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Effects of Quantitative Neuromuscular Monitoring on Postoperative Residual Paralysis
Emily A. Covington
The University of Kansas


Effects of Quantitative Neuromuscular Monitoring on Postoperative Residual Paralysis
A significant concern for anesthesia providers when administering neuromuscular
blocking agents (NMBAs) is overdosage leading to residual paralysis. The train-of-four (TOF)
stimuli, delivered by the peripheral nerve stimulator (PNS), allow the provider a qualitative and
indirect assessment regarding the depth of the neuromuscular blockade (Hemmerling et al.,
2004). With the presence of four muscle contractions in the absence of palpable fade the patient
may still have up to 70% receptor blockade (Wehbe, Mathieu, & Hemmerling, 2012). There is a
significant relationship regarding qualitative versus quantitative neuromuscular monitoring and
patient outcomes.
The aim is to evaluate patient outcomes when using quantitative neuromuscular
monitoring provided by the Relaxofon. This device is based on the principle of phonomyography
and the commonly used TOF stimulation (Wehbe et al., 2012). It delivers an objective TOF
reading to the anesthesia provider in with the goal of preventing risks associated with the
subjective TOF assessments (Wehbe et al., 2012). Further clinical data of the Relaxofon is
necessary to evaluate its clinical utility. The incidence of postoperative residual paralysis will be
examined using quantitative monitoring after the administration of a NMBA.
There are numerous monitoring techniques available to measure neuromuscular blockade
intensity (Trager, Michaud, Deschamps, & Hemmerling, 2006). Currently, the PNS is most
commonly used in the operating room, supplying the provider a visual and tactile assessment of
the associated muscle. Clinicians are unable to reliably exclude residual neuromuscular
blockade when using conventional peripheral nerve stimulators because fade is difficult to detect

subjectively when TOF ratios are between 0.4 and 0.9 (Capron, Fortier, Racine, & Donati,
2006). Mechanomyography is the gold standard for neuromuscular monitoring; however, a
difficult set-up it is technically arduous to set up which prevents its use clinically (Hemmerling
et al., 2004). Numerous studies have compared the use of additional monitoring techniques to
Hemmerling et al. (2004) compared the onset and offset of the NMBAs using
mechanomyography and phonomyography monitoring techniques. Both methods showed close
similarity when measuring onset, offset, and maximum effect of the NMBA at the adductor
pollicis muscle (Hemmerling et al., 2004). An additional study proposed a new monitoring tool
to measure the depth of anesthesia after administration of the NMBA. This device, Relaxofon,
has the ability to record the real time phonomyographic signal and calculate the TOF ratio
(Wehbe et al., 2012). Thus, Relaxofon resulted in is a reliable device for measuring quantitative
neuromuscular receptor blockade and detecting residual paralysis (Wehbe et al., 2012). It is of
interest that this device may reduce the incidence of postoperative residual paralysis. to become a
It is hypothesized that quantitative neuromuscular monitoring provided by the Relaxofon
will decrease the incidence of postoperative residual paralysis in patients receiving NMBAs.
A quasi-experimental or controlled trial without randomization will be used for this
study. This method allows the investigator to measure the impact that quantitative neuromuscular
monitoring provided by the Relaxofon has on the incidence of postoperative muscle weakness.

Time series design will be the selected quasi-experimental design utilized. The year prior to
introducing the Relaxofon, the occurrence of postoperative residual paralysis will be collected at
four consecutive 3-month periods. After implementation of the Relaxofon, the frequency of
postoperative residual paralysis will be gathered at four separate instances. This design will
allow the ability to attribute change due to the use of quantitative neuromuscular monitoring,
when compared to the commonly used qualitative technique.
Convenience sampling will permit the use of the most accessible people as participants.
Prior to introducing the Relaxofon, approximately 50 individuals with an American Society of
Anesthesiologists (ASA) physical status of one or two will be evaluated for residual paralysis
when using the PNS. After implementation of the Relaxofon, 50 additional cases with an ASA
status of one or two will be evaluated for the same outcome. These cases will include individuals
undergoing general surgery procedures lasting less than two hours receiving NMBA. Patients
with coexisting neuromuscular disease or on medication known to interact with neuromuscular
transmission will be excluded.
This study will take place in the operating room at an academic medical hospital.
Education and instructions will be provided for the Relaxofon prior to implementing this device.
Each investigator providing results and evaluation for this study will be expected to demonstrate
competency when using this device.
The independent variables are the PNS and the Relaxofon, after intravenous
administration of NMBAs. Airway patency, the ability to overcome airway resistance, airway

protection, and the ability to clear secretions will be evaluated postoperatively to assess the
dependent variable of residual paralysis.
On admission to the postanesthesia care unit (PACU) and at 30 minutes and 60 minutes
post arrival each subject will be evaluated for residual paresis criteria including: general
weakness, facial weakness, facial numbness, five second eye opening, five second head lift, five
second hand grip, five second tongue protrusion, object tracking with eyes, blurry vision, double
vision, ability to speak, ability to cough, ability to smile, ability to swallow, ability to breath
deeply, and the tongue depressor test (Murphy et al., 2013). A 16-point scoring system will be
developed including the previously mentioned criteria. A score of zero will signify extreme
residual paralysis, and a score of 16 will represent full recovery from the NMBA.
Submission to the Institutional Review Board (IRB) is mandatory. The IRB must accept
the proposed plan for continuation of the study. Once approved, written informed consent will be
obtained from the selected participants. The consent must include adequate information about the
research. The applicant must comprehend the information, and have the ability to accept or
decline participation voluntarily.
Data Analysis
An parametric independent t-test will be used to statistically analysisze the data collected.
The subjects being assessed with the PNS will be placed in the first group. The second group will
include the subjects being evaluated with the Relaxofon. Each group will be analyzed
postoperatively for residual muscle weakness by using the 16-point scoring system (Murphy et

al., 2013). Based on the hypothesis, the results will demonstrate significantly different means
between the two groups, with the Relaxofon group having a smaller incidence of residual
Patients undergoing a surgical procedure, routinely receive a realm of medications
perioperatively. The medications provided by the anesthesia provider may interfere with patient
recovery leading to a higher incidence of residual paresis not linked to the administration of
NMBAs. Consequently, these procedures cannot be accomplished without the use of a
multimodal pharmacological regimen.
Perioperative hypothermia may limit appropriate interpretation of evoked responses.
Thus, it is crucial that the anesthesia provider perform interventions to promote normothermic
conditions for the subject being studied. However, some surgical procedures may hinder
neuromuscular monitoring by restricting normothermia.
The Relaxofon is a new device that is not commercially available. However, the device is
speculated to be obtainable within the next two years (Wehbe et al., 2012). In order to complete
this study, access to the quantitative neuromuscular monitoring device is required.
If using the Relaxofon provides evidence for decreasing the incidence of residual muscle
weakness, facilities administering anesthesia may have to compare patient outcomes to its
overall cost effectiveness. Hence, the quantitative neuromuscular monitoring advancement
provided by the Relaxofon may possibly decrease hospital costs associated with this serious
complication and improve patient safety.


Capron, F., Fortier, L. P., Racine, S., & Donati, F. (2006). Tactile fade detection with hand or
wrist stimulation using train-of-four, double-burst stimulation, 50-hertz tetanus, 100-hertz
tetanus, and acceleromyography. Anesthesia & Analgesia, 102(5), 1578-1584. doi:
Hemmerling, T. M., Michaud, G., Trager, G., Deschamps, S., Babin, D., & Donati, F. (2004).
Phonomyography and mechanomyography can be used interchangeably to measure
neuromuscular block at the adductor pollicis muscle. Anesthesia & Analgesia, 98(2), 377-
381. doi: 10.1213/01.ANE.0000096003.64059.97
Murphy, G. S., Szokol, J. W., Avram, M. J., Greenberg, S. B., Shear, T., Vender, J. S.,Landry,
E. (2013). Postoperative residual neuromuscular blockade is associated with impaired
clinical recovery. Anesthesia & Analgesia. Advance online publication. doi:
Trager, G., Michaud, G., Deschamps, S., & Hemmerling, T. M. (2006). Comparison of
phonomyography, kinemyography and mechanomyography for neuromuscular
monitoring. Canadian Journal of Anesthesia, 53(2), 130-135. doi: 10.1007/BF03021816
Wehbe, M., Mathieu, P. A., & Hemmerling, T. M. (2012). Relaxofon: A neuromuscular blockade
monitor for patients under general anesthesia. Paper presented at the Engineering in
Medicine and Biology Society, 2012 Annual International Conference of the IEEE. doi:
Very nicely done Emily. You write very well and with a little polishing could certainly write for
publication someday. Good ideas and you covered everything in the guideline for the
assignment I think. pb Score = 98%