Is it always necessary to antagonize residual neuromuscular block? Do children differ from adults?

Is it always necessary to antagonize residual neuromuscular block? Do children differ from adults? Use of an anticholinesterase at the end of surgery, to antagonize residual neuromuscular block induced by a non-depolarizing drug, is commonplace; it is easy to forget that such drugs were not always given routinely. When the clinical use of " Intocostrin " (a biologically standardized extract of curare) was first described in 25 patients by Griffith and Johnson in 1942, it was only recommended that an ampoule of the antidote, prostigmine, be readily available 1 ; there was no mention of administering the antagonist. Indeed, it is difficult to determine how anti-cholinesterases came into regular use. 2 Neostigmine was noted only to be given " seldomly " by Prescott and colleagues in 1946, in doses of up to 5 mg, even though these workers were using tubocurarine 0.4 mg kg 91 for abdominal surgery. 3 Undoubtedly, failure to use an anticholinesterase was a factor in the morbidity associated with the use of small doses of non-depolarizing neuromuscular blocking drugs in patients breathing spontaneously, and a reason why such techniques fell into disrepute in the early 1950s. 4 Unfounded fears of neostigmine causing cardiac arrest were probably a reason for its omission. 5 With the increasing use of larger doses of tubocurarine or pancuronium and controlled ventilation many, although not all, clinicians began to administer neostigmine 5 mg to adults. 5 6 Large doses of anticholinesterase were used in children at this time: neostigmine 0.08 mg kg 91 was given to antagonize tubocurarine in neonates, who were thought to need an even higher dose than adults to obtain reliable recovery. 7 With the advent of the intermediate-acting non-depolarizing agents, atracurium and vecuronium, the need for such high doses of anticholinesterase was questioned. 8 Clinicians soon realized that recovery from these agents was more rapid than with tubocurarine or pancuronium. The greater clearance of the newer drugs from plasma, and hence a more rapid decrease in relaxant concentration at the post-synaptic nicotinic receptor allowed, on some occasions , for the omission of an anticholinesterase. This has some benefits; nausea and vomiting may be less common in patients who are not given neostigmine after the use of a non-depolarizing drug. 9 Any detrimental effect of neostigmine on a newly created gut anastomosis can also be avoided. 10 But careful monitoring of neuromuscular block is always necessary if anticholinesterases are …