Double burst stimulation2,3: a new stimulating pattern for residual neuromuscular block

We investigated whether double burst stimulation2, 3 (DBS2,s) 1 at submaximal current was useful to diagnose level of recovery from neuromuscular block. At varying degrees of vecuronium neuromuscular block, fade or waxing (the feeling that the muscular contraction in response to the second burst was stronger than that to the first) in response to DBS2, s delivered at 50, 30, or 20 mA was determined in 120 adult patients. Discomfort associated with the DBS2, s applied at 50, 30, or 20 mA was examined using 10 cm-visual analog scale (VAS) in 15 awake volunteers.When TOF ratios were 0. 31-0.40, 0.41-0.50, 0.51-0.60, 0.61-0.70, 0.71-0.80, and 0.81-1.00, the probabilities of detection of fade were 91, 70, 50, 16, 10, and 0% at a stimulating current of 50 mA; 84, 61, 33, 13, 0, and 0% at 30 mA; 97, 71, 38, 9, 3, and 0% at 20 mA. When TOF ratios were 0.61-0.70, 0.71-0.80, 0.81-0.90, and 0.91-1.00, the probabilities of detection of waxing were 19, 51, 84, and 98% at 50 mA; 11, 54, 68, and 93% at 30 mA; 9, 59, 63, and 96% at 20 mA. The probabilities of detection of fade or waxing did not differ at 50, 30, and 20 mA. The VAS associated with the DBS2, s delivered at 50, 30, and 20 mA were 8.7 + 1.7, 6.8 • 3.6, and 4.3 Neuromuscular monitoring in paediatric intensive care patientsIt seems sensible to monitor neuromuscular blockade with an apparatus that can measure the train of four (TOF) response, if only to focus the minds of clinicians on the therapy being used. In practice, the TOF response is usually observed at the thumb, by stimulating the ulnar nerve. The problem is that the response of the adductor pollicis does not reflect the degree of paralysis of other muscles. The muscles of the diaphragm, the orbicularis otis and the larynx have a different response to muscle relaxants than does the adductor pollicis. Therefore, a child could be coughing or bucking the ventilator while the TOF response at the adductor pollicis still shows full paralysis. We demonstrated that in 25% of paediatric patients, there was definite movement while the TOF still showed 0-1 twitches and the observation was repeated in a subsequent study. 1 In my opinion, clinical monitoring provides adequate and pertinent information. If possible, drugs should be administered as boluses rather than infusions to allow a 'drug holiday' and prevent infusions for going on unchecked for days.If formal comparisons are made between the adductor pollicis and other untested muscles, it is conceivable that we will find that the thumb TOF, which is the gold standard of neuromuscular blockade monitoring, to be irrelevant! Dr. Sanjiv Nichani Children's Hospital, Leicester, UK

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Double burst stimulation2,3 at submaximal current

Saitoh

Makita

Tanaka

1997

Can J Anaesth

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RETRACTED: Tactile evaluation of fade of the train-of-four and double-burst stimulation using the anaesthetist’s non-dominant hand

Saitoh

Narumi

Fujii

et al. 1999

British Journal of Anaesthesia

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We have studied detection of fade in response to train-of-four (TOF), double-burst stimulation3,3 (DBS3,3) or DBS3,2, assessed tactilely by the anaesthetist using the index finger of the non-dominant hand and the thumb of the patient, compared with that assessed when the index finger of the dominant hand was used. The probability of detection of any fade in response to TOF or DBS3,3 using the non-dominant hand was significantly less than when the dominant hand was used (P < 0.05). The probability of identification of fade in response to DBS3,2 assessed using the non-dominant hand was comparable with that evaluated using the dominant hand when TOF ratios were 0-0.9, but when TOF ratios reached 0.91-1.00, detection using the non-dominant hand was significantly less common than with the dominant hand (12% vs 33%; P < 0.05). Using the non-dominant hand, the probability of detection of fade in response to ulnar nerve stimulation was less than that with the dominant hand and only the absence of DBS3,2 fade ensured sufficient recovery of neuromuscular block.

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Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis

Fruergaard

Viby‐Mogensen

Berg

et al. 1998

Acta Anaesthesiol Scand

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Background: Routine perioperative monitoring with accelero‐myography might prevent residual block, whereas routine tactile evaluation of the response to train‐of‐four (TOF) nerve stimulation does not. The purpose of this prospective, randomised and blinded study was to evaluate the effect of manual evaluation of the response to double burst stimulation (DBS3.3) upon the incidence of residual block.Methods: Sixty adult patients scheduled for elective abdominal surgery were included in the study. Pancuronium 0.08 to 0.1 mg kg−1 was given for relaxation and tracheal intubation. For maintenance of neuromuscular block, pancuronium 1–2 mg was administered. The patients were randomly allocated into two groups. In group DBS (double burst stimulation) the degree of block during anaesthesia was assessed by manual evaluation of the response to TOF nerve stimulation. During reversal, when no fade was detectable in the TOF response, the stimulation pattern was changed to DBS3.3. The trachea was extubated when the anaesthetist judged the neuromuscular function to have recovered adequately and no fade in the DBS3.3 response could be felt. In group CC (clinical criteria) patients were managed without the use of a nerve stimulator, and the level of neuromuscular block and reversal were evaluated solely on the basis of clinical criteria. In both groups, the TOF ratio was measured by mechanomyography immediately after tracheal extubation. Also, the ability to sustain head lift for 5 s, to protrude the tongue, to open the eyes, and to lift one arm to the opposite shoulder were tested.Results: The TOF ratio, as measured immediately after tracheal extubation, was significantly lower in group CC than in group DBS (means: 0.68 and 0.78, respectively), and the incidence of residual neuromuscular block defined as a TOF ratio <0.7 was significantly higher in group CC than in group DBS (57 and 24%, respectively). The time from the first TOF measurement until the TOF ratio reached 0.8 was significantly longer in group CC than in group DBS (means: 11.5 and 6.2 min, respectively). No significant differences between the two groups of patients were found in duration of anaesthesia, in times from end of surgery to injection of neostigmine, tracheal extubation or TOF ratio 0.8, in dose of pancuronium, or in any other postoperative variable.Conclusion: Routine perioperative manual evaluation of the responses to TOF and DBS3.3 decreased the incidence and the degree of residual block following the use of pancuronium. It did not, however, exclude clinically significant residual paralysis, nor did it influence the amount of pancuronium used during the operation, the duration of anaesthesia or the time from end of surgery to tracheal extubation or to sufficient recovery of neuromuscular function (TOF=0.8).

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Double burst stimulation2,3: a new stimulating pattern for residual neuromuscular block

Cited by 3 publications

References 11 publications

Double burst stimulation2,3 at submaximal current

Double burst stimulation2,3 at submaximal current

RETRACTED: Tactile evaluation of fade of the train-of-four and double-burst stimulation using the anaesthetist’s non-dominant hand

Tactile evaluation of the response to double burst stimulation decreases, but does not eliminate, the problem of postoperative residual paralysis

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