Chapter 2 Principles of neuromuscular monitoring

Fuchs‐Buder, Thomas

doi:10.1007/978-3-642-13477-7_2

Cited by 2 publications

(2 citation statements)

References 25 publications

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“…However, the upper airway muscles are more sensitive , and the effects of neostigmine may last longer in these muscles. This is of clinical concern, as residual muscle weakness may lead to pulmonary complications, including pharyngeal dysfunction, aspiration, pneumonia and atelectasis .…”

Section: Discussionmentioning

confidence: 99%

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

et al. 2018

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Neostigmine reverses non-depolarising neuromuscular blockade, but may cause muscle weakness when administered after full recovery of neuromuscular function. We hypothesised that neostigmine in therapeutic doses impairs muscle strength and respiratory function in awake healthy volunteers. Twenty-one volunteers were randomised to receive two doses of either intravenous (i.v.) neostigmine 2.5 mg with glycopyrrolate 450 μg (neostigmine group, n = 14) or normal saline 0.9% (placebo group, n = 7). The first dose was administered immediately after obtaining baseline measurements, and the second dose was administered 15 min later. All 14 volunteers in the neostigmine group received the first dose, mean (SD) 35 (5.8) μg.kg , but only nine of these volunteers agreed to receive the second dose, 34 (3.5) ?g.kg . The primary outcome was hand grip strength. Secondary outcomes were train-of-four ratio, single twitch height, forced expiratory volume in 1 s, forced vital capacity, forced expiratory volume in 1 s/forced vital capacity ratio, oxygen saturation, heart rate and mean arterial pressure. The first dose of intravenous neostigmine with glycopyrrolate resulted in reduced grip strength compared with placebo, -20 (20) % vs. +4.3 (9.9) %, p = 0.0016; depolarising neuromuscular blockade with decreased single twitch height, -14 (11) % vs. -3.8 (5.6) %, p = 0.0077; a restrictive spirometry pattern with decreased predicted forced expiratory volume in 1 s, -15 (12) % vs. -0.47 (3.4) %, p = 0.0011; and predicted forced vital capacity, -20 (12) % vs. -0.59 (3.2) %, p < 0.0001 at 5 min after administration. The second dose of neostigmine with glycopyrrolate further decreased grip strength mean (SD) -41 (23) % vs. +1.0 (15) %, p = 0.0004; single twitch height -25 (15) % vs. -2.5 (6.6) %, p = 0.0030; predicted forced expiratory volume in 1 s -23 (24) % vs. -0.7 (4.4) %, p = 0.0063; and predicted forced vital capacity, -27.1 (22.0) % vs. -0.66 (3.9) %, p = 0.0010. Train-of-four ratio remained unchanged (p = 0.22). In healthy volunteers, therapeutic doses of neostigmine induced significant and dose-dependent muscle weakness, demonstrated by a decrease in maximum voluntary hand grip strength and a restrictive spirometry pattern secondary to depolarising neuromuscular blockade.

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Section: Discussionmentioning

confidence: 99%

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

et al. 2018

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“…However, there may be some limitations on its precision 10,12 . Preload, applied using a simple mechanical device (TOF-watch hand adapter) that separates the thumb and index finger, has been shown to improve the precision of AMG [13][14][15] . This fixation of the thumb, effectively applying a small preload or stretch may also improve EMG results by reducing changes in the position of the electrodes in relation to the muscle 16 .…”

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The Effect of Preload on Electromyographic Train-Of-Four Ratio at the First Dorsal Interosseous Muscle during Spontaneous Recovery from Neuromuscular Blockade

Bansal

Stewart

Phillips

et al. 2018

Anaesth Intensive Care

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Accurate and reliable quantitative neuromuscular function monitoring is desirable for the optimal management of neuromuscular blockade, selection of the most appropriate reversal agent and dosage, and assessing the completeness of reversal to exclude residual neuromuscular blockade. Applying preload to the thumb may affect the precision of electromyography. This study compared the precision and agreement of electromyography with and without preload during recovery from non-depolarising neuromuscular blockade. After induction of anaesthesia and before neuromuscular blockade, the supramaximal current required at the first dorsal interosseous muscle with and without preload was determined. During recovery, train-of-four ratios were recorded using electromyography every 20 seconds. Alternating pairs of measurements (with and without preload) were obtained until spontaneous recovery was achieved. The preload device applied a resting tension of 75-150 g to the thumb. Bland-Altman analysis for repeated measurements was used to assess precision and agreement of electromyography responses with and without muscle preload. Two hundred and seventy-five sets of repeated measurements were collected from 35 participants. The repeatability coefficient for train-of-four ratios recorded by electromyography with a preload was 0.030 (95% confidence intervals, CI, 0.028 to 0.031) versus 0.068 (95% CI 0.064 to 0.072) without. Train-of-four ratios with preload demonstrated a bias of +0.038 (95% CI 0.037 to 0.042) compared to electromyography without, with 95% limits of agreement of 0.035-0.111. Preload significantly improved the precision of electromyographic train-of-four ratios, with 95% of consecutive measurements differing by less than 3%. Furthermore, electromyography with preload demonstrated a positive bias of 0.04 compared with electromyography alone, the clinical significance of which requires further research.

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Chapter 2 Principles of neuromuscular monitoring

Cited by 2 publications

References 25 publications

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

Therapeutic doses of neostigmine, depolarising neuromuscular blockade and muscle weakness in awake volunteers: a double‐blind, placebo‐controlled, randomised volunteer study

The Effect of Preload on Electromyographic Train-Of-Four Ratio at the First Dorsal Interosseous Muscle during Spontaneous Recovery from Neuromuscular Blockade

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