1
|
Wedemeyer Z, Bowdle A, Jelacic S, Lopez A, Silliman W, Michaelsen KE. Evolution of a laboratory mechanomyograph. J Clin Monit Comput 2024:10.1007/s10877-024-01175-w. [PMID: 38758405 DOI: 10.1007/s10877-024-01175-w] [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: 02/26/2024] [Accepted: 05/04/2024] [Indexed: 05/18/2024]
Abstract
Mechanomyography is currently the accepted laboratory reference standard for quantitative neuromuscular blockade monitoring. Mechanomyographs are not commercially available. Previously, a mechanomyograph was built by our laboratory and used in several clinical studies. It was subsequently redesigned to improve its usability and functionality and to accommodate a wider range of hand sizes and shapes using an iterative design process. Each version of the redesigned device was initially tested for usability and functionality in the lab with the investigators as subjects without electrical stimulation. The redesigned devices were then assessed on patients undergoing elective surgery under general anesthesia without neuromuscular blocking drugs. Since the patients were not paralyzed, the expected train-of-four ratio was 1.0. The device accuracy and precision were represented by the train-of-four ratio mean and standard deviation. If issues with the device's useability or functionality were discovered, changes were made, and the redesign processes repeated. The final mechanomyograph design was used to collect 2,362 train-of-four ratios from 21 patients. The mean and standard deviation of the train-of-four ratios were 0.99 ± 0.030. Additionally, the final mechanomyograph design was easier to use and adjust than the original design and fit a wider range of hand sizes. The final design also reduced the frequency of adjustments and the time needed for adjustments, facilitating data collection during a surgical procedure.
Collapse
Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Aidan Lopez
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA
| | - Kelly E Michaelsen
- Department of Anesthesiology, University of Washington, Box 356540, 1959 NE Pacific Street, Seattle, WA, 98195-6540, USA.
| |
Collapse
|
2
|
Verdonck M, Carvalho H, Fuchs-Buder T, Brull SJ, Poelaert J. Machine learning based analysis and detection of trend outliers for electromyographic neuromuscular monitoring. J Clin Monit Comput 2024:10.1007/s10877-024-01141-6. [PMID: 38573367 DOI: 10.1007/s10877-024-01141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/09/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE Neuromuscular monitoring is frequently plagued by artefacts, which along with the frequent unawareness of the principles of this subtype of monitoring by many clinicians, tends to lead to a cynical attitute by clinicians towards these monitors. As such, the present study aims to derive a feature set and evaluate its discriminative performance for the purpose of Train-of-Four Ratio (TOF-R) outlier analysis during continuous intraoperative EMG-based neuromuscular monitoring. METHODS Patient data was sourced from two devices: (1) Datex-Ohmeda Electromyography (EMG) E-NMT: a dataset derived from a prospective observational trial including 136 patients (21,891 TOF-R observations), further subdivided in two based on the type of features included; and (2) TetraGraph: a clinical case repository dataset of 388 patients (97,838 TOF-R observations). The two datasets were combined to create a synthetic set, which included shared features across the two. This process led to the training of four distinct models. RESULTS The models showed an adequate bias/variance balance, suggesting no overfitting or underfitting. Models 1 and 2 consistently outperformed the others, with the former achieving an F1 score of 0.41 (0.31, 0.50) and an average precision score (95% CI) of 0.48 (0.35, 0.60). A random forest model analysis indicated that engineered TOF-R features were proportionally more influential in model performance than basic features. CONCLUSIONS Engineered TOF-R trend features and the resulting Cost-Sensitive Logistic Regression (CSLR) models provide useful insights and serve as a potential first step towards the automated removal of outliers for neuromuscular monitoring devices. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
Collapse
Affiliation(s)
- Michaël Verdonck
- Department of Business Informatics and Operations Management, University Ghent, Tweekerkenstraat 2, Ghent, 9000, Belgium.
| | - Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Jette, Belgium
- Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Oostende, Belgium
| | - Thomas Fuchs-Buder
- University of Lorraine, Centre Hospitalier Universitaire de Nancy/Hôpitaux de Brabois, Lorraine, France
| | - Sorin J Brull
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
| |
Collapse
|
3
|
Ishihara T, Clark-Price SC, Lin HC, Bayne JE, Martin-Flores M. Onset and duration of action of escalating doses of atracurium in anesthetized healthy goats. Vet Anaesth Analg 2024; 51:160-167. [PMID: 38242755 DOI: 10.1016/j.vaa.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/20/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE The aim of this study was to describe the onset and duration of action of escalating doses of atracurium in healthy, anesthetized goats. STUDY DESIGN Randomized, blinded, triple crossover study. Animals A total of eight (five males and three females) healthy goats weighing 42.7-123.5 kg and aged from 11 months to 8 years. METHODS Goats were anesthetized three times with propofol and anesthesia was maintained with isoflurane. One of three doses of atracurium was administered intravenously 30 minutes after induction: 0.25 mg kg-1 (AT25), 0.5 mg kg-1 (AT50) or 0.75 mg kg-1 (AT75). Acceleromyographic train-of-four ratio (TOFR) followed by train-of-four counts (TOFC) were recorded at 30 second intervals after atracurium administration to determine blockade onset (TOFC = 0). The TOFR followed by TOFC were recorded at 5 minute intervals until return to pre-atracurium baseline (TOFR = 1.0). Normally distributed data were analyzed with repeated measures anova and a Tukey multiple comparison test. Data not normally distributed were analyzed with a Friedman test and a Dunn's multiple comparison test. RESULTS For AT50 and AT75, 100% of goats achieved TOFC = 0 after atracurium administration. For AT25, however, 87.5% of goats achieved TOFC = 0 after atracurium administration. The onset time was shorter for AT75 [1.5 (0.5-1.5) minutes; median (range)] than for AT25 [2 (1-4) minutes] (p = 0.048). The duration of action [from onset time to complete reversal (TOFR = 1.0)] was significantly shorter for AT25 (52 ± 12 minutes, mean ± SD) than for AT50 (77 ± 18 minutes) (p < 0.001) and AT75 (85 ± 16 minutes) (p < 0.001). There was no significant difference in duration between AT50 and AT75 (p = 0.238). CONCLUSIONS AND CLINICAL RELEVANCE Doses of 0.5 and 0.75 mg kg-1 atracurium may produce complete neuromuscular blockade in healthy, anesthetized goats.
Collapse
Affiliation(s)
- Toshitsugu Ishihara
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Stuart C Clark-Price
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA.
| | - Hui-Chu Lin
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Jenna E Bayne
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, USA
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| |
Collapse
|
4
|
Guo S, Moore J, Moradi L, Rosero E, Sabuncu AC. A compressomyograph train of four monitoring device. Med Eng Phys 2024; 125:104127. [PMID: 38508804 DOI: 10.1016/j.medengphy.2024.104127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 01/16/2024] [Accepted: 02/18/2024] [Indexed: 03/22/2024]
Abstract
The monitoring of the neuromuscular blockade is critical for patient's safety during and after surgery. The monitoring of neuromuscular blockade often requires the use of Train of Four (TOF) technique. During a TOF test two electrodes are attached to the ulnar nerve, and a series of four electric pulses are applied. The electrical stimulation causes the thumb to twitch, and the amount of twitch varies depending on the amount of neuromuscular blockade in patient's system. Current medical devices used to assist anesthesiologists to perform TOF monitoring often require free hand movement and do not provide accurate or reliable results. The goal of this work is to design, prototype and test a new medical device that provides reliable TOF results when thumb movement is restricted. A medical device that uses a pressurized catheter balloon to detect the response thumb twitch of the TOF test is created. An analytical model, numerical study, and mechanical finger testing were employed to create an optimum design. The design is tested through a pilot human subjects study. No significant correlation is reported with subjects' properties, including hand size.
Collapse
Affiliation(s)
- Shu Guo
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Joe Moore
- Worcester Polytechnic Institute, 2808 Matsu Ln, Opelika, AL 36804, USA
| | - Lee Moradi
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA
| | - Eric Rosero
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
| | - Ahmet C Sabuncu
- Worcester Polytechnic Institute, 100 Institute Road, Worcester, MA 01609, USA.
| |
Collapse
|
5
|
Wedemeyer Z, Jelacic S, Michaelsen K, Silliman W, Togashi K, Bowdle A. Comparative performance of stimpod electromyography with mechanomyography for quantitative neuromuscular blockade monitoring. J Clin Monit Comput 2024; 38:205-212. [PMID: 37831378 DOI: 10.1007/s10877-023-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The purpose of this study was to compare the Stimpod electromyograph neuromuscular blockade monitor to mechanomyography, which is widely considered to be the reference standard. METHODS The Stimpod electromyograph was used with its designated electrode array on the same hand as the mechanomyograph. Pairs of train-of-four measurements were recorded every 0.5-2 min. When the train-of-four count was zero on the electromyograph monitor, pairs of post tetanic count measurements were recorded every 2.5 min, instead of train-of-four measurements. Measurements were recorded from immediately after induction of anesthesia until just before emergence. Stimulation current was set to 60 mA with a duration of 200 microsec. The mechanomyography recording system recorded each twitch waveform for analysis. High resolution electromyograph waveforms were also recorded using a datalogger accessory provided by the manufacturer, facilitating inspection of individual waveforms. The administration of neuromuscular blocking drugs was left up to the discretion of the anesthesia care team. RESULTS Twenty-three patients contributed 1,088 data pairs suitable for analysis. Bland-Altman analysis of 415 pairs of train-of-four ratios showed a bias of 0.028 and limits of agreement of -0.18 and 0.24. Two hundred seventy-three train-of-four count data pairs were compared by Cohen's quadratically weighted kappa which was calculated to be 0.44, indicating moderate agreement. Three hundred thirty-eight post tetanic count data pairs were compared by Cohen's quadradically weighted kappa which was calculated to be 0.80, indicating substantial agreement. CONCLUSION The electromyograph produced results that were comparable to the mechanomyograph.
Collapse
Affiliation(s)
- Zain Wedemeyer
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Srdjan Jelacic
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kelly Michaelsen
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Willis Silliman
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Kei Togashi
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA
| | - Andrew Bowdle
- Department of Anesthesiology, University of Washington, Mail Stop, Seattle, WA, 98195, USA.
| |
Collapse
|
6
|
Baik HJ. Agreement of Posttetanic Count between Monitors: Reply. Anesthesiology 2023; 139:911-912. [PMID: 37722096 DOI: 10.1097/aln.0000000000004703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Affiliation(s)
- Hee Jung Baik
- College of Medicine, Ewha Womans University, Seoul, Republic of Korea.
| |
Collapse
|
7
|
Makino M, Kaneko S, Sato S, Kawazoe Y, Ichinomiya T, Murata H, Yoshitomi O, Hara T. Effects of the attachment method of the stimulating electrodes Nihon-Kohden NM-345Y™ and changes in forearm position on stimulus current values during calibration in electromyography-based neuromuscular monitoring: a single-center experimental study. J Anesth 2023; 37:888-895. [PMID: 37653275 DOI: 10.1007/s00540-023-03250-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The traditionally recommended method for attaching electromyography (EMG) electrodes (NM-345Y™) during EMG-based neuromuscular monitoring developed by Nihon-Kohden may decrease the monitoring accuracy when forearm limb position changes. This study investigated methods for attaching stimulating electrodes that maintained stable EMG-based neuromuscular monitoring accuracy, regardless of forearm limb position changes. METHODS This single-center experimental study recruited 28 healthy adults from October 2022 to December 2022. The NM-345Y™ was attached to the forearm using three patterns: Pattern N, electrodes attached according to the attachment pattern recommended by Nihon-Kohden; Pattern U, electrodes attached along the ulnar nerve identified using an ultrasound device; Pattern C, electrodes attached where the ulnar nerve crosses the line connecting the centers of the anode and cathode of the stimulating electrodes. The stimulus current values during calibration were measured at three forearm positions for each attachment pattern: supination 90 degrees; pronation 0 degrees; pronation 90 degrees. The differences in stimulus current values caused by forearm position changes were calculated as the difference between values at supination 90 degrees and pronation 0 degrees and between values at supination 90 degrees and pronation 90 degrees. RESULTS Pattern C showed significantly smaller differences than Pattern N between the stimulus current values at supination 90 degrees and pronation 0 degrees (p = 0.018) and between the stimulus current values at supination 90 degrees and pronation 90 degrees (p = 0.008). CONCLUSION Crossing the ulnar nerve with the line connecting the anode and cathode of the stimulating electrodes may stabilize EMG-based neuromuscular monitoring accuracy.
Collapse
Affiliation(s)
- Madoka Makino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Yurika Kawazoe
- Clinical Research Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Osamu Yoshitomi
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| |
Collapse
|
8
|
Carvalho H, Verdonck M, Eleveld DJ, Ramirez D, D'Haese J, Flamée P, Geerts L, Wylleman J, Cools W, Barbe K, Struys MMRF, Poelaert J. Neuromuscular end-point predictive capability of published rocuronium pharmacokinetic/pharmacodynamic models: An observational trial. J Clin Anesth 2023; 90:111225. [PMID: 37542918 DOI: 10.1016/j.jclinane.2023.111225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/16/2023] [Accepted: 07/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Objective neuromuscular monitoring remains the single most reliable method to ensure optimal perioperative neuromuscular management. Nevertheless, the prediction of clinical neuromuscular endpoints by means of Pharmacokinetic (PK) and Pharmacodynamic (PD) modelling has the potential to complement monitoring and improve perioperative neuromuscular management.s STUDY OBJECTIVE: The present study aims to assess the performance of published Rocuronium PK/PD models in predicting intraoperative Train-of-four (TOF) ratios when benchmarked against electromyographic TOF measurements. DESIGN Observational trial. SETTING Tertiary Belgian hospital, from August 2020 up to September 2021. PATIENTS AND INTERVENTIONS Seventy-four patients undergoing general anaesthesia for elective surgery requiring the administration of rocuronium and subject to continuous EMG neuromuscular monitoring were included. PK/PD-simulated TOF ratios were plotted and synchronised with their measured electromyographic counterparts and their differences analysed by means of Predictive Error derivatives (Varvel criteria). MAIN RESULTS Published rocuronium PK/PD models overestimated clinically registered TOF ratios. The models of Wierda, Szenohradszky, Cooper, Alvarez-Gomez and McCoy showed significant predictive consistency between themselves, displaying Median Absolute Performance Errors between 38% and 41%, and intra-individual differences (Wobble) between 14 and 15%. The Kleijn model outperformed the former with a lower Median Absolute Performance Error (16%, 95%CI [0.01; 57]) and Wobble (11%, 95%CI [0.01; 34]). All models displayed considerably wide 95% confidence intervals for all performance metrics, suggesting a significantly variable performance. CONCLUSIONS Simulated TOF ratios based on published PK/PD models do not accurately predict real intraoperative TOF ratio dynamics. TRIAL REGISTRATION NCT04518761 (clinicaltrials.gov), registered on 19 August 2020.
Collapse
Affiliation(s)
- Hugo Carvalho
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium; Department of Anesthesiology and Reanimation, AZ Sint Jan Brugge-Oostende, Belgium.
| | - Michaël Verdonck
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Douglas J Eleveld
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - David Ramirez
- Servicio Anestesiología y Reanimación, Fundación Valle de Lili, Cali, Colombia
| | - Jan D'Haese
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Panagiotis Flamée
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Lieselot Geerts
- Department of Anaesthesia, Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jasper Wylleman
- Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Belgium
| | - Wilfried Cools
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kurt Barbe
- Interfaculty Center Data Processing and Statistics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Michel M R F Struys
- Head of Department, Professor, Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Basic and Applied Medical Sciences, Ghent University, Gent, Belgium
| | - Jan Poelaert
- Department of Anesthesia, AZ Maria Middelares Gent, Ghent, Belgium
| |
Collapse
|
9
|
Fuchs-Buder T, Brull SJ, Fagerlund MJ, Renew JR, Cammu G, Murphy GS, Warlé M, Vested M, Fülesdi B, Nemes R, Columb MO, Damian D, Davis PJ, Iwasaki H, Eriksson LI. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision. Acta Anaesthesiol Scand 2023; 67:994-1017. [PMID: 37345870 DOI: 10.1111/aas.14279] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.
Collapse
Affiliation(s)
- Thomas Fuchs-Buder
- Department of Anaesthesia, Critical Care & Perioperative Medicine, University Hospital Nancy, Nancy, France
| | - Sorin J Brull
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Guy Cammu
- Department of Anesthesiology, Critical Care and Emergency Medicine, Aalst, Belgium
| | - Glenn S Murphy
- Department of Anesthesiology, NorthShore University HealthSystem, Chicago, Illinois, USA
| | - Michiel Warlé
- Department of Surgery, Radbound University Medical Center, Nijmegen, The Netherlands
| | - Matias Vested
- Department of Anesthesia Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Béla Fülesdi
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Reka Nemes
- Department of Anesthesiology and Intensive Care, University of Debrecen, Debrecen, Hungary
| | - Malachy O Columb
- Anaesthesia & Intensive Medicine, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniela Damian
- Anesthesiology and Perioperative Medicine, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Peter J Davis
- Anesthesia and Pediatrics, UPMC Children's Hospital, Pittsburgh, Pennsylvania, USA
| | - Hajime Iwasaki
- Department of Anesthesiology and Crtical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Lars I Eriksson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
10
|
Tseng CT, Sakai DM, Lorenzutti AM, Martin-Flores M. Evaluation of a three-axial acceleromyography monitor in dogs compared with mechanomyography. Vet Anaesth Analg 2023; 50:408-414. [PMID: 37500406 DOI: 10.1016/j.vaa.2023.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE To compare the ratio of the train-of-four (TOF) and double burst stimulation (DBS) obtained with three-axial acceleromyography (AMG) and mechanomyography (MMG) in dogs during recovery from a rocuronium-induced neuromuscular block. STUDY DESIGN Prospective, randomized, experimental study. ANIMALS A total of six intact healthy adult male Beagle dogs, weighing 9.1 ± 1.9 kg and aged 3-5 years. METHODS Dogs were anesthetized with intravenous (IV) dexmedetomidine and propofol, and isoflurane in oxygen. Neuromuscular function was measured with AMG and MMG in the contralateral thoracic limbs. Rocuronium (0.5 mg kg-1) was administered IV, and the TOF and DBS ratios measured. During neuromuscular block offset, MMG values were recorded when AMG first reached ratios of 0.9 and 1.0. True recovery from neuromuscular block was determined as MMG ratio ≥ 0.9. The false-positive (AMG ≥ 0.9 or 1.0, and MMG ratio < 0.9) rate was determined. Paired values were compared, and bias and limits of agreement were calculated. Receiver operating characteristic (ROC) curves were created. RESULTS When AMG first reached 0.9 and 1.0 during recovery, MMG values were lower (p < 0.040). When AMG reached 0.9, the false-positive rate was 29% with TOF and 27% with DBS. It decreased to 12% (TOF) and 11% (DBS) when a ratio of 1.0 was used. AMG values were higher than paired MMG values (p < 0.001). The AMG overestimated MMG by 24% and 22% for TOF and DBS, respectively. Areas under the ROC curves (95% confidence interval) were 0.91 (0.89, 0.94) and 0.86 (0.81, 0.94) for TOF and DBS, respectively. CONCLUSIONS and clinical relevance The three-axial AMG monitor overestimated neuromuscular function and, in some cases, indicated adequate recovery despite the MMG ratio being < 0.9. A TOF or DBS ratio of at least 1.0 should be considered when monitoring recovery of neuromuscular block with this AMG device.
Collapse
Affiliation(s)
- Chia T Tseng
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA; Crown Veterinary Specialists, Lebanon, NJ, USA
| | - Daniel M Sakai
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA; Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA, USA.
| | - Augusto M Lorenzutti
- Facultad de Ciencias Agropecuarias, IRNASUS CONICET, Universidad Catolica de Cordoba, Cordoba, Argentina
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| |
Collapse
|
11
|
Chaves-Cardona HE, Fouda EA, Hernandez-Torres V, Torp KD, Logvinov II, Heckman MG, Renew JR. Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:393-400. [PMID: 37137388 PMCID: PMC10362458 DOI: 10.1016/j.bjane.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. METHODS One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg-1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. RESULTS Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. CONCLUSIONS The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. CLINICAL TRIAL NUMBER AND REGISTRY URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.
Collapse
Affiliation(s)
- Harold E Chaves-Cardona
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Eslam A Fouda
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Vivian Hernandez-Torres
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Klaus D Torp
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Ilana I Logvinov
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Michael G Heckman
- Mayo Clinic Jacksonville, Division of Clinical Trials and Biostatistics, Florida, USA
| | - Johnathan Ross Renew
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA.
| |
Collapse
|
12
|
Kalsotra S, Rice-Weimer J, Tobias JD. Intraoperative electromyographic monitoring in children using a novel pediatric sensor. Saudi J Anaesth 2023; 17:378-382. [PMID: 37601498 PMCID: PMC10435795 DOI: 10.4103/sja.sja_160_23] [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: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 08/22/2023] Open
Abstract
Background Train-of-four (TOF) monitoring is essential in optimizing perioperative outcomes as a means to assess the depth of neuromuscular blockade and confirm recovery following the administration of neuromuscular blocking agents (NMBAs). Quantitative TOF monitoring has been limited in infants and children primarily due to lack of effective equipment. The current study evaluates a novel electromyography (EMG)-based TOF monitor with a recently developed pediatric-sized self-adhesive sensor in infants and children. Methods Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm. The muscle action potentials from the adductor pollicis muscle were recorded throughout surgery at 20-second intervals. Data from the monitor's built-in memory card were later retrieved and analyzed. Results The final study cohort included 51 patients who ranged in age from 0.2 to 7.9 years and in weight from 4.2 to 36.0 kilograms. Thirty patients weighed less than 15 kgs. Supramaximal stimulus current intensity (mA) at a pulse width of 200 μsec was 30 mA in 8%; 40 mA in 29%; 50 mA in 16%; and 60 mA in 20% of the patients. Supramaximal stimulus current intensity (mA) at a pulse width of 300 μsec was 50 mA in 4%; 60 mA in 24%. The muscle action potential baseline amplitude was 8.7 ± 3.3 mV and recovered to 7.2 ± 3.7 mV after antagonism of neuromuscular blockade. The average baseline TOF ratio was 100 ± 3% and recovered to 98 ± 7% after antagonism of neuromuscular blockade. No technical issues were noted with application of the sensor or subsequent use of the monitor. Conclusion Neuromuscular monitoring can be performed intraoperatively in pediatric patients who are less than 8 years of age using a novel commercially available EMG-based monitor with a recently developed pediatric sensor. The novel sensor allows use of an EMG-based monitor in infants and children in whom acceleromyography or subjective (visual) observation of the TOF response may not be feasible. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level, baseline amplitude of the muscle action potential) was feasible in pediatric patients of all sizes including those weighing less than 15 kilograms or when there was limited access to the extremity being monitored.
Collapse
Affiliation(s)
- Sidhant Kalsotra
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie Rice-Weimer
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
13
|
Calef A, Castelgrande R, Crawley K, Dorris S, Durham J, Lee K, Paras J, Piazza K, Race A, Rider L, Shelley M, Stewart E, Tamok M, Tate J, Dodd-O JM. Reversing Neuromuscular Blockade without Nerve Stimulator Guidance in a Postsurgical ICU-An Observational Study. J Clin Med 2023; 12:jcm12093253. [PMID: 37176693 PMCID: PMC10179105 DOI: 10.3390/jcm12093253] [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: 01/26/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
We aimed to determine if not using residual neuromuscular blockade (RNB) analysis to guide neuromuscular blockade reversal administration in the postsurgical ICU resulted in consequences related to residual weakness. This single-center, prospective study evaluated 104 patients arriving in a postcardiac surgical ICU. After demonstrating spontaneous movement and T > 35.5 °C, all patients underwent RNB evaluation, and neostigmine/glycopyrrolate was then administered. When patients later demonstrated an adequate Rapid Shallow Breathing Index, negative inspiratory force generation, and arterial blood gas values with minimal mechanical ventilatory support, RNB evaluation was repeated in 94 of the 104 patients, and all patients were extubated. Though RNB evaluation was performed, patients were extubated without considering these results. Eleven of one hundred four patients had not achieved a Train-of-Four (TOF) count of four prior to receiving neostigmine. Twenty of ninety-four patients demonstrated a TOF ratio ≤ 90% prior to extubation. Three patients received unplanned postextubation adjunct respiratory support-one for obvious respiratory weakness, one for pain-related splinting compounding baseline disordered breathing but without obvious benefit from BiPAP, and one for a new issue requiring surgery. Residual neuromuscular weakness may have been unrecognized before extubation in 1 of 104 patients administered neostigmine without RNB analysis. ICU-level care may mitigate consequences in such cases.
Collapse
Affiliation(s)
- Andrea Calef
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Rashel Castelgrande
- Department of Surgery, Anne Arundel Medical Center, Anne Arundel, MD 21401, USA
| | - Kristin Crawley
- Department of Surgery, Medstar Medical Group, Baltimore, MD 21201, USA
| | - Sara Dorris
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Joanna Durham
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Kaitlin Lee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jen Paras
- Department of Surgery, INOVA Fairfax Hospital, Fairfax, VA 22042, USA
| | - Kristen Piazza
- Department of Surgery, University of Maryland St Joseph Hospital, Baltimore, MD 21201, USA
| | - Abigail Race
- Department of Surgery, North Shore University Hospital, Manhasset, NY 11030, USA
| | - Laura Rider
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Michael Shelley
- Department of Surgery, Maine Medical Center, Portland, ME 04103, USA
| | - Emily Stewart
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Miranda Tamok
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jennifer Tate
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jeffrey M Dodd-O
- Department of Anesthesiology, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| |
Collapse
|
14
|
Oh SK, Lim BG, Kim H, Lee JH, Lee JE. Performance of a new auxiliary device based on wrist brace to improve accuracy and feasibility in neuromuscular monitoring with acceleromyography in prone-positioned patients undergoing lumbar spine surgery: a prospective randomized clinical trial. J Clin Monit Comput 2023:10.1007/s10877-023-01000-w. [PMID: 37004664 DOI: 10.1007/s10877-023-01000-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 03/21/2023] [Indexed: 04/04/2023]
Abstract
Accuracy of acceleromyography (AMG) is not be comparable to that of mechanomyography or electromyography (EMG). In particular, the prone position may reduce the accuracy and feasibility of AMG. We developed a new device based on wrist brace to allow free thumb movement and fix the other parts of the hand and wrist. We aimed to test whether the brace applied to the AMG would increase precision of AMG and agreement with the EMG in the prone position. Fifty-seven patients, undergoing lumbar surgery under general anesthesia, were randomly assigned to groups to which AMG was applied with or without (no) brace (29 in group B vs. 28 in group NB). EMG was performed in the contralateral arm. Repeatability coefficients of the first twitch height (T1) and train-of-four (TOF) ratio were assessed from nine consecutive measurements during spontaneous recovery from rocuronium-induced neuromuscular block and the AMGs of the two groups were compared in prone position. The agreement between AMG and EMG in each group was assessed using the Bland-Altman method. In group B, the repeatability coefficient of T1 was significantly lower during the recovery to T1 of 25% and TOF ratio of 0.9 (P = 0.017 and 0.033, respectively), indicating higher precision. The mean differences of bias (95% limits of agreement) between AMG and EMG in TOF ratio of 0.9 were 6.839 (- 26.54 to 40.22) in group NB and 3.922 (- 21.83 to 29.67) in group B. The wide limits of agreement in group NB was slightly narrowed in group B but without significance. Trial registration: registered on the UMIN Clinical Trials Registry in August 2020 (UMIN000041310).
Collapse
Affiliation(s)
- Seok Kyeong Oh
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Gun Lim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Heezoo Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Hak Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jae Eun Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
15
|
Joo H, Cho S, Lee JW, Kim WJ, Lee HJ, Woo JH, Lee G, Baik HJ. Comparison of Contralateral Acceleromyography and Electromyography for Posttetanic Count Measurement. Anesthesiology 2023; 138:241-248. [PMID: 36520831 DOI: 10.1097/aln.0000000000004466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Electromyography has advantages over mechanomyography and acceleromyography. Previously, agreement of the train-of-four counts between acceleromyography and electromyography was found to be fair. The objective of this study was to assess the agreement of posttetanic count including agreement of neuromuscular blockade status (intense block, posttetanic count equal to 0; or deep block, posttetanic count 1 or greater and train-of-four count equal to 0) between acceleromyography and electromyography. METHODS Thirty-six patients, aged 20 to 65 yr, participated in this study. A dose of 0.6 mg/kg rocuronium, with additional dose of 0.3 mg/kg if required, was administered to the patients. The train-of-four and posttetanic counts were monitored in the contralateral arm using electromyography at the first dorsal interosseus or adductor pollicis, and acceleromyography at the adductor pollicis. Posttetanic count measurements were performed at 6-min intervals; the responses were recorded until the train-of-four count reached 1. The authors evaluated the agreement of degree of neuromuscular blockade (intense or deep block) and that of posttetanic count between acceleromyography and electromyography. RESULTS The authors analyzed 226 pairs of measurements. The percentage agreement indicating the same neuromuscular blockade status (intense or deep block) between acceleromyography and electromyography was 73%. Cohen's kappa coefficient value was 0.26. After excluding data with acceleromyography-posttetanic counts greater than 15, a total of 184 pairs of posttetanic counts were used to evaluate the agreement between the two monitoring methods. For acceleromyography-posttetanic count, 42 (23%) pairs had the same electromyography-posttetanic count, and 93 (50%) pairs had more than the electromyography-posttetanic count. The mean posttetanic count on electromyography was 38% (95% CI, 20 to 51%) lower than that on acceleromyography (P = 0.0002). CONCLUSIONS Acceleromyography frequently counted more twitches than electromyography in posttetanic count monitoring. Acceleromyography- and electromyography-posttetanic counts cannot be used interchangeably to assess the degree of neuromuscular blockade. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Hyunyoung Joo
- Department of Anesthesiology and Pain Medicine, Daniel Hospital, Bucheon, Republic of Korea
| | - Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Won Joong Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Giyear Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| |
Collapse
|
16
|
Quantitative Monitoring Practice Change: Reply. Anesthesiology 2023; 138:121-122. [PMID: 36512694 DOI: 10.1097/aln.0000000000004401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
17
|
Quantitative Monitoring Practice Change: Comment. Anesthesiology 2023; 138:120-121. [PMID: 36512702 DOI: 10.1097/aln.0000000000004400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
18
|
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]
|
19
|
Sato H, Iwasaki H, Doshu-Kajiura A, Katagiri S, Takagi S, Luthe SK, suzuki T. Comparison of two electromyography-based neuromuscular monitors, AF-201 P and TetraGraph, in rocuronium-induced neuromuscular block: a prospective comparative study. Anaesth Crit Care Pain Med 2022; 41:101145. [DOI: 10.1016/j.accpm.2022.101145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/13/2022] [Accepted: 07/25/2022] [Indexed: 12/01/2022]
|
20
|
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]
|
21
|
Quantitative Neuromuscular Monitoring in Clinical Practice: A Professional Practice Change Initiative. Anesthesiology 2022; 136:901-915. [PMID: 35188958 DOI: 10.1097/aln.0000000000004174] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Residual neuromuscular blockade can be avoided with quantitative neuromuscular monitoring. The authors embarked on a professional practice initiative to attain documented train-of-four ratios greater than or equal to 0.90 in all patients for improved patient outcomes through reducing residual paralysis. METHODS The authors utilized equipment trials, educational videos, quantitative monitors in all anesthetizing locations, and electronic clinical decision support with real-time alerts, and initiated an ongoing professional practice metric. This was a retrospective assessment (2016 to 2020) of train-of-four ratios greater than or equal to 0.9 that were documented before extubation. Anesthesia records were manually reviewed for neuromuscular blockade management details. Medical charts of surgical patients who received a neuromuscular blocking drug were electronically searched for patient characteristics and outcomes. RESULTS From pre- to postimplementation, more patients were assigned American Society of Anesthesiologists Physical Status III to V, fewer were inpatients, the rocuronium average dose was higher, and more patients had a prereversal train-of-four count less than 4. Manually reviewed anesthesia records (n = 2,807) had 2 of 172 (1%) cases with documentation of train-of-four ratios greater than or equal to 0.90 in November 2016, which was fewer than the cases in December 2020 (250 of 269 [93%]). Postimplementation (February 1, 2020, to December 31, 2020), sugammadex (650 of 935 [70%]), neostigmine (195 of 935 [21%]), and no reversal (90 of 935 [10%]) were used to attain train-of-four ratios greater than or equal to 0.90 in 856 of 935 (92%) of patients. In the electronically searched medical charts (n = 20,181), postimplementation inpatients had shorter postanesthesia care unit lengths of stay (7% difference; median [in min] [25th, 75th interquartile range], 73 [55, 102] to 68 [49, 95]; P < 0.001), pulmonary complications were less (43% difference; 94 of 4,138 [2.3%] to 23 of 1,817 [1.3%]; P = 0.010; -1.0% difference [95% CI, -1.7 to -0.3%]), and hospital length of stay was shorter (median [in days] [25th, 75th], 3 [2, 5] to 2 [1, 4]; P < 0.001). CONCLUSIONS In this professional practice initiative, documentation of train-of-four ratios greater than or equal to 0.90 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. EDITOR’S PERSPECTIVE
Collapse
|
22
|
Tobias J, Owusu-Bediako K, Munch R, Mathias J. Feasibility of intraoperative quantitative neuromuscular blockade monitoring in children using electromyography. Saudi J Anaesth 2022; 16:412-418. [PMID: 36337401 PMCID: PMC9630696 DOI: 10.4103/sja.sja_326_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Quantitative train-of-four (TOF) monitoring remains essential in optimizing anesthetic outcomes by assessing the depth and recovery from neuromuscular blockade. Despite this, residual neuromuscular blockade, defined as a TOF ratio <0.90, remains a concern in both adult and pediatric patients. Quantitative TOF monitoring has seen limited use in infants and children primarily due to a lack of effective equipment. This study evaluates a new electromyography (EMG)-based TOF monitor in pediatric patients undergoing inpatient surgical procedures including laparoscopic (restricted arm access) surgery. Methods: Pediatric patients undergoing inpatient surgery requiring the administration of neuromuscular blocking agents (NMBAs) were enrolled. The EMG electrodes were placed along the ulnar nerve on the volar aspect of the arm to provide neurostimulation. The muscle action potentials from the abductor digiti minimi muscle were recorded. Neuromuscular responses were recorded by the device throughout surgery at 20-s intervals until after tracheal extubation. Data recorded on the monitor's built-in memory card were later retrieved and analyzed. Results: The study cohort included 100 pediatric patients (62% male). The average age was 11 years (IQR: 8, 13) and the average weight was 39.6 kg (30, 48.7). Automatic detection of supramaximal stimulus was obtained in 95% of patients. The muscle action potential mean baseline amplitude (in mV) was 7.5 mV (6, 9.2). The baseline TOF ratio was 100% (100, 104). After administration of a neuromuscular blocking agent, monitoring of the TOF ratio was successful in 93% of the patients. After antagonism of neuromuscular blockade, monitoring was possible in 94% of patients when using an upgraded algorithm. The baseline amplitude recovered to 6.5 mV (5, 7.8), and the TOF ratio recovered to a mean of 90.1% (90,97) before tracheal extubation. Conclusion: Our results indicate that neuromuscular monitoring can be performed intraoperatively in pediatric patients weighing between 20 and 60 kg using the new commercially available EMG-based monitor. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level and baseline amplitude of the muscle action potential) by an adult neuromuscular monitor is feasible in pediatric patients receiving nondepolarizing neuromuscular blocking agents.
Collapse
|
23
|
Yhim HB, Jang YE, Lee JH, Kim EH, Kim JT, Kim HS. Comparison of the TOFscan and the TOF-Watch SX during pediatric neuromuscular function recovery: a prospective observational study. Perioper Med (Lond) 2021; 10:45. [PMID: 34886885 PMCID: PMC8662865 DOI: 10.1186/s13741-021-00215-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/19/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND TOFscan is a three-dimensional acceleromyography neuromuscular monitoring device that does not require initial calibration before muscle relaxant injection. This study aimed to compare TOFscan with TOF-Watch SX, the currently widely accepted uni-dimensional acceleromyography, for use among the pediatric population. We aimed to assess the agreement between TOFscan with TOF-Watch SX in the pediatric population's neuromuscular recovery. METHODS A total of 35 children aged 6-12 years were enrolled. Prior to any muscle relaxant injection, TOFscan and TOF-Watch SX were applied at each opposite arm and monitoring began concurrently throughout neuromuscular recovery. Calibration was performed for TOF-Watch SX, and train-of-four values were recorded every 15 s. Agreement between the two devices was evaluated with Modified Bland-Altman analysis. RESULTS The bias between TOF-Watch SX and TOFscan were all within the 95% limits of agreement. The bias and standard deviation were smaller and the limit of agreement was narrower in the normalized group than in the non-normalized group [normalized bias -0.002 (95% CI, -0.013 to 0.010), standard deviation (SD) 0.111 vs non-normalized bias 0.010 (95% CI, -0.003 to 0.0236), SD 0.127]. CONCLUSIONS TOFscan reliably demonstrated lack of bias and good concordance with TOF-Watch SX throughout the neuromuscular recovery, especially when normalized. Despite technical limitations, the two devices were unbiased along the path of spontaneous and pharmacological reversal in pediatric patients. TRIAL REGISTRATION ClinicalTrials.gov NCT03775603. Registered on 13 March 2018.
Collapse
Affiliation(s)
- Hyung-Been Yhim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ji-Hyun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hee-Soo Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea. .,Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| |
Collapse
|
24
|
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Giudici G, Piccioni F, Proto P, Valenza F. A comparison of accelerometric monitoring by TOF Watch® SX and electromyographic monitoring by Tetragraph® for recovery from neuromuscular blockade. J Clin Anesth 2021; 75:110481. [PMID: 34388509 DOI: 10.1016/j.jclinane.2021.110481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/31/2021] [Accepted: 08/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neuromuscular monitoring has become a standard of care for management of anesthesia. While acceleromyography (AMG) is the most common technology used in clinical practice, guidelines suggest that electromyographic (EMG) devices are ideal for quantitative neuromuscular monitoring. The Tetragraph® is an EMG monitor that has recently been marketed. STUDY OBJECTIVE The aim of this study is to assess the agreement during recovery from neuromuscular blockade of this new monitor with the TOF Watch® SX, and to compare intraobserver variability for the two devices. DESIGN Single-center, prospective, observational clinical study. SETTING Operating room. PATIENTS Twenty-three patients were enrolled and twenty patients were included in the analysis. INTERVENTION A comparison of TOF-ratios measured sequentially from the same hand with the Tetragraph and TOF Watch SX was conducted during spontaneous recovery of neuromuscular function from patients that received rocuronium during surgery. MAIN OUTCOME MEASURES We used Bland-Altman plots for repeated measures to compare TOF-ratios obtained sequentially by the two devices. Subsequent measures with the same device were used to calculate intraobserver variability for each monitor. MAIN RESULTS The bias between AMG and EMG for TOF-ratios range between 0.2 and 1.0 was 0.13 (95% CI 0.08 to 0.18) and the limits of agreement (LoA) were - 0.11 (95% CI -0.20 to -0.06) and 0.37 (95% CI 0.32 to 0.46), respectively. Agreement slightly improved for TOF-ratios higher than 0.8 compared with lower TOF-ratios: the bias was 0.12 (95% CI 0.08 to 0.17) and 0.13 (95% CI 0.08 to 0.19), respectively. EMG relative intraobserver variability was lower compared with AMG (2.0%, IQR 0.0% to 4.5% vs. 3.2%, IQR 1.2% to 6.0%, P = 0.001). CONCLUSIONS Bias between the TOF Watch SX and the Tetragraph TOF-ratios is in line with previous results for AMG and EMG monitors.
Collapse
Affiliation(s)
- Giorgio Giudici
- Department of Health Sciences, University of Milan, Milan, Italy.
| | - Federico Piccioni
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Paolo Proto
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| | - Franco Valenza
- Department of Health Sciences, University of Milan, Milan, Italy; Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
| |
Collapse
|
27
|
Ipsilateral and Simultaneous Comparison of Responses from Acceleromyography- and Electromyography-based Neuromuscular Monitors. Anesthesiology 2021; 135:597-611. [PMID: 34329371 DOI: 10.1097/aln.0000000000003896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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
Collapse
|
28
|
Verdonck M, Carvalho H, Berghmans J, Forget P, Poelaert J. Exploratory Outlier Detection for Acceleromyographic Neuromuscular Monitoring: Machine Learning Approach. J Med Internet Res 2021; 23:e25913. [PMID: 34152273 PMCID: PMC8768027 DOI: 10.2196/25913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/18/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background Perioperative quantitative monitoring of neuromuscular function in patients receiving neuromuscular blockers has
become internationally recognized as an absolute and core necessity in modern anesthesia care. Because of their kinetic nature, artifactual recordings of acceleromyography-based neuromuscular monitoring devices are not unusual. These generate a great deal of cynicism among anesthesiologists, constituting an obstacle toward their widespread adoption. Through outlier analysis techniques, monitoring devices can learn to detect and flag signal abnormalities. Outlier analysis (or anomaly detection) refers to the problem of finding patterns in data that do not conform to expected behavior. Objective This study was motivated by the development of a smartphone app intended for neuromuscular monitoring based on combined accelerometric and angular hand movement data. During the paired comparison stage of this app against existing acceleromyography monitoring devices, it was noted that the results from both devices did not always concur. This study aims to engineer a set of features that enable the detection of outliers in the form of erroneous train-of-four (TOF) measurements from an acceleromyographic-based device. These features are tested for their potential in the detection of erroneous TOF measurements by developing an outlier detection algorithm. Methods A data set encompassing 533 high-sensitivity TOF measurements from 35 patients was created based on a multicentric open label trial of a purpose-built accelero- and gyroscopic-based neuromuscular monitoring app. A basic set of features was extracted based on raw data while a second set of features was purpose engineered based on TOF pattern characteristics. Two cost-sensitive logistic regression (CSLR) models were deployed to evaluate the performance of these features. The final output of the developed models was a binary classification, indicating if a TOF measurement was an outlier or not. Results A total of 7 basic features were extracted based on raw data, while another 8 features were engineered based on TOF pattern characteristics. The model training and testing were based on separate data sets: one with 319 measurements (18 outliers) and a second with 214 measurements (12 outliers). The F1 score (95% CI) was 0.86 (0.48-0.97) for the CSLR model with engineered features, significantly larger than the CSLR model with the basic features (0.29 [0.17-0.53]; P<.001). Conclusions The set of engineered features and their corresponding incorporation in an outlier detection algorithm have the potential to increase overall neuromuscular monitoring data consistency. Integrating outlier flagging algorithms within neuromuscular monitors could potentially reduce overall acceleromyography-based reliability issues. Trial Registration ClinicalTrials.gov NCT03605225; https://clinicaltrials.gov/ct2/show/NCT03605225
Collapse
Affiliation(s)
- Michaël Verdonck
- Department of Anesthesiology and Perioperative Medicine, Vrije Universiteit Brussel, Jette, Belgium
| | - Hugo Carvalho
- Department of Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Brussel, Belgium
| | - Johan Berghmans
- Department of Anesthesiology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Patrice Forget
- Department of Anaesthesia, University of Aberdeen, Aberdeen, United Kingdom
| | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, Universitair Ziekenhuis Brussel, Brussel, Belgium
| |
Collapse
|
29
|
Lee W. The latest trend in neuromuscular monitoring: return of the electromyography. Anesth Pain Med (Seoul) 2021; 16:133-137. [PMID: 33845547 PMCID: PMC8107252 DOI: 10.17085/apm.21014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/21/2021] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Wonjin Lee
- Department of Anesthesiology and Pain Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea.,Paik Institute for Clinical Research, Inje University College of Medicine, Busan, Korea
| |
Collapse
|
30
|
Train-of-four monitoring with the twitchview monitor electctromyograph compared to the GE NMT electromyograph and manual palpation. J Clin Monit Comput 2020; 35:1477-1483. [PMID: 33165706 DOI: 10.1007/s10877-020-00615-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/29/2020] [Indexed: 12/19/2022]
Abstract
The purpose of this study was to compare train-of-four count and ratio measurements with the GE electromyograph to the TwitchView electromyograph, that was previously validated against mechanomography, and to palpation of train-of-four count. Electrodes for both monitors were applied to the same arm of patients undergoing an unrestricted general anesthetic. Train-of-four measurements were performed with both monitors approximately every 5 min. In a subset of patients, thumb twitch was palpated by one of the investigators. Eleven patients contributed 807 pairs of train-of-four counts or ratios. A subset of 5 patients also contributed palpated train-of-four counts. Bland-Altman analysis of the train-of-four ratio found a bias of 0.24 in the direction of a larger ratio with the GE monitor. For 72% of data pairs, the GE monitor train-of-four ratios were larger. For 59% of data pairs, the GE monitor train-of-four counts were larger (p < 0.0001). For 11% of data pairs, the GE monitor train-of-four count was 4 when the Twitchview monitor count was zero. When manual palpation of train-of-four count was compared to train-of-four count determined by the monitors, 70% of data pairs were identical between palpation and TwitchView train-of-four count, while 30% of data pairs were identical between palpation and GE train-of-four count. For 7% of data pairs, the GE monitor train-of-four count was 4 when the palpation count was 0. The GE electromyograph may overestimate the train-of-four count and ratio. The GE electromyograph frequently reported 4 twitches when none were actually present due to misinterpretation of artifacts.
Collapse
|
31
|
Bowdle A, Jelacic S. Progress towards a standard of quantitative twitch monitoring. Anaesthesia 2020; 75:1133-1135. [PMID: 32412668 PMCID: PMC7496266 DOI: 10.1111/anae.15009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2020] [Indexed: 11/27/2022]
Affiliation(s)
- A. Bowdle
- Department of AnaesthesiologyUniversity of WashingtonSeattleWashingtonUSA
| | - S. Jelacic
- Department of AnaesthesiologyUniversity of WashingtonSeattleWashingtonUSA
| |
Collapse
|
32
|
Counting train-of-four twitch response: comparison of palpation to mechanomyography, acceleromyography, and electromyography. Br J Anaesth 2020; 124:712-717. [DOI: 10.1016/j.bja.2020.02.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022] Open
|
33
|
Nemes R, Renew JR. Clinical Practice Guideline for the Management of Neuromuscular Blockade: What Are the Recommendations in the USA and Other Countries? CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00389-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Purpose of Review
This review addresses various societal guidelines, standards, and consensus statements regarding optimal neuromuscular blockade management. We discuss the historical evolution of neuromuscular management as a means of identifying possible future trends.
Recent Findings
While a recent international panel of experts has called for abandoning clinical assessment and subjective evaluation using a peripheral nerve stimulator in favor of adopting quantitative monitoring, few anesthesia societies mandate similar practices at the moment.
Summary
The current status of neuromuscular monitoring in the world is still variable and unsatisfactory. Nevertheless, a positive trend can be observed in the anesthesia community to adopt and learn this neglected technique. The development of user-friendly monitoring devices should also help this process, but anesthesia national societies still need to do a lot to replace outdated and substandard practices.
Collapse
|