Neuromuscular monitoring is proposed to be part of standard anaesthetic monitoring to objectively assess the effects of non-depolarising neuromuscular blocking agents (NMBA) [1, 2]. NMBA's use during anaesthesia induction enables the optimisation of intubation conditions during conventional laryngoscopy [3]. The current clinical standard for neuromuscular monitoring is acceleromyography [4]. In most cases, an electrical stimulus is passed through adhesive electrodes that are placed over the ulnar nerve on the medial lower arm to stimulate the nerve (e.g., TOF-Scan, TOF-Watch). The stimulated motor response is then measured in the form of acceleration. The most commonly applied pattern is the train-of-four (TOF), in which the motor responses from the fourth and first stimuli are compared and expressed as a percentage, also
Purpose
The aim of this study was to compare two devices for neuromuscular monitoring during anesthetic induction. TOF-Cuff® was installed on the lower leg stimulating the tibial nerve, while the more conventional TOF-Scan® was installed over the ulnar nerve at the wrist.
Methods
Twenty adult patients were enrolled in this prospective, controlled study. Train-of-four (TOF) was recorded every 15 s until TOF ratio of 0%. Mean arterial blood pressure (MAP) was assessed with TOF-Cuff® and with standard anesthesia monitoring from the brachial artery. MAP was measured before and after anesthetic induction. Time to TOF ratio = 0% was compared with one-sample t test and Bland–Altman plots.
Results
Patients received 0.53 ± 0.09 mg atracurium per kg body weight intravenously. Mean time to TOF ratio = 0% was 150.8 s (± 43.7) for TOF-Scan®, and 174.4 s (± 42.7) for TOF-Cuff® (p = 0.1356). Bias was − 15.9 (95% confidence interval − 37.5 to 5.6) with 95% limits of agreement of − 95.2 to 63.3. Twenty-five percent of the patients had a technical issue with a TOF-Cuff® measurement. For MAP, mean difference was 1.4 (95% confidence interval − 2.4 to 5.2) with 95% limits of agreement of − 22.7 to 25.5.
Conclusion
The time from administration of a common dose of atracurium to a TOF ratio of 0% assessed with TOF-Cuff® stimulating the tibial nerve compared to TOF-Scan® stimulating the ulnar nerve showed large limits of agreement in Bland–Altman analysis. There was a high failure rate with TOF-Cuff® measurements on the lower leg.
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