In clinical anesthesia, the degree of neuromuscular blockade should be quantitatively evaluated by mechanical myography (MMG) or electromyography (EMG). Only in a very few departments, however is the neuromuscular function routinely evaluated by such equipment because of economical reasons and difficulty of handling. To establish a simple method of monitoring neuromuscular function during anesthesia, we have been studying how to evaluate the degree of neuromuscular blockade by using only a nerve stimulator.Previously, Viby-Mogensen and his colleagues showed that the "period of no response to twitch and TOF stimulation" and "surgical relaxation" simply by feeling the posttetanic twitch response (posttetanic count) or the number of responses to the TOF stimulationb", However, when there was a reaction to all four stimuli on TOF stimulation (recovery phase), especially when the TOF ratio exceeds 0.4, it was extremely difficult to detect the fade". To overcome this difficulty, "double burst stimulation (DBS)" was applied to manual evaluation of neuromuscular transmission". This DBS consists of two very short bursts that are separated by 750 msec, Each burst consists of three supramaximal stimulation, which are separated by an interval of 20 msec. (fig. 1). Our preliminary study revealed that DBS was a little more painful than TOF stimulation but much less than tetanic stimulation (50 Hz, 5 sec.) in the awake volunteers. When DBS was applied during the recovery phase, two evoked responses were observed. The previous pattern of DBS was called "double burst three three (DBS 3 . 3 ) " , and the results .of clinical study were that, the DBS 3 . 3 was significantly better than the TOF stimulation when the TOF ratio was below 0.8 4 ,5 . In other words, it was easier to detect the fade by using the DBS 3 . 3 than with TOF stimulation. However, we were interested in whether or not the adequate recovery from neuromuscular blockade in the end of anesthesia could be determined manually or tactilely. Considering that a TOF ratio of about 0.75 is regarded as reflection of clinically adequate recovery, although the DBS 3 . 3 was statistically superior to the TOF stimulation, the result does not match the clinical needs. Because, even the DBS 3 . 3 was applied, the investigator could detect the fade in the DBS responses in a very few trials when the TOF ratio was between 0.6 and 0.7 5 . Consequently, we investigated whether, by changing the stimulation pattern in the
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