Measure ID

Percentage of pediatric patients ≤ 5 years old who receive appropriate initial dosing of non-depolarizing neuromuscular blocking drugs (NMB) intraoperatively.

Measure Type
Available for Provider Feedback

Infants should receive lower doses (mg/kg) of nondepolarizing neuromuscular blocking agents (NMBA) than older children, as those lower doses are produce similarly rapid onset time and efficacy1. The benefit of clinical elevated doses of NMBA in infants is questionable, while the risks are significant, including the potential for markedly prolonged activity2, prolongation of time under anesthesia3, respiratory adverse eventsand inadequate subsequent reversal which may result in sudden respiratory failure5,6.

NMBA and neuromuscular monitoring are commonly misused in pediatric anesthesiaand this is an important area for quality improvement. While any administrations of neuromuscular blockade may result in relative overdose with prolonged effect, the first dose is typically the most carefully considered by anesthesiologists and those they supervise (CRNAs, AAs and trainees) and therefore most appropriate for creation of an MPOG measure to educate all providers on this issue.

Measure Time Period
  • Patients ≤ 5 years of age (as determined by Age Group value codes < 6)
  • Patients who receive a bolus of non-depolarizing NMB during the measure time period
  • Age > 5 years
  • ASA 6 including Organ Procurement (CPT: 01990)
  • Patients who do not receive non-depolarizing NMB during the measure time period
  • Patients who receive non-depolarizing infusion during the measure time period
  • Patients without documented weight
  • Patients who were not extubated before Anesthesia End.
Success Criteria

The first dose of neuromuscular blocker is below an expert opinion-based threshold, during the time period of Anesthesia start and Extubation, as follows:



 Infants (mg/kg)

 AgeGroup value_code 1,2,3

 Children (mg/kg)

 AgeGroup value_code 4,5


 ≤ 0.1

 ≤ 0.2


 ≤ 0.5

 ≤ 0.5


 ≤ 0.5

 ≤ 1.2


 ≤ 0.1

 ≤ 0.1


 ≤ 0.1

 ≤ 0.1

Other Measure Details

Algorithm for determining patients who remained intubated postoperatively:

  1. Was the patient transported to PACU? If Yes, Include.  If No, then 
  2. Was extubation time prior to Anesthesia End? If Yes, Include. If No or missing, then,
  3. Was MPOG concept 50380 ‘Emergence - ETT in place, patient manually ventilated’ documented between procedure end and anesthesia end? If Yes, exclude. If no, then,
  4. Were sedation medication infusions continued after Anesthesia End? If Yes, exclude. If no, then include

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Risk Adjustment

Not applicable

Provider Attribution

Provider(s) signed into the case during the time of NMB administration

MPOG Concept Used


  • 10043  Atracurium
  • 10129  Cisatracurium
  • 10344  Pancuronium
  • 10393  Rocuronium
  • 10446  Vecuronium


  • 50127 Intubation Extubated Awake or Deep
  • 50202 Emergence - Patient Extubated
  • 50145 Airway - Laryngeal mask airway removed (deep or awake)
MPOG Phenotypes Used
  1. Eck JB. Neuromuscular blocking agents. In: Davis PJ, Cladis FP, eds. Smith’s Anesthesia for Infants and Children. 10th ed. Elsevier, Inc; 2021:257-278.
  2. Soffer OD, Kim A, Underwood E, Hansen A, Cornelissen L, Berde C. Neurophysiological Assessment of Prolonged Recovery From Neuromuscular Blockade in the Neonatal Intensive Care Unit. Front Pediatr 2020;8:580.
  3. Gilbertson LE, Fiedorek MC, Fiedorek CS, Trinh TA, Lam H, Austin TM. Prolonged neuromuscular block after rocuronium administration in laparoscopic pyloromyotomy patients: A retrospective bayesian regression analysis. Paediatr Anaesth 2021;31:290–7.
  4. Scheffenbichler FT, Rudolph MI, Friedrich S, Althoff FC, Xu X, Spicer AC, Patrocínio M, Ng PY, Deng H, Anderson TA, Eikermann M. Effects of high neuromuscular blocking agent dose on post-operative respiratory complications in infants and children. Acta Anaesthesiol Scand 2020;64:156–67.
  5. Carollo DS, White WM. Postoperative Recurarization in a Pediatric Patient After Sugammadex Reversal of Rocuronium-Induced Neuromuscular Blockade: A Case Report. A A Pract 2019;13:204–5.
  6. Renew JR, Tobias JD, Brull SJ. The Time to Seriously Reassess the Use and Misuse of Neuromuscular Blockade in Children Is Now. Anesth Analg 2021;132:1514–7.
Measure Authors
 Measure Authors  Institution
 Meridith Wade MSN, RN  University of Michigan
 Bishr Haydar, MD  University of Michigan
 Rob Coleman  University of Michigan
 MPOG Pediatric Subcommittee  


Measure Reviewer(s)
Next Review: 2025
 Date Reviewed  Reviewer  Institution  Summary  QC Vote





Published Date: 2022
Date Criteria Revision