monitoring. Before delving deeper into perioperative clinicians’ clinical reasons to administer medications, which are cautioned against at the extremes of age per boxed warnings, it was deemed worthwhile to first explore the ground reality of whether succinylcholine use among pediatric patients has been actually zero and whether midazolam use among the geriatric patients has been actually declining. The purpose of this retrospective study was to trend the annual prevalence of succinylcholine use among patients at a tertiary care children’s hospital and midazolam use among patients at a tertiary care adults’ hospital during the 14-year period from July 1 2009 to June 30, 2023. The July–June cycles were chosen as the annual periods to align with the July–June cycles of graduate medical education at the academic center-associated children’s and adults’ hospitals. After institutional review board approval for exempt research, the institute’s information technology team ran a query in the institute’s electronic health records (EHRs) to extract census reports for the 14-year period (July 1, 2009–June 30, 2023) about (a) the cumulative number of all unique patients managed annually at the children’s hospital, and (b) the cumulative number of all unique patients managed annually at the adults’ hospital. For these census reports, the EHR system deemed uniqueness to each patient based on their non-overlapping unique patient identification numbers (PTIDs) in the system. Concurrently, census reports for the same 14-year period extracted (a) the cumulative number of all unique patients managed annually at the children’s hospital who were aged 8 years or less at the time of their management, and (b) the cumulative number of all unique patients managed annually at the adults’ hospital who were aged 65 years or more at the time of their management. Thereafter, census reports for the same 14-year period extracted (a) the annual number of all unique patients (all ages vs. those aged 8 years or less) with even a single-recorded succinylcholine use during their management at the children’s hospital, and (b) the annual number of all unique patients (all ages vs. those aged 65 years or more) with even a single-recorded midazolam use during their management at the adults’ hospital. Finally, the corresponding annual census reports were calculated (a) for those aged more than 8 years when managed at the children’s hospital, and (b) for those aged less than 65 years when managed at the adults’ hospital. The annual trends in the census reports were analyzed with a linear regression model and polynomial regression model whereafter P < 0.05 was considered to be a statistically significant trend. According to the 14 years’ cumulative PTIDs’ census, 1,316,610 patients were managed at the children’s hospital, whereas 1,049,449 patients were managed at the adults’ hospital. As numerically documented in Table 1 and graphically documented in Figure 1, the numbers of unique patients managed at the hospitals have been significantly (P < 0.001) trending down, irrespective of their age groups over the 14 years. However, the percentage of those aged 65 years and more is significantly (P < 0.001) trending up in the adults’ hospital, whereas the percentage of those aged 8 years and less has been static with insignificant (P = 0.22) changes in the trend at the children’s hospital as graphically documented in Figure 2. Contrary to the belief, succinylcholine use was NOT zero at the children’s hospital when annually 0.01% to 0.02% of patients aged 8 years and less had recorded succinylcholine use per their EHRs as documented in Table 1. Interestingly, as depicted in Figure 3, midazolam use at the adults’ hospital followed an order 4 (quantic) polynomial trending with two valleys, one each at the beginning of each decade, plus one hill in the middle of the decade, which was significant (P < 0.001) with the recurrence of midazolam uptrend in recent years, indicating that midazolam use is not decreasing anymore with midazolam uptrend breaching the 25% mark among those aged 65 years or more, whereas midazolam uptrend closing in on the 20% mark among those aged less than 65 years.Table 1: The 14-year census report of children’s hospital in terms of succinylcholine use and adults’ hospital in terms of midazolam useFigure 1: Trends in annually managed unique patients over the 14 yearsFigure 2: 14-year trends in annual percentages of managed patients by their ageFigure 3: 14-year trends in annual percentages of succinylcholine and midazolam use with linear trend lines of succinylcholine use among ≤ 8 years and > 8 years almost completely overlapping, thus becoming almost indistinguishable graphicallyThis retrospective study has a few limitations. As unique PTIDs were segregated according to the annual periods, some of these unique PTIDs might have recurred in different annual periods, which may mean that the actual cumulative census of unique patients might have been less than 1,316,610 at the children’s hospital and similarly less than 1,049,449 patients at the adults’ hospital. Moreover, the trend of annually declining numbers of unique patients at the hospitals could correspondingly neither detect nor reflect the trend in the actual total patient visits at the hospitals. As these census reports covered the entire hospital’s unique patients, the recorded use of succinylcholine and midazolam would not have been limited to perioperative scenarios but might have included critical care scenarios and emergency care scenarios as well while assuming that other benzodiazepines might have been prescribed by internal medicine physicians and hospitalists in the medical surgical floors instead of prescribing midazolam, which might have been primarily prescribed by perioperative physicians, critical care physicians, and emergency room physicians. Reviewing multimillion EHRs individually would have been impossibly tedious for the two-author team unless an artificially intelligent software could have been developed or employed to extract the comprehensive multiyear details about each perioperative pediatric use of succinylcholine with its indication, followed by its outcome and each perioperative geriatric use of midazolam with its indication followed by its outcome. Moreover, the frequency of cardiac dysrhythmias and arrest after succinylcholine among pediatric patients aged 8 years or less and cognitive dysfunction after midazolam among geriatric patients aged 65 years or more could not be tabulated because EHR query could NOT extract information about side effects after succinylcholine or midazolam. Summarily, although the United States Food and Drug Administration expects anesthesiologists to consider precluding the pediatric use of succinylcholine and DROP-Benzo initiative by Mark D. Neuman’s team expects anesthesiologists to consider limiting the geriatric use of midazolam,[1,2,4,5] the ground reality at the retrospectively studied medical center in the United States is that succinylcholine use in patients 8 years and younger is NOT zero, whereas midazolam use in patients 65 years and older is NOT decreasing anymore. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Annals of Cardiac Anaesthesia
Authors: Deepak Gupta, Maria M. Zestos
Institutions: Wayne State University, Detroit Medical Center
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4404600478