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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background The authors observed increased pharmaceutical costs after the introduction of sugammadex in our institution. After a request to decrease sugammadex use, the authors implemented a cognitive aid to help choose between reversal agents. The purpose of this study was to determine if sugammadex use changed after cognitive aid implementation. The authors’ hypothesis was that sugammadex use and associated costs would decrease. Methods A cognitive aid suggesting reversal agent doses based on train-of-four count was developed. It was included with each dispensed reversal agent set and in medication dispensing cabinet bins containing reversal agents. An interrupted time series analysis was performed using pharmaceutical invoices and anesthesia records. The primary outcome was the number of sugammadex administrations. Secondary outcomes included total pharmaceutical acquisition costs of neuromuscular blocking drugs and reversal agents, adverse respiratory events, emergence duration, and number of neuromuscular blocking drug administrations. Results Before cognitive aid implementation, the number of sugammadex administrations was increasing at a monthly rate of 20 per 1,000 general anesthetics (P < 0.001). Afterward, the monthly rate was 4 per 1,000 general anesthetics (P = 0.361). One month after cognitive aid implementation, the number of sugammadex administrations decreased by 281 per 1,000 general anesthetics (95% CI, 228 to 333, P < 0.001). In the final study month, there were 509 fewer sugammadex administrations than predicted per 1,000 general anesthetics (95% CI, 366 to 653; P < 0.0001), and total pharmaceutical acquisition costs per 1,000 general anesthetics were $11,947 less than predicted (95% CI, $4,043 to $19,851; P = 0.003). There was no significant change in adverse respiratory events, emergence duration, or administrations of rocuronium, vecuronium, or atracurium. In the final month, there were 75 more suxamethonium administrations than predicted per 1,000 general anesthetics (95% CI, 32 to 119; P = 0.0008). Conclusions Cognitive aid implementation to choose between reversal agents was associated with a decrease in sugammadex use and acquisition costs.

Struvite calculi result from urinary tract infections secondary to urease-producing bacteria. To prevent recurrent infection and stone formation complete removal of struvite calculi is recommended. Two illustrative reports of patients with renal struvite calculi are presented in which 10% hemiacidrin (Renacidin) irrigation was instituted for stone dissolution. After surgical removal of the calculi a nephrostomy tube was placed in the renal pelvis. With confirmation of residual struvite calculi, 10% hemiacidrin irrigation was initiated. Urine cultures, electrolytes and nephrotomograms were performed and adverse effects monitored. Using strict aseptic technique and appropriate precautions, hemiacidrin irrigation safely dissolves struvite calculi.