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Current Use, Monitoring and Reversal of Neuromuscular Block in Pediatric Anesthesia and Intensive Care: A Web-Based
Giulia Bonatti1, Mirjana Gander2, Arash Afshari3
1Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
Insights
Pediatric tracheal intubation practices vary widely, with many children intubated without neuromuscular blocking agents and extubated without consistent reversal, raising patient safety concerns.
Area of Science:
- Pediatric Anesthesiology
- Pharmacology
- Patient Safety
Background:
- Neuromuscular blocking agents (NMBAs) are recommended for pediatric tracheal intubation by ESAIC and ESPA.
- Real-world data on NMBA use, monitoring, and reversal in children is limited.
Purpose of the Study:
- To assess self-reported NMBA practice patterns in pediatric anesthesia across Europe and beyond.
- To characterize NMBA usage prior to the joint ESAIC/ESPA guidelines.
Main Methods:
- Anonymous, cross-sectional survey of pediatric anesthesiologists.
- Survey conducted from November 12 to December 12, 2025, across 43 countries.
- Targeted members of ESAIC, ESPA, and national pediatric societies.
Main Results:
- Rocuronium was the most common NMBA for tracheal intubation.
- NMBAs were not always used for intubation in neonates and infants.
- Consistent NMBA reversal and quantitative monitoring were uncommon; Sugammadex use was 47%.
Conclusions:
- Pediatric NMBA use in clinical practice is heterogeneous.
- Lack of consistent NMBA use and reversal poses patient safety risks.
- Quantitative neuromuscular monitoring is underutilized in pediatric anesthesia.
Background:
Neuromuscular blocking agents are recommended by the European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Paediatric Anaesthesia (ESPA) for facilitating tracheal intubation in children. Despite these recommendations, real-world data on how neuromuscular blocking agents are used, monitored, and reversed remain scarce.
Aims:
To identify and characterize self-reported neuromuscular blocking agent practice patterns across European and non-European countries, in the period preceding publication of the joint ESAIC and ESPA guidelines.
Methods:
We conducted an anonymous, cross-sectional survey between 12 November and 12 December 2025, targeting members of the ESAIC, ESPA, and the French and Spanish national pediatric anesthesiology societies involved in pediatric airway management across 43 countries.
Results:
The survey was accessed by 904 persons, and 874 responses were included in the analysis. Most participants were from Europe (83.5%) and worked in mixed pediatric anesthesia and intensive care settings (71.2%). Rocuronium was the most frequently used neuromuscular blocking agent for both routine tracheal intubation (68%; 95% CI 65%-71%) and rapid sequence intubation (67%; 95% CI 64%-70%). Neuromuscular blocking agents were used "always" or "mostly" before routine intubation in 47% of neonates (≤ 30 days) and 50% of infants (< 1 year), whereas "rarely" or "never" use was reported in 30% and 24%, respectively. Most respondents (56%) assessed adequacy of neuromuscular block using a fixed time interval after neuromuscular blocking agent administration. Reversal was administered "always" before extubation by 27% of respondents, while 9.3% reported "rarely" and 2.9% "never." Only half of participants used quantitative neuromuscular monitoring to guide reversal. Sugammadex was used by 47%.
Conclusions:
Self-reported clinical practice regarding neuromuscular blocking agent use in pediatric patients remains heterogeneous. Children are frequently intubated without neuromuscular blocking agents and extubated without consistent reversal. Quantitative neuromuscular monitoring remains uncommon. These practice patterns raise concerns for patient safety.
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