Anesth Pain Med.  2024 Oct;19(Suppl 1):S12-S24. 10.17085/apm.23158.

Neuromuscular blockade monitoring in pediatric patients

• Ozgen ZSU

• KMID: 2563583
• DOI: http://doi.org/10.17085/apm.23158

Abstract

The administration of neuromuscular blocking agents (NMBAs), the cornerstone of pediatric anesthesia, facilitates intubation and muscle relaxation during surgery. However, NMBAs can also lead to serious complications including respiratory depression, residual paralysis, and prolonged recovery. Neuromuscular monitoring (NMM) in pediatric patients is therefore essential, as it is in adults, to ensure adequate paralysis during surgery and prompt recovery from NMBA-induced paralysis. This article aimed to provide a comprehensive overview of NMM in pediatric anesthesia including the various available methods, their advantages and disadvantages, and the importance of a standardized NMM approach.

Keyword

Neuromuscular blockers, monitorization; Neuromuscular monitorization; Pediatric Anesthesia; Train-of-four; Quantitative neuromuscular monitorization

Figure

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  Fig. 1. NMB after a normal intubating dose of a non-depolarizing NMBA, as classified using PTC and TOF stimulation. NBM: neuromuscular blockade, NMBA: neuromuscular blocking agents, PTC: post-tetanic count, TOF: train-of-four, N/A: non applicable. Adapted from the article of Heier and Caldwell (Anesthesiology 2006; 104: 1070-8) [43].

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  Fig. 2. (A) The adult and pediatric versions of the TetraSens™ self-adhesive sensor. The adult sensor measures approximately 9 inches in length compared to 7 inches for the pediatric sensor. The skin was prepped with an alcohol swab and the sensor was placed. (B) The pediatric sensor or recording electrodes (TetraSens™ Pediatric) was placed on the palmar surface of the adductor pollicis muscle and its insertion on the medial aspect of the proximal phalanx of the thumb. The stimulating electrodes were placed along the ulnar nerve on the volar surface of the forearm. After the sensor was placed on the patient, the electrodes were connected using the cord to the TetraGraph™ (Senzime AB). The device automatically determines the stimulating current necessary for maximal muscle contraction, to ensure consistent recruitment of all muscle fibers. Adapted from the article of Heier and Caldwell (Anesthesiology 2006; 104: 1070-8) [43].

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  Fig. 3. Traditional NMM placement in pediatric patient. NMM: neuromuscular monitoring.

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  Fig. 4. Anatomy of the muscles innervated by the ulnar nerve.

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