The European Journal of Anaesthesiology has just published the “2025 ESAIC and ESPA Guidelines on neuromuscular block in anaesthetized children”. ESAIC is the European Society of Anaesthesiology and Intensive Care and ESPA is the European Society of Paediatric Anaesthesiology.
These specific pediatric guidelines were preceded by several guidelines pertaining to monitoring of neuromuscular block published by adult oriented anesthesia societies, including the American Society of Anesthesiologists, the European Society of Anesthesiology, the Association of Anaesthetists of Great Britain and Ireland and the Australian and New Zealand College of Anaesthetists (ANZCA). Thus we would tend to expect that the pediatric guidelines would be similar, while taking into account any unique pediatric considerations.
As we noted in a previous Substack post, and another Substack post, it appears that to a large extent, neuromuscular blockade in babies and small children can be managed in a manner similar to adults. In this instance, kids do seem to be “small adults” (with apologies to our pediatric anesthesia colleagues).
What was expected
Not surprisingly then, the new pediatric guidelines recommend the use of quantitative neuromuscular block monitoring to guide administration and reversal of neuromuscular blocking drugs, as did all of the previous adult-oriented guidelines—
“We recommend, whenever an NMBA is used, quantitative neuromuscular monitoring be applied to modulate the level of neuromuscular block and to rule out a residual neuromuscular block before extubation.(Strong recommendation based on moderate level of evidence)”
And the guidelines recommend sugammadex over neostigmine for reversal of aminosteroid neuromuscular blocking drugs—
“We recommend sugammadex over neostigmine for the reversal of aminosteroid NMBA in children due to its faster recovery time, shorter time to extubation, and more effective reversal of moderate and deep block. (Strong recommendation based on moderate level of evidence)”
What was a surprise
But if the story ended there, it wouldn’t make a very interesting Substack post, would it? As it turns out, there are a couple of surprises in the new pediatric guidelines that are worth noting and exploring further.
The first surprise (a pleasant surprise) is—
“We suggest electromyography-based rather than acceleromyography-based quantitative neuromuscular monitoring…”.
We agree with this completely. See our previous post “It’s time to say goodbye to acceleromyography” for the rationale for this. However, this recommendation was frankly a bit of a surprise to us because the previously published guidelines of the American Society of Anesthesiologists do not express any preference for electromyography versus acceleromyography.
We have to quibble with another related recommendation—
“Whatever the type of neuromuscular monitoring device used, calibration before administering a NMBA is important to improve the reliability of subsequent TOF monitoring.”
Neuromuscular block monitors are NOT CALIBRATED and do not require calibration. This was explained in a previous post, which we will quote from below—
“Twitch monitors are NOT “calibrated”. They can determine the supramaximal current for ulnar nerve stimulation
Scheffenibichler et al published an article in 2025 that illustrates one of the enduring misconceptions about neuromuscular blockade monitoring. The study claimed to examine how “calibration” of an electromyograph affects the precision (repeatability) of train-of-four measurement. In my opinion, this is complete nonsense. Calibration means to adjust a measuring device to a known standard. This is not possible for any commercially available twitch monitor, and the importance of this is not just a semantic nicety. What twitch monitors actually are capable of doing, is to determine the supramaximal current for stimulating the ulnar nerve. As I explained in a previous post—”All of the quantitative neuromuscular block monitors that I know of determine the “supramaximal” current by administering a stepwise series of increasing currents until the amplitude of the twitch response becomes maximal. Then an additional amount of current is added (supramaximal) as a safety margin, to be sure that the ulnar nerve is being adequately stimulated. This procedure has to be carried out after the patient is asleep but BEFORE administering a neuromuscular blocking drug. Alternatively, the operator may simply select the highest possible current, which is usually in the range of 60-80 mA, depending upon the particular monitor.”
Note that last sentence. Effective use of a neuromuscular block monitor does not even require determining the supramaximal current. Just turn the current up “all the way” (60-80 mA), ensuring that a supramaximal current will be administered.
Let’s make a New Year’s Resolution for 2026. Let’s stop talking about “calibrating” neuromuscular block monitors and instead describe what they actually do, which is to determine the supramaximal current for ulnar nerve stimulation.”
Another surprise to us was the recommendation that neostigmine not be administered to pediatric patients with myasthenia gravis—
“Neostigmine should not be used in children with myasthenic disorders, as it can contribute to postoperative cholinergic or myasthenic crises and is contraindicated in some forms of congenital myasthenia.”
Two references are offered in support of this recommendation, but neither of them actually supports the recommendation, do not involve children as subjects, and do not warn against the use of neostigmine.
To the best of our knowledge and also based on current reviews of pediatric myasthenia, anticholinesterase agents such as physostigmine, neostigmine and edrophonium are useful in the diagnosis and treatment of myasthenia in children, as they are in adults. So we are really unable to understand why these guidelines would suggest specifically avoiding neostigmine or stating that neostigmine is “contraindicated”.
What do you think? If you have any experience with neostigmine in kids with myasthenia, let us know in the comments.
Not a surprise, but definitely an error
Finally it’s notable that the guidelines authors make the same mistake as was made in the American Society of Anesthesiologists guidelines when it comes to monitoring the effects of succinylcholine—
“Standard TOF monitoring cannot be used to evaluate a depolarising block [eg succinylcholine] due to the absence of fade, and only the decrease in height of the single twitch can be observed.”
This statement reflects a commonly believed MYTH about succinylcholine and train-of-four monitoring. In fact succinylcholine, whether administered by bolus or infusion, reliably produces fade in the train-of-four in every patient. We previously explained this in a post entitled “The Myth of Phase 1 and Phase 2 Block from Succinylcholine”.
Are we trying to tell you that guidelines documents can contain errors? Well, yes we are. As Captain Barbossa famously said in Pirates of the Caribbean (Curse of the Black Pearl)—
“First, your return to shore was not part of our negotiations nor our agreement, so I must do nothin’. And secondly, you must be a pirate for the Pirate’s Code to apply, and you’re not. And thirdly, the Code is more what you’d call “guidelines” than actual rules. Welcome aboard the Black Pearl, Miss Turner.”