Age-Specific Pharmacology of Neuromuscular Blocking Agents: A Comprehensive Review

Neuromuscular blocking agents (NMBAs) are essential in anesthesia, used primarily for intubation and synchronizing mechanical ventilation. They can be divided into depolarizing and non-depolarizing agents with an addition of reversal agents, which can be used to avoid residual muscle blockade. Their pharmacological properties vary among age groups due to physiological differences. In children, immature liver and kidney function, body composition, and immature neuromuscular junction influence drug properties. Elderly patients tend to have reduced organ function, more comorbidities, and greater vulnerability to stress. Ensuring anesthesia safety and preventing complications often requires adjusting doses and delivery regimens, which can be problematic, especially among inexperienced anesthesia personnel. To address this issue, we created this review to clarify dosage differences and their physiological bases. The article provides an overview of numerous clinical studies, including recent ones conducted on age-diverse patient populations, which, combined with an explanation of the pharmacological basis of NMBAs, is a valuable resource for anesthesiology with various levels of experience. The manuscript was based on 131 articles dating from 1987 to 2025, as well as the authors' knowledge and clinical experience.