Pediatric Neuromuscular Monitoring: Anatomy Matters

Monitoring the effect of neuromuscular blocking drugs is a salient component of anesthetic management. This is relevant both in terms of optimizing conditions for airway management as well as readiness for extubation and spontaneous, unassisted ventilation. In the recent past, there has been a gradual appreciation for the use of quantitative monitoring techniques which have demonstrated superiority over manual or visual inspection of neuromuscular blockade. However, there is a need for a better understanding of these techniques in the pediatric population at different anatomic sites. Tobias et al compared electromyography in 50 pediatric patients at the adductor pollicis and flexor hallucis brevis under general anesthesia. They observed that the onset and recovery of neuromuscular blockade at the posterior tibial nerve was delayed by 90 and 190 seconds respectively. These differences may inform how we manage pediatric patients when electing to use quantitative monitoring at the posterior tibial nerve. A visual summary of this article is presented in this infographic, though the reader is strongly encouraged to review the cited article for a more thorough understanding of the illustrated concepts.