Effect of neostigmine at different levels of mivacurium-induced neuromuscular blockade

The effectiveness of neostigmine 40 μg/kg for antagonism of two different levels of neuromuscular blockade, induced by a bolus dose of mivacurium 0.15 mg/kg, was studied in 45 patients. The patients were anaesthetized with thiopentone, fentanyl, nitrous oxide in oxygen, and enflurane. Neostigmine was administered at either 10% recovery of the twitch height (TH10) at the adductor pollicis muscle ( n =14) or upon reappearance of the first response at the orbicularis oculi muscle (OO1) after train-of-four (TOF) stimulation ( n = 16), the latter representing a deeper degree of neuromuscular blockade. Fifteen of the 45 patients did not receive neostigmine (control group). Neostigmine administration at OO1 rather than at TH10 at the adductor pollicis muscle caused reversal of neuromuscular blockade to occur 8 min earlier and shortened the time to reach 25% recovery of the twitch height (TH25) at the adductor pollicis muscle by about 5 min, compared with the control group. However, the time needed to reach a T4/T1 ratio ≥0.8 was similar in both the early and late neostigmine administration groups, being 9 min faster than in the control group. It can be concluded that there is no advantage in administering neostigmine at profound neuromuscular blockade to achieve clinically adequate recovery (T4/T1 ratio ≥0.8). However, the time between injection of mivacurium and TH25 may be shortened by using neostigmine at profound neuromuscular blockade, a procedure which may be useful in case of unpredictably difficult intubation, since diaphragmatic movements usually reappear at TH25.     

Mivacurium in children with Duchenne muscular dystrophy

The authors retrospectively reviewed their experience with mivacurium for neuromuscular blockade in seven children with Duchenne muscular dystrophy. Mivacurium was administered to seven children ranging in age from 8.3 to 14.4 years and in weight from 29 kg to 68 kg during either posterior spinal fusion or lower extremity release. An initial bolus dose of 0.2 mg·kg^?1 was followed by a continuous infusion. Neuromuscular blockade was monitored with a standard twitch monitor and the TOF (2 Hz for 2 s). Complete suppression of all four twitches occurred in 1.5 to 2.6 min. The continuous infusion was started with the return of the first twitch and adjusted to maintain one twitch. Time to recovery of the first twitch varied from 12 to 18 min. Continuous infusion requirements varied from 3 to 20 μg·kg^?1 with an average for the case of less than 10 μg·kg^?1 min^?1 in five of the seven patients. A moderate increase in sensitivity to mivacurium in this patient population is suggested by a decrease in infusion requirements and a prolonged effect following the initial dose.     

Reversal of rocuronium-induced neuromuscular blockade by pyridostigmine in patients with Duchenne muscular dystrophy

BACKGROUND: The aim of this study was to investigate the effect and safety of pyridostigmine for the reversal of a neuromuscular block (NMB) in patients with Duchenne muscular dystrophy (DMD). In patients with DMD recovery from a rocuronium-induced NMB is markedly delayed. METHODS: Fourteen DMD patients (aged between 11 and 19 years) scheduled for elective scoliosis repair were studied. Following tracheal intubation without muscle relaxant, all patients received a single dose of rocuronium 0.6 mg.kg(-1). NMB was monitored by acceleromyography at the adductor pollicis muscle. When the first twitch height (T1) of the train-of-four (TOF) had recovered to 25% seven patients received either pyridostigmine 0.1 mg.kg(-1) (the anticholinergic drug with a long duration of action) or saline in a blinded manner. The times to attain TOF ratio of 0.9 were recorded. For comparison the Mann-Whitney U-test was used. RESULTS: Recovery to TOF ratio of 0.9 was significantly (P < 0.05) accelerated by pyridostigmine [84 (median), 57-141(range)] compared with controls (148, 84-243 min). The recovery time (time between T1 of 25% and TOF of 90%) was also significantly (P < 0.01) shortened by pyridostigmine (15, 8-49 vs 76, 43-144 min, respectively). Time to recovery of T(1) to 90% was not different between the groups (108, 63-134 vs 169. 61-208 min, respectively). CONCLUSIONS: Pyridostigmine 0.1 mg.kg(-1) effectively reversed a rocuronium-induced NMB in DMD patients.     

Onset and duration of rocuronium-induced neuromuscular blockade in patients with Duchenne muscular dystrophy

BACKGROUND: In patients with Duchenne muscular dystrophy (DMD) the response to nondepolarizing muscle relaxants is scarcely documented and conflicting. The current study was conducted to determine the time to peak effect and the time for complete spontaneous recovery after a single dose of 0.6 mg/kg of rocuronium in patients with DMD. METHODS: Twenty-four patients (12 with DMD, 12 controls, aged 10-16 yr) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of 0.6 mg/kg of rocuronium. The complete time course of onset and spontaneous recovery were recorded RESULTS: Significant (P < 0.01) increase in the onset times to 95% neuromuscular block was observed in DMD patients (median, 203 s; range, 90-420 s) compared with controls (median, 90 s; range, 60-195 s). The time between rocuronium administration and recovery of first twitch of the train-of-four to 90% was significantly (P < 0.01) prolonged in DMD compared with controls (median, 132 min; range, 61-209 min versus 39 min; 22-55 min). The recovery index was also significantly prolonged in the DMD group compared with controls (median, 28 min, range, 15-70 min versus 8 min; 3-14 min). CONCLUSIONS: The most striking and surprising result of this study is the delayed onset of blockade in DMD after a standard dose of rocuronium. This effect should be kept in mind in situations when a rapid airway protection is necessary in DMD patients. The documented very long recovery from rocuronium-induced block emphasizes the need for careful assessment of neuromuscular function in DMD patients.     

Recovery from mivacurium-induced neuromuscular blockade after neurosurgical procedures of long duration

Study Objective: To determine if recovery following prolonged (5 hours in length or greater) infusions of mivacurium is different from recovery after single bolus administration.

Design: open-labelled, controlled study.

Setting: Inpatient neurosurgical service at a university hospital.

Patients: 36 patients between the ages of 18 to 65 without significant history of renal, hepatic, cardiac, or metabolic disease undergoing neurosurgical procedures. 21 patients had craniotomies or skull base procedures of an estimated length of 5 hours or greater; 15 patients (control) underwent short neurosurgical operations (two hours or less).

Interventions: Intravenous (IV) mivacurium 0.15 mg/kg was given with stable general anesthesia with 70% nitrous oxide in oxygen, 0.2% to 0.3% end-tidal isoflurane, and continuous infusion of fentanyl. The control group was allowed to recover spontaneously after single bolus administration while neuromuscular blockade was maintained in the study group with a continuous infusion of mivacurium until 30 minutes before completion of surgery, at which time the infusion was discontinued and neuromuscular function was allowed to recover spontaneously.

Measurements and Main Results: The evoked compound electromyogram of the adductor pollicis brevis muscle was measured during stimulation of the ulnar nerve at 2 Hz for 2 seconds at 10-second intervals. Measurements included time to 50% and 90% depression of twitch (T₁ of the TOF response), time to T₁ equal to 25% (T₁25), 50% (T₁50), and 75% (T₁75) of baseline, and TOF ratio (TR) at 10%, 25%, 50%, and 75% recovery. Recovery index (RI), which is T₁75 minus T₁25, was also determined. All mivacurium infusion rates decreased during surgery. Recovery rates were significantly longer in the long infusion (LI) group than the control group. RI was also increased in the LI group compared with the single bolus control (11.3 ± 1.2 minutes vs. 7.1 ± 0.8 minutes p < 0.05).

Conclusions: Recovery following mivacurium by prolonged continuous infusion was slower than that observed after single bolus administration in this patient population. Clinically, this increased time to recovery may be insignificant.     

Onset and duration of mivacurium-induced neuromuscular blockade in children with Charcot-Marie-Tooth disease. A case series with five children

BACKGROUND: The Charcot-Marie-Tooth (CMT) disorders are a group of hereditary motor and sensory neuropathies characterized clinically by peripheral muscle wasting and weakness. We hypothesized that unknown involvement of the muscle used for monitoring neuromuscular block may account for the conflicting reports about the effect of nondepolarizing neuromuscular agents in these patients. The aim of this study was to compare onset and recovery from mivacurium-induced neuromuscular block on the adductor pollicis and orbicularis oculi muscles. METHODS: We used mivacurium 0.2 mg.kg(-1) in five children (aged 7-12 years) with CMT type I undergoing propofol-fentanyl-oxygen-air anesthesia for orthopedic surgery. Using acceleromyography, neuromuscular transmission was monitored in parallel in the eye and thumb muscles, and onset and duration times were recorded. RESULTS: Following bolus administration of 0.2 mg.kg(-1) of mivacurium the onset time ranged between 135 and 240 s and 75 and 165 s in the eye and in the thumb, respectively. The recovery time varied between 5.3 and 16 min and 6 and 31.3 min in the eye and in the thumb, respectively. CONCLUSIONS: In our small series of patients with CMT the clinical duration of mivacurium-induced neuromuscular block was similar to data known from children without neuromuscular disease.     

Monitoring of neuromuscular block after administration of vecuronium in patients with diabetes mellitus

Background. We studied the supramaximal current for ulnar nervestimulation during electromyographic monitoring of onset andrecovery of neuromuscular block using a neuromuscular transmissionmodule (M-NMT Module, Datex-Ohmeda) in patients with Type 2diabetes undergoing anaesthesia with nitrous oxide, oxygen,isoflurane and fentanyl. Methods. Thirty-six diabetic patients were randomly assignedto a post-tetanic count (PTC) group (n=17) or train-of-four(TOF) group (n=19). In addition, 30 non-diabetic patients weredivided into control PTC (n=15) and TOF groups (n=15). Results. In the diabetic patients (diabetes PTC and diabetesTOF groups), the mean supramaximal stimulating current was significantlyhigher than in the non-diabetic patients (control PTC and TOFgroups) (50.5 (SD 14.1) vs 33.4 (6.1) mA, P<0.01). Onsetof neuromuscular block (time to disappearance of T1) after vecuronium0.1 mg kg^–1 in the diabetic patients did not differ significantlyfrom that in the non-diabetic patients (276 (77) vs 244 (44)s, P=0.055). Time to return of PTC1 did not differ significantlybetween the diabetes and control PTC groups (21.0 (12.1) vs15.7 (5.0) min, P=0.126). Times to return of T1 and T4 in thediabetes TOF group were significantly longer than in the controlTOF group (T1: 37.5 (15.2) vs 25.7 (7.6) min, P=0.01; T4: 61.4(23.7) vs 43.5 (11.4) min, P=0.01). During recovery, PTC andT4/T1 in the diabetes PTC and TOF groups were similar to thosein the control PTC and TOF groups, respectively. T1/T0 in thediabetes TOF group was significantly less than in the controlTOF group, 80–120 min after vecuronium (P<0.05). Conclusions. In diabetic patients, supramaximal current is higherthan in non-diabetic patients. After vecuronium, onset of neuromuscularblock and recovery of PTC or T4/T1 are not altered, but timeto return of T1 or T4, and recovery of T1/T0 are delayed indiabetic patients. Br J Anaesth 2003; 90: 480–6     

Reversal of rocuronium‐induced profound neuromuscular block by sugammadex in Duchenne muscular dystrophy

A case is reported in which a child with Duchenne muscular dystrophy received a dose of sugammadex to reverse a rocuronium‐induced profound neuromuscular block. Sugammadex is the first selective relaxant binding agent and reverses rocuronium‐ and vecuronium‐induced neuromuscular block. A fast and efficient recovery from profound neuromuscular block was achieved, and no adverse events or other safety concerns were observed.     

Effect of metoclopramide on mivacurium-induced neuromuscular block

In order to investigate the effect of metoclopramide on the duration of action of mivacurium, 45 patients were randomized into three groups. Group M10 (n = 15) and M20 (n = 15) received 10 and 20 mg of metoclopramide i.v., respectively, and group S (n = 15) received saline 2 min before induction of anesthesia with fentanyl, thiopental and mivacurium. Plasma cholinesterase activity (pCHE) was measured before induction of anesthesia and 2 min after injection of metoclopramide and saline. Neuromuscular block was monitored by a force transducer using train of four nerve stimulation. Anesthesia was maintained with isoflurane and N2O. Time to recovery of a twitch height of 90% was significantly prolonged in group M10 and M20 (44 +/- 15 and 57 +/- 10 min) as compared to group S, 32 +/- 9 min, P < 0.05). A slight but significant decrease in pCHE was observed in group M20. Because of the risk of prolonged duration of action of mivacurium, neuromuscular blockade should always be monitored whenever metoclopramide is given before injection of mivacurium.     

Prolonged mivacurium neuromuscular block in children

The authors report two cases of prolonged neuromuscular block after administration of mivacurium in children with previously undiagnosed plasma cholinesterase deficiency related to homozygous atypical genotype. Their anaesthetic management is described as well as determination of the phenotype of both children and their family.     

Epidurally administered mepivacaine delays recovery of train-of-four ratio from vecuronium-induced neuromuscular block

BACKGROUND: The aim of this study was to examine the efficacy of epidurally administered mepivacaine on recovery from vecuronium-induced neuromuscular block. METHODS: Eighty patients were randomly assigned to one of two study groups. They were either given epidurally a bolus of 0.15 ml kg(-1) of mepivacaine 2%, followed by repetitive injections of 0.1 ml kg(-1) h(-1) throughout the study, or were not given epidurally. General anaesthesia was induced and maintained with fentanyl, propofol and nitrous oxide. Neuromuscular block was induced with vecuronium 0.1 mg kg(-1) and monitored using acceleromyographic train-of-four (TOF) at the adductor pollicis. Patients in each treatment group were randomized to receive neostigmine 0.04 mg kg(-1) at 25% recovery of the first twitch of TOF or to recover spontaneously to a TOF ratio of 0.9. The effect of epidural mepivacaine on speed of spontaneous and facilitated recovery of neuromuscular function was evaluated. RESULTS: The time from administration of vecuronium to spontaneous recovery to a TOF ratio of 0.9 was significantly longer in the epidural mepivacaine group [105.4 (14.2) min] as compared with the control group [78.5 (9.1) min, P < 0.01]. Neostigmine administered at 25% of control in T1 shortened recovery from neuromuscular block, however the time required for facilitated recovery to a TOF ratio of 0.9 in the epidural group was significantly longer than that in the control group [7.6 (1.6) min vs 5.8 (2.1) min, P < 0.01]. CONCLUSIONS: In clinical anaesthesia, it should be recognized that epidurally administered mepivacaine delays considerably the TOF recovery from neuromuscular block.     

Rocuronium 0.3 mg x kg-1 (ED95) induces a normal peak effect but an altered time course of neuromuscular block in patients with Duchenne's muscular dystrophy

BACKGROUND: In patients with Duchenne's muscular dystrophy (DMD) recovery from neuromuscular block is delayed. It has been assumed that this is because of a higher potency of muscle relaxants in this patient cohort. We determined the peak effect, and the time course of action of rocuronium 0.3 mg x kg(-1) (ED(95)) in DMD patients. METHODS: Twenty-four patients (12 with DMD and 12 controls; aged 10-18 years) were studied. All patients were anesthetized with propofol and fentanyl/remifentanil. Neuromuscular transmission was monitored by acceleromyography. After induction all patients received a single dose of rocuronium 0.3 mg x kg(-1). The complete time course of action as onset, peak effect and spontaneous recovery was recorded. RESULTS: The onset time (s) to maximum block was significantly (P < 0.01) prolonged in DMD patients (median: 315; range: 120-465) compared with controls (195, 75-270). The peak effect (% twitch depression relative to baseline) was not different between the groups (DMD: 59-100; controls: 28-100). In the DMD group, recovery was significantly (P < 0.01) delayed compared with controls at all recorded time points. The clinical duration (min) was 40.3 (22-89) in the DMD group vs 9.8 (6-17) in the control group (P < 0.01). CONCLUSIONS: The similar peak effect in both groups does not confirm the thesis of rocuronium having a higher potency in DMD patients. The documented very long recovery after the ED(95) of rocuronium emphasizes the need for careful assessment of neuromuscular function in DMD patients.     

Influence of plasma cholinesterase activity on recovery from mivacurium-induced neuromuscular blockade in phenotypically normal patients

The significance of plasma cholinesterase (pChe) activity for the duration of action of mivacurium in phenotypically normal patients was evaluated in 35 patients during neurolept anaesthesia. The response to train-of-four nerve stimulation was recorded using a Myograph 2000. Ten patients with normal pChe (Group I) and five patients with decreased pChe activity (Group 2) were given a small test dose of mivacurium 0.03 mg kg-1. Mivacurium 0.1 mg kg-1 was administered following spontaneous recovery from the first dose. The mean suppression of the height of the first (T1) of the train-of-four responses following mivacurium 0.03 mg kg-1 patients with normal and decreased enzyme activity was 40% and 56%, respectively, and the mean T1 suppression after mivacurium 0.1 mg kg-1 was 100% in both groups. The times to different levels of twitch height recovery following the 0.1 mg kg-1 dose did not differ between the two groups of patients. Another 20 patients with normal or decreased pChe activity (Group 3) were given mivacurium 0.2 mg kg-1. In this group the time to maximum block was 1.4 min (1.0-4.0) mean (range) and the time to reappearance of the T1 response was 15.0 min (7.4-22.7) (range). An inverse relationship was found between the patients' pChe activity and the time to first response. It is concluded that mivacurium is short-acting in patients with normal pChe phenotype and normal to low-normal pChe activity. No patient with very low pChe activity was included in the study. A prolonged response to mivacurium may, however, be expected in these patients.     

Treatment and complications in flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy) with posterior-only pedicle screw instrumentation

Literature has described treatment of flaccid neuromuscular scoliosis using different instrumentation; however, only one article has been published using posterior-only pedicle screw fixation. Complications using pedicle screws in paralytic neuromuscular scoliosis has not been described before. To present results and complications with posterior-only pedicle screws, a retrospective study was carried out in 27 consecutive patients with flaccid neuromuscular scoliosis (Duchenne muscular dystrophy and spinal muscular atrophy), who were operated between 2002 and 2006 using posterior-only pedicle screw instrumentation. Immediate postoperative and final follow-up results were compared using t test for Cobb angle, pelvic obliquity, thoracic kyphosis and lumbar lordosis. Perioperative and postoperative complications were noted from the hospital records of each patient. Complications, not described in literature, were discussed in detail. Average follow-up was 32.2 months. Preoperative, immediate postoperative and final follow-up Cobb angle were 79.8°, 30.2° (63.3% correction, p < 0.0001) and 31.9°, respectively; and pelvic obliquity was 18.3°, 8.9° (52% correction, p < 0.0001) and 8.9°. Postoperative thoracic kyphosis remained unchanged from 27.6° to 19.9° (p = 0.376); while lumbar lordosis improved significantly from +15.6° to −22.4° lordosis (p = 0.0002). Most patients had major to moderate improvement in postoperative functional and ambulatory status compared to the preoperative status. Thirteen (48.1%) perioperative complications were noted with five major complications (four respiratory in the form of hemothorax or respiratory failure that required ventilator support and one death) and eight minor complications (three UTI, two atelectasis, two neurological and one ileus). Postoperatively, we noted complications, such as coccygodynia with subluxation in 7, back sore on the convex side in 4 and dislodging of rod distally in 1 patient making a total of 12 (44.4%) postoperative complications. Of 12 postoperative complications, 6 (50%) required secondary procedure. We conclude that although flaccid neuromuscular scoliosis can be well corrected with posterior-only pedicle screw, there is a high rate of associated complications.     

Infusion of amino acid enriched solution hastens recovery from neuromuscular block caused by vecuronium

We investigated the effect of an amino acid infusion on neuromuscularblock produced by vecuronium, and on rectal temperature andsurface temperature over the adductor pollicis muscle. Sixtyadult patients undergoing general anaesthesia were randomlydivided into four groups of 15 patients each: amino acid (AA)-post-tetaniccount (PTC); AA-train-of-four (TOF); control (C)-PTC; or C-TOFgroup. In the AA-PTC and AA-TOF groups, after a bolus of vecuronium0.1 mg kg^–1, a continuous infusion of an 18 amino acidenriched solution (AMIPAREN^®) was started at a rate of 166kJ h^–1. In the C-PTC and C-TOF groups, normal saline wasadministered. Time from vecuronium to the return of the PTCin the AA-PTC group was significantly shorter than in the C-PTCgroup (mean (SD), 13.3 (4.5) versus 18.0 (5.6) min, P<0.05).Times to return of T1, T2, T3, and T4 (first, second, third,and fourth twitch of TOF) in the AA-TOF group were significantlyshorter than in the C-TOF group (21.1 (4.5) versus 28.0 (8.2)min for T1, P<0.05). PTC in the AA-PTC group was significantlygreater than in the C-PTC group; 25–35 min after administrationof vecuronium (P<0.05). T1/T0 and T4/T1 in the AA-TOF groupwere significantly higher than in the C-TOF group, 40–120and 50–120 min after vecuronium respectively (P<0.05).Rectal temperature and surface temperature over the adductorpollicis muscle in the AA-PTC and AA-TOF groups were significantlyhigher than in the control groups 50–120 and 100–120min after vecuronium respectively (P<0.05). Infusion of aminoacid enriched solution hastens recovery from neuromuscular block. Br J Anaesth 2001; 86: 814–21     

Acute heart failure during spinal surgery in a boy with Duchenne muscular dystrophy

Patients with Duchenne muscular dystrophy (DMD) are at highrisk of perioperative complications. DMD may be accompaniedby heart failure resulting from dystrophic involvement of themyocardium, which can be subclinical in the early stages ofthe disease. This case demonstrates that a normal preoperativeECG and echocardiograph cannot exclude the development of heartfailure during anaesthesia in DMD patients undergoing majorsurgery. Br J Anaesth 2003; 90: 800–4     

肌松监测部位的研究进展

拇内收肌对尺神经处4个成串刺激的机械力学反应通常用来监测麻醉期间的神经肌肉功能.这种方法已成为肌松监测的金标准.然而,仅对拇内收肌进行肌松监测是不够的.在不能用拇内收肌进行监测时,推荐应用其他监测部位.呼吸相关肌肉在近年来被用于监测神经肌肉功能.     

Normalization of acceleromyographic train-of-four ratio by baseline value for detecting residual neuromuscular block

Background. This study was designed to recognize the importanceof normalizing postoperative acceleromyographic train-of-four(TOF) ratio by the baseline TOF value obtained before neuromuscularblock for ensuring adequate recovery of neuromuscular function. Methods. In 120 patients, TOF responses of the adductor pollicisto the ulnar nerve stimulation were monitored by acceleromyography(AMG) during anaesthesia using propofol, fentanyl and nitrousoxide. Control TOF stimuli were administered for 30 min. A TOFratio measured at the end of control stimulation was regardedas a baseline value. Neuromuscular block was induced with vecuronium0.1 mg kg^–1 and was allowed to recover spontaneously.Duration to a TOF ratio of 0.9 as calculated by AMG (DUR-raw0.9) was compared with that of 0.9 as corrected by the baselineTOF ratio (i.e. 0.9xbaseline TOF ratio; DUR-real 0.9). Results. Baseline TOF ratios ranged from 0.95 to 1.47. The averageTOF ratios observed every 5 min were constant throughout controlstimulation from at time zero mean (SD) [range]; 1.11 (0.09)[0.94–1.42] to at 30 min 1.13 (0.11) [0.95–1.47].The DUR-real 0.9 was 91.0 (18.0) [51.3–131.0] min andwas significantly longer than the DUR-raw 0.9 (81.2 (16.3) [41.3–123.0]min). Conclusions. Baseline TOF ratios measured by AMG are usuallymore than 1.0 and vary widely among patients. Therefore a TOFratio of 0.9 displayed postoperatively on AMG does not alwaysrepresent adequate recovery of neuromuscular function and shouldbe normalized by baseline value to reliably detect residualparalysis.     

Comparison of a new neuromuscular transmission monitor compressomyograph with mechanomyograph

BACKGROUND: We developed a new neuromuscular transmission monitor, the compressomyograph (CMG, European patent number: EP 06018557.6, US patent number: US 60/824.541). This is the first preliminary report comparing neuromuscular block monitored by CMG and the Relaxometer mechanomyograph (MMG). METHODS: The two monitors were randomly allocated to the left or right hands of 16 patients. T1, first twitch of the train-of-four (TOF) expressed as percentage of control response, and the TOF ratio (T4:t1) were used to evaluate the neuromuscular block produced by rocuronium 0.6 mg kg(-1). RESULTS: The CMG monitor exhibited no pre-relaxation reverse fade (T4>T1) or T1 exceeding 100%. There was no significant difference in mean (SD) onset time, Dur(25) (time to T1 25% recovery), or Dur(0.9) (time to 0.9 TOF ratio recovery) measured by the CMG [2.4 (0.9), 22.6 (4.1), 43.1 (10.3) min, respectively] compared with MMG [2.1 (0.9), 22.9 (3.3), 43.3 (10.0) min, respectively]. According to Bland and Altman analysis, the bias (upper and lower limits of agreement) for T1% was -0.3% (+13.4% and -13.8%) and for TOF ratio was -0.009 (+0.068 and -0.085). CMG showed 100% sensitivity and 75% specificity in indicating full relaxation for tracheal intubation, and 80% sensitivity with 86% specificity in predicting MMG 0.9 TOF ratio. CONCLUSIONS: The CMG could be a reliable clinical monitor in the daily anaesthesia practice that does not require time to set up or rigid support of the arm.