Neuromuscular blockade guidelines in paediatric patients: another clinical practice gap to fill!

No guidelines on the use of muscle relaxants in anaesthetised children have been published so far, although they are frequently used in this population. For example, in APRICOT, 60.8 % of tracheal intubations were performed with a muscle relaxant¹. In addition, muscle relaxation is rarely monitored in children, especially in neonates and infants: neuromuscular monitoring was used in only 16% of the children who had received a muscle relaxant in the APRICOT study ^2, and the situation is similar in North America³. This absence of monitoring increases the risk of residual paralysis or even recurarization^4,5. In addition, the pharmacology and dosage of neostigmine and sugammadex in infants and children is based either on a few old studies⁶ or suggested as similar to adults due to a lack of age-specific studies^7,8. 

An update of current evidence or expert opinion on those issues is thus needed. After witnessing a case of recurarisation following the reversal of a rocuronium-induced neuromuscular block in an infant, J-P Salaün and F Veyckemans decided to answer the informal call for specific paediatric guidelines included in the “Peri-operative management of neuromuscular blockade. A guideline from the European Society of Anaesthesiology and Intensive Care » published in 2023⁹. They contacted the ESAIC Guidelines Committee and applied for new guidelines and updated proposals entitled “Muscle relaxation in anaesthetised children: indications, monitoring and reversal”. The project was approved by the ESAIC board and supported by the European Society for Paediatric Anaesthesiology. An ad hoc international task force was set up under the direction of Francis Veyckemans. 

To take into account the specific pharmacologic differences between children and adults, the task force decided with Carolina Romero and Arash Afshari, the current and former chairpersons of the ESAIC Guidelines Committee, and with the support of the Editor-in-Chief of the European Journal of Anaesthesiology, to split the task and the final publication into two complementary parts: 

– a publication on the developmental aspects of the neuromuscular junction and the pharmacology (PK/PD) of the current neuromuscular blocking agents and their antagonists to be written under the lead of Professor Vera Saldien and Tom Hansen 

– a formal clinical guideline using the usual ESAIC guidelines process and template to answer the same three main clinical queries as in the adult guidelines⁹: 

• Q1: Is myorelaxation necessary to facilitate tracheal intubation in children? In addition, specific locations such as the emergency room, NICU, and PICU and situations such as rapid sequence induction will be considered. 
• Q2: does neuromuscular blockade affect outcomes in children? This will consider not only the OR but also the NICU and PICU. 
• Q3: what are the strategies for diagnosing and treating residual neuromuscular paralysis in children? This will include neuromuscular monitoring and the use of neostigmine and sugammadex. 

A fourth question, Q4, entitled special conditions, is dedicated to specific considerations regarding muscular blockade in children with muscle disease, cerebral palsy, epilepsy, etc. 

These queries were divided into specific Population/Intervention/Comparison/Outcome (PICO) groups. The trial search and Cochrane information specialist Janne Vendt (Copenhagen University Hospital, Copenhagen, Denmark) started the literature search strategy in May-June 2024. The task force members are currently checking and summarising the titles resulting from the searches in the Cochrane, Medline via Ovid, and Epistemonikos Libraries. 

The task force’s goal is to present the guidelines during the ESAIC Congress in Presentation in Lisbon 2025. 

Authors

• Francis Veyckemans (MD) – UCLouvain Medical School, Brussels, Belgium. 
• Carolina Soledad Romero (MD, MStat, PhD) – Consultant Anaesthesiologist and Critical Care at Hospital General Universitario. Assistant Professor at Universidad Europea de Valencia. ESAIC Guidelines Committee Chair & Senior Methodologist. ESAIC Research Mentorship Programme Leader. US GRADE & Evidence Foundation Scholar. 

*Composition of the task force 

A Afshari, G Bonatti, N Disma, T Engelhardt, A Fuchs, T Fuchs-Buder, T Hansen, O Karam, 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-Sternber. 

References

1. Engelhardt T, Virag K, Veyckemans F, Habre W.Airway Management in Paediatric Anaesthesia in Europe – Insights from APRICOT (Anaesthesia Practice in Children Observational Trial): A prospective multicentre observational study in 261 hospitals in Europe. Br J Anaesth 2018, 121; 66-75. 

2. Habre W, Disma N, Virag K, Becke K, Hansen T et al. Incidence of severe critical events in paediatric anaesthesia: a prospective multicentre observational study in 261 hospitals in Europe. Results of APRICOT. The Lancet Resp Medicine 2017, 5: 412-425. 

3. Faulk DJ, Austin TM, Thomas JJ, Strupp K, Macrae AW, Yaster M. A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade. Anesth Analg 2021;132 :1518-1526. 

4. Cates AC, Freundlich RE, Clifton JC, Lorinc AN. Analysis of the factors contributing to residual weakness after sugammadex administration in pediatric patients under 2 years of age. Paediatric Anaesthesia 2024; 34: 28-34. 

5. Salaun JP, Decary E, Veyckemans F. Recurarisation after sugammadex in children: review of case reports and recommendations. Br J Anaesth 2024 ; 132:410-4 

6. Fisher DM, Cronnelly R, Miller RD, Sharma M Anesthesiology. 1983; 59:220-225 

7. Cortinez LI, Anderson B.J. Sugammadex dose in infants (editorial). Paediatric Anaesthesia 2023; 33: 5-6. 

8.  Grigg E. Sugammadex and neuromuscular reversal: special focus on neonatal and infant populations. Curr Opin Anaesthesiol. 2020; 33: 374-380. 

9. Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska A-M, , Schmartz D, Hinkelbein J, Longrois D, Popp M,  de Boer HD, Sorbello M, Jankovic R, Kranke P. Peri-operative management of neuromuscular blockade. A guideline from the European Society of Anaesthesiology and Intensive Care » Eur J Anaesthesiol 2023; 40: 82–94.