scholarly journals The latest trend in neuromuscular monitoring: return of the electromyography

2021 ◽  
Author(s):  
Wonjin Lee
Keyword(s):  
Neuromuscular Blockade ◽  
Monitoring System ◽  
Gold Standard ◽  
Neuromuscular Monitoring ◽  
Residual Neuromuscular Blockade ◽  
Train Of Four

To reduce the risk of residual neuromuscular blockade, neuromuscular monitoring must be performed. Acceleromyography (AMG)-based neuromuscular monitoring was regarded as “clinical gold standard” and widely applied. However, issues related to patient’s posture and overestimation of train-of-four ratio associated with AMG-based neuromuscular monitoring have increased. Recently, electromyography (EMG)-based neuromuscular monitoring is receiving renewed attention, since it overcomes AMG’s weaknesses. However, both AMG-based and EMG-based systems are useful when certain considerations are followed. Ultimately, to assure the patient’s good outcomes, the choice of monitoring system is not as important as the monitoring itself, which should be always implemented in such patients.

Comparison of the TOFscan and the TOF-Watch SX during Recovery of Neuromuscular Function

2018 ◽  
Vol 129 (5) ◽  
pp. 880-888 ◽  
Author(s):  
Glenn S. Murphy ◽  
Joseph W. Szokol ◽  
Michael J. Avram ◽  
Steven B. Greenberg ◽  
Torin D. Shear ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Spontaneous Recovery ◽  
Three Dimensional ◽  
Tracheal Extubation ◽  
Neuromuscular Function ◽  
Neuromuscular Monitoring ◽  
Limits Of Agreement ◽  
Train Of Four ◽  
Good Agreement

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Quantitative neuromuscular monitoring is required to ensure neuromuscular function has recovered completely at the time of tracheal extubation. The TOFscan (Drager Technologies, Canada) is a new three-dimensional acceleromyography device that measures movement of the thumb in multiple planes. The aim of this observational investigation was to assess the agreement between nonnormalized and normalized train-of-four values obtained with the TOF-Watch SX (Organon, Ireland) and those obtained with the TOFscan during recovery from neuromuscular blockade. Methods Twenty-five patients were administered rocuronium, and spontaneous recovery of neuromuscular blockade was allowed to occur. The TOFscan and TOF-Watch SX devices were applied to opposite arms. A preload was applied to the TOF-Watch SX, and calibration was performed before rocuronium administration. Both devices were activated, and train-of-four values were obtained every 15 s. Modified Bland–Altman analyses were conducted to compare train-of-four ratios measured with the TOFscan to those measured with the TOF-Watch SX (when train-of-four thresholds of 0.2 to 1.0 were achieved). Results Bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at nonnormalized train-of-four ratios between 0.2 and 1.0 were 0.021 and −0.100 to 0.141, respectively. When train-of-four measures with the TOF-Watch SX were normalized, bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at ratios between 0.2 and 1.0 were 0.015 and −0.097 to 0.126, respectively. Conclusions Good agreement between the TOF-Watch SX with calibration and preload application and the uncalibrated TOFscan was observed throughout all stages of neuromuscular recovery.

scholarly journals Quantitative Relationships between Pulmonary Function and Residual Neuromuscular Blockade

2018 ◽  
Vol 2018 ◽  
pp. 1-6
Author(s):  
ShuYing Fu ◽  
WenDong Lin ◽  
XiNing Zhao ◽  
ShengJin Ge ◽  
ZhangGang Xue
Keyword(s):  
Pulmonary Function ◽  
Neuromuscular Blockade ◽  
Demographic Data ◽  
Preoperative Evaluation ◽  
Tracheal Extubation ◽  
Postanesthesia Care Unit ◽  
Predictive Values ◽  
Residual Neuromuscular Blockade ◽  
Significant Difference ◽  
Train Of Four

Background. Neuromuscular blockade is a risk factor for postoperative respiratory weakness during the immediate postoperative period. The quantitative relationships between postoperative pulmonary-function impairment and residual neuromuscular blockade are unknown. Methods. 113 patients who underwent elective laparoscopic cholecystectomy were enrolled in this study. They all had a pulmonary-function test (PFT) during the preoperative evaluation. Predictive values based on demographic data were also recorded. The train-of-four ratio (TOFR) was recorded at the same time as the PFT and at every 5 minutes in the qualified 98 patients in the postanesthesia care unit (PACU). We analyzed the degree of PFT recovery when the TOFR had recovered to different degrees. Results. There was a significant difference (P<0.05) between the preoperative baseline value and the postoperative forced vital capacity at each TOFR point, except at a TOFR value of 1.1. There was also a significant difference (P<0.05) between the preoperative baseline value and the postoperative peak expiratory flow at each TOFR point. Conclusions. Postoperative residual neuromuscular blockade was common (75.51%) after tracheal extubation, and pulmonary function could not recover to an acceptable level (85% of baseline value), even if TOFR had recovered to 0.90. Trial Registration. Chinese Clinical Trial Register is ChiCTR-OOC-15005838.

scholarly journals The Association Between Residual Neuromuscular Blockade (RNMB) and Critical Respiratory Events: A Prospective Cohort Study

2020 ◽  
Author(s):  
Faraj Alenezi ◽  
Khalid Alnababtah ◽  
Mohammed Alqahtani ◽  
Mohammed Al Harbi
Keyword(s):  
Cohort Study ◽  
General Anaesthesia ◽  
Neuromuscular Blockade ◽  
Prospective Cohort Study ◽  
Prospective Cohort ◽  
Neuromuscular Monitoring ◽  
Adult Patients ◽  
Residual Neuromuscular Blockade ◽  
Respiratory Events ◽  
Pacu Stay

Abstract Background: Inadequate neuromuscular recovery might impair pulmonary function among adult patients who undergo general anaesthesia and might thus contribute to critical respiratory events in the post-anaesthesia care unit (PACU). The aim of this study to investigate whether critical respiratory events (CREs) that described in a modified Murphy’s criteria are significantly associated with residual neuromuscular blockade (RNMB).Method: A prospective cohort study from January to March 2017 from a tertiary hospital from Saudi Arabia for thirty adult patients over 18 years old scheduled for elective surgery under general anaesthesia with neuromuscular blocking drugs (NMBDs) were enrolled in the study. The Mann-Whitney U tests, Chi-Square tests and Independent-Samples T tests were used. The Train-of-four (TOF) ratios were measured upon arrival in the PACU by using Acceleromyography with TOF-Scan. Subjects’ demographics, perioperative data, and the occurrence of postoperative CREs in the PACU were recorded.Results: 26 (86.7%) patients out of thirty in the study has received Rocuronium as NMBDs while Neostigmine as a reversal drug with only 23 (76.7%). The incidence of RNMB (TOF ratio < 0.9) was in 16 patients (53.3%). The incidence of RNMB was significantly higher in female patients (p= 0.033), in patients who had not undergone quantitative neuromuscular monitoring before extubation (p= 0.046) and in patients with shorter duration of surgery (p= 0.001). Postoperative CREs occurred in twenty patients (66.7%), and there were significantly more of these CREs among patients with RNMB (P= 0.001). In addition, a statistically significant difference was observed in the occurrence of CREs according to body mass index (P= 0.047).Conclusion: This research showed that RNMB is a significant contributing factor to the development of critical respiratory events during PACU stay. Therefore, optimal antagonism of neuromuscular blockade and routine quantitative neuromuscular monitoring are recommended to reduce the incidence of RNMB.

scholarly journals Usefulness of intra-operative neuromuscular blockade monitoring and reversal agents for postoperative residual neuromuscular blockade: a retrospective observational study

2019 ◽  
Author(s):  
Gonzalo Domenech ◽  
Matias Kampel ◽  
Maria Eugenia Garcia Guzzo ◽  
Delfina Sanchez Novas ◽  
Sergio Terrasa ◽  
...  
Keyword(s):  
Neuromuscular Blockade ◽  
Multivariable Analysis ◽  
Perioperative Period ◽  
University Hospital ◽  
Exclusion Criterion ◽  
Adductor Pollicis Muscle ◽  
Residual Neuromuscular Blockade ◽  
Reversal Agents ◽  
Elective Surgical Procedures ◽  
Train Of Four

Abstract Background: Current neuromuscular blockade (NMB) management techniques cannot completely prevent residual NMB (RNMB) during the postoperative period. Evidently, compliance to NMB monitoring is persistently low, and the risk of RNMB during the perioperative period remains underestimated. We have not found publications that report the incidence of RNMB in a university hospital where access to quantitative NMB monitoring and sugammadex is unlimited and where NMB management is not protocolised. The primary aim of this study was to estimate the incidence of RNMB in patients managed with or without sugammadex or neostigmine as antagonists and quantitative NMB monitoring in the operating room. The secondary aim was to explore the associations between RNMB and potentially related variables. Methods: This retrospective observational cohort study was conducted at a tertiary referral university hospital in Buenos Aires, Argentina. Records created between June 2015 and December 2015 were reviewed. In total, 240 consecutive patients who had undergone elective surgical procedures requiring NMB were included. All patients were monitored via acceleromyography at the adductor pollicis muscle within 5 min of arrival in the postanaesthesia care unit. Scheduled recovery in the intensive care unit was the only exclusion criterion. The primary outcome was the presence of RNMB, defined as a train-of-four ratio of <0.9. The secondary outcomes were the associations between RNMB and potentially related variables. Results: RNMB was present in 1.6% patients who received intra-operative quantitative NMB monitoring and 32% patients whose NMB was not monitored (P<0.01). Multivariable analysis revealed that the use of intra-operative quantitative NMB monitoring and sugammadex were associated with a lower incidence of RNMB, with calculated odds ratios of 0.04 (95% confidence interval [CI]: 0.005 to 0.401) and 0.18 (95% CI: 0.046 to 0.727), respectively. Conclusions: The results of the present study suggest that quantitative intra-operative NMB monitoring and use of sugammadex are associated with a decreased incidence of RNMB in the PACU, reinforcing the contention that the optimal strategy for RNMB avoidance is the use of quantitative NMB monitoring and eventual use of reversal agents, if needed, prior to emergence from anaesthesia.

Neuromuscular Blockers and Reversal Agents

2019 ◽  
Author(s):  
Kristen Flight ◽  
Jennifer J Yang ◽  
Lindsay M Urben ◽  
Michael J Schontz
Keyword(s):  
Neuromuscular Blockade ◽  
Neuromuscular Transmission ◽  
Muscle Relaxation ◽  
Neuromuscular Blocking ◽  
Neuromuscular Monitoring ◽  
Clinical Effects ◽  
Duration Of Action ◽  
Residual Neuromuscular Blockade ◽  
Neuromuscular Blocking Drugs ◽  
Reversal Agents

Neuromuscular blocking drugs, which include depolarizing and nondepolarizing drugs, are used to facilitate intubation and provide skeletal muscle relaxation during surgery and in the intensive care unit. The agents differ in their mechanism, duration of action, side-effect profile, and metabolism. Succinylcholine is the only depolarizing agent in clinic use and is typically used for emergent control of the airway, rapid sequence intubations, and short surgical procedures. The risk of hyperkalemia in certain clinical conditions and risk of malignant hyperthermia in susceptible individuals limit the use of succinylcholine in specific patient populations. Nondepolarizing agents vary in their duration of action, but all provide muscle relaxation for a longer duration than succinylcholine. Clinical effects of neuromuscular blocking drugs can be assessed with neuromuscular monitoring, although there is significant variability among providers in the regular use of neuromuscular monitoring. Reversal agents are used to restore neuromuscular transmission, as residual neuromuscular blockade after extubation has been associated with multiple adverse events, including hypoxemia, atelectasis, and aspiration. Sugammadex is an encapsulating agent capable of immediately reversing the effects of rocuronium-induced neuromuscular blockade that will likely impact the way many providers administer rocuronium and may decrease the future use of succinylcholine. This review contains 4 figures, 6 tables, and 41 references. Keywords: hyperkalemia, neuromuscular monitoring, neuromuscular transmission, nondepolarizing neuromuscular blocking agents, residual neuromuscular blockade, reversal agents, succinylcholine sugammadex, sugammadex

scholarly journals Improving Neuromuscular Monitoring and Reducing Residual Neuromuscular Blockade With E-Learning: Protocol for the Multicenter Interrupted Time Series INVERT Study

2017 ◽  
Vol 6 (10) ◽  
pp. e192 ◽  
Author(s):  
Jakob Louis Demant Thomsen ◽  
Ole Mathiesen ◽  
Daniel Hägi-Pedersen ◽  
Lene Theil Skovgaard ◽  
Doris Østergaard ◽  
...  
Keyword(s):  
Time Series ◽  
Neuromuscular Blockade ◽  
Interrupted Time Series ◽  
Neuromuscular Monitoring ◽  
Residual Neuromuscular Blockade ◽  
E Learning

scholarly journals The Effect of Preload on Electromyographic Train-Of-Four Ratio at the First Dorsal Interosseous Muscle during Spontaneous Recovery from Neuromuscular Blockade

2018 ◽  
Vol 46 (6) ◽  
pp. 614-619
Author(s):  
A. Bansal ◽  
P. A. Stewart ◽  
S. Phillips ◽  
S. Liang ◽  
X. Wang
Keyword(s):  
Neuromuscular Blockade ◽  
Spontaneous Recovery ◽  
Repeated Measurements ◽  
First Dorsal Interosseous ◽  
Reversal Agent ◽  
Residual Neuromuscular Blockade ◽  
Train Of Four ◽  
First Dorsal Interosseous Muscle ◽  
Induction Of Anaesthesia ◽  
Dorsal Interosseous Muscle

Accurate and reliable quantitative neuromuscular function monitoring is desirable for the optimal management of neuromuscular blockade, selection of the most appropriate reversal agent and dosage, and assessing the completeness of reversal to exclude residual neuromuscular blockade. Applying preload to the thumb may affect the precision of electromyography. This study compared the precision and agreement of electromyography with and without preload during recovery from non-depolarising neuromuscular blockade. After induction of anaesthesia and before neuromuscular blockade, the supramaximal current required at the first dorsal interosseous muscle with and without preload was determined. During recovery, train-of-four ratios were recorded using electromyography every 20 seconds. Alternating pairs of measurements (with and without preload) were obtained until spontaneous recovery was achieved. The preload device applied a resting tension of 75–150 g to the thumb. Bland–Altman analysis for repeated measurements was used to assess precision and agreement of electromyography responses with and without muscle preload. Two hundred and seventy-five sets of repeated measurements were collected from 35 participants. The repeatability coefficient for train-of-four ratios recorded by electromyography with a preload was 0.030 (95% confidence intervals, CI, 0.028 to 0.031) versus 0.068 (95% CI 0.064 to 0.072) without. Train-of-four ratios with preload demonstrated a bias of +0.038 (95% CI 0.037 to 0.042) compared to electromyography without, with 95% limits of agreement of 0.035–0.111. Preload significantly improved the precision of electromyographic train-of-four ratios, with 95% of consecutive measurements differing by less than 3%. Furthermore, electromyography with preload demonstrated a positive bias of 0.04 compared with electromyography alone, the clinical significance of which requires further research.

Predictive Study of Pharmacological Reversal for Residual Neuromuscular Blockade, Early and Late Postoperative Pulmonary Complications: A Prospective, Observational, Cohort Study

2021 ◽  
Author(s):  
Cristian Aragón-Benedí ◽  
Ana Pascual-Bellosta ◽  
Sonia Ortega-Lucea ◽  
Sara Visiedo-Sanchez ◽  
Javier Martinez-Ubieto
Keyword(s):  
Cohort Study ◽  
Neuromuscular Blockade ◽  
Demographic Data ◽  
Pulmonary Complications ◽  
Neuromuscular Monitoring ◽  
Observational Cohort Study ◽  
Prospective Observational Cohort Study ◽  
Postoperative Pulmonary Complications ◽  
Residual Neuromuscular Blockade ◽  
Observational Cohort

Abstract Background The primary objective was to assess the incidence of residual neuromuscular blockade and postoperative pulmonary complications according to spontaneous or pharmacological neuromuscular reversal, comparing neostigmine and sugammadex. The secondary objective was to present a prognostic model to predict the probability of having residual neuromuscular blockade depending on patient's comorbidities and intraoperative neuromuscular blocking agents management. Methods Single-center, prospective, observational, cohort study including patients undergoing surgical procedures with general anaesthesia divided into four groups: cisatracurium, cisatracurium with neostigmine antagonism, rocuronium, and rocuronium with sugammadex antagonism. A binomial generalized linear model was used to predict the residual neuromuscular blockade analyzing patients demographic data, comorbidities, intraoperative neuromuscular monitoring and pharmacological reversal for each patient group. Results A total of 714 patients were analyzed. According to our model, none of the studied comorbidities were a predisposing factor for an increase in residual neuromuscular blockade. However, the use of rocuronium, pharmacological reversal with sugammadex, and, particularly, neuromuscular monitoring during surgery markedly decreased the probability. When using rocuronium, avoidance of neuromuscular monitoring and pharmacological reversal led to an incidence of residual neuromuscular blockade of 41.27%; conversely, the use of neuromuscular monitoring and pharmacological reversal with sugammadex decreased the probability to 2.17%. Conclusions In our study, intraoperative neuromuscular monitoring and pharmacological reversal with sugammadex, unlike neostigmine, were the factors that most effectively reduced the risk of residual neuromuscular blockade as well as early postoperative pulmonary complications in PACU (upper airway obstruction and desaturation) and late postoperative pulmonary complications (pneumonia or atelectasis) within 30 days.

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