Chapter 25

Neuromuscular Transmission Monitoring

Muscle rel axants are empl oyed i n anesthesi a to provi de muscl e rel axati on and/or
aboli sh pati ent movement. Numerous studi es have documented enormous vari at ion
i n pati ents' responses to muscl e rel axants. Di sease states and peri operat ive
medi cati ons can also modi fy t he responses of t hese medi cat ions (1). The dept h of
neuromuscular block (NMB) should be moni t ored when muscle relaxants are used
t o avoi d drug overdosage or underdosage and resi dual NMB duri ng recovery
(2,3,4,5,6, 7).
Equipment
Moni tori ng the magni tude of NMB i s accompl i shed by del i vering an electrical
st i mulus near a peri pheral motor nerve and evaluati ng t he evoked response of the
muscle(s) innervated by that nerve.
Stimulator
Several st imulat ors are shown i n Fi gure 25.1. Desi rable f eatures incl ude
compactness, l ight wei ght , and
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si mpl ici t y. Most are bat tery-operated wi th a means t o check the batt ery status.
Mounti ng brackets f or securi ng the devi ce are desi rable. A sti mul ator may be i n a
module i n a mul t iparameter moni tor. The abi l i ty to del iver i nf ormat i on to an
automated record (Chapt er 28) should be consi dered when choosing a sti mulator.

View Figure

Figure 25.1 Neuromuscular stimulators. A: This simple
device has only two patterns of stimulation: tetanus and
single twitch. The delivered current cannot be varied and is
not displayed. Note the metal ball electrodes. (Courtesy of
Professional Instruments, a subsidiary of Life Tech, Inc.) B:
This unit has three modes of stimulation: single stimulus
(twitch), tetanus, and TOF. The current is varied by using a
rheostat at the side, but there is no display of the current
being delivered. C: This unit has four patterns of
stimulation: single twitch (available at 0.1 and 1 Hz), TOF
(which can be repeated automatically every 12 seconds),
50-Hz tetanus, and DBS. It also is capable of delivering the
stimulus pattern for obtaining a PTC. The selected current is
displayed in the window. Failure to deliver this current will
cause a mark to be displayed to the right of the word
ERROR. Note that the connections for the lead wires are of
different colors. D: This unit has three modes of
stimulation: single stimulus (which can be delivered at 0.1,
1, or 2 Hz), tetanus (which is available at a frequency of 50
to 100 Hz), and TOF. Stimulus current is varied by using a
rheostat at the side. The delivered current is displayed in a
window, to the left of which is an indicator that lights when
a stimulus is being delivered. A battery status check button
is present.

Current
Current, not vol t age, is t he determini ng f actor i n nerve st imul ati on. Because ski n
resi st ance may change, onl y a sti mul ator t hat automati call y adj usts i ts output to
mai ntai n a constant di rect current can ensure unchangi ng sti mulati on wi th changes
i n ski n resistance. Wi pi ng the
P. 807

ski n wi th al cohol wi l l remove i nsul at ing ski n oi l s and l ower the resi stance.
The f orce of muscl e cont racti on i s proporti onal to the number of acti vat ed muscle
f ibers. If a mot or nerve i s st imul ated wi th suff i ci ent current , al l of t he muscl e f ibers
suppl ied by that nerve wi l l cont ract. The current requi red f or t hi s is cal l ed t he
maxi mal current. I n the cli ni cal set ti ng, sti mul i of greater than maxi mal
(supramaximal ) i ntensi t y are used to ensure t hat maxi mal sti mulati on i s del ivered i f
resi st ance i ncreases. In the majori ty of pat ients, a current of 30 mi l l i amperes (mA)
wi l l produce a supramaxi mal response when t he ul nar nerve is st i mulated (8). When
t he post erior ti bi al nerve i s st imul ated, hi gher currents are needed (9). A
supramaxi mal current i s general l y 2.5 t o 3 ti mes hi gher t han the l owest current
capabl e of el i ci ti ng an evoked response (threshol d current ) (10). Hi gher currents
may be needed i n pat ients wi t h edema (11,12) or diabetes (13). Much lower
currents (5 to 8 mA) are needed when needl e el ect rodes are used (14).
A current di spl ay i s usef ul i n al erti ng the user t o the possi bi l i t y of a di sconnecti on,
broken l ead, weak battery, or poorl y conducti ng el ectrodes, because t hese
probl ems wi l l cause the current to be reduced. Some st imulators have an alarm to
warn when t he sel ected current i s not bei ng del ivered.
A submaxi mal current may be bett er f or awake pat i ents or for those recoveri ng f rom
anesthesi a, because pat i ent di scomfort i ncreases wi th t he intensi ty of the
st i mulati ng current (15,16, 17, 18). Use of a submaximal current may resul t i n more
rel i abl e det ecti on of resi dual NMB when vi sual or t acti le moni tori ng i s used (19). A
submaxi mal current i s not rel i abl e f or general NMB moni tori ng.
Frequency
The f requency of sti muli is usual l y expressed in Hertz (Hz), whi ch i s cycl es/second.
One Hz i s one cycle/ second, and 0.1 Hz i s equal to 1 sti mul us every 10 seconds.
Wi th a nondepol ari zi ng block, i ncreased stimul us f requency wi l l shorten the onset
t i me and prol ong t he durat i on of acti on (20,21).
Waveform
The sti mul us waveform shoul d be rectangular (square wave) and monophasi c.
Bi phasic waves may produce repet i tive sti mul at ion, whi ch can l ead to
underest imat i on of t he depth of NMB present.
Durati on
The durat i on should be 300 s or l ess (20). If the durati on of t he pul se i s over 0.5
msec, a second act i on potenti al may be t ri ggered.
Sti mulation Patterns
Single Twitch
Si ngl e-t wi tch (T
1
) st i muli are usual ly deli vered at a f requency of 0. 1 or 1 Hz. A
f requency greater than every 10 seconds i s associ ated wi t h a progressi vel y
di minished response and coul d resul t i n overesti mat ing t he NMB.
The cont rol response strength i s not ed (Fi g. 25.2A). The st rengths of subsequent
t wi t ches are then compared wi t h the cont rol and expressed as a percentage of t he
control (si ngl e-pul se or -t wi t ch depression, T
1
%, T1%, T
1
:T
c
). Wi th both a
nondepolari zi ng and a depol ari zi ng bl ock, there wi l l be progressi ve depressi on of
t he response as the bl ock develops. A decrease i n temperature wi l l al so cause a
reduced response (22,23,24,25,26).
The single st i mul us is useful i n establ ishing a supramaxi mal sti mul us and f or
i denti f yi ng when condi t i ons sat i sfactory f or i nt ubat i on have been achieved. I t can
be used (i n conj uncti on wi th a t etani c sti mul us) t o moni tor deep l evels of NMB (the
post-tetanic count , di scussed bel ow).
There are several di sadvantages associated wi t h usi ng si ngl e t wi tch. There needs
t o be a cont rol . I t cannot disti ngui sh between a depol ari zing and nondepolari zing
bl ock. Most importantl y, the response's return t o cont rol l evel does not guarantee
t hat f ul l recovery f rom NMB has occurred.
Train-of-four
Trai n-of -four (TOF, T
4
, T
4
/ T
1
) consists of f our si ngl e pul ses of equal i ntensi t y
del i vered at i nterval s of 0. 5 seconds (2 Hz) (Fi g. 25.2B) (27). TOF should not be
repeated more f requentl y than every 10 t o 12 seconds (4). Many modern
st i mulators do not all ow the TOF t o be repeat ed more of ten. Use of TOF every 10
seconds wi l l resul t i n a shorter onset ti me for NMB t han i f i t is used every 20
seconds (21,28).
Wi th the cont rol response (bef ore any rel axant has been given), al l f our responses
are the same. The pattern seen wi th a depol ari zi ng bl ock dif fers f rom that of a
nondepolari zi ng bl ock (Fi g. 25. 2B). Wi th a parti al depol ari zi ng bl ock, t here i s an
equal depressi on of al l f our twi tches. Wi th a nondepol ari zi ng bl ock, t here i s
progressive depressi on of hei ght wi t h each t wi t ch (f ade). As the bl ock i s deepened,
t he fourt h twi tch wi l l be el i mi nated f i rst , then t he thi rd, and so on (Fi g. 25.3).
Counti ng the number of t wi t ches (t rai n-of -f our-count or TOFC) permi ts quant i tat ive
assessment of a nondepol ari zing bl ock. Wi th recovery or reversal of a
nondepolari zi ng bl ock, the TOFC i ncreases unti l there are four responses, then
f ade decreases.
The t rain-of -f our rat i o (T
r
, T
4
rati o, T
4
:T
1
, T
r
%, TR%, TOF rati o, TOFR) i s the rati o
of t he ampl i tude of t he fourt h response to that of t he f i rst , expressed as a
percentage or a f racti on. I t provi des an estimati on of the degree of nondepol ari zi ng
NMB. I n the absence of nondepolari zi ng bl ock, the TOFR i s approxi mat el y 1
(100%). The deeper t he bl ock, the l ower the TOFR (Fi g. 25.3). Si nce determi ning
t he TOFR requi res that f our t wi tches be present, i t cannot be used t o moni tor a
deep block.
P. 808



View Figure

Figure 25.2 Patterns of stimulation and response. A:
Single-stimulus stimulation at 1 Hz (1 stimulus/second).
The height of the control twitches are noted. With either a
depolarizing or a nondepolarizing block, twitch height is
decreased. B: Train-of-four stimulation. Four successive
single stimuli are delivered with 0.5-second intervals. With
a nondepolarizing block, there will be progressive
depression of the response with each stimulus (fade). With a
depolarizing block, the responses will be depressed equally.
C, D: Double-burst stimulation. Three stimuli are delivered
at 50 Hz, followed 0.75 seconds later by two or three
similar stimuli. There will be depression of the response to
the second burst with a nondepolarizing block. Note the
increased height of the response to the first burst compared
with that seen with TOF stimulation. TW, time weight TOF,
train of four; DBS, double-burst stimulation.


View Figure

Figure 25.3 Onset and progressive deepening of
nondepolarizing block using train-of-four stimulation.
When there is no NMB present, all four responses are equal.
With onset of the block, there is progressive depression of
twitch height with each twitch (fade). As the block
progresses, the last twitch is lost and the TOFC is less than
4. TOFR, train-of-four ratio; TOFC, train-of-four count.

P. 809


Accurate assessment of the TOFR may not requi re a supramaxi mal st i mul us (15).
Testi ng at 10 mA above t he lowest current at whi ch f our responses can be el ici t ed
may provi de values that are consistent wi t h those of supramaxi mal t esti ng (29).
The TOF patt ern has several advant ages. It i s a more sensi tive i ndicator of resi dual
NMB than the si ngle t wi t ch. A cont rol is not necessary. It can di sti ngui sh bet ween a
depol ari zi ng and a nondepol ari zi ng bl ock and is of val ue in detecti ng and f ol l owi ng
t he development of a phase I I bl ock f ol l owi ng succinyl chol i ne admi ni st rat i on.
The mai n di sadvantage of TOF is i ts poor perf ormance at both extremes of NMB,
deep rel axati on or near compl ete recovery (4, 30,31,32, 33,34,35). Tacti l e or vi sual
observat ion of the TOFR i s of l i ttl e value above a rati o of 0.40.5.
Tetanus
Tetanus is a rapi dly repeated (e.g. , 50, 100 or even 200 Hz) sti mul us. I n the
absence of NMB, thi s causes sustai ned cont racti on of the st i mul ated muscl es. Wi th
a depolari zi ng bl ock, the response wi l l be depressed i n ampl i t ude but sustai ned.
Wi th a nondepol ari zi ng block, t he response i s depressed i n ampl i tude and the
contract i on is not sustained (f ade or decrement ). Wi th prof ound NMB, there i s no
response. Fade af ter 50 Hz tetanic sti mulati on i s a more sensi t i ve index of NMB
t han si ngl e twi t ch but not suff icientl y sensi ti ve t o be used f or assessing adequate
recovery (36). St udi es di ff er on the si gni f icance of f ade af t er 100 Hz (36,37).
The most commonl y used f requency i s 50 Hz, because i t st resses the
neuromuscular j uncti on t o the same extent as a maximal vol untary eff ort. Fade may
not be seen at l ower f requencies when a signi f i cant nondepol ari zi ng block is
present. Use of 100 Hz all ows more sensi t ivi t y i n eval uat i ng resi dual paral ysis (37)
and i s more usef ul i n moni tori ng profound NMB (38).
The durat i on of the tetanic st i mul us is i mportant because i t af fects f ade. The
standard durat i on is 5 seconds. Tetanic st i mul ati on shoul d not be repeated more
of ten t han every 2 mi nut es (39,40). Some newer st i mul ators li mi t how f requentl y i t
can be used.
Post-tetanic f aci l i tat ion (potent i ati on, PTF) i s a temporary increase i n response to
st i mulati on foll owi ng a tetanic sti mulus. I t i s seen wi th a nondepolari zi ng, but not a
depol ari zi ng, block (39,41). It i s maxi mal at around 3 seconds and lasts up to 2
mi nutes.
When t he NMB i s so prof ound t hat t here is no response t o si ngl e twi tch or TOF
st i mulati on, i t may be possi bl e to esti mat e NMB by using the post-t etani c count
(PTC) (42). Thi s is perf ormed by admi nisteri ng a tet ani c st i mul us of 50 Hz f or 5
seconds. Af ter a 3-second pause, si ngl e-t wi tch sti mul i are appl i ed at 1 Hz, and the
number of (post-tetanic) responses i s counted. The number of t wi tches el ici ted
i ncreases as the depth of NMB decreases. The ti me to appearance of the f i rst
t wi t ch i n a TOF i s inversel y rel at ed to t he number of post -t etani c twi tches present
(43,44,45, 46, 47,48,49). An even deeper bl ock can be moni tored by count ing the
number of responses f ol l owi ng 100-Hz tetanus (38).
A si gni f i cant di sadvant age of tet anic st i mulati on i s t hat i t i s very pai nf ul and shoul d
be avoi ded i n the consci ous pati ent.
Double-burst Stimulation
Double-burst st imul at ion (DBS, mi ni tetanus) consi sts of t wo short sequences of 50
Hz t etanic sti mul i separated by 750 msec. The two most commonly used are DBS
3, 3

and DBS
3, 2
. DBS
3, 3
consi sts of three 0.2-msec i mpul ses at 50 Hz, f ol lowed 750
msec l at er by an i denti cal burst (Fi g. 25.2C). DBS
3, 2
consi sts of t hree impulses
f ol l owed by two such impulses 750 msec l ater (Fi g. 25.2D). Another permutati on of
DBS i s DBS
3, 3
80-40, which is t hree sti mul i at 80 Hz f ol l owed 750 msec l at er by
t hree sti mul i at 40 Hz. A modi f i ed DBS consi sti ng of f i rst two st i mul i of 0. 3 ms
durat ion at 50 Hz and t hen t wo sti mul i of 0.2 ms durat ion at 50 Hz has al so been
used (50).
The pri mary use of DBS has been to detect resi dual NMB. Studi es show t hat f ade
(response t o the second burst weaker t han t hat to the f i rst ) i s more readi l y detected
wi th DBS than TOF usi ng vi sual or t acti le moni t ori ng (19,30, 31,32,33, 51,52). I t al so
has been used for i nt raoperat ive assessment of NMB (53). DBS and TOF have a
cl ose rel at ionshi p over a wi de range of NMB (4,54,55). Another use of DBS i s to
assess deep bl ock, si nce t he f i rst twi t ch in doubl e burst can be det ect ed at deeper
bl ock l evels than the fi rst t wi t ch i n TOF (53,56,57, 58).
DBS causes more discomf ort to the awake pati ent than TOF sti mul at ion but l ess
t han tetanic sti mul ati on (16). It can be used at submaxi mal currents. This causes
l ess di scomfort i n the awake pat i ent and, i n most cases, is more rel i abl e than
t est ing wi t h supramaximal sti mul i (10).
DBS shoul d not be repeated at interval s of l ess than 12 seconds (32). Cauti on
shoul d be used when swi tching between doubl e-burst and TOF sti mulat i on (59). Up
t o 92 seconds may be requi red bef ore t he responses are stabi l i zed.
Electrodes
St imul ati on is achi eved by placi ng t wo el ectrodes al ong a nerve and passing a
current through t hem. Sti mulati on can be carri ed out ei t her t ranscutaneously usi ng
surf ace el ect rodes or percutaneousl y wi t h needle el ectrodes.
Types
Surface Electrodes
Surface (gel , patch, pad) el ectrodes have adhesi ve surrounding a gel l ed f oam pad
i n cont act wi t h a metal di sc wi t h a knob f or at tachment to t he el ect ri cal l ead. They
are readi l y avai l able, easi l y appl i ed,
P. 810

di sposabl e, sel f -adheri ng, and comf ortabl e. The el ect rodes can be those usual l y
used to moni tor t he elect rocardi ographi c traci ng. The el ect rode-ski n resistance
decreases wi t h a l arge conducti ng area, as do skin burns and pai n. However, a
l arge conduct ing area may make i t dif fi cul t to obtai n supramaxi mal sti mul ati on and
may sti mulate mul ti pl e nerves, so i t may be bet ter to use pedi at ri c el ect rodes. The
best resul ts are obtai ned i f the ski n is properl y cl eansed and rubbed wi t h an
abrasive (20).
There are el ect rodes speciall y desi gned for peripheral nerve st i mul ati on. These
have a dif f erent thickness than electrocardiogram (ECG) el ect rodes and chemical
buff ers t o mai ntain ski n surf ace pH.
Metal Electrodes
Some st i mulators are suppl i ed wi th t wo metal bal ls or plates spaced about 1 i nch
apart , whi ch at tach di rectl y to t he st imulat or (Fi g. 25.1A). These are conveni ent t o
use but may not make good cont act . Burns have been report ed wi t h thei r use (60).
Needle Electrodes
Needle el ectrodes may be usef ul when supramaxi mal st imul at i on cannot be
achieved by using surf ace electrodes. This usual l y occurs when t he ski n i s
t hickened, cold, or edematous and i n obese, hypothyroi d, di abeti c, or renal f ai lure
pati ents (20,61).
Addi t ional compl icat ions (broken needl es, inf ecti on, burns, and nerve damage) are
associ ated wi th t hei r use. Needl e el ect rodes carry a greater ri sk of di rect muscl e
st i mulati on than surface el ect rodes (62).
Polarity
St imul ators produce a di rect current by usi ng one negative and one posi ti ve
el ect rode. The pol ari t y of t he out let sockets shoul d be i ndi cated on the sti mul at or.
Usual l y, the posi ti ve el ect rode is red, and the negat ive is bl ack. Maximal eff ect is
achieved when t he negat ive el ectrode i s pl aced di rect l y over the most superf ici al
part of the nerve being sti mul at ed (63). The posi t ive electrode shoul d be pl aced
al ong the course of the nerve, usual ly proxi mal l y to avoid di rect muscl e sti mul at i on.
I f the pol ari ty i s unknown, the connecti ons can be reversed t o determi ne whi ch
arrangement evokes t he great er response.
Methods for Evaluating Evoked Responses
Visual
Vi sual assessment can be used to count the number of responses present wi th a
TOF st imul us, to determi ne the PTC, and to detect t he presence of f ade wi th TOF
or DBS. Post t etani c f aci l i t ati on can al so be assessed. Studi es have shown that i t is
di ff i cul t to determi ne the TOFR accurat el y or t o compare a singl e-t wi tch height to
i ts control visual l y (30, 64,65, 66). Vi suall y recognizing f ade wi th TOF sti mul ati on
may be easi er wi th submaxi mal currents (30). Visual l y assessi ng fade wi t h 100-Hz
t etani c sti mul at ion appears to be f ai rl y accurate when eval uat i ng resi dual paral ysis
(38).
For visual assessment, t he observer shoul d be at an angl e of 90 degrees to the
moti on (10).
Tactile
Tacti l e eval uat i on is accompl i shed by placi ng the eval uator' s f ingert i ps l i ghtl y over
t he muscl e to be sti mul ated and feel i ng t he st rengt h of contracti on (Fi g. 25.4). I t i s
more sensi tive than visual moni tori ng f or assessi ng NMB usi ng TOF (33). I t can be
used to eval uate t he presence or absence of responses and/or fade wi t h trai n-of -
f our, doubl e burst , and tet ani c st i mulat i on. The PTC can be determined. I f there i s
a response to al l f our sti mul i wi th TOF st i mulat i on, the TOFR can be esti mat ed.
However, i t is di f f i cul t f or even trai ned observ ers to det ect TOF f ade manual l y
unl ess the TOF rati o i s bel ow 40% (31,32,33, 34,67,68,69,70,71,72,73). Det ecti ng
f ade tact i l el y is somewhat easi er wi t h DBS but cannot be depended on to detect
resi dual paral ysi s (31,32,33,50,72,74). Det ect ion i s bet ter when t he evaluator uses
t he domi nant hand of t he pati ent (67).

View Figure

Figure 25.4 For tactile evaluation of thumb adduction, the
hand is supine and a slight preload is applied. (Picture
courtesy of Biometer.)

P. 811


Mechanomyography
The mechanomyogram (MMG) ut i l i zes a f orce-displ acement transducer, such as a
st rai n gauge, attached to a f i nger or other part of t he body t hat can be rest rai ned
by a prel oad and wi l l move when sti mul ated. The t ransducer converts the
contract i le f orce int o an el ect ri cal si gnal , which i s ampl i f i ed and di spl ayed on a
moni tor screen or recorded on a chart . Si ngl e-t wi tch hei ght, response to t etanic
st i mulati on, and the T
4
rat i o can be accuratel y measured by usi ng an MMG (75).
Usi ng the MMG entai l s a number of di ff icul ti es. These devi ces are cumbersome and
di ff i cul t to set up f or st abl e and accurate measurements (76). Proper t ransducer
ori entati on, isometri c condi t ions, and appl i cat ion of a stabl e prel oad are requi red
(77). Mai ntenance of muscl e temperature wi thin l imi ts i s i mport ant for accurate
resul ts. Mechanomyography i s rarel y used cl i ni cal l y but i s regarded as t he gol d
standard f or sci enti f ic measurement of neuromuscul ar response (5,78).
Acceleromyography
Wi th accel eromyography (ACG, AMG), a thin pi ezoel ect ri c transducer or a smal l
al umi num rod wi t h el ectrodes on both sides i s f ixed to t he movi ng part (79,80) (Fi g.
25.5). When the part moves, a vol tage whi ch i s proport i onal to t he accelerat i on of
t he movi ng part i s generated. This method requi res unrest ricted movement of the
muscle being sti mul ated. An el asti c preload can be appl i ed t o return the moving
part t o i ts ori gi nal posi t i on.
ACG can be used to assess NMB at the hand wi t h the pati ent' s arm t ucked at the
si de as l ong as t he thumb can move f reel y. A protecti ve devi ce can be used to
al l ow t humb mot i on whi l e protect ing t he hand and f orearm (81).
Most studi es show a f ai rl y cl ose rel ati onship between TOFRs measured by ACG
and the MMG (29,80, 82,83,84,85,86,87,88,89,90, 91) or el ectromyography (EMG)
(75,85,92, 93), al though t he resul ts are not i nt erchangeable. Some st udi es show
poor correlati on (94,95). In awake pat ients, the resul ts are aff ect ed by extra
movements to whi ch the thumb may be subj ected, leadi ng to poor repeatabi l i ty (96).
Accel erometry is easy and conveni ent t o use, rel at ive i nexpensi ve, and can be
i nterf aced wi t h a computer. It does not requi re a preload. I t gi ves more accurate
resul ts than visual or tacti l e eval uat i on (68,92).
Kinemyography
Ki nemyography (KMG) ut i l izes a bending sensor that i s placed between t he t humb
and f oref i nger (Fi g. 25. 6). The core of t he sensor i s a pi ezoel ectric materi al (97).
Movement i s det ermined by the change i n shape of the materi al when i t i s bent by
adductor pol l i ci s muscl e cont racti on. When t he pi ezoelectri c materi al changes
shape, t he el ectrical charge i n the materi al i s redist ri buted, and thi s l eads to an
el ect ron fl ow to balance the charges. Thi s fl ow i s measured as a potent ial change
t hat i s proporti onal to the amount of distorti on. The hand need not be immobi l i zed
si nce the posi t i on and di recti on of the thumb do not af f ect the measurement as l ong
as t he thumb is abl e to move f reel y. This devi ce i s i n a modul e that can be
P. 812

added to a mul ti purpose moni tor (Fi g. 25.7). The resul ts of the neuromuscul ar
t est ing are di spl ayed on the moni tor screen. This technol ogy can measure TOF,
doubl e burst, and si ngl e twi t ch.

View Figure

Figure 25.5 Accelerography. The piezoelectric wafer is
attached to the moving part-in this case, the thumb. When
the thumb moves, an electrical signal proportional to the
acceleration is produced. The monitor allows determination
of single-twitch depression, TOF count or ratio and/or the
PTC. Responses can be displayed by using the printer.
(Courtesy of Biometer International A/S.)


View Figure

Figure 25.6 Sensor for kinemyography. The sensor is
secured with tape.

KMG has been compared wi th mechanomyography (98,99). There was agreement
as t o the t i me to i ntubati on and recovery, but KMG l agged behi nd t he MMG i n
determining recovery f rom NMB.
Piezoelectric Film
Thi s met hod uses a disposabl e piezoel ectri c f il m (100). This i s pl aced so t hat i t
spans a movable j oi nt (101). Muscl e movement f rom evoked sti mul at ion bends the
f il m and generates a vol t age t hat i s proporti onal to t he amount of bendi ng. It has
been used on the thumb, f if th di gi t , and the great t oe (101,102). I t can be used wi t h
t he pat ient' s hands tucked at hi s or her sides.
Thi s met hod i s not as accurate as mechanomyography or EMG but may predict
recovery of the TOFR bett er t han vi sual or tact i le eval uati on (100,103,104, 105).
Electromyography
El ect romyography (EMG) i s the process of recordi ng t he el ect ri cal act ivi t y of a
muscle (106,107). When a motor nerve is sti mulated, a bi phasic acti on potent i al i s
generated i n each of the muscl e cel l s i t suppl i es, unl ess some degree of NMB
exists. The sum of a number of t hese act ion potent ial s can be sensed by usi ng
el ect rodes pl aced over the muscl e bei ng sti mul ated. Five electrodes are used. Two
st i mulati ng el ect rodes are pl aced over the nerve to be st i mulated. Three el ect rodes,
t wo receiving (sensi ng, recordi ng) and one ground, are used f or recordi ng. The best
si gnal i s usual l y obt ai ned by pl aci ng the acti ve receivi ng el ect rode over t he bel l y of
t he muscl e wi th t he i ndif f erent (ref erence) el ect rode over t he tendon i nsert i on si t e.
The ground el ect rode, whose funct ion i s to decrease sti mulati on arti facts, i s placed
bet ween t he st i mulati ng and recordi ng el ectrodes. Best resul ts wi l l be seen when
t he el ect rodes have been i n contact wi t h the skin f or at l east 15 mi nut es (cure t i me)
before cal i brat i on. Caref ul ski n preparati on wi l l hel p t o gi ve good resul ts (20).
Movement art i f act can be mi ni mi zed by f i xati on or by appl ying a constant prel oad t o
t he muscl e bei ng recorded (108,109).
EMG of t he larynx can be accompl ished by using ei t her a speci al i zed tracheal t ube
wi th i ncorporated wi re el ect rodes or a superf i ci al el ectrode at t ached ci rcul arl y
around the tube and pl aced bet ween the vocal cords (110).
The evoked EMG si gnal i s f i l t ered, recti f i ed, ampli f i ed, and then di spl ayed and/ or
recorded at a much sl ower speed. Measurements may be made of peak-t o-peak
ampl i tude of the major def l ecti on. The sum of t he ampl i tudes of the maj or posi ti ve
and negat i ve def l ecti ons, or t he area under the curve (i nt egrated EMG), can be
measured (78,111).
An EMG machi ne (Fig. 25. 8) automati cal l y determi nes the supramaxi mal sti mulus,
establ i shes a cont rol
P. 813

response, sti mul ates at a selected i nterval , measures the response, and compares
i t wi th the cont rol . Avai l abl e f eatures i ncl ude an al arm t o warn when t he si ngle
pulse response exceeds a chosen val ue and a pri nter to provi de a permanent
record. Most have al arms for funct ioni ng errors, l oose connecti ons, i ncreased ski n
resi st ance, absence of supramaxi mal sti mul at ion, and the l ike. Most show t he EMG
waveform and automat i cal l y adj ust the gai n so that i t occupi es t he f ul l scal e.

View Figure

Figure 25.7 The TOF count and ratio are shown on the
monitor. The scale at the bottom shows the frequency of
stimulation (every 20 seconds) and how much time has
elapsed since the last stimulus. This information comes
from a Kinemyograph.


View Figure

Figure 25.8 Electromyography monitor. The T
1
%, TOFR,
and TOFC can be measured and are displayed in the boxes
to the right of the printer. Responses can be recorded by
using the printer. A T
1
% high alarm is present. TOF
stimulation is performed automatically every 20 seconds.
(Courtesy of Datex Medical Instrumentation, Inc.)

Wi th a nondepol ari zi ng NMB, the acti on potenti al ampl i tude is decreased, and t here
i s fade wi t h TOF. Frequentl y, the ampl i tude does not return to 100% of control wi th
recovery, al though t he TOFR wi l l equal approxi matel y 100%. Di ff erent hand
posi t i ons may af fect the resul ts (112).
A number of studi es compari ng EMG and MMG have been publ i shed
(86,113,114,115,116,117,118,119,120,121,122,123,124). Wi th a nondepolari zi ng
bl ock, a fai rl y good correlat i on is usual l y seen, al though the t wo t echniques do not
gi ve i dent i cal i nf ormati on. Wi t h a depol ari zing bl ock, the rel at i onship i s more
compl ex, and studies show contradi ct ory resul ts (125). The TOFR determined by
EMG may be less af fected by changes i n t emperature than wi t h t he MMG (123).
The neuromuscul ar trace does not al ways recover to the level of the i ni t ial
cali brati on value. The recovery t i mes of muscl e rel axants can be accurat el y
determined if measurements are ref erenced to t he new basel i ne (126). The l oss of
supramaxi mal sti mulati on i s part l y responsibl e f or the observed changes in t he
evoked el ectromyogram duri ng anesthesi a (127).
EMG has several advantages over mechanomyography. Less i mmobi l i zat i on is
requi red. I t does not requi re bulky apparat us near the muscl e bei ng moni tored. The
hand and arm do not need t o be extended or put on a board (78,128). It can be
used to moni tor muscles not avai lable t o the MMG such as the di aphragm and the
l aryngeal muscl es (20,129,130,131, 132,133, 134,135). I t can be used to assess
motor nerve bl ock induced by regi onal anest hesi a (136).
There are disadvant ages to EMG. It is sensi ti ve to el ectri cal i nterference. The
response may vary according t o the muscl e used. The equi pment i s expensi ve and
t akes some ti me and ef f ort t o set up. Ski n preparat ion and elect rode pl acement
must be done especial l y caref ul l y. Since the si te is not i mmobil i zed, changes i n the
rel ative posi t i on of the recording electrodes cause variat i on i n EMG response.
Temperature pl ays an i mportant rol e i n the response ampl i tude wi t h ampl i t ude
i ncreasi ng wi th decreasi ng muscl e temperature (20).
Phonomyography
Phonomyography (acousti c myography or moni t ori ng) rel i es on the fact that when a
muscle cont racts, l ow-f requency sounds are emi t ted. These acoustic waves
propagat e to the ski n, generati ng waves that can be recorded by a smal l
pi ezoel ect ri c microphone. The
P. 814

si gnal ampl i tude has been shown t o be proporti onal to the degree of muscl e
contract i on.
Thi s met hod has been used to measure responses i n the hand muscl es when the
mi crophone i s t ightl y secured t o the thenar mass t o moni tor the adductor pol l i ci s
muscle, or t o the groove bet ween t he f i rst and second met acarpel bone to moni tor
t he f i rst dorsal int erosseus muscle (137, 138,139,140,141,142). The corrugator
superci l i i muscle can be moni tored by pl acing the mi crophone above the medi al
port ion of the eyebrow (142, 143, 144,145). The muscl es of the l arynx can be
moni tored by pl aci ng the sensor i n the vesti bul ar f ol d j ust l ateral to t he vocal cords
(110, 146,147).
St udi es compari ng phonomyography, ACG, and mechanomyography by usi ng hand
and corrugator superci l i i muscl es show some agreement, al t hough the resul ts are
not i nterchangeabl e (99,140,141,143,144,145,146).
The phonomyogram i s easy to use and can be used on a number of di f f erent
muscles. I t provi des a stabl e basel i ne wi th r el ati vel y f ew di sturbances f rom arti f acts
(145). Data can be t ransf erred to an automated anesthesia record.
Si nce t hi s method moni tors l ow f requency sounds, art i f acts are possible. Vessel
pulsati ons can cause smal l waves i n the baseli ne. Elect rosurgery uni ts may cause
i nterf erence. The mi crophone may come of f the ski n.
Choice of Monitoring Site
The si te of sti mulati on shoul d be away f rom the surgical f iel d. I f vi sual or t acti l e
moni tori ng i s to be used, t he l ocat i on must be accessi bl e t o the anesthesia
provi der. I f a muscl e in an arm or l eg is used, t he bl ood pressure shoul d be
measured on a dif ferent ext remi t y. An art eri ovenous shunt does not contrai ndi cate
t hat arm bei ng used to moni tor NMB (148). I f the pati ent has an upper-mot or-
neuron l esi on, a nerve in an af f ected (pareti c) extremi ty shoul d not be used,
because i t may f al sel y show resi stance to nondepol ari zi ng drugs (149,150). If
possi bl e, t he nerve st imul ator electrodes shoul d be pl aced on a dif f erent ext remi t y
f rom the pul se oxi met er probe to avoi d art i facts (151,152,153).
Ulnar Nerve
The ul nar nerve is most commonl y used, and the adductor pol l i ci s (t humb) muscle
i s most commonl y moni tored. Because this muscl e i s on the si de of t he arm
opposi te t he si te of st imul at ion, t here i s l i t tl e di rect muscl e sti mulati on. However,
resi dual NMB may be easi er t o detect tact i lel y by using t he i ndex f i nger (71).
The ul nar nerve can be sti mul ated at the elbow, wri st, or hand (Fi gs. 25.9, 25. 10).
St imul ati on at t he wri st wi l l produce thumb adducti on and f inger f l exi on. St i mul ati on
at t he el bow produces hand adducti on as wel l . If an MMG or electromyogram i s
used for measuri ng the response, the sti mul at ing electrodes shoul d be pl aced at
t he wri st t o li mi t hand moti on.

View Figure

Figure 25.9 Placement of electrodes for ulnar nerve
stimulation. A: The electrodes are placed along the ulnar
aspect of the distal forearm. B: The electrodes are placed
over the sulcus of the medial epicondyle of the humerus.

At t he wri st , t he two el ectrodes shoul d be pl aced along the medial aspect of the
di stal f orearm, approxi mat el y 2 cm proximal to the proxi mal wri st ski n crease wi th
t he negati ve el ect rode di stal (18) (Fig. 25. 9A). There, t he ul nar nerve is superf i ci al .
Al ternatel y, t he posi ti ve el ect rode may be pl aced on t he dorsal si de of the wri st
(Fi g. 25.10). At the el bow, t he el ect rodes shoul d be pl aced over t he sul cus of the
medi al epi condyl e of the humerus (Fi g. 25.9B). Caut ion must be exercised to
ensure t hat the el ectrodes do not cause ul nar nerve compression (154). The
el ect rodes may al so be placed on the hand wi th t he negati ve el ect rode on the pal m
bet ween t he base of t he thumb and the second f i nger and t he posi t ive electrode i n
t he same posi t i on on the dorsal si de of t he hand (155).

View Figure

Figure 25.10 Alternate placement of electrodes for ulnar
nerve stimulation. The negative electrode is placed along
the ulnar aspect of the ventral side of the wrist. The positive
electrode is placed on the dorsal side.

P. 815



View Figure

Figure 25.11 Sites for electrodes for electromyography
monitoring with ulnar nerve stimulation and recording from
the dorsal interosseous muscle. The active receiving
electrode is placed in the web between the index finger and
the thumb and the reference electrode, at the base of the
second finger. Ref, reference electrode; AR, active
receiving electrode; G, grounding electrode; N, negative-
stimulating electrode; P, positive-stimulating electrode.

When EMG moni tori ng is used, t he recordi ng el ect rodes can be placed over the
hypothenar, t henar, or dorsal i nterosseous muscl e. The electrical resi st ance of the
pal m ski n may vary because of sweat product i on and may be i ncreased in manual
workers (156). The dorsum of the hand is l ess af f ected than the pal m i n both
respects, so t he dorsal i nt erosseous muscl e may be pref erred. To record the
react i on of the dorsal i nterosseous muscl e, the act ive receiving electrode i s pl aced
i n the web between the i ndex fi nger and the thumb and the other el ect rode at the
base of t he second f i nger (Fig. 25. 11). Surface el ect rodes are simpl e to f ix here,
easy to mai nt ai n i n posi t i on, and sel dom are di st urbed by hand movements (157).
For the hypothenar EMG, bot h el ect rodes are pl aced on the pal mar si de over t he
hypothenar emi nence or the active el ectrode i s placed on t he hypothenar eminence
and the other below t he second l ine on the ri ng f i nger or at t he base of the dorsum
of t he f if th f i nger (Fi g. 25.12) (158,159). If the thenar muscle EMG is recorded,
el ect rodes are pl aced on t he thenar eminence and the proxi mal phal anx of the
mi ddl e or i ndex f inger or t he l ateral si de of t he base of the thumb (Fi g. 25. 13).
Abduct ion of the t humb wi t h a constant pret ension wi l l bring the muscl es cl oser to
t he ski n and mi nimi ze movement (14,109).

View Figure

Figure 25.12 Placement of electrodes for electromyography
monitoring from the hypothenar eminence. The active
electrode is placed over the hypothenar eminence. The
reference electrode may be placed more distally on the
hypothenar eminence, below the second line on the ring
finger or at the base of the fifth finger as shown. Ref,
reference electrode; AR, active receiving electrode; G,
grounding electrode; N, negative-stimulating electrode; P,
positive-stimulating electrode.

For tacti l e assessment , the thumb shoul d be held i n sl i ght abduct ion and the
observer's f ingerti ps pl aced over the di stal phal anx i n t he di recti on of movement
(160) (Fi g. 25.4). Prel oadi ng the thumb wi t h a rubber band may i mprove vi sual
assessment (161). I t shoul d be noted that the adductor pol li ci s i s somet imes
suppl ied by the medi an nerve (162).
When moni tori ng t he adductor pol l icis muscl e, i t is i mportant to real i ze that the
onset and durati on of NMB at the l arynx and t he di aphragm are shorter than at t he
peri pheral muscl es (78,131,132,163,164).
Median Nerve
The median nerve i s l arger t han the ulnar but less superf icial (165). It can be
st i mulated at the wri st by pl aci ng the el ect rodes medi al t o where the electrodes
woul d be pl aced for ulnar nerve st i mulati on or at the el bow adjacent to the brachi al
artery. Thi s resul ts i n thumb adducti on. The EMG si gnal can be moni tored f rom the
t henar muscl es.
P. 816



View Figure

Figure 25.13 Placement of electrodes for monitoring the
electromyogram from the thenar eminence. The active
receiving electrode is placed over the thenar eminence. The
reference electrode may be placed as shown here or at the
proximal phalanx of the middle or index finger. Ref,
reference electrode; AR, active receiving electrode; G,
grounding electrode; N, negative-stimulating electrode; P,
positive-stimulating electrode.

Tibial Nerve
To st i mulate the ti bi al nerve at the popl i t eal f ossa, t wo sti mul at i ng el ect rodes are
pl aced along the l at eral si de of t he popl i t eal f ossa. The gast rocnemi us muscle i s
st i mulated. Thi s is usual l y moni tored by the EMG wi t h t he sensi ng el ect rodes over
t he l ateral head of t he gastrocnemius muscl e (166). The use of thi s muscle may
cause si gni f icant l eg movement , whi ch may di st ract the surgeon (78).
Posterior Tibial Nerve
To st i mulate the posteri or ti bi al nerve, el ectrodes are pl aced behind the medial
mal eol us and anteri or t o the Achi l l es tendon at the ankl e (Fi g. 25.14). Sti mul ati on
causes pl antar f l exi on of the f oot and bi g toe. ACG can be used at thi s si te
(9,167,168,169). I f EMG moni tori ng is used, t he receivi ng el ect rodes are pl aced on
t he f l exor hal luci s brevi s on t he pl antar surf ace of the f oot or on t he intermetatarsal
muscles wi t h the ref erence el ect rode on the big t oe (Fig. 25. 15).
The posteri or t i bial nerve si te off ers many advantages. It i s especi al l y usef ul i n
chil dren, when i t i s di ff i cul t to f i nd room on t he arm because of other moni tors or
i nvasive l i nes, and when t he hand is i naccessi bl e or f or other reasons such as
amputati on, burns, i nfect ion, or head and neck procedures (170).

View Figure

Figure 25.14 Placement of electrodes for stimulating the
posterior tibial nerve. The negative electrode is placed
behind the medial malleolus, anterior to the Achilles tendon.
The positive electrode is placed just proximal to the
negative electrode. Stimulation causes plantar flexion of the
great toe.

Compared wi t h t he ul nar nerve, t he posteri or ti bi al nerve displ ays a lag ti me wi t h a
sl ower onset of rel axati on (169,171, 172). Most st udi es show l i tt l e di f ference in t he
t i me t o recovery f rom the neuromuscular rel axati on (170, 171,172,173, 174, 175). The
probabil i ty of t acti l e detecti on of fade i n response to TOF or DBS i s less at the
great t oe t han at the thumb (73).
Peroneal Nerve
To st i mulate the peroneal (l at eral popli t eal ) nerve, el ectrodes are pl aced on the
l ateral aspect of the knee (Fi g. 25.16). It may be necessary to t ry di f f erent posi t ions
t o achi eve the best response (176,177). St imul ati on causes dorsi f l exi on of the f oot .
Compared wi t h t he ul nar nerve, t he peroneal nerve shows a sl ower onset of
rel axat ion and the muscl es show greater resistance to NMB (177).

View Figure

Figure 25.15 Electromyography monitoring using the
posterior tibial nerve. The active receiving electrode is
placed over the flexor hallucis brevis and the reference
electrode, on the big toe. Ref, reference electrode; AR,
active receiving electrode; G, grounding electrode; N,
negative-stimulating electrode; P, positive-stimulating
electrode.

P. 817



View Figure

Figure 25.16 Electrode placement for stimulating the peroneal (lateral
popliteal) nerve. The electrodes are placed lateral to the neck of the
fibula. Stimulation causes dorsiflexion of the foot.

Muscular Branch of the Femoral Nerve
The muscul ar branch of the femoral nerve can be st i mul ated and movement i n t he
vastus medi al i s muscle eval uated. This muscl e can be used to moni tor
neuromuscular functi on i n the prone pati ent . When compared wi th the adductor
pol l icis muscl e, t he onset of NMB and recovery were quicker (178).
Facial Nerve
The f aci al nerve, whi ch enervates the muscl es around t he eye, is one of the easi er
muscles to sti mulate and observe. I t i s most usef ul f or det ecti ng the onset of
rel axat ion i n the muscl es i n the j aw, l arynx, and di aphragm (179). ACG can be used
wi th t he faci al nerve (180, 181,182,183).
Several di ff erent electrode conf i gurat i ons have been used for st i mul at ing t he f aci al
nerve:
The negative el ect rode i s pl aced j ust ant erior to the inf erior part of t he ear
l obe, and the other el ect rode is pl aced just posteri or or i nf eri or to the l obe
(Fi g. 25.17). Sti mul at i on at this si t e wi l l make i t more l i kel y that muscl e
contract i ons are the resul t of nerve st imulati on rat her than di rect muscl e
st i mulati on.
One el ect rode i s placed l ateral to and bel ow t he l ateral canthus of the eye,
and the other el ectrode i s pl aced anteri or t o t he earl obe (184) or 2 cm l at eral
t o and above the l at eral canthus. This pl acement may resul t i n di rect muscle
st i mulati on. If one of these conf i gurat ions is used, low currents (2030 mA)
shoul d be used (110).

View Figure

Figure 25.17 Electrode placement for stimulating the facial
nerve. The negative electrode is placed anterior to the
earlobe. The positive electrode is placed posterior or inferior
to the earlobe.

The corrugated superci li i muscl e shoul d be observed (185). Wi th ACG, the
t ransducer shoul d be placed i n the mi ddl e of t he supercil iary arch (182).
The f aci al muscl es are rel ativel y resist ant to NMB drugs (180, 186). Therefore,
managi ng NMB by sti mul ati ng the faci al nerve wi l l resul t i n greater rel axati on than
f rom st imul ati ng a l i mb nerve if equi val ent responses are used. The faci al nerve
shoul d not be used to assess recovery f rom NMB because the responses may show
compl ete recovery whi l e si gni f i cant NMB is st i l l present (182,183,184, 187,188,189).
Mandibular Nerve
The mandi bul ar nerve, a branch of t he tri gemi nal , suppl ies the masset er muscl e. It
can be sti mul at ed by pl aci ng the negative el ect rode ant eri or and i nferi or to the
zygomat i c arch and by pl aci ng the posi ti ve el ectrode on t he f orehead. Sti mul ati on
causes t he j aw t o cl ose. The onset of NMB i n thi s muscl e i s faster than i n the hand
muscles (190,191). In adul ts, thi s muscle i s more sensi ti ve to both depol ari zing and
nondepolari zi ng drugs than the hand muscles (190,192). In chil dren, the sensi ti vi ty
may be equal (191).
Spinal Accessory Nerve
The spinal accessory nerve can be sti mulated by placing the el ectrodes over the
depressi on bet ween the ramus of t he mandi bl e and t he mastoi d process/
sternocl ei domastoid muscl e (193). St i mulati on causes t he sternomastoi d and
t rapezi us muscl es t o contract .
P. 818

Thi s can cause shoul der and thorax movement wi t h transmissi on to t he abdomen
(194).
Recurrent Laryngeal Nerve
The recurrent l aryngeal nerve i nnervates most of the i ntri nsi c muscl es of the l arynx
(110). I t can be sti mulated percutaneousl y by usi ng two electrodes between the
notch between the thyroi d and the cri coid cart i l ages (110,195). The response can
be measured by pl aci ng the tracheal tube cuf f between the vocal cords and
measuri ng pressure changes wi thi n the cuf f (195) or by usi ng phonomyography wi t h
t he microphone pl aced i n the vesti bul ar f ol d l ateral to the vocal cords (146). EMG
i n the l arynx can be accompl i shed by usi ng a speci al i zed t racheal tube wi th
i ncorporated wi re el ect rodes (196) or an el ect rode attached to t he tube and pl aced
bet ween t he vocal cords (130).
Use
Before Induction
Pri or to anesthesi a inducti on, the sti mulator shoul d be connected t o el ect rodes that
are posi t ioned over the selected nerve. If EMG moni tori ng is to be used, the
receivi ng el ect rodes shoul d be pl aced at least 15 mi nutes bef ore induct ion.
El ect rode si tes shoul d be dry and f ree of excessi ve hai r or scar t i ssue or other
l esi ons. The skin shoul d be thoroughl y cl eansed by usi ng a solvent such as al cohol ,
t hen completel y dri ed and rubbed briskl y wi t h a gauze pad unti l a sl i ght redness i s
vi si bl e.
The el ectrodes shoul d be checked to veri f y t hat the gel i s moi st . It is i mportant to
avoid spreadi ng the gel or overlappi ng adhesive whi le pl acing the el ect rodes. A gel
bri dge bet ween the el ect rodes can short-ci rcui t them and l ead to poor sti mul at ion.
Af ter the l eads are at tached t o the electrode, a piece of tape shoul d be pl aced over
t he l eads to prevent movement . I t is good practice to create a l oop to prevent
el ect rode di spl acement (Fi g. 25.18).
Induction
During i nduct ion, t he neuromuscul ar st i mulator can be used to determi ne the onset
t i me of NMB, detect unusual sensi ti vi t y to relaxants, and det ermi ne whether or not
t he pat ient i s suf f i ci entl y rel axed f or t racheal intubat ion.
Af ter inducti on of anest hesi a but bef ore admi ni steri ng any muscl e relaxants, t he
st i mulator should be turned ON and set t o del iver si ngle-t wi t ch sti muli at 0. 1 Hz.
Appl ying sti mul ati on more f requentl y wi l l make i t appear as i f the t i me of onset of
NMB is short er (197,198, 199). The output of t he st imulat or shoul d be i ncreased
unti l the response does not increase wi th i ncreasi ng current , t hen i ncreased 10% t o
20%. If maxi mal sti mul at ion is not achi eved wi t h a current of 50 t o 70 mA, the
el ect rodes shoul d be checked f or proper pl acement. I f maximal st imul ati on sti l l
cannot be achi eved, needl e elect rodes shoul d be used.
Speci al needl e el ectrodes are avai lable commercial l y, but ordi nary i nj ect i on
needl es can be used. They shoul d be short and thi n. The needl es shoul d be pl aced
subcutaneousl y. Insert i ng them deeper may produce di rect muscl e exci tati on and/or
cause damage to the nerve. The angl e of i nsert i on shoul d be paral l el t o the nerve.
There shoul d be at l east a f ew centi meters between the needl es. They shoul d be
f ixed in pl ace wi t h t ape. The l ead shoul d be att ached to t he shaf t of the needl e
unl ess the needl e has a metal hub.
Correct EMG el ect rode pl acement shoul d be veri f i ed by observi ng the qual i ty of t he
evoked wavef orm, whi ch shoul d approximate a si ne wave. The gain control shoul d
be adjusted so that the wavef orm occupi es t he ful l scal e.
Intubation
Compl et e rel axati on of the j aw, l aryngeal and pharyngeal muscl es, and di aphragm
i s needed for excel l ent i ntubati ng condi ti ons and to reduce the ri sk of trauma. I t
shoul d be kept in mi nd that the response t o i ntubati on i s a functi on of bot h
muscul ar bl ock and the l evel of anesthesi a. It
P. 819

i s possibl e to i nt ubate a pat ient wi th l ess-t han-complete paral ysi s i f a suf f i ci ent
depth of anesthesi a i s present (200).

View Figure

Figure 25.18 Electrodes in place. Creating loops and
securing the wires with tape will decrease the likelihood that
the wires will be pulled off the electrodes.

The onset of NMB wi l l be f aster i n cent rall y l ocated muscles such as the
di aphragm, faci al , l aryngeal , and j aw muscles t han peri pheral muscl es such as the
adductor pol l i ci s (110,190, 201, 202,203,204,205,206,207,208,209,210).
The di aphragm, eye muscl es, and most l aryngeal muscl es are more resi stant to
nondepolari zi ng relaxants than are peri pheral muscl es (211,212). The diaphragm is
resi st ant to succinyl chol i ne, t hough the l aryngeal muscl es are sensi t ive t o i t . The
masseter muscle i s rel at i vel y sensi t ive to both nondepol ari zi ng and depol ari zi ng
rel axants (192,213). I t of ten reacts wi th i ncreased tone i nstead of relaxat ion to
succi nyl chol i ne, parti cul arl y i n chi l dren.
Moni tori ng the response of the eye muscl es wi l l refl ect the t i me of onset and t he
l evel of NMB at the ai rway muscul ature more cl osel y than moni tori ng peri pheral
muscles, whi ch wi l l underesti mate the rate of onset of NMB i n t he ai rway
muscul ature and may overesti mate t he degree of block
(163, 179,202,214, 215, 216,217, 218).
I f the f aci al nerve cannot be used, a peri pheral nerve wi l l suff i ce in most cases. I n
t he majori ty of pat ients, di sappearance of the adductor pol li ci s response is
associ ated wi th good to excel lent i ntubati ng condi t i ons. If t he el ect romyographi c
responses are bei ng moni t ored, moni tori ng at t he hypothenar emi nence may be
pref erabl e (157).
Whatever nerve i s used, i t i s recommended that si ngl e twi t ch at 0.1 Hz be used and
t hat the cl inici an wai t unti l a response i s barel y percept ible before att empt i ng
l aryngoscopy and intubat ion. More rapi d st imul ati on may accelerate the onset of
bl ock at the sti mul ated si te (198,199). Doubl e burst has been used as an i ndicator
of opti mal condi ti ons for tracheal i nt ubat i on (219).
The response to sti mul at ion wi l l usual l y di sappear for a vari able peri od of t i me,
t hen appear and i ncrease progressi vely t o ful l recovery. Addi t ional rel axants shoul d
not be gi ven unti l there i s evi dence of some recovery to make sure that the pati ent
does not have an abnormal response. However, i t i s not necessary t o wai t for
compl ete recovery bef ore givi ng addi t ional rel axants.
Electroconvulsive Therapy
A common error i n el ectroconvul si ve therapy i s del iveri ng t he el ect ri cal sti mul us
prematurely (220). I t i s recommended that a single sti mul us be appl i ed at 1 Hz t o
t he post erior ti bi al nerve (221). When t here i s compl ete abol i t i on of response, the
el ect roconvul si ve therapy should be appl i ed.
Maintenance
During maintenance, the sti mul ator can be used to t i trate t he relaxant dosage to t he
needs of t he operat i ve procedure so both under- and overdosage are avoided. Too
deep an NMB may make i t dif fi cul t t o reverse the rel axant at the termi nat i on of t he
anesthet ic. Underdosage may resul t i n inadequat e rel axati on or undesi rabl e pat ient
movement . In a study of cl osed clai ms against anesthesi ol ogi sts, eye injuri es
const i tut ed 3% of cl ai ms (222). Pati ent movement duri ng anesthesi a was the
mechani sm of i nj ury i n 30% of t hose cases. Peripheral nerve st i mul ators were not
used i n any pat ients who made cl ai ms f or movement under anesthesi a.
The degree of NMB requi red duri ng a surgi cal procedure depends on many f act ors,
i ncl udi ng t he type of surgery, the anesthet ic t echni que, and the dept h of
anesthesi a. I t i s import ant t o prevent cooli ng of the moni t ori ng si te to avoid
i mpai red nerve conducti on or i ncreased skin resi stance, whi ch may resul t i n
overesti mati on of the degree of NMB (26,223, 224).
I t i s i mportant to correl ate t he react i on to nerve st i mul ati on wi th t he pat ient' s
cl i nical condi ti on because there may be a di screpancy between the degree of
rel axat ion of the moni tored muscles and that of the muscles at t he si te of surgery.
I f the surgeon bel i eves t hat rel axati on i s inadequat e, the anesthesi a provider
shoul d conf i rm that the depth of anest hesi a i s suff i ci ent and the degree of NMB i s
adequate. I t shoul d be confi rmed that the st i mulator i s worki ng properl y. If i t does
not di spl ay the del ivered current , el ectrodes may be placed on the user' s arm and a
l ow current used t o conf i rm proper f uncti on.
TOF i s commonl y regarded as t he most usef ul pattern f or moni tori ng NMB duri ng
mai ntenance. Supramaxi mal currents are t radi t i onal l y used. A submaximal current
may be used, but this i s controversi al (15, 18, 19,30,104,225,226). The goal f or most
cases i n whi ch abdomi nal muscle rel axat ion i s requi red shoul d be t o mai ntai n at
l east one response to TOF st i mulati on i n a peri pheral nerve (227,228). If no
response i s present , f urther administrat ion of rel axants is not indicat ed. If two
responses are present, abdomi nal rel axati on may be adequate using balanced
anesthesi a (229). Presence of t hree t wi tches is usual l y associ ated wi t h adequate
rel axat ion i f a vol at i le anest het ic agent i s used. Deeper l evels of NMB may be
requi red f or upper abdomi nal or chest surgery or i f di aphragmat ic paral ysis i s
needed. If t he f aci al muscl es are used, at l east one twi t ch shoul d be added to t he
ment i oned recommendat i ons.
Muscle rel axants are someti mes admi ni stered i n cases such as eye surgery or l aser
surgery on t he vocal cords to guarant ee that movement does not occur. To ensure
t otal di aphragmati c paral ysi s, t he NMB should be so i nt ense t hat there i s no
response to post -t etani c
P. 820

st i mulati on (i .e., the PTC i s 0) (230,231). One approach i s to gi ve a bol us of a
short -acti ng muscl e rel axant when t he PTC i s 1 (232). Al ternati vel y, the t wi tch
response at a resi stant muscl e such as the orbi cul aris ocul i may be moni tored and
a dose of relaxant given as soon as there i s any response.
Recovery and Reversal
At t he end of a procedure, a st i mul ator al l ows t he anesthesi a provi der t o det ermi ne
whether or not the block is reversi bl e and adj ust the dose of reversal agent, if
requi red, t o the pati ent 's requi rements (233). Numerous st udi es have shown that
some pati ents ent ering the postanesthesi a care uni t have an unacceptabl e l evel of
bl ock
(69,234,235,236,237,238,239,240,241,242,243,244,245,246,247,248,249,250,251,2
52,253). A nerve sti mul ator may det ect residual NMB, which coul d lead to l if e-
t hreateni ng compl i cat ions (74,254, 255, 256,257,258).
When rel axat i on is no l onger requi red, admi ni st rati on of NMB drugs shoul d be
di scont inued. As recovery progresses, the responses to TOF wi l l progressi vel y
appear, then f ade wi l l di sappear. The ease of reversi ng a nondepol ari zi ng bl ock i s
i nversel y related to the degree of bl ock at the ti me of reversal (6,259). I f the f i rst
t wi t ch (T
1
) i s present , i t can be est i mated how quickly t he bl ock can be reversed.
The t i me depends on the rel axant that has been used.
Recovery is governed by t he sensi ti vi ty of the muscl e and rate t hat t he drug
di sappears f rom the plasma. I t is best t o use a peri pheral muscl e t o moni tor
recovery, because i ts compl et e recovery woul d indicate that residual muscul ar
weakness cont ri buti ng to probl ems wi th ai rway pat ency or respi rati on is unl i kel y
(110, 188,202,205, 260, 261,262). The probabi l i ty of det ect ing f ade by usi ng the
i ndex f i nger i s greater t han if the t humb or great toe i s used (71,73).
I n t he past, many investi gat ors thought that a TOFR of 0. 7 was adequat e (4,263).
However, a normal response to hypoxemia, protect ion f rom pul monary
compl i cati ons, and absence of heavi ness of the eyel ids, vi sual di sturbances,
di ff i cul ty swal lowi ng, or pati ent anxi et y may requi re a hi gher rat i o
(4,264,265,266,267,268,269,270,271,272,273). Most i nvesti gators now recommend
t hat the TOFR at t he adductor pol l icis be at l east 90% measured by
mechanomyography bef ore extubati on (248,266,275,276). Thi s is probabl y most
rel i abl y accompl i shed by usi ng ACG and achi eving a TOFR at least 90% of the
basel ine (68,91, 92,254,257, 277,278,279,280). I f EMG moni tori ng i s bei ng used,
resi dual anestheti c ef fects usual l y prevent t he return of T
1
t o the preanestheti c
reference level , but the TOFR shoul d exceed 90% (281).
Resi dual NMB cannot be rel iabl y detect ed by usi ng TOF sti mulati on if vi sual and/or
t act i l e moni tori ng i s used (19). Detect ion may be somewhat bet ter when using DBS
(30,31,52, 282). Both may be more rel i abl e at detect i ng fade at l ower currents (19).
Cl inical cri teri a i n an awake pati ent have been used to ascertai n whet her t he return
of muscl e st rength i s adequate. These i ncl ude the abi l i t y t o (a) open t he eyes for 5
seconds and not experi ence di pl opi a, (b) sustai n t ongue protrusi on, (c) sustai n
head l i f t for at least 5 seconds, (d) sustai n hand grip, (e) sustai n leg l i f t ing i n
chil dren, (f ) cough ef f ect ivel y, and (g) swal l ow. A more sensi t ive test may be t he
abi l i t y to resi st removing a t ongue blade f rom clenched teeth (268). Cl ini cal cri t eria
i n an asl eep pati ent i nclude an adequat e t i dal vol ume and an i nspi ratory force of at
l east 25 cm H
2
O negati ve pressure. Subj ecti ng the pati ent to negat ive i nspi ratory
pressure can cause pul monary edema. These cli ni cal cri t eria do not excl ude
cl i nical ly si gnif icant resi dual paral ysis (248,272,283).
Postoperative Period
Even if a nerve sti mul ator has not been used during an operat ion, i t can be used
postoperati vel y. If t he pati ent i s not ful l y anestheti zed, i t is pref erabl e t o use l ess
t han supramaxi mal st imulat i on (15,29,284). Thi s decreases t he di scomf ort
associ ated wi th st i mulati on and may i mprove the visual assessment accuracy (30).
Long-term Muscle Relaxant Infusions
Long-term muscl e rel axants i nf usi ons are someti mes used in cri ti cal care areas.
NMB moni tori ng shoul d be used to avoi d overdosage
(285, 286,287,288, 289, 290,291, 292). A number of f actors uni que to t he cri t i cal care
sett ing aff ect t he response to NMB drugs (12, 286). Prol onged paral ysi s is
someti mes seen despi t e moni tori ng (293, 294).
Nerve Location
A peripheral nerve sti mulator may be used to locat e nerves f or regi onal block (295).
The current needed i s f ar bel ow t hat needed f or moni tori ng NMB. St i mulators wi th
di ff erent current out puts for both f uncti ons are avai l able (296,297).
Hazards
Burns
Burns have been reported when usi ng a st imul ator wi t h metal bal l el ect rodes (298).
Needle el ectrodes may be associ ated wi t h l ocal t issue burns f rom el ect rosurgi cal
uni ts because t hey provi de good contact wi t h mi ni mal resistance for exi t of hi gh-
f requency current over a smal l area of skin (299). Severe burns resul ti ng i n
permanent l oss of hand f unct i on caused by a nerve sti mulator have been report ed
(300).
P. 821


Nerve Damage
The pressure of an el ect rode on a nerve can resul t i n pal sy (154). Thumb
paresthesi as were report ed in pati ents whose muscul ar f uncti on was moni tored by
using an MMG (301). Nerve damage can resul t f rom int raneural placement of a
needl e electrode.
Complications Associated with Needle Electrodes
Compl i cat i ons associ at ed wi th needl e electrodes i ncl ude inf ecti on, bleedi ng, and
pai n.
Pain
Pat i ent di scomf ort wi l l be reduced by usi ng l ower currents and avoi di ng tet ani c or
doubl e-burst sti mulat i on when the pat ient i s not f ul ly anest het i zed (16,18).
Electrical Interference
The use of a nerve st imulator may cause changes in t he ECG traci ng or i nterfere
wi th an i mpl anted pacemaker (302,303, 304,305).
Incorrect Information
Wi th some st i mul ators, when the bat teries are l ow, onl y three pul ses are generated
duri ng TOF sti mul at ion (306). This coul d l ead to i ncorrect i nterpretat ion of the
degree of NMB.
A potent i al l y conf using user i nterface on a neuromuscul ar transmissi on modul e has
been report ed (307). The modul e provided a bar graph vi sual i ndi cat ion of the f our
responses to TOF sti mul at ion. However, i f the responses were great er t han 120% of
t he cont rol response, the bar graph represent ati ons were chopped off . As a resul t,
al l f our t wi tches could appear t o be of the same hei ght when the TOF rati o was
bel ow 100%.
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Questions
For the f ol lowing quest ions, sel ect t he correct answer
1. The waveform for sti mulati on should be
A. Bi phasi c
B. Rounded
C. Monophasi c
D. Sl opi ng
E. Notched
Vi ew Answer2. The twi tch frequency for the TOF sti mulati on is
A. 1 Hz f or 1 second
B. 2 Hz f or 2 seconds
C. 2 Hz f or 1 second
D. 1 Hz f or 2 seconds
E. 3 Hz f or 2 seconds
Vi ew Answer3. The ti me i nterval between TOF stimulations shoul d be at
l east
A. 4 seconds
B. 8 seconds
C. 12 seconds
D. 20 seconds
E. 22 seconds
Vi ew Answer4. The frequency of si ngl e-twi tch stimul ation shoul d not
exceed
A. 0.01 Hz
B. 0.1 Hz
C. 1 Hz
D. 1.5 Hz
E. 10 Hz
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
5. TOF sti mulati on
A. Can be used i f onl y one t wi t ch i s present
B. Can be used to det ermi ne reversi bi l i ty f rom NMB
C. Can be moni t ored by ACG
D. Shoul d be performed once every 5 seconds
Vi ew Answer6. Supramaxi nal stimulation refers to the
A. Vol t age used to sti mulate t he nerve
B. Current used to sti mul ate a nerve
C. Vol tage above that necessary f or maxi mal st imulat i on
D. Current hi gher than that needed f or maxi mal sti mu-lat i on
Vi ew Answer7. Single-twi tch sti mulati on
A. Cannot disti nguish between depolari zi ng and nondepolari zi ng bl ocks
B. Is useful for i denti f yi ng sat isfactory condi ti ons f or i ntubat i on
C. I s not usef ul f or assessing recovery f rom NMB
D. I s not usef ul t o det ermi ne supramaxi mal st imulus
Vi ew Answer8. Factors affecti ng the TOFR i ncl ude
A. The nat ure of the NMB (depol ari zi ng or nondepol ari zi ng)
B. Depth of the NMB
C. The nerve bei ng moni tored
D. An upper-mot or-neuron l esion
Vi ew Answer9. Advantages of TOF sti mulati on include
A. I t i s more sensi tive than the si ngl e t wi tch
B. I t can detect a phase II block
C. I t can disti ngui sh between depolari zi ng and nondepol ari zi ng bl ocks
D. I t i s easy to det ect f ade wi th visual or tacti l e met hods
Vi ew Answer10. DBS
A. Consi sts of two short tetanic st i mul i separated by 750 ms
B. Is pri maril y used to det ermi ne resi dual NMB
C. I s more sensi ti ve t han TOF sti mulati on for det ermi ni ng f ade
D. Causes l ess di scomf ort t han TOF sti mul ati on
Vi ew Answer11. With tetani c sti mulati on,
A. I f no relaxants are present , t here wi l l be a contracti on fol l owed by relaxat ion of
t he sti mul ated muscles
B. I f there i s a depolari zi ng bl ock, there wi l l be a sust ai ned contract i on of l ower
magni tude
C. Prof ound bl ock wi l l show muscl e movement af ter 10 seconds of st imul at ion
D. I f a nondepol ari zing block is present , there wi l l be a nonsustai ned contracti on of
t he muscl e
Vi ew Answer12. For tetanic sti mulation, 50 Hz is most often used
because
A. I t i s more physi ol ogi c
B. I f the f requency i s greater than 50 Hz, t he fade wi l l be l ess pronounced
C. I f the f requency i s less than 50 Hz, t he fade wi l l be more pronounced
D. I t st resses the neuromuscul ar j uncti on si mi lar to a vol untary eff ort
Vi ew Answer13. Post-tetani c faci l itati on
A. Is maxi mal i n 3 seconds and l asts f or up to 2 mi nutes
B. Is temporary
C. I s used to determi ne t he depth of bl ock in prof oundl y relaxed pati ents.
D. Occurs wi t h depol ari zing bl ocks
Vi ew Answer14. ACG
A. Ut i l i zes a pi ezoel ect ri c sensor t hat produces an electroni c si gnal proporti onal t o
t he amount of movement
B. Is useful in pati ents whose extremi ti es are tucked
C. Requi res a prel oad
D. Can be i nterfaced wi t h a computer
Vi ew Answer15. The el ectromyograph
A. Cannot be used to moni tor t he di aphragm
B. Measures a bi phasic acti on i n each muscl e sti mul ated
C. Cannot be used wi th muscl es that cannot be used wi th t he MMG
D. Uses st imul ati ng elect rodes pl aced i n a si mi l ar f ashi on as other moni tori ng
t echnol ogi es
Vi ew Answer16. The facial nerve
A. Is rel at i vel y resistant to muscl e rel axants
B. Can be used wi th ACG
C. May show compl et e recovery when si gni f i cant NMB st i ll exi sts
D. I s usef ul i n determining the relaxat ion of the j aw and di aphragm
Vi ew AnswerP. 827


17. Duri ng induction of anesthesia,
A. The sti mul ator shoul d be appl i ed pri or t o i nducti on
B. The facial nerve is most useful for determi ni ng the ti me for i ntubati on
C. Supramaxi mal st i mulati on shoul d be determi ned af ter i nducti on but bef ore t he
admi ni st rati on of rel axant
D. To determi ne opti mal ti me of i ntubat ion, a nerve shoul d be sti mul at ed at 1 Hz
Vi ew Answer18. The PTC
A. Is the number of responses af ter appl i cati on of a tetanic st i mulus of 50 Hz f or 3
seconds
B. Is pai nf ul f or t he pati ent
C. I s di rectl y proporti onal to t he degree of neuromuscul ar bl ock present
D. I s usef ul f or assessi ng deep NMB
Vi ew Answer19. Needle electrodes
A. May be usef ul when the skin i s col d
B. Are useful wi t h hypert hyroi d pati ents
C. Carry a risk of di rect muscl e sti mul ati on
D. Shoul d be inserted perpendi cul ar t o the nerve t o be st i mul ated
Vi ew Answer20. Cli nical cri teria useful to determine the adequacy of
recovery from NMB i ncl ude
A. A i nspi ratory f orce of at l east -20 cm H
2
O pressure
B. Sustained hand gri p
C. Sustained head l if t f or 10 seconds
D. Adequate ti dal vol ume
Vi ew Answer21. Concerni ng recovery from NMB,
A. Moni tori ng t he adductor pol l i ci s i s preferabl e to moni tori ng the orbi cul aris ocul i
B. DBS i s less sensi ti ve than TOF moni tori ng
C. Recovery i s faster in t he di aphragm than i n adduct or pol l i ci s
D. Adequate cl i nical recovery has occurred when t he TOFR i s above 0.7
Vi ew Answer22. Concerni ng DBS,
A. I t consi sts of two bursts of 100 Hz tetanus
B. The t wo bursts are separat ed by 750 ms
C. I s not usef ul i n moni tori ng prof ound NMB
D. The DBS rat io has simi l ar properti es to the TOFR
Vi ew Answer