[Overdose of vecuronium during general anesthesia to an infant]

We experienced an accidental case in which 5 mg of vecuronium was administered to a 5 kg infant boy, aged 2 months, incrementally for 55 minutes during general anesthesia. He received general anesthesia at the hospital where there is no anesthesiologist. After surgery the surgeon felt an unusual situation during emergence period from general anesthesia and then noticed overdose of vecuronium. They got in touch with our department immediately and requested us to follow him up. When we reached at the bedside, we could not observe voluntary movement by him. By using neuromuscular monitoring, we could determine that a paralysis was still maintained. After a while, he started to move and breathe himself. Extubation was performed safely 4 and half hours after the final administration of vecuronium. Finally, he could recover with no adverse effect. To predict the optimal dose of a non-depolarizing muscle relaxant to a pediatric patient, routine monitoring of neuromuscular block is effective and essential.