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Research Snapshot Theater: Quality and Patient Safety, Pediatric IV

Reducing Neuromuscular Blockade Exposure in a Pediatric ICU: A Quality Improvement (QI) Study

Monday, March 23, 2026
11:30 AM - 12:30 PM Central Time
Location: Connections Central - RST 10

  • Nour Y. Gebara, MD (she/her/hers)

    Baylor College of Medicine Texas Children's Hospital, Texas

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • JM

    Julia G. Mancebo, MD

    Pediatric Critical Care Fellow
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • EC

    Emma Crotty, MBBS

    Pediatric Critical Care Fellow
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • VL

    Vida Laudarji, MD

    Pediatric Critical Care Fellow
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • KB

    Katie Brandewie, MD

    Pediatric Critical Care Fellow
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • Jordan Marquess, MD (she/her/hers)

    Baylor College of Medicine Texas Children's Hospital

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • Charli Fox, MD

    Baylor College of Medicine Texas Children's Hospital

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • Carlos R. Vargas, MD (he/him/his)

    Baylor College of Medicine Texas Children's Hospital, Texas

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • KL

    Katherine I. Lemming, PharmD, BCPPS

    Clinical Pharmacy Specialist
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • JB

    Jenna Bartlett, PharmD, BCPPS

    Clinical Pharmacy Specialist
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • MM

    Megan Moore, PharmD

    Clinical Pharmacy Specialist
    Baylor College of Medicine/ Texas Children's Hospital

    Disclosure information not submitted.

  • TF

    Thomas Fogarty, MD, FAAP

    Assistant Professor
    Baylor College of Medicine/ Texas Children's Hospital, Texas

    Disclosure information not submitted.

  • Venessa L. Pinto, MBBS, FAAP (she/her/hers)

    Baylor College of Medicine Texas Children's Hospital, Texas

    Disclosure(s): No relevant financial relationship(s) to disclose.

Introduction: Neuromuscular blockade (NMB) use in pediatric ICUs prevents movement, decreases ventilator dysynchrony, and metabolic demand. While helpful in septic shock and intracranial hypertension, overuse is linked to myopathy, prolonged ventilation, exposure keratopathy, and pressure ulcers. Review of limited pediatric studies suggests a correlation between cumulative NMB dose and prolonged recovery. Pediatric critical care fellows led a QI project to reduce cumulative NMB exposure by 10% in patients on NMB infusions for >24hrs in our quaternary pediatric ICU from February to August 2025.


Methods: We created cause-and-effect and key driver diagrams and surveyed attendings and advanced practice providers (APPs) to understand NMB practices and perceptions. Primary outcome was cumulative NMB exposure per patient in mg/kg; process measures included Train-of-Four (TOF) monitoring and rate of NMB holidays (>1hr); the balancing measure was unplanned extubations on infusions. We used Plan-Do-Study-Act (PDSA) cycles. Interventions involved focused education for prescribers—physicians, APPs, and residents—via presentations and onboarding. Nurses were educated on NMB use and monitoring; TOF monitor availability increased. Posters were placed in workrooms. EMR interventions weren’t feasible within our timeline.


Results: Pre-intervention surveys showed a gap between perceived and documented NMB holiday practices. During our baseline period (July-Dec ’24), 110 (68%) patients were on rocuronium, 23 (14%) on cisatracurium, and 29 (18%) on vecuronium. From Feb-Jun’25, cumulative rocuronium dose rose slightly from a median of 7.8 to 8.6 mg/kg/day per rocuronium exposure. NMB holiday rate increased from 15% at baseline to 25% during the last 3 months, associated with project team presence on units. Documented TOF fluctuated around 2.1% of NMB patients. Unplanned extubations were not due to lack of NMB.


Conclusions: Patient census, acuity, and NMB indications variability may impact cumulative exposure. We identified a need to improve process measures to improve outcomes. Future work will target optimizing best practices for TOF monitoring and NMB holidays to decrease NMB-associated morbidity. EMR-based interventions not reliant on individuals will be needed for long-term impact.