- Single dose neuromuscular blockade is common practice in pediatric patients, but age ranges and pharmacokinetic and pharmacodynamic variations are large in this population and even one dose can affect perioperative outcomes in children. In particular, there is a higher risk of postoperative residual curarization (PORC) in children because of their unique pharmacokinetic and pharmacodynamic profiles.
- The authors conducted a systematic review and meta-analysis of 71 randomized controlled trials and controlled clinical trials (including 4319 patients) that compared the time to neuromuscular recovery following single-dose administration of different NMBA treatments across pediatric age groups.
- The meta-analysis demonstrated the following:
- Recovery after NMB is faster in children aged 2-11 years compared to neonates (<28 days) and infants (28 days to 12 months).
- A log-linear relationship was observed between the dose of NMBA and the duration of neuromuscular blockade, with higher doses predictably extending block duration.
- The use of volatile anesthetics significantly prolongs recovery from neuromuscular blockade by an average of 30-50%, particularly in younger due to their higher sensitivity to these agents.
- Potentiation by volatile anesthetics is age and time-dependent with children under 3 years of age requiring significantly longer to recover from neuromuscular blockage when volatile anesthetics are also used, as compared with older children receiving the same NMBA and anesthetic.
- Significant interindividual variability was noted, underlining the necessity for quantitative monitoring to prevent PORC, especially in pediatric patients where surgical procedures are often brief.
- Monitoring techniques present different challenges in children, particularly the reliability of acceleromyography (AMG).
- The authors suggest the following:
- When possible, avoid using NMBAs altogether.
- Anesthesiologists should tailor NMBA doses based on the patient’s age.
- Lower weight-adjusted doses might be necessary in younger patients to avoid prolonged recovery.
- Accurate quantitative neuromuscular monitoring should be used to adequately assess recovery, even after a single dose.
- For shorter surgeries or when rapid recovery is needed, shorter-acting NMBAs like mivacurium or cisatracurium may be advantageous.
- Total intravenous anesthesia (TIVA) may reduce the impact of volatile agents on NMBA recovery, particularly in infants and neonates.
Summary of "Spontaneous recovery from neuromuscular block after a single dose of a muscle relaxant in pediatric patients: A systematic review using a network meta-analytic and meta-regression approach"
Summary published January 27, 2025
