Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade

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.

Clinical assessment and train-of-four measurements in critically ill patients treated with recommended doses of cisatracurium or atracurium for neuromuscular blockade: a prospective descriptive study

“…As it is already known in the operating room setting [10, 11], our study shows that an overall clinical assessment of the depth of a neuromuscular blockade is not correlated with the TOF count in critically ill patients. This finding has already been described in three previous studies, where the clinical assessment was performed by nurses and not by physicians, and two of these studies took place in pediatric ICUs [15–17].…”

“…The TOF delivers 4 supramaximal electrical impulses that involve four equally strong twitches of the stimulated muscle. A fade of the twitches appears when the neuromuscular blockade increases [10, 11]. To homogenize practices, both neuromuscular monitors were used in the same way, without acceleromyography: the intensity of the stimulating current was set at 50 mA, and the TOF count was visually assessed.…”

“…Using TOF monitoring in the ICU may result in a reduction of NMBAs’ dose and a subsequent decrease risk of complications related to prolonged and/or excessive blockade, such as intensive care unit-acquired weakness (ICU-AW) [8, 9]. The benefits and limitations of TOF stimulation were primarily determined from studies performed in operative room patients [10, 11], with results that may not be generalizable to ICU patients. In critically ill patients, the duration of neuromuscular blockade is longer, sepsis and/or shock is often present, and pharmacokinetic is difficult to predict [12–14].…”

Examining influences of neuromuscular block post tetanic monitoring technique on the quality of surgical conditions: Neuromuscular block and quality of surgical conditions

“…Mišićni relaksanti se, takođe, koriste pre laringoskopija i endotrahealne intubacije, kako bi se obezbedili što bolji uslovi za ovu proceduru i smanjila mogućnost nastanka komplikacija 5 . Ponavljana upotreba mišićnih relaksanata za vreme operacije, naročito u velikim dozama, može biti povezana sa različitim neželjenim efektima i može predstavljati veliki problem anesteziologu 6 . Subjektivna procena neuromišićnog bloka fokusirana na nekim kliničkim znacima, kao što su vizuelna i taktilna procena, može biti veoma teška i sprovedena samo nad budnim pacijentima.…”

“…Adekvatna dubina bloka je jako varijabilna i zavisi od mnogih faktora, kao što su vrsta i stadijum operativnog zahvata, individualne osobine pacijenta i hirurga, kao i vrsta anestezije. Blok ne treba da bude dublji nego što je potrebno, naročito za operacije u donjem delu stomaka 6 . Stoga se upotreba perifernog nervnog stimulatora čini više nego opravdana, onda kada je potrebna mišićna relaksacija i kada se upotrebljavaju mišićni relaksanti.…”