Does Electromyography Improve Precision and Reliability of Neuromuscular Monitoring in Paediatric Patients

Study Overview
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Brief Summary
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Neuromuscular monitoring is used as a standard surveillance method of neuromuscular function to ensure full recovery at the end of anaesthesia. The currently available devices properly provide respective information in adults but not in children. Furthermore, response to neuromuscular blocking agents differs between adults and children due to age-related differences in body composition, physiological function, and acetylcholine receptor density. Recently, electromyographic (EMG) technologies to monitor neuromuscular function were increasingly developed including disposables for nerve stimulation and measurement of the compound muscle action potential in children. However, it is still unclear whether the precision and reliability of these devices is superior to the currently available neuromuscular monitoring for children based on kinemyography (KMG). The ETCETERA study will test the hypothesis that neither EMG nor KMG provides inferior train-of-four readings to the respective reference method in infants and children below five years.

Detailed Description
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The ETCETERA trial is a randomized clinical agreement study which will prospectively enrol sixty-four children below five years of age scheduled for elective, non-cardiac surgery requiring general anaesthesia and neuromuscular blockade for optimisation of surgical conditions. The children's neuromuscular function is measured on one hand with EMG and on the other hand with KMG in a randomised fashion. Additionally, randomisation will be stratified upon age groups: 1) neonates: birth to <28 days, 2) infants 28 days to ≤3 months, 3) toddlers: >3 months to ≤2 years, 4) children >2 years to <5 years. Based on the high failure rate of currently available neuromuscular monitoring devices in infants and neonates, in this randomised agreement study we will primarily compare precision and reliability of EMG and KMG-measured Train-of-Four (TOF) values during spontaneous recovery from a rocuronium-induced neuromuscular blockade in neonates, infants, toddlers, and children <5 years using the age-appropriate paediatric sensors.

Official Title
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Original Title: Does ElecTromyography Improve preCision and Reliability of nEuromuscular moniToring in paEdiatRic pAtients - A Monocentric Randomized Prospective Agreement Study - ETCETERA

Conditions
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Neuromuscular Blockade, Residual, Postoperative Complications

Intervention / Treatment
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* Device: Electromyography (EMG)
* Device: Kinemyography (KMG)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: children and infants < 5 years non-cardiac surgery requiring general anaesthesia and neuromuscular blockade signed informed written consent American Society of Anesthesiologists physical status <4 intraoperative positioning with access to both arms Exclusion Criteria: allergy to neuromuscular blocking agents allergy to neuromuscular monitoring adhesive electrode neurologic disease surgical procedures outside the operating room children receiving neuromuscular blocking agents immediately before surgery

Ages Eligible for Study
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Minimum Age: 1 Hour
Maximum Age: 5 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| neonates<br>birth to <28 days | Device: Electromyography (EMG)<br>* Measurement of the compound muscle action potential for the assessment of neuromuscular function<br>Device: Kinemyography (KMG)<br>* Measurement of the muscle velocity for the assessment of neuromuscular function<br>|
| infants<br>28 days to ≤3 months | Device: Electromyography (EMG)<br>* Measurement of the compound muscle action potential for the assessment of neuromuscular function<br>Device: Kinemyography (KMG)<br>* Measurement of the muscle velocity for the assessment of neuromuscular function<br>|
| toddlers<br>>3 months to ≤2 years | Device: Electromyography (EMG)<br>* Measurement of the compound muscle action potential for the assessment of neuromuscular function<br>Device: Kinemyography (KMG)<br>* Measurement of the muscle velocity for the assessment of neuromuscular function<br>|
| children<br>>2 years to <5 years | Device: Electromyography (EMG)<br>* Measurement of the compound muscle action potential for the assessment of neuromuscular function<br>Device: Kinemyography (KMG)<br>* Measurement of the muscle velocity for the assessment of neuromuscular function<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Precision of TOF (train of four) measurements | The primary endpoint is the repeatability coefficient r defined as 1.96 times the standard deviation of the differences between two consecutive TOF ratio measurements on the same patient under identical conditions. The repeatability coefficient and its confidence intervals will be calculated using a linear mixed regression model for EMG and KMG measured TOF ratios independently at baseline and at complete neuromuscular recovery, i.e., at TOF ratio > 0.9 and compared between techniques using F-tests with a non-inferiority approach. | intraoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Agreement of TOF values during spontaneous recovery of neuromuscular function | Agreement of TOF during spontaneous recovery of neuromuscular function, agreement of TOF at baseline and agreement of the final TOF at >0.9 and 1.0 will be verified. The repeatability coefficient and its confidence intervals will be calculated using a linear mixed regression model for EMG and KMG measured TOF ratios independently at baseline and at complete neuromuscular recovery, i.e., at TOF ratio > 0.9 and compared between techniques using F-tests with a non-inferiority approach. | intraoperatively | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Electromyography, Neuromuscular Blockade, Postoperative Complications