Neuromuscular Blockade

  • Michael P. Eaton
  • A. Marika Stone


Neuromuscular blocking agents (NMB) are frequently used in the Pediatric Intensive Care Unit (PICU), and their use has been correlated with severity of illness measures. While their use may be associated with improvements in measured physiologic variables, these agents are also associated with multiple and potentially fatal adverse effects. A thorough understanding of the physiology and pharmacology of neuromuscular blockade is required for the safe and effective use of these medications.


Pediatric Intensive Care Unit Neuromuscular Blockade Malignant Hyperthermia Malignant Hyperthermia Neuromuscular Blocking Agent 
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Suggested Readings

  1. Bada HS, Burnette TM, Arheart KL, Shull N, Mirro R, Korones SB. Pancuronium attenuates associated hemodynamic and transcutaneous oxygen tension changes during nursery procedures. J Perinatol. 1995;15:119–23.PubMedGoogle Scholar
  2. Banwell BL, Mildner RJ, Hassall AC, Becker LE, Vajsar J, Shemie SD. Muscle weakness in critically ill children. Neurology. 2003;61: 1779–82.PubMedGoogle Scholar
  3. Berg H. Is residual neuromuscular block following pancuronium a risk factor for postoperative pulmonary complications? Acta Anaesthesiol Scand Suppl. 1997;110:156–8.PubMedCrossRefGoogle Scholar
  4. Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for post-operative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997;41:1095–103.PubMedCrossRefGoogle Scholar
  5. Brandom BW, Taiwo OO, Woelfel SK, Schön H, Gronert BJ, Cook DR. Spontaneous versus edrophonium-induced recovery from paralysis with mivacurium. Anesth Analg. 1996;82:999–1002.PubMedGoogle Scholar
  6. Cheng CA, Aun CS, Gin T. Comparison of rocuronium and suxamethonium for rapid tracheal intubation in children. Paediatr Anaesth. 2002;12:140–5.PubMedCrossRefGoogle Scholar
  7. Clarens DM, Kelly KJ, Gilliland SS, Kohls PK, Nahum A, Vance-Bryan K. A retrospective analysis of long-term use of nondepolarizing neuromuscular blocking agents in the intensive care unit, and guidelines for drug selection. Pharmacotherapy. 1993;13:647–55.PubMedGoogle Scholar
  8. Cools F, Offringa M. Neuromuscular paralysis for newborn infants receiving mechanical ventilation. Cochrane Database Syst Rev. 2000;4:CD002773.PubMedGoogle Scholar
  9. de Ruiter J, Crawford MW. Dose-response relationship and infusion requirement of cisatracurium besylate in infants and children during nitrous oxide-narcotic anesthesia. Anesthesiology. 2001;94:790–2.PubMedCrossRefGoogle Scholar
  10. Driessen JJ, Robertson EN, Booij LH. Which is better in children: edrophonium or neostigmine? Br J Anaesth. 2000;84:293–4.PubMedGoogle Scholar
  11. Eikermann M, Hunkemoller I, Peine L, et al. Optimal rocuronium dose for intubation during inhalation induction with sevoflurane in children. Br J Anaesth. 2002;89:277–81.PubMedCrossRefGoogle Scholar
  12. Engbaek J, Ostergaard D, Skovgaard LT, Viby-Mogensen J. Reversal of intense neuromuscular blockade following infusion of atracurium. Anesthesiology. 1990;72:803–6.PubMedCrossRefGoogle Scholar
  13. Eriksson LI, Lennmarken C, Jensen E, Viby-Mogensen J. Twitch tension and train-of-four ratio during prolonged neuromuscular monitoring at different peripheral temperatures. Acta Anaesthesiol Scand. 1991;35:247–52.PubMedCrossRefGoogle Scholar
  14. Geller TJ, Kaiboriboon K, Fenton GA, Hayat GR. Vecuronium-associated axonal motor neuropathy: a variant of critical illness polyneuropathy? Neuromuscul Disord. 2001;11:579–82.PubMedCrossRefGoogle Scholar
  15. Gutmann L, Blumenthal D, Schochet SS. Acute type II myofiber atrophy in critical illness. Neurology. 1996;46:819–21.PubMedGoogle Scholar
  16. Gwinnutt CL, Meakin G. Use of the post-tetanic count to monitor recovery from intense neuromuscular blockade in children. Br J Anaesth. 1988;61:547–50.PubMedCrossRefGoogle Scholar
  17. Hansen-Flaschen J, Cowen J, Raps EC. Neuromuscular blockade in the intensive care unit. More than we bargained for. Am Rev Respir Dis. 1993;147:234–6.PubMedCrossRefGoogle Scholar
  18. Heier T, Caldwell JE, Sessler DI, Miller RD. The effect of local surface and central cooling on adductor pollicis twitch tension during nitrous oxide/isoflurane and nitrous oxide/fentanyl anesthesia in humans. Anesthesiology. 1990;72:807–11.PubMedCrossRefGoogle Scholar
  19. Kalli I, Meretoja OA. Duration of action of vecuronium in infants and children anaesthetized without potent inhalation agents. Acta Anaesthesiol Scand. 1989;33:29–33.PubMedCrossRefGoogle Scholar
  20. Kovarik WD, Mayberg TS, Lam AM, Mathisen TL, Winn HR. Succinylcholine does not change intracranial pressure, cerebral blood flow velocity, or the electroencephalogram in patients with neurologic injury. Anesth Analg. 1994;78:469–73.PubMedCrossRefGoogle Scholar
  21. Larsson L, Li X, Edstrom L, et al. Acute quadriplegia and loss of muscle myosin in patients treated with nondepolarizing neuromuscular blocking agents and corticosteroids: mechanisms at the cellular and molecular levels. Crit Care Med. 2000;28:34–45.PubMedCrossRefGoogle Scholar
  22. Meakin G, Walker RW, Dearlove OR. Myotonic and neuromuscular blocking effects of increased doses of suxamethonium in infants and children. Br J Anaesth. 1990;65:816–8.PubMedCrossRefGoogle Scholar
  23. Meretoja OA. Is vecuronium a long-acting neuromuscular blocking agent in neonates and infants? Br J Anaesth. 1989;62:184–7.PubMedCrossRefGoogle Scholar
  24. Meretoja OA, Wirtavuori K, Neuvonen PJ. Age-dependence of the dose-response curve of vecuronium in pediatric patients during balanced anesthesia. Anesth Analg. 1988;67:21–6.PubMedCrossRefGoogle Scholar
  25. Minton MD, Grosslight K, Stirt JA, Bedford RF. Increases in intracranial pressure from succinylcholine: prevention by prior nondepolarizing blockade. Anesthesiology. 1986;65:165–9.PubMedCrossRefGoogle Scholar
  26. Moore EW, Hunter JM. The new neuromuscular blocking agents; do they offer any advantages? Br J Anaesth. 2001;87:912–25.PubMedCrossRefGoogle Scholar
  27. Movius AJ, Martin LD. Sedation, analgesia, and neuromuscular blockade during pediatric mechanical ventilation. Respir Care Clin N Am. 1996;2:509–43.PubMedGoogle Scholar
  28. Murray MJ, Strickland RA, Weiler C. The use of neuromuscular blocking drugs in the intensive care unit: a U.S. Perspective. Intensive Care Med. 1993;19 (Suppl 2) S40–4.PubMedCrossRefGoogle Scholar
  29. Pace NL. Prevention of succinylcholine myalgias: a meta-analysis. Anesth Analg. 1990;70:477–83.PubMedCrossRefGoogle Scholar
  30. Pena O, Prestjohn S, Guzzetta CE. Agreement between muscle movement and peripheral nerve stimulation in critically ill pediatric patients receiving neuromuscular blocking agents. Heart Lung. 2000;29:309–18.PubMedCrossRefGoogle Scholar
  31. Playfor SD, Thomas DA, Choonara I. Sedation and neuromuscular blockade in paediatric intensive care: a review of current practice in the UK. Paediatr Anaesth. 2003;13:147–51.PubMedCrossRefGoogle Scholar
  32. Ruff RL. Acute illness myopathy. Neurology. 1996;46:600–1.PubMedGoogle Scholar
  33. Russell WC, Greer R, Harper NJ. The effect of neuromuscular blockade on oxygen supply, consumption, and total chest compliance in patients with high oxygen requirements undergoing mechanical ventilation. Anaesth Intensive Care. 2002;30:192–7.PubMedGoogle Scholar
  34. Saldien V, Vermeyen KM. Neuromuscular transmission monitoring in children. Paediatr Anaesth. 2004;14:289–92.PubMedCrossRefGoogle Scholar
  35. Segredo V, Matthay MA, Sharma ML, Gruenke LD, Caldwell JE, Miller RD. Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients. Anesthesiology. 1990;72:566–70.PubMedCrossRefGoogle Scholar
  36. Segredo V, Caldwell JE, Matthay MA, Sharma ML, Gruenke LD, Miller RD. Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med. 1992;327: 524–8.PubMedCrossRefGoogle Scholar
  37. Sener EB, Ustun E, Kocamanoglu S, Tur A. Prolonged apnea following succinylcholine administration in undiagnosed acute organophosphate poisoning. Acta Anaesthesiol Scand. 2002;46:1046–8.PubMedCrossRefGoogle Scholar
  38. Silverman DG, Donati F. Neuromuscular effects of depolarizing relaxants. In: Silverman DG, editor. Neuromuscular block in perioperative and intensive care. Philadelphia: J.B. Lippincott Company; 1994. p. 239–54.Google Scholar
  39. Silverman DG, Donati F. Factors affecting pseudocholinesterase and the pharmacokinetics and pharmacodynamics of succinylcholine. In: Silverman DG, editor. Neuromuscular block in perioperative and intensive care. Philadelphia: J.B. Lippicott Company; 1994. p. 255–75.Google Scholar
  40. Silverman DG, Standaert FG. Anatomy and physiology of neuromuscular transmission. In: Silverman DG, editor. Neuromuscular block in perioperative and intensive care. Philadelphia: J.B. Lippincott Company; 1994. p. 1–10.Google Scholar
  41. Strange C, Vaughan L, Franklin C, Johnson J. Comparison of train-of-four and best clinical assessment during continuous paralysis. Am J Respir Crit Care Med. 1997;156:1556–61.PubMedGoogle Scholar
  42. Strazis KP, Fox AW. Malignant hyperthermia: a review of published cases. Anesth Analg. 1993;77:297–304.PubMedGoogle Scholar
  43. Szenohradszky J, Fogarty D, Kirkegaard-Nielsen H, Brown R, Sharma ML, Fisher DM. Effect of edrophonium and neostigmine on the pharmacokinetics and neuromuscular effects of mivacurium. Anesthesiology. 2000;92:708–14.PubMedCrossRefGoogle Scholar
  44. Tabarki B, Coffiniéres A, Van Den Bergh P, et al. Critical illness neuromuscular disease: clinical electrophysiological and prognostic aspects. Arch Dis Child. 2002;86:103–7.PubMedCrossRefGoogle Scholar
  45. Ueda N, Masuda Y, Muteki T, Harada H, Tsuda H, Tobata H. Double burst stimulation with submaximal current. Eur J Anaesthesiol. 1994;11:403–6.PubMedGoogle Scholar
  46. Wierda JM, Meretoja OA, Taivainen T, Proost JH. Pharmacokinetics and pharmacokinetic-dynamic modelling of rocuronium in infants and children. Br J Anaesth. 1997;78:690–5.PubMedGoogle Scholar
  47. Williams S, Horrocks IA, Ouvier RA, et al. Critical illness polyneuropathy and myopathy in pediatric intensive care: a review. Pediatr Crit Care Med. 2007;8:18–22.PubMedCrossRefGoogle Scholar
  48. Willson DF, Jiao JH. Improved oxygenation after discontinuing neuromuscular blockade. Intensive Care Med. 1997;23:214–7.PubMedCrossRefGoogle Scholar
  49. Zelicof-Paul A, Smith-Lockridge A, Schnadower D, et al. Controversies in rapid sequence intubation in children. Curr Opin Pediatr. 2005;17:355–62.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of Rochester School of Medicine and DentistryRochesterUSA
  2. 2.Department of AnesthesiologyUniversity of Nebraska Medical Center College of Medicine, Children’s Hospital & Medical CenterOmahaUSA

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