Simple subjective Peripheral Nerve stimulatorQuantitative electromyographic recording at adductor pollicis muscle and stimulation of the ulnar nerve
In anesthesia, neuromuscular blocking agents may be required to facilitate endotracheal intubation and provide optimal surgical conditions. When neuromuscular blocking agents are administered, neuromuscular function of the patient must be monitored.[1]Neuromuscular function monitoring is a technique that involves the electrical stimulation of a motor nerve and monitoring the response of the muscle supplied by that nerve.[2] It may be used from the induction of to recovery from neuromuscular blockade. Importantly, it is used to confirm adequacy of recovery after the administration of neuromuscular blocking agents.[3] The response of the muscles to electrical stimulation of the nerves can be recorded subjectively (qualitative) or objectively (quantitatively). Quantitative techniques include electromyography, acceleromyography, kinemyography, phonomygraphy and mechanomyography. Neuromuscular monitoring is recommended when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.[citation needed]
When train of four monitoring is "used continuously, each set (train) of stimuli normally is repeated every 10th to 12th second. Each stimulus in the train causes the muscle to contract, and 'fade' in the response provides the basis for evaluation." These sets are called trains because their shape bears the resemblance of a train.[4] In train of four monitoring, "peripheral nerve stimulation can ensure proper medication dosing and thus decrease the incidence of side effects" by "assessing the depth of neuromuscular blockade".[5]
Before the patient is fully awake, voluntary muscle testing is not possible and indirect clinical tests, such as apparent muscle tone and pulmonary compliance, can be affected by factors other than PORC. Direct neuromuscular monitoring avoids these problems and allows the doctor to remedy PORC before it becomes a source of patient distress.[6][7][8][9][10]
^Ortega R, Brull SJ, Prielipp R, Gutierrez A, De La Cruz R, Conley CM (January 2018). "Monitoring Neuromuscular Function". The New England Journal of Medicine. 378 (4): e6. doi:10.1056/NEJMvcm1603741. PMID 29365307.
^Naguib M, Brull SJ, Johnson KB (January 2017). "Conceptual and technical insights into the basis of neuromuscular monitoring". Anaesthesia. 72 Suppl 1 (S1): 16–37. doi:10.1111/anae.13738. PMID 28044330.
^Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, Love NJ, Misra U, Morris C, Nathanson MH, Rodney GE, Verma R, Pandit JJ (January 2016). "Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland". Anaesthesia. 71 (1): 85–93. doi:10.1111/anae.13316. PMC 5063182. PMID 26582586.
^"Train-of-Four Stimulation". Churchill Livingstone. 2000. Archived from the original on 11 September 2014. Retrieved 10 September 2014.
^Saenz AD, Maillie S, Eiger G (12 July 2013). Spencer DC (ed.). "Peripheral Nerve Stimulator - Train of Four Monitoring". Medscape. Retrieved 10 September 2014.
^Viby-Mogensen J. "Chapter 39: Neuromuscular Monitoring" (PDF). Miller's Anesthesia (5th ed.). Churchill Livingstone, Inc.
^Harvey AM, Masland RL (1941). "Actions of durarizing preparations in the human". Journal of Pharmacology and Experimental Therapeutics. 73 (3): 304–311.
^Botelho SY (November 1955). "Comparison of simultaneously recorded electrical and mechanical activity in myasthenia gravis patients and in partially curarized normal humans". The American Journal of Medicine. 19 (5): 693–6. doi:10.1016/S0002-9343(55)80010-1. PMID 13268466.
^Christie TH, Churchill-Davidson HC (April 1958). "The St. Thomas's Hospital nerve stimulator in the diagnosis of prolonged apnoea". Lancet. 1 (7024): 776. doi:10.1016/s0140-6736(58)91583-6. PMID 13526270.
^Engbaek J, Ostergaard D, Viby-Mogensen J (March 1989). "Double burst stimulation (DBS): a new pattern of nerve stimulation to identify residual neuromuscular block". British Journal of Anaesthesia. 62 (3): 274–8. doi:10.1093/bja/62.3.274. PMID 2522790.
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