Ease of Application of Various Neuromuscular Devices for Routine Monitoring

Renew, J. Ross; Hex, Karina O.; Johnson, Patrick W.; Lovett, Pamela; Pence, Richard A.

doi:10.1213/ane.0000000000005213

Cited by 13 publications

(11 citation statements)

References 24 publications

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“…Their common feature is their user-friendly interface, but validation studies are needed to compare their performance and usability to existing monitors and to prove their consistency and reliability in the clinical setting. [10][11][12][13][14][15][16] Until recently, the most frequently used neuromuscular monitors were acceleromyography-based devices. To obtain precise train-of-four ratio measurements with these devices, clinicians need to take several precautions (such as fixation of the arm in supine position, use of preload on the thumb, calibration of the device, and normalization of results).…”

Section: What We Already Know About This Topicmentioning

confidence: 99%

“…The Bland-Altman analysis of normalized data showed that the bias when the acceleromyography trainof-four ratio reading was greater than or equal to 80% (n = 2,929 data pairs) was 1.3 ± standard error 1.0 with limits of agreement -14.0 to 16 S2 (http://links.lww.com/ALN/C662). The bias was less (-0.5 ± standard error 0.9), and the limits of agreement were similar (-14.7 to 13.6) when the EMG reading was greater than or equal to 80% (n = 2,284 data pairs; table 2, fig.…”

Section: Primary Endpointmentioning

confidence: 99%

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Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

et al. 2021

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Background The paucity of easy-to-use, reliable objective neuromuscular monitors is an obstacle to universal adoption of routine neuromuscular monitoring. Electromyography (EMG) has been proposed as the optimal neuromuscular monitoring technology since it addresses several acceleromyography limitations. This clinical study compared simultaneous neuromuscular responses recorded from induction of neuromuscular block until recovery using the acceleromyography-based TOF-Watch SX and EMG-based TetraGraph. Methods Fifty consenting patients participated. The acceleromyography and EMG devices analyzed simultaneous contractions (acceleromyography) and muscle action potentials (EMG) from the adductor pollicis muscle by synchronization via fiber optic cable link. Bland–Altman analysis described the agreement between devices during distinct phases of neuromuscular block. The primary endpoint was agreement of acceleromyography- and EMG-derived normalized train-of-four ratios greater than or equal to 80%. Secondary endpoints were agreement in the recovery train-of-four ratio range less than 80% and agreement of baseline train-of-four ratios between the devices. Results Acceleromyography showed normalized train-of-four ratio greater than or equal to 80% earlier than EMG. When acceleromyography showed train-of-four ratio greater than or equal to 80% (n = 2,929), the bias was 1.3 toward acceleromyography (limits of agreement, –14.0 to 16.6). When EMG showed train-of-four ratio greater than or equal to 80% (n = 2,284), the bias was –0.5 toward EMG (–14.7 to 13.6). In the acceleromyography range train-of-four ratio less than 80% (n = 2,802), the bias was 2.1 (–16.1 to 20.2), and in the EMG range train-of-four ratio less than 80% (n = 3,447), it was 2.6 (–14.4 to 19.6). Baseline train-of-four ratios were higher and more variable with acceleromyography than with EMG. Conclusions Bias was lower than in previous studies. Limits of agreement were wider than expected because acceleromyography readings varied more than EMG both at baseline and during recovery. The EMG-based monitor had higher precision and greater repeatability than acceleromyography. This difference between monitors was even greater when EMG data were compared to raw (nonnormalized) acceleromyography measurements. The EMG monitor is a better indicator of adequate recovery from neuromuscular block and readiness for safe tracheal extubation than the acceleromyography monitor. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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confidence: 99%

Section: Primary Endpointmentioning

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Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

et al. 2021

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“…The reasons for avoidance of monitoring include the belief that it is not necessary, overconfidence in current practice, lack of knowledge/ equipment, inability to use equipment, and/or distrust of equipment. 33,34 Contemporary quantitative monitors have been shown relatively easy to use, 35 which contributed to our department-wide adoption. Acceleromyography yields higher train-of-four ratios compared with electromyography, leading some experts to recommend train-of-four ratios greater than or equal to 1.0 for acceleromyography and train-of-four ratios greater than or equal to 0.9 for electromyography.…”

Section: Quantitative Monitoring Practice Changementioning

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Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative

et al. 2022

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Background Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. We embarked on a professional practice initiative to attain train-of-four (TOF) ratio ≥ 0.90 documentation for all patients for improved patient outcomes through reducing residual paralysis. Methods We utilized equipment trials, educational videos, quantitative monitors in all anesthetizing location, electronic clinical decision support with real time alerts and initiated an ongoing professional practice metric. This was a retrospective assessment (2016-2020) of TOF ratio ≥ 0.9 documentation prior to extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients receiving a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. Results From pre- to post-implementation, more patients were ASA 3-5, fewer were inpatients, rocuronium average dose was higher, and more patients had a pre-reversal TOF count < 4. Manually reviewed anesthesia records (n=2807) had 2/172 (1%) cases with TOF ratio ≥ 0.90 documentation in November 2016 which was less than the 250/269 (93%) cases in December 2020. Post-implementation (2/1/2020-12/31/2020) sugammadex 650/935 (70%), neostigmine 195/935 (21%), and no reversal 90/935 (10%) were used to attain TOF ratio ≥ 0.90 in 856/935 (92%) of patients. In the electronically searched medical charts (n=20181), post-implementation inpatients had a shorter PACU length of stay (7% difference, median minutes [25th, 75th percentile], 73 [55,102] to 68 [49,95], p<0.001), pulmonary complications were less (43% difference, 94/4138 (2.3%) to 23/1817 (1.3%), p=0.010, difference -1.0%, 95% CI -1.7% to -0.3%) and hospital length of stay was less (median days [25th, 75th percentile], 3 [2,5] to 2 [1,4], p<0.001). Conclusions In this professional practice initiative TOF ratio ≥ 0.90 documentation occurred for 93% of patients in a busy clinical practice. Return of strength documentation is an intermediate outcome, and only one of many factors contributing to patient outcomes.

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“…This intricate and time-consuming requirement was a frequent complaint, along with the inability to use the motion-dependent acceleromyographic monitor in settings in which the patient’s arms were placed under surgical drapes and away from the anesthesiologist’s access. However, with new electromyography-based devices, problems of application, calibration, and intraoperative use appear to have been solved: “It takes a little over 18 seconds longer to apply a quantitative neuromuscular monitor than a peripheral nerve stimulator during clinical care.” 14…”

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Quantitative Neuromuscular Monitoring: “Love All, Trust a Few, Do Wrong to None”

Fülesdi

Brull

2022

Anesthesia &Amp; Analgesia

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Ease of Application of Various Neuromuscular Devices for Routine Monitoring

Cited by 13 publications

References 24 publications

Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors

Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative

Quantitative Neuromuscular Monitoring: “Love All, Trust a Few, Do Wrong to None”

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