Agreement between muscle movement and peripheral nerve stimulation in critically ill pediatric patients receiving neuromuscular blocking agents

Objective The purpose of this study was to determine the degree of agreement between clinically observed muscle movement(s) and train-of-four scores obtained by peripheral nerve stimulation during a neuromuscular blocking agent infusion and after it was discontinued.Design The study included a method-comparison design.Setting Subjects were located in the pediatric intensive care unit of a metropolitan children's hospital.Patients Study patients included 27 children who required neuromuscular blocking agent infusions.Outcome measures Outcome measures were determined by clinical observation of muscle movement and train-of-four scores obtained from peripheral nerve stimulation during and after a neuromuscular blocking agent infusion.Results Poor agreement was found between observed muscle movement and corresponding train-of-four scores during therapeutic infusions (most kappa were less than 0.30), whereas fair to substantial agreement was found between the 2 techniques after the infusion was discontinued (kappa ranging from 0.34 to 0.70).Conclusion Until additional research is available, nurses must titrate the neuromuscular blocking agent infusion on the basis of the clinical endpoints for paralysis in combination with an assessment of the child's movements and response to peripheral nerve stimulation to prevent overdose and prolonged muscle paralysis.