Running head: QUASI-EXPERIMENTAL DESIGN CRITICAL REVIEW 1

A Critical Review of a Quasi-Experimental Design Comparing Three Neuromuscular Blockade

Monitoring Techniques
Emily A. Covington
The University of Kansas














QUASI-EXPERIMENTAL DESIGN CRITICAL REVIEW 2
A Critical Review of a Quasi-Experimental Design Comparing Three Neuromuscular Blockade
Monitoring Techniques
Overview
This paper is a critique of an article written by Trager, Michaud, Deschamps, &
Hemmerling (2006) titled Comparison of phonomyography, kinemyography and
mechanomyography for neuromuscular monitoring. The authors compared phonomyography
(PMG) and kinemyography (KMG) monitoring techniques to mechanomyography (MMG), the
gold standard for monitoring neuromuscular blockade. According to Trager et al. (2006), the
aim of this study is to establish the agreement associated between PMG, KMG, and MMG
monitoring techniques after administration of a neuromuscular blocking agent. The authors of
this study found that MMG and PMG show satisfactory agreement for determining onset time
and train-of-four recovery. This article provides the reader with acceptable and reputable
information regarding neuromuscular monitoring; furthermore, the methods used to perform this
study are suitable for a quasi-experimental design. Anesthesia providers may use this article for
further investigation concerning this topic. In addition, the authors deliver evidence-based
research allowing for implementation into the clinical setting.
Summary
Mechanomyogarphy is the gold standard for monitoring neuromuscular blockade in the
clinical setting (Trager et al., 2006). However, due to MMG monitoring limitations and
requirements this method is rarely used in the operating room (Murphy & Brull, 2012).
Kinemyography uses Newtons second law to evaluate the force of muscle contraction to avoid
postoperative residual paralysis associated with administering neuromuscular blocking agents
(Murphy & Brull, 2012). Many advantages and disadvantages are also associated with KMG
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monitoring (Murphy & Brull, 2012). Trager et al. (2006) purpose that PMG monitoring has
many advantages when compared to MMG and KMG. The purpose of this article was to
compare and determine the agreement of PMG, KMG, and MMG, for detection of
neuromuscular blockade after a dose of mivacurium during train-of-four stimulation (Trager et
al., 2006). The intent of this study is to provide evidence that other neuromuscular monitoring
tools deliver findings equal to the MMG results (Trager et al., 2006). The general content of
Trager, Michaud, Deschamps, and Hemmerlings (2012) article provides background
information regarding multiple neuromuscular monitoring techniques. The article compares
PMG, KMG, and MMG monitoring techniques, while also offering clinical advantages
associated with their findings (Trager et al., 2006).
Critique
Introduction
According to Trager et al. (2006), the purpose of their study was to compare and
determine the agreement of PMG, KMG, and MMG, for detection of neuromuscular blockade
after a dose of mivacurium during train-of-four stimulation. The purpose of this this study was
easy to locate, clearly stated, and relevant to the field of anesthesia. The independent variable is
a nominal measurement and is defined as the type of monitoring including: PMG, KMG, and
MMG (Trager et al., 2006). The time to attain a train-of-four ratio of 0.25, 0.50, 0.75, and 0.90
is the dependent variable. The population of interest was clearly identified as patients
undergoing surgery who received neuromuscular blockers. Trager et al. (2006) hypothesized
that PMG and KMG are in good agreement with the gold standard for neuromuscular
monitoring. A particular strength of this study is the purpose and hypothesis. In addition, they
provided evidence for their study based on a theoretical framework.
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Trager et al. (2006) offered a theory to support the use of additional neuromuscular
monitoring tools in the clinical setting. The background literature provided in this article
regarding PMG, KMG, and MMG is an apparent strength. The study expressed various
advantages and disadvantages behind each method.
Methods
The article outlines a quasi-experimental design with the type of monitoring as the
independent variable and the time to reach a train-of-four ratio as the dependent variable. This
design choice strengthens their study. Due to ethical concerns this study did not justify the use
of sample randomization. Trager et al. (2006) included 14 patients undergoing general surgery
in their study. The patient exclusion criteria included: coexisting neuromuscular disease, use of
medications known to interact with neuromuscular transmission, and presenting atypical
pseudocholinesterase. The sample size was calculated based on previous findings, for a power of
0.8. Thus, the sample selected for the study showed external validity and representation of the
population. Prior to performing their research, approval from the local ethics committee and
informed consent was obtained. An additional strength was the human subject considerations
that Trager et al. (2006) used to prevent subject harm.
Results
Trager et al. (2006) used instruments suitable for measuring their variables; however,
Cronbachs alpha was not reported. Therefore, the reader is unable to assess its internal
consistency, which is classified as one of the studys weaknesses. The authors reported a
represented confidence level of 95%, while also revealing precision as standard deviation of the
mean and minimal bias, both of which are recognized as a strength.
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The SPSS statistical software was used to analyze the reported data. In this study, the
ANOVA test was used to compare the data between all methods. Trager et al. (2006) also used
Lins concordance correlation coefficient at all time periods for each method. The Lins
concordance correlation coefficient is helpful in quantifying the agreement of a new test and a
gold standard test. Both the ANOVA and Lins concordance correlation coefficient were
acceptable choices for analyzing the data. Trager et al. (2006) found onset times and peak
effects measured via MMG and PMG to be comparable. They revealed neuromuscular blockade
offset measured via the three methods not to be statistically significant (Trager et al., 2006).
Discussion
The conclusions are drawn from and consistent with the results. Trager et al. (2006) also
reported previous information regarding neuromuscular blockade monitoring techniques from
previous studies. A significant strength includes the discussion provided by Trager, Michaud,
Deschamps, and Hemmerling on their findings in relation to results from similar research
articles. This study suggests that both PMG and KMG monitoring methods may be used in place
of MMG to monitor neuromuscular blockade. Both of which have various advantages when
compared to the gold standard.
Conclusion
Overall, Trager et al. (2006) provided satisfactory evidence for using a more user-friendly
approach when monitoring neuromuscular blockade. Mechanomyography is the gold standard
for monitoring; however, it is rarely used in the clinical setting due to its limitations. This article
delivers information that will definitely benefit anesthesia practice. A significant concern
associated with administration of neuromuscular blocking agents is an overdose leading to
residual paralysis (Grayling & Sweeney, 2007). The evidence presented in this article may assist
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providers in adequately monitoring blockade and promote reduction in the incidence of
postoperative residual paralysis.





















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References
Grayling, M., & Sweeney, B. P. (2007). Recovery from neuromuscular blockade: A survey of
practice. Anaesthesia, 62, 806-809. doi:10.1111/j.1365-2044.2007.05101.x
Murphy, G. S., & Brull, S. J. (2012). Residual neuromuscular block: Lessons unlearned.
Anesthesia & Analgesia, 111,(1), 129-140. doi: 10.1213/ANE.0b013e3181da8312
Trager, G., Michaud, G., Deschamps, S., & Hemmerling, T. M. (2006). Comparison of
phonomyography, kinemyography and mechanomyography for neuromuscular
monitoring. Canadian Journal of Anesthesia, 53(2), 130-135. doi: 10.1007/BF03021816