Neuromuscular-blocking agents for tracheal intubation in pediatric patients (0-12 years): A systematic review and meta-analysis.


The outcome of this study is unlikely to surprise any anaesthetists, however it is likely to confirm your existing practices.


  • A systematic review and meta-analysis comparing intravenous neuromuscular blockade (NMBA) with no NMBA for tracheal intubation.
  • Included RCTs of 0-12 year old children, ASA class I and II, requiring intubation for elective or emergency surgery in which anaesthesia was induced with intravenous or inhalational agents, with or without opioids.
  • All RCTs from 1990 to 2018 were included. A total of 22 trials and 1651 patients were identified and included in the meta-analysis.
  • The methodology followed the Cochrane Collaboration for quality assessment and statistical analysis including exploring heterogeneity and meta-analysis.
  • Due to the number of study arms with a light-to-moderate plane of anaesthesia during tracheal intubation the conclusion of the review is: “NMBA during light-to-moderate plane of anaesthesia can improve the quality and success rate of tracheal intubation and results in better haemodynamic stability during induction of anaesthesia”.
  • The review goes on to say that an adequate dose of NMBA will improve intubation conditions, however a smaller amount of NMBA can improve intubation conditions during light-to-moderate planes of anaesthesia with decreased risk of residual postoperative neuromuscular blockade.
  • Timing of intubation also impacts on intubating conditions, with a higher proportion of excellent intubating conditions obtained by delaying intubation, especially if a lower dose non-depolarising NMBA have been used.
  • Sufficient depth of anaesthesia in a non-NMBA technique can, in experienced hands and in the right patient group, be an acceptable technique. The most useful techniques in the review being 2-4 microgram/kg of remifentanil supplementing either 3-4 mg/kg of propofol or high dose sevoflurane. The reviewers confirm that these drug combinations can reduce heart rate and blood pressure. The addition of remifentanil at 3-4 micrograms/kg can also significantly delay the return of spontaneous ventilation.
  • Intubations with propofol and alfentanil combinations had a remarkably low rate of acceptable intubating conditions.
  • Higher blood pressure and heart rate and less arrhythmias were found in the NMBA groups, the reviewers say this could be explained by the light-to-moderate plane of anaesthesia at the time of intubation.


Reviewed by Dr Jon Salicath