Quantitative Train-of-Four Monitoring Using the TetraGraph™ to Evaluate Rocuronium Requirements During Renal Transplantation in a Pediatric Patient.

The pharmacokinetics of neuromuscular blocking agents (NMBAs) may be altered in patients with renal insufficiency or failure, including alterations in the volume of distribution or elimination of the primary drug and its metabolites. In this patient population, monitoring of the end-organ effects of NMBAs may be useful to guide initial and subsequent dosing, as well as reversal of neuromuscular blockade. Train-of-four (TOF) monitoring remains the most commonly used technique to monitor the end-organ effect of NMBAs and the neuromuscular junction. Here we present the use of an electromyography (EMG)-based TOF monitor in a 9-year-old boy with end-stage renal disease during intraoperative anesthetic care for renal transplantation. The perioperative management of such patients, including dosing of NMBAs and use of neuromuscular blockade monitoring, is discussed.