Effect of Adjunctive Train-of-Four Monitoring Using Peripheral Nerve Stimulation on Neuromuscular Blocking Agent Dose in PICU Patients: A Randomized Crossover Study

Objective: Continuous neuromuscular blocking agent (NMBA) infusion is common in the PICU. There are no pediatric trials evaluating the effect of train-of-four (TOF) monitoring on NMBA dosing. We therefore aimed to determine the effect of adjunctive TOF monitoring using peripheral nerve stimulation on NMBA dosing compared with clinical assessment alone in PICU patients. Design: Randomized crossover study (Thai Clinical Trial Registry, TCTR20240328002). Setting: Fourteen-bed general PICU. Patients: Age 30 days to 18 years who received continuous cisatracurium infusion and were expected to continue the infusion for the next 48 hours. Interventions: Patients were randomized to start day-1 intervention with either adjunctive TOF or clinical assessment. Crossover occurred each morning between adjunctive TOF and clinical assessment. On adjunctive TOF day, patients received TOF monitoring, and the results were reported to the clinical team. The clinical team used TOF results together with clinical assessment of the depth of paralysis to adjust cisatracurium dosing on adjunctive TOF day. On the clinical assessment day, patients received TOF monitoring but the results were concealed from the clinical team. The clinical team used only clinical assessment of the depth of paralysis to adjust cisatracurium dosing on the clinical assessment day. Measurements and Main Results: Pairwise comparison was made between the consecutive adjunctive TOF day and clinical assessment day in the same patient. Sixteen patients completed the study. There were no significant differences on adjunctive TOF day vs. clinical assessment day for total daily cisatracurium dose (median interquartile range: 34.0 mg 20.0, 72.8 vs. 35.4 mg 16.8, 59.0, p = 0.87) and for average cisatracurium dose (mean ± sd : 2.36 ± 1.21 vs. 2.41 ± 1.35 µg/kg/min; mean difference –0.06 95% CI –0.22 to 0.11 µg/kg/min, p = 0.48). Conclusions: Adjunctive TOF monitoring did not lead to significant difference in cisatracurium dosing compared with clinical assessment alone.