The Corrugator Supercilii, Not the Orbicularis Oculi, Reflects Rocuronium Neuromuscular Blockade at the Laryngeal Adductor Muscles

Plaud, Benoît; Debaene, B.; Donati, François

doi:10.1097/00000542-200107000-00019

Cited by 135 publications

(114 citation statements)

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“…9 The corrugator supercilii muscle (CSM) is a convenient monitoring site, but it is not recommended to guide management of neuromuscular recovery because it recovers faster than the APM or the upper airway muscles in patients without the disease. 10,11 In contrast, it has been previously shown that MG patients exhibit greater sensitivity at the CSM than at the APM. 12 Nevertheless, it is uncertain whether recovery is faster at the CSM than at the APM in patients with myasthenia gravis, particularly when reversal drugs are used to antagonize neuromuscular blockade.…”

Section: Résumémentioning

confidence: 94%

Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis

Iwasaki

Takahoko

Otomo

et al. 2013

Can J Anesth/J Can Anesth

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Section: Résumémentioning

confidence: 94%

Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis

Iwasaki

Takahoko

Otomo

et al. 2013

Can J Anesth/J Can Anesth

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“…It is supplied by the facial nerve and is often confused with the orbicularis oculi. 20 The corrugator supercilii response can be seen by stimulating a branch of the facial nerve lateral to the eye. This eyebrow muscle recovers earlier than the adductor pollicis and approximately at the same time as the diaphragm.…”

Section: Monitoring Sitementioning

confidence: 99%

“…This eyebrow muscle recovers earlier than the adductor pollicis and approximately at the same time as the diaphragm. 6,20 As a result, when four corrugator supercilii responses are visible, the adductor pollicis is expected to lag behind, with fewer twitches seen and perhaps none at all. If reversal is guided by corrugator supercilii responses, more residual paralysis is expected to occur.…”

Section: Monitoring Sitementioning

confidence: 99%

“…Le sourcilier est un petit muscle qui déplace le sourcil vers le bas et l'intérieur, comme lorsqu'on fronce les sourcils. Il est innervé par le nerf facial et on le confond souvent avec l'orbiculaire de l'oeil 20 La réponse du sourcilier peut être observée en stimulant une branche du nerf facial latérale à l'oeil. Ce muscle sourcilier récupère plus rapidement que l'adducteur du pouce et plus ou moins au même moment que le diaphragme.…”

Section: Le Site De Monitorageunclassified

“…Ce muscle sourcilier récupère plus rapidement que l'adducteur du pouce et plus ou moins au même moment que le diaphragme. 6,20 Par conséquent, on s'attend à un délai dans les réponses de l'adducteur du pouce, et à ce que lorsque quatre réponses sont visibles au sourcilier, il en ait moins, voire aucune, au niveau du pouce. Si la décision de neutraliser le bloc est fondée sur la réponse du sourcilier, une curarisation résiduelle plus importante est probable.…”

Section: Le Site De Monitorageunclassified

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Residual paralysis: a real problem or did we invent a new disease?

Donati

2013

Can J Anesth/J Can Anesth

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Purpose Over the past three decades, many studies have shown a high proportion of patients in the recovery room with residual neuromuscular blockade after anesthesia. The purpose of this Continuing Professional Development module is to present the physiological consequences of residual paralysis, estimate the extent of the problem, and suggest solutions to prevent its occurrence. Principal findings Residual paralysis is defined as a train-of-four ratio (TOFR) \ 0.9 at the adductor pollicis. While tidal volume and, to a lesser extent, vital capacity are well preserved as the intensity of blockade increases, the probability of airway obstruction, impaired swallowing, and pulmonary aspiration increases markedly as TOFR decreases. In recent studies, incidences of residual paralysis from 4-57% have been reported, but surveys indicate that anesthesiologists estimate the incidence of the problem at 1% or less. The decision to administer neostigmine or sugammadex should be based on the degree of spontaneous recovery at the adductor pollicis muscle (thumb), not on recovery at the corrugator supercilii (eyebrow). The most important drawback of neostigmine is its inability to reverse profound blockade, which is a consequence of its ceiling effect. When spontaneous recovery reaches the point where TOFR [ 0.4 or four equal twitch responses are seen, reduced doses of neostigmine may be given. The dose of sugammadex required in a given situation depends on the intensity of blockade. Conclusion Careful monitoring and delaying the administration of neostigmine until four twitches are observed at the adductor pollicis can decrease the incidence of residual paralysis. The clinical and pharmacoeconomic effects of unrestricted sugammadex use are unknown at this time. ObjectivesAfter reading this module, the reader should be able to:1. Describe the physiological effects of residual neuromuscular blockade 2. Define and justify the current threshold used for residual paralysis 3. Interpret the information provided by qualitative and quantitative monitors 4. Decide the dose and timing of administration of neostigmine 5. Manage neuromuscular blockade and reversal during and after anesthesia.In 1979, Viby-Mogensen et al. 1 reported that 42% of patients receiving non-depolarizing neuromuscular blocking agents during anesthesia followed by neostigmine at the end of the procedure had neuromuscular weakness in the recovery room, as documented by a train-of-four ratio 123Can J Anesth/J Can Anesth (2013) 60:714-729 DOI 10.1007 (TOFR) \ 0.7. This first description of what was later termed residual paralysis, residual curarization, or postoperative residual curarization was followed by many other observations in many countries around the world and in different settings. The introduction of shorter-acting agents, such as vecuronium and atracurium and later rocuronium and cisatracurium, to replace the longer-acting agents available in 1979 led to a decrease in the incidence of residual paralysis. 2 Nevertheless, many lines of evidence now...

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Pharmacology

Mazoit¹

2020

Gregory's Pediatric Anesthesia

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The Corrugator Supercilii, Not the Orbicularis Oculi, Reflects Rocuronium Neuromuscular Blockade at the Laryngeal Adductor Muscles

Abstract: Muscles around the eye vary in their response to rocuronium. The response of the superciliary arch (corrugator supercilii) reflects blockade of laryngeal adductor muscles. However, the eyelid (orbicularis oculi) and thumb (adductor pollicis) have similar sensitivities.

Cited by 135 publications

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Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis

Monitoring of neuromuscular blockade in one muscle group alone may not reflect recovery of total muscle function in patients with ocular myasthenia gravis

Residual paralysis: a real problem or did we invent a new disease?

Pharmacology

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