Background
Neuromuscular blocking agents are recommended by the European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Paediatric Anaesthesia (ESPA) for facilitating tracheal intubation in children. Despite these recommendations, real-world data on how neuromuscular blocking agents are used, monitored, and reversed remain scarce.
Aims
To identify and characterize self-reported neuromuscular blocking agent practice patterns across European and non-European countries, in the period preceding publication of the joint ESAIC and ESPA guidelines.
Methods
We conducted an anonymous, cross-sectional survey between 12 November and 12 December 2025, targeting members of the ESAIC, ESPA, and the French and Spanish national pediatric anesthesiology societies involved in pediatric airway management across 43 countries.
Results
The survey was accessed by 904 persons, and 874 responses were included in the analysis. Most participants were from Europe (83.5%) and worked in mixed pediatric anesthesia and intensive care settings (71.2%). Rocuronium was the most frequently used neuromuscular blocking agent for both routine tracheal intubation (68%; 95% CI 65%–71%) and rapid sequence intubation (67%; 95% CI 64%–70%). Neuromuscular blocking agents were used “always” or “mostly” before routine intubation in 47% of neonates (≤ 30 days) and 50% of infants (< 1 year), whereas “rarely” or “never” use was reported in 30% and 24%, respectively. Most respondents (56%) assessed adequacy of neuromuscular block using a fixed time interval after neuromuscular blocking agent administration. Reversal was administered “always” before extubation by 27% of respondents, while 9.3% reported “rarely” and 2.9% “never.” Only half of participants used quantitative neuromuscular monitoring to guide reversal. Sugammadex was used by 47%.
Conclusions
Self-reported clinical practice regarding neuromuscular blocking agent use in pediatric patients remains heterogeneous. Children are frequently intubated without neuromuscular blocking agents and extubated without consistent reversal. Quantitative neuromuscular monitoring remains uncommon. These practice patterns raise concerns for patient safety.
Clinical Implications
• What is already known about the topic?
- ○Neuromuscular blocking agents facilitate tracheal intubation in children and are recommended by the guideline.
- ○Real-world practice among European pediatric anesthetists and intensivists prior to guideline publication had not previously been described.
• What new information this study adds?
- ○This large multinational survey shows that pre-guideline clinical practice was highly heterogeneous.
- ○Children were frequently intubated without neuromuscular blocking agents, quantitative monitoring was used by only half of respondents, and consistent reversal before extubation was reported by fewer than one in three clinicians.
- ○These findings identify critical education and training gaps that must be addressed to support safe and effective implementation of the new guidelines.