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Emily Covington Module 1 Assignment

Quantitative Neuromuscular Monitoring

Neuromuscular blocking agents (NMBAs) are an important aspect of the anesthesia
providers armamentarium. These agents are routinely used in the operating room to facilitate
endotracheal intubation and improve intraoperative surgical conditions. However, risks may also
be associated with their administration. A significant concern for anesthesia providers when
administering 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. The commonly used
TOF stimulation delivers electrical stimuli to the selected nerve while supplying the provider a
visual and tactile assessment of the associated muscle. It is of interest that with four muscle
contractions in the absence of palpable fade; the patient may still have up to 70% receptor
blockade. There is a significant relationship regarding quantitative versus qualitative
neuromuscular monitoring and patient outcomes.
One study compared the onset and offset of the NMBA using mechanomyography, the
gold standard, and phonomyography monitoring techniques. Both methods showed close
similarity when measuring onset, offset, and maximum effect of the NMBA at the adductor
pollicis muscle. 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. Thus, Relaxofon resulted in a
reliable device for measuring neuromuscular receptor blockade and preventing residual paralysis.
Theoretically, a device providing electromyographic and phonomyographic monitoring
will provide a quantitative measurement preventing risks associated with the subjective TOF
assessment alone. The quantitative reading will assure the provider of full neuromuscular
recovery (TOF ratio >0.9). Further clinical data of the Relaxofon is necessary to evaluate its
clinical utility regarding incidence of residual paralysis and overall cost effectiveness. The
quantitative neuromuscular monitoring advancement provided by the Relaxofon may allow the
high incidence of postoperative residual paralysis to become a rarity.

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
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: