Understanding Neuromuscular Monitoring

Author(s):

Paweł Radkowski*, Agnieszka Baranska, Justyna Dawidowska Fidrych, Marcin Mieszkowski, Oliwia Mandziuk-Radkowska, Bartosz Kedziora and Jakub Rusc

Introduction: Neuromuscular blocking agents are an important component of anesthesia. The effect of muscle relaxants is possible to evaluate by using instrumental objective neuromuscular monitoring. It cannot be determined by clinical tests. The procedure that allows us to measure the muscular response to electrical stimulation of the compatible motor nerve is called relaxometry. Despite anesthesia societies’ recommendations, objective neuromonitoring is still not routinely used in clinical practice.

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Aim: The aim of this paper is to present the basic principles of neurostimulation, patterns of nerve stimulation and equipment used for neuromuscular monitoring.

Result: The adductor pollicis muscle is routinely used to monitor neuromuscular transmission (gold standard), nevertheless it cannot be regarded as representative for some muscle groups such as the larynx, diaphragm, and eye muscles which are more resistant against no depolarizing muscle relaxants.

Discussion: The Train of Four stimulation (TOF) predicts the optimal time for intubation, maintains the desired depth of the intraoperative blockade and the correct estuation time. Monitoring of deep muscular blockade is only possible with the Post Tetanic Count (PTC). Acceleromyography is the most popular method of neuromuscular monitoring.

Conclusions: Because there is an individual variability in the action of muscle relaxants, every surgery the requires the administration of these drugs must be objectively monitored. Exclusion of residual neuromuscular block is possible only when the TOF ratio ≥ 0.9 in electromyography, compressomyography and kinemyography or=1,0 in acceleromyography.