European Journal of Anaesthesiology最新文献

Neuromuscular blocking agents (NMBAs) are critical components in paediatric anaesthesia, facilitating intubation, surgical procedures and mechanical ventilation in neonates, infants and children. This narrative review examines the pharmacological properties, clinical applications, monitoring, reversal and safety of NMBAs across paediatric populations. Given the unique physiological characteristics of neonates and infants - including hepatic and renal maturation, and neuromuscular junction development - NMBA metabolism, efficacy and adverse effects in these age groups differ markedly from those in older children and adults. These physiological factors necessitate specific approaches to NMBA selection, dosing and monitoring to ensure effective blockade while minimising risks. Emphasis is placed on understanding how the pharmacokinetics and pharmacodynamics of commonly used NMBAs vary with age, influencing onset, duration and recovery. Additionally, practical strategies for the safe and effective monitoring of neuromuscular blockade using quantitative monitoring techniques are discussed to avoid residual neuromuscular blockade. Recent advances in the reversal of neuromuscular blockade, including the use of sugammadex, offer promising improvements in paediatric anaesthesia safety, though their application in neonatal populations requires further study. Finally, the review discusses current research trends, highlighting the need for age-specific guidelines and pharmacologic innovations that address the challenges unique to NMBA use in neonates, infants, and children.

Background: Use of neuromuscular blocking agents (NMBAs) is recommended by European Society of Anaesthesiology and Intensive Care in neonates (<1 month) and infants (<1 year) to facilitate tracheal intubation, but the use in other paediatric age groups is still debated.

Objective: We assessed the effects of avoidance versus use of NMBA for facilitation of tracheal intubation in children and infants. The primary outcome was incidence of difficult tracheal intubation.

Design: A systematic review of randomised controlled trials with meta-analyses and trial sequential analysis.

Eligibility criteria: Paediatric patients undergoing tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy with or without NMBAs for any type of procedure requiring general anaesthesia.

Data sources: A systematic search up to 8 July 2025 in Medical Literature Analysis and Retrieval System Online ( MEDLINE), Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials (CENTRAL), BioSciences Information Service of Biological Abstracts (BIOSIS), International Web of Science and Advanced Google and Cumulative Index to Nursing & Allied Health Literature (CINAHL). Trial registries were explored to uncover unpublished data or supplementary trials, http://links.lww.com/EJA/B253 .

Results: We identified 47 randomised clinical trials ( n  = 2276). Three trials were categorised as 'low risk of bias'. Thirty trials reported the primary outcome. Avoidance of NMBAs was associated with increased risk of difficult tracheal intubation with a risk ratio (RR) of 3.47 [95% confidence interval (CI), 2.52 to 4.77, P  < 0.001, I2  = 18%] and moderate certainty of evidence. The trial sequential analysis resulted in α -spending adjusted RR of 3.68 when avoiding NMBAs (95% CI, 2.22 to 6.11; α  = 5%, β  = 90%). We found no significant increased risk of serious adverse events comparing avoidance and use of NMBA (very low certainty of evidence).

Conclusion: Using NMBAs for facilitation of tracheal intubation reduces the incidence of difficult tracheal intubation compared to avoidance of NMBA in children and infants.

Background: Neonates and infants are among the most vulnerable populations to undergo procedures necessitating general anaesthesia and are at risk for postoperative neurological complications. The objective of this study was to assess the association between interventions for intra-operative physiologic instability and the development of postoperative neurological complications in a cohort of neonates and infants undergoing operative and nonoperative procedures.

Methods: Data for this study were extracted from the NECTARINE study: a prospectively collected cohort of neonates and infants receiving anaesthesia for operative and nonoperative procedures from 165 participating hospitals in 31 countries.In a multivariable logistic regression model predicting the development of a neurologic complication up to 30 days postoperatively, exposures of interest were binary indicators of unexpected intra-operative instability of systemic homeostasis necessitating a corrective action (based on blood pressure, heart rate, end-tidal and/or blood CO 2 , glucose and sodium).

Results: One hundred and forty out of 5504 (2.5%) neonates and infants developed a postoperative neurologic complication. No statistically significant association was found between interventions for intra-operative physiologic instability and the development of a postoperative neurologic complication.

Conclusion: In this secondary analysis of neonates and infants undergoing cardiac and noncardiac procedures, we found a higher rate of neurologic complications compared to adult populations undergoing noncardiac surgery. There was no association between unexpected intra-operative instability of systemic homeostasis necessitating a corrective action and subsequent neurologic complications; however, these findings do not necessarily indicate the absence of any effect of physiological disturbances on neurologic outcomes.