Effect of neuromuscular blocking agents on tracheal intubation quality in paediatric patients: a systematic review using network meta-analysis and meta-regression

Background: This meta-analysis is the first to compare tracheal intubation conditions and haemodynamic responses produced by various types and doses of neuromuscular blocking agents (NMBAs) in paediatric anaesthesia while also exploring factors associated with variability in outcomes. Methods: Randomised controlled and controlled clinical trials involving healthy paediatric participants (0–12 yr) were included. Trials compared intubation conditions using various NMBA interventions or NMBA-free settings under direct laryngoscopy. Outcomes included odds ratios (ORs) for excellent and acceptable intubation conditions, and mean differences for MAP and HR. Bayesian network, pairwise, and cumulative meta-analyses, along with meta-regression, assessed NMBA effectiveness and covariate effects. Results: Data from 105 trials (8008 participants) were analysed. Suxamethonium ≥1.50 mg kg⁻¹ and rocuronium ≥0.90 mg kg⁻¹ provided similar intubation conditions, though not consistently within 60 s. Other NMBAs were, on average, slower and less effective. Opioids decreased MAP and HR but did not improve intubation conditions when combined with suxamethonium ≥1.00 mg kg⁻¹ or rocuronium ≥0.90 mg kg⁻¹. Non depolarising NMBAs enhanced excellent (OR: 2.97 [1.82–5.10]) and acceptable intubation conditions (OR: 2.29 [1.14–4.39]) more in younger children (1.64 [1.08–2.20] yr) than in older ones (5.53 [4.04–7.01] yr). Intubation without NMBAs was most difficult in neonates and infants, with conditions improving until about age 4 yr. Beyond this, the difference in intubation quality between groups with and without NMBAs increased with age, indicating a greater benefit of using NMBAs in older children. Values are mean (95% credible interval). Conclusions: We present a meta-analytical approach to synthesise and consolidate evidence from previous research and demonstrate how neuromuscular blocking agent type and dose, intubation timing, age, and induction drugs affect the safety and efficacy of paediatric airway management. Low-to-moderate confidence can be assigned to the recommendations from this meta-analysis. Systematic review protocol: PROSPERO (CRD42018097146).