2025 ESAIC and ESPA Guidelines on neuromuscular block in anaesthetised children
Indications, monitoring and reversal.
European Journal of Anaesthesiology
Submitted July 2026 by Dr Eamonn Upperton
Review summary
This is the first guideline on the use of neuromuscular blocking agents (NMBAs) in anaesthetised children, developed by a task-force appointed by the ESAIC guidelines committee.
The committee set out to answer four questions (which we will explore below) surrounding the use of NMBAs in the paediatric population, by generating 20 specific research questions to be answered by the literature.
The result is a systematic and in-depth exploration of the topic. Some recommendations support existing trends in practice (i.e. NMBAs make intubating easier), and others provide impetus for change (i.e. moving to EMG neuromuscular block monitoring).
Key findings
The guidelines used four questions to ground their recommendations:
1. Is neuromuscular blockade necessary to facilitate tracheal intubation in children, including specific considerations for some subgroups?
Recommendation (paraphrased):
- Use NMBA for intubating neonates and children, when spontaneous ventilation is not required.
- If no NMBA is used, adjuvants such as propofol or opioids are recommended.
- Rocuronium is preferred over suxamethonium
These recommendations are primarily based upon studies measuring the quality of the laryngoscopic view, number of laryngoscopy attempts, and the rates of successful intubation. They also rightly highlight common consequences of intubating without muscle relaxant (eg. coughing, breath holding, closed vocal cords) which might be considered inconveniences, but are clearly avoidable.
The authors' caveat in their recommendation - 'where spontaneous ventilation is not required' - could be emphasised more, in my view. The rare, challenging situation of an anatomically difficult airway in a small child is one where being facile with an anaesthetic technique that maintains spontaneous ventilation and oxygenation for prolonged attempts and intubation might be the only path to success. Does experience with NMBA-free intubation outside this scenario help build the skills necessary to confidently run such a technique?
2. Does neuromuscular block affect surgical conditions in children?
Recommendation (paraphrased):
- Neuromuscular blockade can be used selectively; minor procedures such as inguinal hernia repair do not benefit, while deep neuromuscular blockade can be considered for major procedures or where optimisation of surgical conditions or ventilation is required.
The support for neuromuscular blockade with LMAs (specifically second-generation) is a welcome and sensible recommendation, quoting improved operating conditions and reduced adverse events during short laparoscopic procedures.
3. What are the strategies for the diagnosis and treatment of residual neuromuscular block in children?
Recommendations (paraphrased):
- Neuromuscular block monitoring should be used to modulate depth of blockade and to prevent residual block on extubation.
- EMG-based monitoring is preferable to acceleromyography-based monitoring
- Sugammadex is preferred to neostigmine
- Specific recommendations on the use of NMBA and reversal drugs in various neuromuscular diseases are also detailed
There is evidently significant variability in practice between clinicians and culturally between institutions on neuromuscular block monitoring in children. For neonates and small children, in particular, there are technical challenges with getting an accurate reading with many acceleromyographic devices. As described in the guideline, this may be mitigated with newer EMG-based devices which are more reliable in this population.
As the guideline's discussion notes, certain studies showing almost 30% residual neuromuscular blockade in children are perhaps overstating the issue, having used neostigmine reversal for too-deep a block.
Many of these quoted studies have as an endpoint 'respiratory complications' - which does not distinguish consequential from transient adverse events. It is therefore difficult to ascertain the clinical impact of these interventions.
While not entirely convincing that there is an epidemic of children suffering from residual neuromuscular blockade in PACUs, the guideline is clear that this is becoming easier to prevent with sugammadex and new neuromuscular blockade monitoring equipment.
4. Neuromuscular block in special conditions
Recommendations: The guideline issues recommendations for:
- Myaesthenic syndromes
- Muscular dystrophies
- Myotonic disorders
- Mitochondrial and metabolic disorders
- Cerebral palsy
These are in-depth and very helpful guidance for clinicians navigating the care of patients with these complex conditions; the full text of these recommendations can be accessed here.
Bottom line
The task-force took a systematic, thorough approach to developing their research questions which has resulted in practical and sensible guidance for clinicians. While there will always be some nuance that a guideline cannot account for, the arguments for increased use of neuromuscular blockade, its monitoring, and appropriate reversal are compelling.
