Double burst monitoring during surgical degrees of neuromuscular blockade: A comparison with train-of-four

With double burst stimulation (DBS) it is possible to monitor more profound degrees of neuromuscular blockade than with train-of-four stimulation (TOF). It may therefore be indicated to change between DBS and TOF stimulation during moderate to profound degrees of neuromuscular blockade. Consequently, the aim of the study was to evaluate and compare the twitch height of the first twitch (D1) in DBS and the twitch height of the first twitch (T1) in TOF stimulation during moderate to profound degrees of neuromuscular blockade. Thirty-three patients scheduled for gynaecological laparotomy under general anaesthesia were studied. Mechanomyography was used for neuromuscular monitoring. The T1 twitch height before atracurium was administered served as the control twitch height (T1 control). T1 control was considered as 100%. A constant degree of neuromuscular blockade was maintained at a T1 twitch height at a point between 4 and 11% of T1 control, using a continuous infusion of atracurium. Sequences of 16 DBS and 16 TOF stimulations were given. Two different DBS patterns were examined: DBS_3,350/50, (3 stimuli at 50 Hz followed 0.75 sec later by 3 stimuli at 50 Hz), and DBS_3,380/40, (3 stimuli at 80 Hz followed 0.75 sec later by 3 stimuli at 40 Hz). The data were analysed by the method described by Bland and Altman (1). The D1 repeatability coefficients of 1.72% for DBS_3,350/50 and 1.20% for DBS_3,380/40 were significantly greater than the repeatability coefficient of 1.02% for T1 (p<0.05). The D1 bias of 16.7% for DBS_3,350/50 was significantly less than the D1 bias of 25.7% for DBS_3,380/40 (p<0.05). The limits of agreement between D1 and T1 were 0.1 to 33.3% for DBS_3,350/50 and 2.9 to 48.5% for DBS_3,380/40. In conclusion: The repeatability of responses to DBS and TOF stimulations during moderate to profound degrees of neuromuscular blockade where only one twitch is consistently present is satisfactory. The responses to DBS were greater than responses to TOF as indicated by a positive bias of DBS. The limits of agreement between DBS and TOF responses were so wide that they cannot be used interchangeably.     

Differential effect of pancuronium at the adductor pollicis, the first dorsal interosseous and the hypothenar muscles. An electromyographic and mechanomyographic dose-response study

Cumulative dose-response curves were constructed from evoked compound electromyographic (EMG) recordings in man to compare the sensitivity to pancuronium of the adductor pollicis, the hypothenar and the first dorsal interosseous muscles. Also, the EMG and mechanomyography-based sensitivity of the adductor pollicis muscle were compared. The EMG and the mechanomyogram were evaluated in random sequence in each of 21 adult thiopental, fentanyl and diazepam anesthetized patients. The EMG-based ED50 were 36-38 micrograms.kg-1 with no differences between muscles. The EMG-based ED90 of the adductor pollicis and the hypothenar muscles were 62-65 micrograms.kg-1 compared to the 60 micrograms.kg-1 of the first dorsal interosseous muscle (P < 0.05). ED50 (34 micrograms.kg-1), and ED90 (56 micrograms.kg-1) obtained from the adductor pollicis mechanomyogram were significantly lower than those based on the EMG (P < 0.05). It is concluded that differences in sensitivity to pancuronium exist between the three muscles when evaluated from the EMG, and that the apparent sensitivity of a given muscle to a muscle relaxant may depend upon whether the response is evaluated using EMG or mechanomyography.     

Intubating conditions and onset of neuromuscular block of rocuronium (Org 9426); a comparison with suxamethonium

The intubating conditions and neuromuscular blocking profile following 600 micrograms.kg-1 rocuronium (Org 9426) have been investigated in patients under various experimental conditions. They were compared with conditions following 1.5 mg.kg-1 suxamethonium, preceded by a precurarising dose (10 mg) of gallamine, and with those in a control group in the absence of a muscle relaxant. Rocuronium produced good to excellent intubating conditions at 60 as well as at 90 s after administration, even though there was only a partial blockade of the adductor pollicis muscle. Intubating conditions following suxamethonium were comparable with those after rocuronium. Half of the control patients could be intubated. The clinical duration and the recovery time of 600 micrograms.kg-1 of rocuronium were 24(4) and 9(3) min (mean(s.d.)), respectively. Rocuronium may have a major advantage over existing non-depolarising muscle relaxants due to the early presence of excellent intubating conditions. The results indicate that rocuronium may replace suxamethonium in procedures in which rapid sequence induction is required.     

A comparison of acceleromyography and mechanomyography for determination of the dose–response curve of rocuronium in children

In order to compare an acceleromyograph (TOF-Guard^TM) with a mechanomyograph (Grass FT03), the dose–response relationship of rocuronium was simultaneously determined in both arms of 15 children aged 3–11 years during anaesthesia with thiopentone, alfentanil and nitrous oxide. Three subgroups of five children received rocuronium 120, 180 or 240 μg.kg⁻¹ randomly. The effective doses to produce 50% and 95% depression of the first twitch of the train-of-four determined by acceleromyography were 206 and 337 μg.kg⁻¹, respectively, while these values determined by mechanomyography were 151 and 331 μg.kg⁻¹, respectively. The dose–response curve obtained by acceleromyography was steeper and shifted to the right compared with that obtained by mechanomyography (p < 0.0001). The difference between the effective dose producing 50% twitch depression determined by the two devices was highly significant (p < 0.0001). In 13 out of 15 children, the acceleromyograph control train-of-four ratio was significantly greater than unity. Although there was a good correlation ( r  = 0.85) between simultaneous pairs of measurements of neuromuscular block, the acceleromyograph exhibited a bias of −25% relative to the mechanomyograph with wide limits of agreement (−62 to +12%). We conclude that acceleromyographic and mechanomyographic measurements should not be used interchangeably when determining the potency of muscle relaxants.     

Fatigue and the electromechanical efficiency of the vastus medialis and vastus lateralis muscles

CONTEXT: The relationship between the amplitudes of the mechanomyographic (MMG) and electromyographic (EMG) signals has been used to examine the "electromechanical efficiency" (EME) of normal and diseased muscle. The EME may help us to better understand the neuromuscular relationship between the vastus medialis and vastus lateralis muscles. OBJECTIVE: To examine the EME of the vastus medialis and vastus lateralis muscles during a fatiguing task. DESIGN: Repeated-measures design. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Ten healthy males (age = 23.2 +/- 1.2 years) with no history of knee injury. INTERVENTION(S): Seventy-five consecutive, maximal concentric isokinetic leg extensions at a velocity of 180 degrees /s. MAIN OUTCOMES MEASURE(S): Bipolar surface EMG electrodes were placed over the vastus medialis and vastus lateralis muscles, with an MMG contact sensor placed adjacent to the superior EMG electrode on each muscle. The MMG and EMG amplitude values (root mean squares) were calculated for each of the 75 repetitions and normalized to the highest value from the 75 repetitions. The EME was expressed as the ratio of the log-transformed normalized MMG amplitude to the normalized EMG amplitude. For each muscle, the linear relationship for the normalized-group mean EME was determined across the 75 repetitions. RESULTS: Linear regression indicated decreases in torque (R(2) = .96), vastus medialis EME (R(2) = .73), and vastus lateralis EME (R(2) = .73). The slopes for the vastus medialis and vastus lateralis EME were not different (P > .10). CONCLUSIONS: The similarities in the fatigue-induced decreases in EME for the vastus medialis and vastus lateralis muscles suggested that symmetry was present between the muscles in the electric and mechanical responses to repeated, maximal muscle actions. The EME measurements may provide a unique insight into the influence of fatigue on the contractile properties of skeletal muscle, including alterations that occur to the intrinsic electric and mechanical components. The EME may be useful in assessing and quantifying clinically relevant asymmetries in vastus medialis and vastus lateralis muscle function in those with knee injuries.     

基于肌音信号短时傅里叶变换的桡侧腕屈肌疲劳程度研究

肌肉疲劳是由运动引起的肌肉最大随意收缩力减小的现象,其研究可应用于生理医学的职业病预防或体育工程的运动员训练等方面。本文采用短时傅里叶变换对肌音信号进行处理,提取频域特征平均功率频率（Mean Power Frequency,MPF）和中值频率（Median Frequency,MDF）,研究其与肌肉疲劳程度之间的关系。9名健康的男性志愿者参与了本次试验,采用等值于60%最大随意收缩力（MVC）的力产生恒力肌肉疲劳,同步记录每一位受试者桡侧腕屈肌的肌音信号,对提取的频域参数进行分析。将持续30 s的肌肉疲劳过程分为6个时间阶段（每个阶段为5 s）,并对每个时间阶段内的MPF和MDF计算均值。结果表明,随着肌肉疲劳程度加深,肌音信号的MPF和MDF在每个时间阶段内的均值均呈现近似线性下降的趋势。在30 s肌肉疲劳过程中,从第1阶段（1~5 s）到第6阶段（26~30 s）,MPF均值下降了15.8%,MDF均值下降了26.1%。基于短时傅里叶变换提取的MPF和MDF指标能良好地反映疲劳敏感性和稳定性,在评定肌肉静态疲劳方面是较好的参考指标。本文采用的方法和得到的结果为后期更深入地使用肌音信号对肌肉疲劳程度进行量化研究提供了依据。     

Monitoring of neuromuscular transmission by electromyography (II)

The feasibility of the compound electromyogram (EMG) was evaluated during onset and recovery from pancuronium block in the tibialis anterior muscle of ten cats. The evoked EMG area, amplitude and duration of the total response and of the major negative deflection were evaluated and compared to the mechanomyogram during 0.1 Hz and train-of-four (TOF) stimulation. EMG areas and amplitudes were found to be linearly and similarly related to the mechanomyogram during onset and recovery. Slopes of the regression lines ranged between 1.00–1.02 and between 1.10–1.22 during onset and recovery, respectively, with high individual correlation coefficients (>0.95). The TOF ratio of the mechanomyogram was linearly related to the EMG TOF ratio during onset and to the square root of the EMG TOF ratio during recovery, with no differences between EMG areas and amplitudes, suggesting a higher initial recovery of the TOF ratio of the mechanomyogram during recovery. EMG duration increased as the level of block increased but was unsuitable for neuromuscular monitoring. Evaluation of the agreement between the two methods showed that the EMG may be from 15% below to 10% above the mechanomyogram during onset and from 40% below to 45% above the mechanomyogram during recovery, in spite of high correlation coefficients. In contrast, agreement between EMG parameters was found to be high. In conclusion, EMG is more reliable than the mechanomyogram for evaluation of neuromuscular transmission in the cat. EMG amplitudes and areas both reflect the degree of neuromuscular blockade equally well     

The cuff method: a pilot study of a new method of monitoring neuromuscular function

BACKGROUND: A new method of monitoring neuromuscular blockade based on a modified blood pressure cuff that incorporates stimulating electrodes was compared with mechanomyography (MMG) ('gold standard'). METHODS: Forty adults and 20 children (ASA I-II) underwent neuromuscular blockade monitoring on the contralateral arms and on the same arm using the new cuff method and MMG. Only train-of-four (TOF) ratios > 0.1 and T(1) heights > 0 were studied. Supramaximal stimulation was also assessed. A device based on a PC with an analogue-to-digital conversion card was used to control and synchronize MMG and the cuff method. The agreement between both methods was assessed using the statistical method of Bland and Altman. RESULTS: When TOF ratios were >0.7, the bias between the two methods was -0.04 with the limits of agreement ranging from -0.21 to -0.12 (95% CI -0.06 to -0.02). The T(1) > 0 heights bias was -0.01 with the limits of agreement ranging from -0.26 to 0.24 (95% CI -0.02 to -0.003). The sensitivity of the cuff method was 88%, with a specificity of 85% and an accuracy of 86%. CONCLUSION: This pilot study indicates that the cuff method could be useful to monitor neuromuscular blockade according to the bias and limits of agreement compared with MMG, particularly when the degree of blockade was evaluated by TOF ratios > 0.7. The new cuff method is easy and simple to use. However, further studies in a larger number of patients are necessary to confirm these favourable preliminary results.