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Current Anesthesiology Reports
Erschienen in: Current Anesthesiology Reports 1/2024

28.09.2023 | Neuromuscular Blockade (CA Lien, Section Editor)

Monitoring the Depth of Neuromuscular Blockade

verfasst von: Larry Lindenbaum, MD, Bradley J. Hindman, MD, Michael M. Todd, MD

Erschienen in: Current Anesthesiology Reports | Ausgabe 1/2024

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Abstract

Purpose of Review

In 2023, the American Society of Anesthesiologists published its first practice guideline document regarding the monitoring and antagonism of neuromuscular blockade. Those guidelines specifically recommend the use of QUANTITATIVE neuromuscular blockade monitoring — and recommend AGAINST relying on clinical assessments or dependence on the use of peripheral nerve stimulator (PNS — qualitative monitoring). This article reviews the data behind those recommendations.

Recent Findings

We describe the general failure of most clinical assessments (e.g., head lift, grip strength) to verify full reversal [as defined as a train-of-four (TOF) ratio of > 0.9 using quantitative methods] as well as the insensitivity of information obtained by the use of a PNS, such as the visual assessment of the TOF, tetanus, or double-burst stimulation (DBS) — although we recognize that a PNS can be used to titrate intraoperative dosing of neuromuscular blocking drugs and under very limited conditions can allow successful reversal with either neostigmine or sugammadex. Finally, we review quantitative technology and pros and cons of different methods (acceleromyography, electromyography, kinemyography) and attempt to provide evidence that even with the use of sugammadex, it is impossible to reliably ensure complete reversal without such quantitative monitoring.

Summary

Careful — and ideally quantitative — neuromuscular blockade monitoring is the only known method for ensuring complete reversal after any surgical procedure involving non-depolarizing relaxants.
Fußnoten
1
The fact that a high-frequency stimulus (e.g., 50–100 Hz) tetanus could evoke “fade” in the presence of paralytic drugs had been known for decades.
 
2
None of these monitors — nor PNS units — should be used on the face. The potential for egregiously misleading results is too great, either because of direct muscle stimulation or because of the huge difference in the dose–response characteristics of facial muscles to neuromuscular blockade as compared with the ulnar nerve [1].
 
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Metadaten
Titel
Monitoring the Depth of Neuromuscular Blockade
verfasst von
Larry Lindenbaum, MD
Bradley J. Hindman, MD
Michael M. Todd, MD
Publikationsdatum
28.09.2023
Verlag
Springer US
Erschienen in
Current Anesthesiology Reports / Ausgabe 1/2024
Elektronische ISSN: 2167-6275
DOI
https://doi.org/10.1007/s40140-023-00580-2

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