Four reasons why you should use quantitative monitoring
Jan 18, 2024
By AnnaMaria Tahlén, Content Manager at Senzime
Monitoring the depth of neuromuscular blockade is vital to ensure patient safety during anesthesia. This also applies to pediatric patients.
Despite that, quantitative monitoring, or even any kind of monitoring for neuromuscular blockade at all is not commonly used for the pediatric population. To ensure all children get a safe anesthesia procedure, which all kids deserve, quantitative neuromuscular monitoring is the way to go.
In this blog, you will learn four reasons why you should be using quantitative neuromuscular monitoring for pediatric patients.
Children face the same high risk of complications from the use of paralyzing drugs as adults. Several studies have stated an incidence of postoperative residual neuromuscular blockade (RNMB) ranging from 25-50% in children, largely depending on the antagonist agent.
In a study done by Ledowski (2015), the incidence of RNMB was 28.1% overall. Severe RNMB (TOF ratio < 0.7) was found in 6.5% after both no reversal and neostigmine, respectively. Another study (Klucka J et al. from 2019) showed rates of RNMB to be 48.2% prior to tracheal extubation. In addition, a quality assurance study from 2020 (Vested M et al.). found that on children under the age of three years who received one dose of neuromuscular blocking agents during anesthesia, only 16% had a TOF ratio <0.9 at the end of the surgery.
All these studies clearly show that RNMB is an issue for pediatric patients, and therefore it is important to use quantitative neuromuscular monitoring to eliminate potential complications.
Pediatric patients’ responses to neuromuscular blocking agents can vary a lot between individuals due to many factors. One aspect is age, where pediatric patients show age-dependent responses with regards to the dose and to the duration of action of blocking agents.
A still highly relevant publication from 1996 (Taivainen T, et al), documents that infants and children have a greater sensitivity to rocuronium compared to adults. Another age aspect is the differences in respiratory anatomy and physiology. These differences--such as immature respiratory control, smaller and more collapsible airways--may make children more susceptible to complications from RNMB, according to von Ungern-Sternberg BS et al. from 2006.
Some might say that children are just like small adults, and that might be the case in some way, but you also need to consider all the large individual variations when pediatric patients are undergoing surgery. Quantitative monitoring will give you great guidance from start to finish of a case with a pediatric patient.
Although the recent guidelines for neuromuscular blockade management were developed for an adult pediatric population, you can somewhat apply to children, too. In our recent virtual round table, experts point out that the guidelines talk about the benefit you get with a quantitative monitor vs. a peripheral nerve stimulator. You can also apply this to pediatric patients. It is just as important for those patients to think about monitoring, the experts in the roundtable state.
When it comes to choosing technology, the roundtable panel points out electromyography (EMG) as a reliable technology. This is because it can be used for all surgical cases, whether it is a robotic case or not. Children often have their arms tucked no matter the case, the roundtable panel states. EMG measures the compound muscle action potential so the arm can be tucked, and you still get a reliable measurement. With EMG monitoring, you don’t need to worry about thumb movement or even thumb access.
With the rise of sugammadex use, you might often hear that the drug is the monitor. This is what several experts have heard, as they pointed out in our recent virtual roundtable . They have heard from several colleagues that “well, I don’t need a monitor, I have sugammadex”. Even though sugammadex is a highly effective drug, you should combine this drug and quantitative monitoring to ensure patient safety, according to the experts in the virtual roundtable.
Not only does the combination of sugammadex and quantitative monitoring help ensure patient safety, but it can also save costs. Studies shows that using EMG quantitative monitoring can lead to reduced cost of reversal drugs compared to the cost associated with routine use of sugammadex for all patients.
In a recent study, the use of sugammadex aliquots combined with quantitative neuromuscular monitoring with TetraGraph could result in a net yearly savings of approximately 370,000 USD and a net savings per case of $46. The same study also showed that 20% of the patients did not require any sugammadex because a TOF ratio ≥ 90% was achieved spontaneously, measured with help from TetraGraph. In short, monitoring can help optimize the reversal strategy and save costs of the reversal drug used.
To summarize, there are several reasons why you should quantitatively monitor your pediatric patients during a case, and it is as important for children as it is for adults.
It might be even more important due to the large variations of how children respond to neuromuscular blocking agents.
Quantitative monitoring of neuromuscular blockade helps you as a clinician to make proactive decisions. When you know the current level of muscle paralysis you can make proactive decisions about NMBA dosing, type of reversal agent and reversal dose, if spontaneous recovery is an option, if the patient has gotten to adequate recovery phase and when it is safe to extubate.
Having a safe anesthesia procedure is something that every child deserves.
Take a look at our quantitative neuromuscular monitor TetraGraph and the pediatric-focused sensor TetraSens Pediatric, made by a soft material and especially designed for children.
Haberkorn, et al. A quality improvement project to reduce sugammadex cost and waste by using aliquots and quantitative neuromuscular monitoring. Abstract presented at SPA-AAP annual congress, April 2023
Klucka J et al. Residual neuromuscular block in paediatric anaesthesia. Br J Anaesth. 2019
Vested M et al. Incidence of residual neuromuscular blockade in children below 3 years after a single bolus of cisatracurium 0.1 mg/kg: a quality assurance study. Acta Anaesthesiol Scand. 2020
Ledowski et al., Postoperative Residual Neuromuscular Paralysis at an Australian Tertiary Children's Hospital, Anesthessiol Res Pract. 2015.
Taivainen T, et al. Rocuronium in infants, children and adults during balanced anaesthesia. Paediatr Anaesth. 1996
Decrease of functional residual capacity and ventilation homogeneity after neuromuscular blockade in anesthetized young infants and preschool children. Anesthesiology. 2006
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