Sri Sathya Sai Institute of

Higher Medical Sciences,

Whitefield, Bangalore

Department of Anesthesiology & Critical Care Medicine

Neuromuscular Monitoring
-Dr Preethi B Reddy, DNB Resident

PATTERNS OF SIMULATION

OBJECTIVES OF NM
MONITORING

Single-Twitch Stimulation

To evaluate the degree of neuromuscular

blockade during and after anesthesia
Monitoring onset of NM Blockade.
Assessing patients recovery from blockade to
minimize risk of residual paralysis.

MONITORING MECHANISMS

Tetanic Stimulation

Mechanomyography

SENSITIVITIES OF MUSCLE
GROUPS TO NDMRS
Train-of-Four Stimulation

In order from most resistant to most sensitive

1. Vocal cords
2. Diaphragm
3. Orbicularis Oculi
4. Abdominal rectus
5. Adductor pollicis
6. Masseter
7. Pharyngeal muscles
8. Extraocular muscles
FEATURE
Current
strength

ST

TOF

TETANUS

DBS

Post-Tetanic Count Stimulation

Electromyograhy

Accelerography
Double-Burst Stimulation

PTC

Non deploarizing NM Blockade

Supramaxi Supra or
Supra or
Supra or
Supra or
mal
submaxima submaxima submaxima submaxima
l
l
l
l

Frequency/Des 0.1 1 Hz
cription

2 Hz four
stimuli

Prerelaxant
Control

Needed

Not needed Not needed Not needed Not needed

Pain on
stimulation

-/+

Sensitivity of
manual
detection
(visual/tactile)

Not
sensitive

Not
Sensitive
sensitive at
TOF ratio
of 0.4-0.7

Alteration of
subsequent
responses

Not altered Not altered Altered

Not altered Altetred
(posttetanic
facilitation
)

Interval
between
successive
stimuli

5 sec

Receptor
occupancy
detection

75-90%

Sensitivity for
detection of
subtle block

Not
sensitive

12 sec

30 50 Hz 3 impulses
for 5 sec
at 50 Hz
repeated
after 750
msec

++

6 min

30 Hz for 5
sec, 3 sec
later ST at
1 Hz

++

Highly
sensitive

Sensitive

Kinemyography
Application of NMJ monitoring
TOF RATIO

0.70 0.75

SIGNS AND SYMPTOMS

Diplopia and viaual disturbances
Decreased hand grip
Inability to maintain opposition of the incisor teeth
Tongue depressor test negative
Inability to sit up without assisstance

12 15 sec 6 min

Severe facial weakness

Speaking a major effort
Overall weakness and tiredness

70 90%

70 90%

70 90%

>90% also

0.85 0.90

Diplopia and viaual disturbances

Generalised fatigue

Monitoring of Not useful

profound block

Sensitive

Sensitive

Sensitive

Not
applicable

Not useful

Not useful

Not useful

Useful

> 0.90

Excludes clinically important residual neuromuscular blockade

CLINICAL
OBJECTIVE

SITE

TWITCH
MODALITY

TARGET
RESPONSE

Fast onset/tracheal Orbicularis oculi

intubation

Single twitch or
train-of-four

0 twitches

Profound
blockade

Adductor pollicis
Orbicularis oculi

Post tetanic count

Train-of-four

Relaxant
dependant

Adequacy of
relaxation
(abdominal
surgery)

Adductor pollicis

Train-of-four
count

One to two
twitches present

Predicting
reversible block
(when no TOF
response present)

Adductor pollicis

Post tetanic count

Relaxant
dependant

Detecting
reversible block

Adductor pollicis

Train-of-four
count

At least two
twitche spresent

Detecting
adequate
neuromuscular
function

Adductor pollicis

Double-burst
stimulus

No fade present

Phonomyography