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Radkowski P, Barańska A, Mieszkowski M, Dawidowska-Fidrych J, Podhorodecka K. Methods for Clinical Monitoring of Neuromuscular Transmission in Anesthesiology - A Review. Int J Gen Med 2024; 17:9-20. [PMID: 38196564 PMCID: PMC10771978 DOI: 10.2147/ijgm.s424555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/08/2023] [Indexed: 01/11/2024] Open
Abstract
The administration of general anesthesia is a crucial aspect of surgery. However, it can pose significant risks to patients, such as respiratory depression and prolonged neuromuscular blockade. To avoid such complications, it is essential to monitor neuromuscular transmission during anesthesia. While clinical tests have been used for decades to evaluate muscle function, they are now known to be unreliable, and relying on them increases the risk of postoperative complications. Thankfully, there are now six methods available for neuromuscular monitoring during anesthesia: mechanomyography, acceleromyography, electromyography, kinemyography, phonomyography, and compressomyography. Each of these methods differs in terms of their approach and methodology, and their importance in clinical practice varies accordingly. Mechanomyography involves measuring the mechanical response of a muscle to nerve stimulation, while acceleromyography measures the acceleration of muscle contraction. Electromyography records the electrical activity of muscles, while kinemyography tracks muscle movement. Phonomyography records the sound waves produced by contracting muscles, and compressomyography involves monitoring the pressure changes in a muscle during contraction. Overall, understanding the differences between these methods and their clinical significance is crucial for anesthesiologists. This review aims to provide an updated understanding of the current methods available for neuromuscular monitoring during anesthesia, so that anesthesiologists can make informed decisions about patient care and reduce the risk of postoperative complications.
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Affiliation(s)
- Paweł Radkowski
- Department of Anaesthesiology and Intensive Care, Regional Specialist Teaching Hospital, Olsztyn, Poland
- Department of Anaesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
- Department of Anaesthesiology and Intensive Care, Hospital zum heiligen Geist, Fritzlar, Germany
| | - Agnieszka Barańska
- Department of Anaesthesiology and Intensive Care, Regional Specialist Teaching Hospital, Olsztyn, Poland
| | - Marcin Mieszkowski
- Department of Anaesthesiology and Intensive Care, Regional Specialist Teaching Hospital, Olsztyn, Poland
- Department of Anaesthesiology and Intensive Care, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | | | - Katarzyna Podhorodecka
- Department of Anaesthesiology and Intensive Care, Regional Specialist Teaching Hospital, Olsztyn, Poland
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Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, Szokol JW, Eriksson LI, Yaster M, Grant MD, Agarkar M, Marbella AM, Blanck JF, Domino KB. 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13-41. [PMID: 36520073 DOI: 10.1097/aln.0000000000004379] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.
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Cha YM, Faulk DJ. Management of Neuromuscular Block in Pediatric Patients — Safety Implications. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00537-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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4
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Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study. J Clin Anesth 2022; 78:110673. [DOI: 10.1016/j.jclinane.2022.110673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/06/2022] [Accepted: 01/28/2022] [Indexed: 11/24/2022]
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Munsterman C, Broussard T, Strauss P. Botulinum Toxin A Injection and Perianesthesia Neuromuscular Monitoring: Case Report and Review. J Perianesth Nurs 2021; 37:11-18. [PMID: 34802920 DOI: 10.1016/j.jopan.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 11/16/2022]
Abstract
The popularity of looking younger has been facilitated by the availability of botulinum toxin (BoNT) injection. In 2019, over 7.7 million injections of BoNT occurred, making it the number one minimally invasive cosmetic procedure in the United States. With the ease of patients obtaining BoNT in an outpatient setting, coupled with the fact that it is considered a minimally invasive procedure, most patients do not disclose the use of BoNT during the preoperative anesthesia evaluation. This case report involves a female whose recent BoNT injections interfered with neuromuscular (NM) monitoring during anesthesia. Neuromuscular monitoring was performed using the orbicularis oculi muscle with repeated train-of-four (TOF) 0/4. It was not until completion of procedure when the arms were accessible that the adductor pollicis muscle was assessed with a TOF of 2/4. During postoperative follow up, the patient revealed she had received BoNT injections prior to surgery. A review of BoNT pharmacology, barriers to NM monitoring and use of sugammadex are discussed. This case demonstrates the importance of ascertaining BoNT injection history in any case in which access to the ulnar nerve or tibial nerve is not available.
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Affiliation(s)
| | | | - Penelope Strauss
- The University of Texas Health Science Center at Houston, Houston, TX
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Abstract
Neuromuscular monitoring is essential for optimal management of neuromuscular blocking drugs. Postoperative residual neuromuscular blockade continues to occur with an unacceptably high incidence and is associated with adverse patient outcomes. Use of a peripheral nerve stimulator and subjective tactile or visual assessment is useful for intraoperative management of neuromuscular blockade, especially when the patient's hand is accessible. Quantitative monitoring is necessary for confirmation of adequate reversal and for identification of patients who have recovered spontaneously and therefore should not receive pharmacologic reversal agents. Guidelines, as well as more user-friendly monitoring equipment, have created momentum toward improving routine perioperative neuromuscular monitoring.
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Affiliation(s)
- Stephan R Thilen
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Avenue, Box 359724, Seattle, WA 98104, USA.
| | - Wade A Weigel
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 9th Avenue, Mailstop B2-AN, Seattle, WA 98101, USA
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Comparison between the trapezius and adductor pollicis muscles as an acceleromyography monitoring site for moderate neuromuscular blockade during lumbar surgery. Sci Rep 2021; 11:14568. [PMID: 34267301 PMCID: PMC8282790 DOI: 10.1038/s41598-021-94062-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 07/06/2021] [Indexed: 11/08/2022] Open
Abstract
Acceleromyography at the adductor pollicis located in a distal part of the body may not reflect the degree of neuromuscular blockade (NMB) at the proximally located muscles manipulated during lumbar surgery. We investigated the usefulness and characteristics of acceleromyographic monitoring at the trapezius for providing moderate NMB during lumbar surgery. Fifty patients were randomized to maintain a train-of-four count 1–3 using acceleromyography at the adductor pollicis (group A; n = 25) or the trapezius (group T; n = 25). Total rocuronium dose administered intraoperatively [mean ± SD, 106.4 ± 31.3 vs. 74.1 ± 17.6 mg; P < 0.001] and surgical satisfaction (median [IQR], 7 [5–8] vs. 5 [4–5]; P < 0.001) were significantly higher in group T than group A. Lumbar retractor pressure (88.9 ± 12.0 vs. 98.0 ± 7.8 mmHg; P = 0.003) and lumbar muscle tone in group T were significantly lower than group A. Time to maximum block with an intubating dose was significantly shorter in group T than group A (44 [37–54] vs. 60 [55–65] sec; P < 0.001). Other outcomes were comparable. Acceleromyography at the trapezius muscle during lumbar surgery required a higher rocuronium dose for moderate NMB than the adductor pollicis muscle, thereby the consequent deeper NMB provided better surgical conditions. Trapezius as proximal muscle may better reflect surgical conditions of spine muscle.
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Neuromuscular blockade at the orbicularis oculi muscle in a patient with myasthenia gravis. J Clin Monit Comput 2020; 34:1385-1386. [DOI: 10.1007/s10877-019-00422-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/13/2019] [Indexed: 10/25/2022]
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Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
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Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
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Krijtenburg P, Honing G, Martini C, Olofsen E, van Elst H, Scheffer G, Dahan A, Keijzer C, Boon M. Comparison of the TOF-Cuff® monitor with electromyography and acceleromyography during recovery from neuromuscular block. Br J Anaesth 2019; 122:e22-e24. [DOI: 10.1016/j.bja.2018.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/02/2018] [Accepted: 11/02/2018] [Indexed: 11/24/2022] Open
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Mazzinari G, Errando CL, Díaz-Cambronero O, Martin-Flores M. Influence of tetanic stimulation on the staircase phenomenon and the acceleromyographic time-course of neuromuscular block: a randomized controlled trial. J Clin Monit Comput 2018; 33:325-332. [PMID: 29777332 DOI: 10.1007/s10877-018-0157-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 05/15/2018] [Indexed: 12/19/2022]
Abstract
During neuromuscular monitoring, repeated electrical stimulation evokes muscle responses of increasing magnitude ('staircase phenomenon', SP). We aimed to evaluate whether SP affects time course and twitches' values of an acceleromyographic assessed neuromuscular block with or without previous tetanic stimulation. Fifty adult patients were randomized to receive a 50 Hz tetanic stimulus (S group) or not (C group) before monitor calibration. After 20 min of TOF ratio (TOFr) stimulation rocuronium was administered. Onset time of block (primary endpoint), recovery of T1 to 25%, TOFr to 0.9, and recovery index were compared. We also compared T1 and TOFr at baseline, post-stimulation, and during recovery from block. Moreover the correlation between T1 at maximum recovery and (a) baseline T1 and (b) post-stimulation T1 along with T1/TOFr ratio during recovery were evaluated. After stimulation median T1 increased (32%) in group C and decreased (16%) in group S (P = 0.0001). Onset time (Median [IQR] in seconds) was 90 (29-77) vs. 75 (28-60) in C and S group (P = 0.002). Time [Mean (SD) in minutes] to normalized TOFr 0.9 were 70.13 (14.9) vs. 62.1 (21.2) in C and S groups (P = 0.204). TOFr showed no differences between groups at any time point. T1 at maximum recovery showed a stronger correlation with post-stabilization T1 compared to baseline. (ρ = 0.80 and ρ = 0.85, for C and S groups.) Standard calibration does not ensure twitch baseline stabilization and prolongs onset time of neuromuscular block. TOF ratio is not influenced by SP.
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Affiliation(s)
- Guido Mazzinari
- Servicio de Anestesiología. Hospital de Manises, Avenida de la Generalitat Valenciana, 50, 46940, Manises, Valencia, Spain. .,Perioperative Medicine Research Group. Instituto de Investigación Sanitaria la Fe, Valencia, Spain.
| | - Carlos L Errando
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor. Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Oscar Díaz-Cambronero
- Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Perioperative Medicine Research Group. Instituto de Investigación Sanitaria la Fe, Valencia, Spain
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
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Quantitative Neuromuscular Monitoring: Current Devices, New
Technological Advances, and Use in Clinical Practice. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0261-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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13
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Ross Renew J, Brull SJ. The Effect of Quantitative Neuromuscular Monitoring on the Incidence of Residual Neuromuscular Blockade and Clinical Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0156-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Thilen SR, Bhananker SM. Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2016; 6:164-169. [PMID: 27524943 PMCID: PMC4963456 DOI: 10.1007/s40140-016-0155-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This review provides recommendations for anesthesia providers who may not yet have quantitative monitoring and sugammadex available and thus are providing care within the limitations of a conventional peripheral nerve stimulator (PNS) and neostigmine. In order to achieve best results, the provider needs to understand the limitations of the PNS. The PNS should be applied properly and early. All overdosing of neuromuscular blocking drugs should be avoided and the intraoperative neuromuscular blockade should be maintained only as deep as necessary. The adductor pollicis is the gold standard site and must be used for the pre-reversal assessment, also when the ulnar nerve and thumb were not accessible intraoperatively. Spontaneous recovery should be maximized and neostigmine should be administered after a TOF count of 4 has been confirmed at the adductor pollicis. Extubation should not occur within 10 min after administration of an appropriate dose of neostigmine.
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Affiliation(s)
- Stephan R. Thilen
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Ave, Box 359724, Seattle, WA 98104 USA
| | - Sanjay M. Bhananker
- Department of Anesthesiology & Pain Medicine, University of Washington, 325 Ninth Ave, Box 359724, Seattle, WA 98104 USA
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Martin-Flores M, Tseng CT, Sakai DM, Romano M, Campoy L, Gleed RD. Positive and negative staircase effect during single twitch and train-of-four stimulation: a laboratory study in dogs. J Clin Monit Comput 2016; 31:337-342. [PMID: 26879564 DOI: 10.1007/s10877-016-9842-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 02/10/2016] [Indexed: 11/28/2022]
Abstract
A positive staircase effect is well documented during neuromuscular monitoring. However, the increase in twitch amplitude may not remain stable over time. We compared the staircase phenomenon and twitch stability during single twitch (ST) or train-of-four (TOF) stimulation in anesthetized dogs. Force of contraction was measured in ten dogs. Each thoracic limb was stimulated with ST 0.1 Hz or TOF q 12 s for 25 min (random order). No neuromuscular blockers were administered. Every 5 min, ST and T1 amplitudes were compared within and between groups. Stability of twitch amplitude (<5 % change in 5 min) was also evaluated. ST and T1 amplitude increased over time without significant differences between groups. After 10 min of ST stimulation, the average ST amplitude had increased significantly to 107 %, and remained unchanged thereafter. T1 amplitude was significantly greater than baseline only at 5 (111 %) and 10 min (109 %); a decline towards baseline occurred thereafter. Stability was reached after 15 min for all dogs in the ST group, however, three dogs continued to have changes >5 % with TOF. An initial increase in ST amplitude remained stable over the observation period, but the increase in T1 amplitude during TOF was frequently followed by a decay. A stable twitch amplitude (variation <5 % in 5 min) was observed in all dogs with ST after 15 min of stimulation, which was not the case during TOF stimulation. Therefore, it appears at least in dogs, that ST might offer some advantages over T1 for measuring twitch amplitude.
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Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA.
| | - Chia T Tseng
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA
| | - Daniel M Sakai
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA
| | - Marta Romano
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA
| | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA
| | - Robin D Gleed
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Box 32, 930 Campus Rd, Ithaca, NY, 14853, USA
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Choe WJ, Kim JH, Park SY, Kim J. Electromyographic response of facial nerve stimulation under different levels of neuromuscular blockade during middle-ear surgery. J Int Med Res 2013; 41:762-70. [PMID: 23660086 DOI: 10.1177/0300060513484435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate facial nerve monitoring in patients receiving the partial nondepolarizing neuromuscular blocking agents (NMBAs), remifentanil and propofol. METHODS Patients with normal facial function and advanced middle-ear disease were enrolled. For total intravenous anaesthesia (TIVA), propofol and remifentanil were infused as induction/maintenance anaesthesia. Stimulation thresholds and amplitudes were recorded at each train-of-four (TOF) nerve stimulation level. Time differences between start of TOF and electromyographic (EMG) amplitude decreases (Ti), and between complete recovery of TOF and EMG amplitudes (Tr), were calculated. RESULTS Fifteen patients were enrolled. Mean ± SD Ti was 3.4 ± 1.28 min; Tr was 18.7 ± 4.41 min. Amplitude of stimulation was apparent mostly at TOF level 1. In most cases, no or a weak response (<100 µV) was observed at TOF 0. Mean ± SD threshold of electrical stimulation was 0.31 ± 0.10 mA at TOF 1. At TOF > 2, all cases showed EMG response on electrical stimulation. CONCLUSIONS Induction of TIVA using propofol and remifentanil provided reliable conditions for delicate microsurgery. Minimal NMBA use, considered as producing TOF levels >1, was sufficient for facial nerve monitoring in neuro-otological surgery.
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Affiliation(s)
- Won Joo Choe
- Department of Anaesthesiology and Pain Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Gyeonggi-do, Republic of Korea
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Brull SJ, Kopman AF, Naguib M. Management Principles to Reduce the Risk of Residual Neuromuscular Blockade. CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-013-0014-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Saitoh Y, Sashiyama H, Oshima T, Nakata Y, Sato J. Assessment of neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles. J Anesth 2011; 26:28-33. [PMID: 22045128 DOI: 10.1007/s00540-011-1262-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 10/11/2011] [Indexed: 01/25/2023]
Abstract
PURPOSE We studied neuromuscular block at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles in anesthetized patients. METHODS Fifty-four adult patients undergoing air-oxygen-sevoflurane-fentanyl and epidural anesthesia were randomly divided into orbicularis oris, corrugator supercilii, and adductor pollicis groups of 18 patients each. In the three groups, the degree of neuromuscular block caused by rocuronium 0.6 mg/kg was monitored at the orbicularis oris, corrugator supercilii, and adductor pollicis muscles acceleromyographically. RESULTS Onset of neuromuscular block did not significantly differ among the three groups [157 ± 60, 186 ± 73, and 148 ± 45 s; mean ± standard deviation (SD)]. Minimum value of 1st stimulation in train-of-four (T1)/control at the corrugator supercilii group was significantly higher than in the orbicularis oris and adductor pollicis groups (0.108 ± 0.066 vs. 0.021 ± 0.024 and 0.002 ± 0.007; P < 0.001). T1/control at the orbicularis oris group was significantly higher than at the adductor pollicis group 30 min after rocuronium (P < 0.05). T1/control at the corrugator supercilii group was significantly higher than at the orbicularis oris and adductor pollicis groups 10-30 and 10-40 min, respectively, after rocuronium (P < 0.05). Train-of-four ratios at the orbicularis oris and corrugator supercilii groups were significantly higher than at the adductor pollicis group 40-120 min after rocuronium (P < 0.05). CONCLUSION The corrugator supercilii muscle is more resistant to rocuronium than the orbicularis oris and adductor pollicis muscles. Recovery of neuromuscular block at the orbicularis oris muscle is slower than that at the corrugator supercilii muscle but was faster than that at the adductor pollicis muscle.
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Affiliation(s)
- Yuhji Saitoh
- Department of Anesthesiology, Yachiyo Medical Center, Tokyo Women's Medical University, 477-96 Owada-Shinden, Yachiyo, Chiba, 276-8524, Japan.
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Lee HJ, Kim KS, Shim JC, Yoon SW. A comparison of the accuracy of ulnar versus median nerve stimulation for neuromuscular monitoring. Korean J Anesthesiol 2011; 60:334-8. [PMID: 21716963 PMCID: PMC3110291 DOI: 10.4097/kjae.2011.60.5.334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 11/15/2010] [Accepted: 11/17/2010] [Indexed: 12/19/2022] Open
Abstract
Background Inexperienced anesthesiologists are frequently unclear as to whether to stimulate the ulnar or median nerve to monitor the adductor pollicis. The primary purpose of this study was to determine whether monitoring the adductor pollicis by positioning the stimulating electrodes over the median nerve is an acceptable alternative to applying electrodes over the ulnar nerve. Methods In 20 patients anesthetized with propofol and remifentanil, one pair of stimulating electrodes was positioned over the ulnar nerve. A second pair was placed over the median nerve on the other hand. The acceleromyographic response was monitored on both hands. Rocuronium 0.6 mg/kg was administered. Single twitch (ST) and train-of-four (TOF) stimulations were applied alternatively to both sites. Results None of the patients showed a twitch response at either site after injection of rocuronium. There were no differences in the mean supramaximal threshold, mean initial TOF ratio, or mean initial ST ratio between the two sites. Bland-Altman analysis revealed a bias (limit of agreement) in the TOF and ST ratios over the median nerve of 7% (± 31%) and 26% (± 73%), respectively, as compared with the ulnar nerve. The median nerve TOF ratio was overestimated by 16.2%, as compared with that of the ulnar nerve value, and the median nerve ST ratio was overestimated by 72.9%, as compared to that of the ulnar nerve. Conclusions The ulnar and median nerves cannot be used interchangeably for accurate neuromuscular monitoring.
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Affiliation(s)
- Hee Jong Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Korea
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Recordings of long-latency trigeminal somatosensory-evoked potentials in patients under general anaesthesia. Clin Neurophysiol 2011; 122:1048-54. [DOI: 10.1016/j.clinph.2010.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2009] [Revised: 08/20/2010] [Accepted: 08/21/2010] [Indexed: 11/17/2022]
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Saitoh Y, Oshima T, Nakata Y. Acceleromyographic monitoring of neuromuscular block over the orbicularis oris muscle in anesthetized patients receiving vecuronium. J Clin Anesth 2010; 22:318-23. [PMID: 20650376 DOI: 10.1016/j.jclinane.2009.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 08/09/2009] [Accepted: 09/16/2009] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVE To evaluate the level of neuromuscular block acceleromyographically over the orbicularis oris muscle. DESIGN Prospective, randomized, controlled study. SETTING Operating room of a university-affiliated hospital. PATIENTS 36 adult, ASA physical status I and II women scheduled for mastectomy with air-oxygen-isoflurane-fentanyl anesthesia. INTERVENTIONS Patients were randomized to two groups. In the orbicularis oris group (n=18), the facial nerve was stimulated and movement of the orbicularis oris muscle was measured acceleromyographically. In the control group (n=18), adduction of the thumb was quantified mechanically. MEASUREMENTS Onset and recovery of neuromuscular block caused by vecuronium 0.1 mg/kg were compared between the groups. MAIN RESULTS Time to onset of neuromuscular block in the orbicularis oris group was significantly shorter than in the control group (176 + or - 52 vs. 220 + or - 34 sec, mean + or - SD; P = 0.004). Times to return of the first, second, third, or fourth (T1, T2, T3, or T4) response of train-of four (TOF), and recovery of T1/control were comparable between the groups. Train-of-four ratio (T4/T1) in the orbicularis oris group was significantly higher than in the control group 50 to 120 minutes after vecuronium administration (P < 0.05). CONCLUSION Depth of neuromuscular block can be assessed acceleromyographically over the orbicularis oris muscle. Onset of neuromuscular block is quicker and recovery of TOF ratio is faster over the orbicularis oris muscle than at the thumb in patients receiving vecuronium.
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Affiliation(s)
- Yuhji Saitoh
- Department of Anesthesiology, Tsujinaka Hospital Kashiwanoha, Chiba 277-0871, Japan.
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Saitoh Y, Oshima T, Nakata Y. Monitoring of vecuronium-induced neuromuscular block at the sternocleidomastoid muscle in anesthetized patients. J Anesth 2010; 24:838-44. [PMID: 20725751 DOI: 10.1007/s00540-010-1012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2010] [Accepted: 07/30/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To assess the degree of neuromuscular block acceleromyographically at the sternocleidomastoid muscle. METHODS Eighteen adult patients scheduled for air-oxygen-sevoflurane-fentanyl and epidural anesthesia were studied. In the patients, the right accessory nerve and the sternocleidomastoid muscle were stimulated and the contraction of the sternocleidomastoid muscle was evaluated acceleromyographically. Simultaneously, the response of the adductor pollicis muscle was measured electromyographically. Supramaximal stimulating current, degree of maximum neuromuscular block after vecuronium 0.1 mg/kg, and onset of or recovery from vecuronium-induced neuromuscular block were compared between the two muscles. RESULTS The supramaximal stimulating current at the sternocleidomastoid muscle was significantly higher than that at the adductor pollicis muscle (54.8 ± 7.1 vs. 33.7 ± 10.3 mA, mean ± SD, P < 0.001). The onset of neuromuscular block at the sternocleidomastoid muscle did not significantly differ from that at the adductor pollicis muscle (214 ± 117 vs. 161 ± 87 s, P = 0.131). The degree of maximum neuromuscular block at the sternocleidomastoid muscle was significantly less than that at the adductor pollicis muscle (93.6 ± 3.1 vs. 99.2 ± 2.5%, P < 0.001). During recovery from neuromuscular block, T1/control and train-of-four ratio measured at the sternocleidomastoid muscle were significantly higher than those at the adductor pollicis muscle 10-30 and 40-120 min after vecuronium, respectively (P < 0.05). CONCLUSION The sternocleidomastoid muscle is more resistant to vecuronium than the adductor pollicis muscle. Recovery from neuromuscular block is faster at the sternocleidomastoid muscle than at the adductor pollicis muscle.
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Affiliation(s)
- Yuhji Saitoh
- Department of Anesthesiology, Tsujinaka Hospital Kashiwanoha, 148-6 Kashiwanoha Campus, 178-2 Wakashiba, Kashiwa, Chiba 277-0871, Japan.
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Hattori H, Saitoh Y, Nakajima H, Sanbe N, Akatu M, Murakawa M. Visual evaluation of fade in response to facial nerve stimulation at the eyelid. J Clin Anesth 2005; 17:276-80. [PMID: 15950852 DOI: 10.1016/j.jclinane.2004.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2003] [Accepted: 08/03/2004] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE The aim of this study is to investigate the probability of visual detection of fade in response to train-of-four (TOF) stimulation, double-burst stimulation3,3 (DBS(3,3)), or DBS(3,2) at the eyelid in comparison to that at the thumb. DESIGN This is a randomized single-blinded study. SETTING The study took place at the University hospital. PATIENTS AND MEASUREMENTS Sixty adult patients underwent general anesthesia. INTERVENTIONS AND MEASUREMENTS Patients were randomly divided into either the eyelid group (n = 30) or the thumb group (n = 30). In the eyelid group, at the varying degrees of neuromuscular block caused by vecuronium, TOF, DBS(3,3), or DBS(3,2) were given at the temporal branch of the facial nerve, and the probability of visual detection of fade in response to TOF, DBS(3,3), or DBS(3,2) was determined at the eyelid. Similarly, in the thumb group, the probability of visual detection of fade in response to TOF, DBS(3,3), or DBS(3,2) was examined at the thumb. MAIN RESULTS When the true TOF ratios were 0 to 0.60, the probability of detection of TOF fade in the eyelid group was significantly lower than in the thumb group (P < .05). At the true TOF ratios of 0.31 to 0.70, the probability of visual detection of DBS(3,3) fade in the eyelid group was significantly less than in the thumb group (P < .05). When the true TOF ratios were 0.81 to 1.00, the probability of detection of DBS(3,2) fade in the eyelid group was significantly higher than in the thumb group (P < .05). CONCLUSION The probability of visual detection of fade in response to TOF or DBS(3,3) is lower at the eyelid than the thumb. In contrast, DBS(3,2) fade tends to be seen more frequently at the eyelid than at the thumb.
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Affiliation(s)
- Hisashi Hattori
- Department of Anesthesiology, Fukushima Medical University School of Medicine, Fukushima 960-1295, Japan.
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Nepveu ME, Donati F, Fortier LP. Train-of-Four Stimulation for Adductor Pollicis Neuromuscular Monitoring Can Be Applied at the Wrist or Over the Hand. Anesth Analg 2005; 100:149-154. [PMID: 15616069 DOI: 10.1213/01.ane.0000141525.09320.c8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Adductor pollicis stimulation over the ulnar nerve at the wrist is the standard method of monitoring neuromuscular function. Stimulation over a muscle is believed to cause direct muscle contraction, but evidence for this is lacking. In this study we sought to determine whether direct muscle stimulation occurred during stimulation of the adductor pollicis in the hand and whether the responses were comparable to those observed with stimulation at the wrist. In 20 patients anesthetized with sevoflurane, 1 pair of stimulating electrodes was positioned over the ulnar nerve at the wrist. A second pair was placed between the first and second metacarpals on the palmar and dorsal aspects of the hand. The acceleromyographic response was monitored. Rocuronium 0.6 mg/kg was administered. Train-of-four (TOF) stimulations were applied at the wrist site until maximal blockade. Then, stimulation was applied to the hand site. During recovery, both sites were monitored alternately. After injection of rocuronium, 17 of 20 patients showed no twitch response at either site. One patient had a response at both stimulation sites, and two patients had responses only at the wrist site. With a Bland and Altman analysis, TOF ratios during recovery at the hand showed a bias of 0.5% and limits of agreement of +/-11.8% as compared with the wrist. Stimulation in the hand causes no direct muscle stimulation because the response is no more than that produced by stimulation at the wrist. Both sites yield comparable TOF ratios.
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Affiliation(s)
- Marie-Eve Nepveu
- Department of Anesthesiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
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