Conceptual and technical insights into the basis of neuromuscular monitoring

Abstract

Summary Unrecognised postoperative residual neuromuscular block remains a frequent occurrence in recovery rooms. Evidence indicates that current practice continues to perpetuate the status quo, in which 10–40% of patients experience postoperative residual weakness. A departure from the current practice requires small efforts on the clinicians’ part. This review addresses several selected core questions regarding neuromuscular blockade monitoring and provides a framework to rationally discuss and develop basic guidelines for the use of neuromuscular blocking agents in patient care.

Neuromuscular monitoring: an update

“…Best indicator of pure neuromuscular function [22]. Comparable with MMG but more consistent in time [23,24].…”

“…Neuromuscular block has faster onset, shorter duration and faster recovery at laryngeal and diaphragmatic muscles than at the APM, although the former are more resistant to NMBAs [22]. Therefore, during surgery, the absence of a twitch at the APM does not guarantee paralysis of the diaphragm [33].…”

“…When the hand is inaccessible, the posterior tibial nerve-flexor hallucis brevis muscle evaluated subjectively or by AMG can be chosen, with similar values compared to APM [39]. Another option is facial muscle monitoring subjectively or by AMG, as long as the stimulator electrodes are moved on the ulnar nerve before extubation, to ensure adequate recovery [22].…”

Clinical Practice Guideline for the Management of Neuromuscular Blockade: What Are the Recommendations in the USA and Other Countries?

“…The introduction of sugammadex into clinical practice represented a significant breakthrough in not only the arena of NMB but also anesthesia in general. This drug has a well-defined dosing scale that provides a fast and reliable reversal for aminosteroidal NMBAs from any depth of blockade [19]. To define the optimal dose, anesthesiologists should determine the level of the neuromuscular blockade at the time of sugammadex administration.…”

“…However, clinical tests and peripheral nerve stimulators had already gained wide acceptance, as the older objective monitoring techniques were only available in dedicated centers. In addition, anesthesiologists would have to take several additional steps to obtain reliable measurements when using AMG [19]. Without immobilization of the arm and fingers, the use of preload to the thumb, and calibration of the device, AMG measurements can be highly variable [40], which deprives the technique of its credibility in the eyes of clinicians.…”