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A Critical Review of a Quasi-Experimental Design for Studying Neuromuscular Blockade

Monitoring for Patients Under General Anesthesia
Emily A. Covington
The University of Kansas

A Critical Review of a Quasi-Experimental Design for Studying Neuromuscular Blockade
Monitoring for Patients Under General Anesthesia
This paper is an academic critique of an article written by Wehbe, Mathieu, and
Hemmerling (2012) titled Relaxofon: A Neuromuscular Blockade Monitor for Patients Under
General Anesthesia. The authors proposed a new quantitative monitoring tool, Relaxofon, to
measure the depth of anesthesia after administration of the neuromuscular blockade agent
(NMBA). The aim of this article is to provide evidence that the Relaxofon is a reliable method
for monitoring neuromuscular blockade. Wehbe et al. (2012) found that the device has the
ability to inform the anesthesia provider regarding the patients depth of neuromuscular
blockade. It is of interest that this quantitative device may reduce the high incidence of
postoperative residual paralysis. However, this article is poorly constructed and the need for
further research is necessary before implementing this tool into the clinical setting.
A significant concern for anesthesia providers when administering NMBAs is an
overdose leading to residual paralysis (Grayling & Sweeney, 2007). Currently, neuromuscular
blockade in the operating room is evaluated via subjective, qualitative monitoring techniques
(Grayling & Sweeney, 2007). The need for objective, quantitative monitoring may serve to
reduce the incidence of postoperative pulmonary complications (Murphy et al., 2013). Wehbe et
al. (2012) discussed various methods for monitoring neuromuscular blockade including:
mechanomyography, electromyography, acceleromyography, and phonomyography. The
foundation behind the Relaxofon device is phonomyography (Wehbe et al., 2012). The authors
rationale for this study stems from numerous articles that offer evidence that phonomyography
shows good agreement with the gold standard of monitoring, mechanomyography (Trager,
Michaud, Deschamps, & Hemmerling, 2006). The purpose of the Relaxofon is to provide a user-
friendly and quantitative monitoring tool to prevent postoperative pulmonary complications
(Wehbe et al., 2012). The general content of Wehbe, Mathieu, and Hemmerlings (2012) article
provides information regarding multiple neuromuscular monitoring techniques. The article also
specifies the background on phonomyography and why it is the foundation behind the Relaxofon
device, as well as the possible clinical advantages associated with its clinical use (Wehbe et al.,
Wehbe et al. (2012) provide relevant research backing the need for a quantitative
neuromuscular monitoring tool. However, the research question and hypothesis are difficult to
locate, and unclear. This weakness leaves the reader unable to fully appreciate the clinical
significance provided by the Relaxofon. Wehbe et al. (2012) clearly state their proposal of a new
neuromuscular monitoring tool. The authors hypothesize that their results may lead to
integrating the Relaxofon to an automated closed-loop anesthesia system (Wehbe et al., 2012).
The assumed hypothesis prevents the reader from understanding the link between the
measurements tested and the research purpose.
A notable asset to this article is the background literature regarding mechanomyography,
electromyography, acceleromyography, and phonomyography. The authors adequately provide
background information regarding phonomyography and the commonly used train-of-four
technique. Both of which are the bases behind their proposed device. The authors explain how
the train-of-four monitoring technique, in combination with phonomyography monitoring will
provide the anesthesia provider with quantitative data. An obvious strength is that the theoretical
framework supports the need for the study. Relaxofon is based on the theory that
phonomyography emits low frequency sounds by muscle contraction (Wehbe et al., 2012).
The article outlines a quasi-experimental study design with the type of monitoring as the
independent variable and the train-of-four measurement as the dependent variable. The
Relaxofon was only tested on one anesthetized patient. The patient studied is an acceptable
subject to test for this study; however, including multiple patients of this caliber would improve
the clinical significance behind this tool. The defined sample is not a good representation of the
population and a weakness in this study. Due to this limitation, providers are unable to safely
incorporate the Relaxofon into their daily practice. Additional weak points identified in this
study include: absence of obtaining informed consent, no approval received from an ethics
committee or institutional review board, and human subject considerations were not addressed.
For evaluation of this particular study, the authors compared manually calculated train-
of-four ratios and calculated train-of-four ratios provided by the Relaxofon. The independent
variable, type of monitoring, is classified as a dichotomous and nominal measurement. The
dependent variable, train-of-four ratios, is an interval measurement. The train-of-four ratio
ranges were partitioned into two groups including: from 0-30% and from 70-100%. The Bland-
Altman test was used to analyze the agreement between the two methods. This test showed no
clinical significant difference between the manual train-of-four ratio calculations and the
Relaxofon calculated train-of-four ratios. In addition, the study calculated the Pearson
correlation coefficient to analyze the linear dependence between both variables. The Pearson
correlation coefficient was 0.996 indicating a very strong relationship between methods. The
statistical tests selected to analyze the data was appropriate for the level of measurements
presented. The instruments used in this study are suitable to measure the variables; however,
Cronbachs alpha was not reported leaving the reader unable to appreciate its internal
consistency. The authors did report their mean bias and precision in relation to their findings,
which is classified as a benefit of the study. Overall, the results demonstrated no clinical
significant differences between the methods. The author reported a represented confidence level
of 95%, while also revealing the calculated precision, both of which are recognized as a strength.
The conclusions are indirectly drawn from the results leaving the reader unable to fully
value the studys findings. The conclusion does not report in context of what is already known
about neuromuscular blockade monitoring; however, it does state its findings as preliminary data
and the need for future studies. An implication for practice is stated in the context of future
plans; however, this study does not clearly state current implications derived from their study.
Due to the small sample size, and other limitations of this study, anesthesia providers
may not find this study advantageous for their daily practice. The idea of creating a quantitative
method for monitoring neuromuscular blockade is a topic of extreme importance in the
anesthesia realm. Recommendations for this study include: increasing the sample size, including
a power analysis, and an increased focus on developing a hypothesis that is clearly answered by
the results. Overall, further research on the Relaxofon is needed to implement its use into daily
anesthesia practice.

Grayling, M., & Sweeney, B. P. (2007). Recovery from neuromuscular blockade: A survey of
practice. Anaesthesia, 62, 806-809. doi:10.1111/j.1365-2044.2007.05101.x
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: