The first guidelines on neuromuscular block in anaesthetised paediatric patients: here they are! 

The creation of an ESAIC-ESPA Task Force on Neuromuscular Block in anaesthetised children was announced in the ESAIC Newsletter in July 2024. The guideline was divided into four main questions and related Population/Intervention/Comparison/Outcome (PICO) groups. The main clinical messages of the Guidelines were already presented during the ESAIC (Lisboa 2025) and ESPA Congresses (Berlin) in 2025 and were finally published in the European Journal of Anaesthesiology and Intensive Care in April 2026 (1). As foreseen, it was accompanied by an update on the developmental aspects of the neuromuscular junction and on the pharmacology of the current neuromuscular blocking agents and their antagonists (2) published in the same issue of the Journal (2). 

The main messages of the Neuromuscular Block in anaesthetised children Guidelines can be summarised as follows:  

Question 1: Is a neuromuscular block necessary to facilitate tracheal intubation in children ? 

Neuromuscular block facilitates tracheal intubation in all age categories: it decreases the risk of difficult intubation and improves the rate of excellent and acceptable intubation conditions, unless spontaneous ventilation needs to be preserved.  However, if using a neuromuscular blocking agent (NMBA) is not possible (allergy, surgical contraindication etc.), one should ensure a sufficient depth of anaesthesia with high-dose opioids and or propofol, sevoflurane or other adjuvants, and have a skilled clinician to intubate. For rapid sequence induction and intubation, rocuronium should be preferred to succinylcholine. 

Question2: Does neuromuscular block affect outcomes in children? 

A deep neuromuscular block is needed only in special circumstances, such as robotic surgery. 

Question 3: What are the strategies for the diagnosis and treatment of residual neuromuscular block in children? 

Quantitative neuromuscular monitoring (TOF ratio) is recommended whenever a NMBA is administered to adapt the dosage to the child’s response and exclude residual muscle block before extubation, which is defined, as in adults, as a TOF ratio ≥ 0.9. The best place to monitor neuromuscular block is the adductor pollicis (thumb), but the flexor hallucis brevis (foot) can be used if needed. EMG-based neuromonitoring is suggested as it is more accurate and reliable than AMG-based monitoring to monitor neuromuscular block recovery. The supramaximal stimulation threshold (often misleadingly called calibration) should be determined before administering a NMBA to obtain the child’s TOFr baseline and improve the reliability of subsequent measurements (3). 

However, the presence of a TOF ratio > 0.9 must be interpreted according to the clinical context because: 

• The upper airway muscles are more sensitive to the effects of the NMBAs than the peripheral muscle response tested 
• AMG-based monitoring tends to overestimate recovery from neuromuscular block due to the reverse fade or staircase phenomenon (4), 
• The response obtained at the level of the tibial nerve is usually delayed as compared with the ulnar nerve (5) 
• NMBAs inhibit the acute hypoxic ventilatory response by acting on the nicotinic acetylcholine receptors present in the chemoreceptors of the carotid bodies; the kinetics of the reversal with neostigmine and sugammadex is different and result in some persisting respiratory dysfunction in the immediate post-reversal period (6) 
• All anaesthetic agents except ketamine also produce a dose-dependent effect on the activity of the upper airway dilating muscles (e.g. genioglossus m). 
• When a TOF ratio  ≥ 0.9 is achieved, 75 % of nicotinic acetylcholine receptors of the neuromuscular junction as still occupied by the  NMBA (2). 

Question 4: Use of neuromuscular block is some special conditions 

In children with a known or suspected neuromuscular disease, succinylcholine should be avoided due to the increased risk of rhabdomyolysis or malignant hyperthermia. A non-depolarising NMBA should be preferred, including for rapid sequence induction and intubation. If using a NMBA is necessary, rocuronium or vecuronium is recommended because they can be reversed with sugammadex thus avoiding the possible side-effects of neostigmine. Moreover, regardless of the NMBA used, the dose should be titrated according to the patient’s baseline TOFr as evaluated with quantitative neuromuscular monitoring. 

When using a NMBA in children with cerebral palsy, quantitative neuromuscular monitoring is suggested to minimise the complications related to their resistance or sensitivity to these agents. In the same way, quantitative neuromuscular monitoring is needed in children with chronic use of anticonvulsant therapy because they may necessitate higher doses or more frequent administration of an aminosteroid NMBA to maintain a stable neuromuscular block. 

But the time has now come to implement these Guidelines in clinical practice, which is the final purpose of this initiative: improving the safe use of NMBA in children. This will need a significant effort at different levels. The first step could be evaluating our current clinical practice and its complication rate to identify areas for improvement using a step-by-step quality improvement strategy. We should also educate the anaesthetic teams and try to set up new protocols despite resistance to change of some individuals: in this context, on-scene leadership is critical. There will also be organisational constraints to challenge, such as buying the necessary equipment. We hope the industry will be able to propose less expensive and more environmentally friendly equipment (reusable or recyclable) soon. Last, as authors of guidelines, we should try to make them more attractive to read and adopt. 

We know that the authors of these guidelines identified some knowledge gaps and hope this will stimulate clinical research in the paediatric population. We therefore look forward to a focused update within 3 to 5 years from now. 

References

1. Veyckemans F, Debouche S, Kaufmann J, Disma N, Amigoni A, Bonati G, Christensen MI, Engelhardt T, Fuchs A, Fuchs-Buder T, Hansen TG, Karlsson J, Kleine-Brueggeney M, Lusardi AC, Riva T, Salaun J-P, Saldien V, Saynhalath R, Scavenius M, Schmartz D, Vanlinthout L, Vieira RC, von Ungern-Sternberg BS, Romero CS, Afshari A. 2025 European Society of Anaesthesiology and Intensive Care and European Society for Paediatric Anaesthesiology Guidelines on neuromuscular block in anaesthetised children: indications, monitoring and reversal. Eur J Anaesthesiol 2026; 43: 295-323. 
2. Saldien V, Veyckemans F, Hansen TG. Development of the neuromuscular junction and neuromuscular blocking agents in neonates, infants and children A narrative review. Eur J Anaesthesiol 2026; 43 :324-34. 
3. Scheffenbichler FT, Ulm B, Borgstedt L, et al. Precision of electromyography according to the calibration approach of neuromuscular monitoring: a randomised prospective agreement study. J Clin Monit Comput 2025; 39:1047–1056. 
4. Zain Wedemeyer Z, Michaelsen KE, Jelacic S, Silliman W, Lopez A, Togashi K, Bowdle A. Accuracy and precision of three acceleromyographs, three electromyographs, and a mechanomyograph measuring the train-of-four ratio in the absence of neuromuscular blocking drugs. Anesthesiology 2024; 141:262–271 
5. Wadland SS, Madsen KPD, Jensen MH, Hovind MF, Sonne M, Bottger M, Afshari A, Mondrup RF, Vested M.  Neuromuscular monitoring of rocuronium 0.6 mg/kg in children aged 3-24 months with electromyography and acceleromyography : an observational study. Pediatr Anesth 2026 ; in press  
6. Snoek MAJ, van Lemmen, van der Schrier R, et al. Recovery of the acute hypoxic ventilatory response after reversal of a minimal neuromuscular block: a randomized controlled trial in healthy, nonobese volunteers. Anesthesiology 2025; 143:873–882. 

Authors

• Francis Veyckemans
• Carolina S Romero

*Composition of the Task Force 

A Afshari, G Bonatti, MI Christensen, N Disma, T Engelhardt, A Fuchs, T Fuchs-Buder, T Hansen, J Karlsson, J  Kaufmannn, M Kleine-Brüggeney, A Lusardi, T Riva, CS Romero, J-P Salaün, V Saldien,  M Scavenius, D Schmartz, R Saynhalat, L Van Linthout, J Vendt, F Veyckemans, R Vieiria, B von Ungern-Sternberg, with the help and support of S Debouche and P Harlet from the ESAIC guidelines team, and R Südy for the infographics.