Neuromuscular monitoring

Dr Sumanth Gutta, Consultant Anaesthetist, Yashoda Hospitals, Hitech

 Why?
1. Exclude clinically significant residual neuromuscular block after
administration of reversal

2. To monitor depth of neuromuscular block - complete relaxation

in robotic surgeries (Diaphragm and laryngeal adductors most
resistant)

3. Neuromuscular blocking drug, Reversal - appropriate dosing

• Risks of residual neuromuscular blockade

• Functional impairment of pharyngeal and upper esophageal
muscles. Most sensitive
• As a result, inability to maintain upper airway
• Hypoxemic events, Blurry vision, Patient distress
Why?
Why?
Guidelines
Guidelines
Guidelines
Levels of block
 How to monitor
1. Clinical
• Tongue protrusion
• Head lift 5 seconds
• Hand grip
• Tidal volumes

2. Objective – quantification with a value

Objective Monitoring
 Monitoring sites
• Ulnar nerve most common site

• Pulse oximeter to be measured from

different arm / leg

• AV fitula is no contraindication

• Motor neuron lesions will give false

readings
Monitoring sites
Monitoring sites
 Electrodes
• Placed along a nerve transcutaneously with
surface electrodes

• Large conducting area makes difficult to

obtain supramaximal stimulation

• Polarity - Positive white/red, Negative

black

• Negative electrode over most superficial

part of the nerve being stimulated

• Positive electrode along course of the

nerve proximally
 Equipment
• Current
• Current, not voltage. Change of
current with regard to skin
resistance
• Supramaximal stimulus. ~50mA.
Higher in those with edema

• Frequency
• One Hz is 1 stimulus per second

• Duration
• In milliseconds
 Methods of detection
• Visual

• Tactile
 Methods of recording
• Mechanomyography - Measures muscle contraction using a force transducer

• Kinemyography - Assesses APM contraction by measuring the degree of bending

of a sensor placed between the thumb and the first finger

• Electromyography - Detects compound muscle action potentials at the

neuromuscular junction

• Acceleromyography - Based on Newton’s Second Law of Motion (i.e., force = mass

x acceleration). AMG utilizes a piezoelectric sensor to measure tissue acceleration
with muscle contraction
Methods of recording
 Methods of recording
• Electromyography Mechanomyography
 Nerve Stimulation Patterns
• Single twitch
• Delivered at a frequency of 0.1 or 1 Hz. Control response strength is noted

• Strengths of subsequent twitches are then compared with the control and
expressed as a percentage of the control

• With both a nondepolarizing block and a depolarizing block, there will be a

progressively depressed response as the block develops
 1. Single twitch
• Single twitch stimulus is useful to establish a supramaximal stimulus and to
identify whether conditions satisfactory for intubation have been achieved

• It can be used (in conjunction with PTC) to monitor deep levels of NMB

• Disadvantages
• Control needed
• Cannot distinguish between depolarizing and nondepolarizing block
• Lower body temperature will cause a reduced response
2. Train of Four
2. Train of Four
 2. Train of Four
• Four single pulses of equal intensity delivered at intervals of 0.5 seconds

• TOF should not be repeated more frequently than every 12 seconds

• Before any relaxant has been given, all four responses are the same

• Pattern with depolarizing block differs from non-depolarizing block

• Nondepolarizing block - Progressive depression of height with each twitch (fade)

• As the block is deepened - the fourth twitch will be eliminated, then the third…
2. Train of Four
2. Train of Four
2. Train of Four
 3. Tetanus
• Rapidly repeated (50 or 100 Hz) stimulus.
More the frequency, more sensitive

• No NMB - causes sustained stimulated muscle

contraction

• Depolarizing block - response will be

depressed in amplitude

• Nondepolarizing block – response is

depressed in amplitude, contraction not
sustained (fade)
 3. Tetanus
• Duration is important because it affects fade. Standard is 5 seconds

• Should not be repeated more often than every 5 minutes

• Tetanic stimulation is very painful. Avoided in conscious patient

 4. PTC
• Post-tetanic facilitation (potentiation, PTF) - temporary
increase in response to stimulation following a tetanic
stimulus. Seen with nondepolarizing block

• When NMB is deep (no response in TOF) - possible to

estimate NMB by using PTC

• PTC - Tetanic stimulus of 50 Hz for 5 seconds. 3-second

pause. Single-twitch stimuli at 1 Hz. Number of post-
tetanic responses is counted

• PTC of 12–15 suggests that the return of a TOF twitch is Suggamadex 2mg/kg can be
imminent administered at PTC of 1-2
4. PTC
Rocuronium recovery chart
 5. Double-Burst Stimulation
• Two short bursts of 50-Hz separated by 0.75 seconds. Interval 12 seconds

• 90 seconds gap needed when switching between DBS and TOF stimulation

• DBS used to detect residual NMB

• Also used to assess deep block since the first twitch in double burst can be
detected at deeper block levels than the first twitch in TOF

• DBS causes more discomfort than TOF stimulation but less than tetanic
stimulation
5. Double-Burst Stimulation
 Problems
• Patient discomfort – Tetanic, DBS

• Electrical interference – ECG trace, Pacemaker

• Low batteries going unchecked

Best Used
 Suggested Evidence-Based Practices
• Use muscle relaxants only when necessary

• Minimum degree of recovery should be a TOF Count of 4 prior to

anticholinesterase reversal

• Use of anticholinesterases in fully recovered patients may induce weakness of

airway muscles

• If TOF ratio is <0.40, use reversal

• If TOF ratio is between 0.40 and 0.90, consider low-dose reversal (50%)
• If TOF ratio is >0.90, no reversal is recommended
 Practical Conditions where NMM is essential
• Infusions of neuromuscular blocking drugs, Long-acting drugs are used, Surgery is
prolonged

• Inadequate reversal may have devastating effects - severe respiratory disease,

morbid obesity

• Liver or renal dysfunction, when pharmacokinetics are altered

• Myasthenia gravis or Eaton–Lambert syndrome

Is it needed?
Further Reading
Thank You