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The call for accurate monitoring during anesthesia

Monitoring the depth of neuromuscular blockade is vital to ensure patient safety during anesthesia.  When depth of neuromuscular blockade is not measured, patients are at a higher risk of postoperative complications.  

Quantitative neuromuscular monitoring is the key to success 

The only reliable way to confirm adequate recovery from neuromuscular blockade and avoid complications is quantitative neuromuscular monitoring.

Guidelines for neuromuscular blockade management

Patients receiving neuromuscular blocking agents should be carefully monitored to ensure the best care and outcomes. 

Recent, and independently developed, guidelines from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ESAIC) strongly recommend and encourage the widespread adoption of quantitative neuromuscular monitoring during anesthesia.

 

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Recommended by ASA and ESAIC

The two leading societies in anesthesiology, ASA and ESAIC, jointly recommends the following: 

  • Using stimulation of the ulnar nerve – one of the nerves in the hand – with quantitative neuromuscular monitoring at the thumb
  • Confirming a TOF ratio greater than or equal to 0.9 before extubation
  • Restructuring the clinical environment by placing quantitative monitors in all anesthetizing locations
  • Appointing a local champion who is supported by leaders
Explore more about guidelines
Key points of the new guidelines for neuromuscular blockade management

What do the new guidelines include? This article will give you an overview of the key points of the guidelines.

Co-author insights on the ASA Neuromuscular Blockade Management Guidelines

With Prof. Lars I. Eriksson, Professor and Academic Chair of Anesthesiology and Intensive Care, at Karolinska institute in Stockholm.

The adequate recovery of 90 % 

The accepted definition for “adequate recovery” from neuromuscular block is the return of the train-of-four (TOF) ratio to, or above 0.9 (90%). This level of recovery restores most of the functional integrity of the muscles involved in airway protection.  

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EMG is the most accurate technology  

Electromyography (EMG) measures the electrical signal during depolarization at the neuromuscular junction. The compound muscle action potential (CMAP) is the first electrical signal that can be measured after neuromuscular transmission. 

How EMG is different

The difference from other technologies is that EMG measures an electrical event that occurs at the neuromuscular junction; the activation of postsynaptic receptors by acetylcholine (a chemical process) that converts it to a mechanical response (excitation- contraction coupling), that results in muscle contraction.

Unlike other technologies such as MMG, AMG, or KMG, EMG does not rely on physical movement to measure function. This makes it a superior indicator of pure neuromuscular function.

Monitoring neuromuscular blockade for pediatric patients 

Studies indicate that children run an equally high risk of complications in the use of NMBAs as adults. Simultaneously, studies on infants indicate that children can have wide variations and longer duration of action after administering this type of drug.

Pediatric solution
Patient safety for your most delicate patients

To minimize anesthesia-related complications in children, we offer a customized sensor for pediatric use together the accurate quantitative neuromuscular monitor TetraGraph.

Further reading

Clinical support

At Senzime, we understand that adopting a new technology or method can be a daunting task. With many of our team members having a clinical background, we understand the challenges you may face.

That’s why we are here to support you every step of the way. For you and for your patients. 

Our expertise

You can be sure that we are here to help you ensure your patients receive appropriate care, every day and in every case.

References

Fuchs-Buder, Thomas; Romero, Carolina S.; Lewald, Heidrun; Lamperti, Massimo; Afshari, Arash; Hristovska, Ana-Marjia; Schmartz, Denis; Hinkelbein, Jochen; Longrois, Dan; Popp, Maria; de Boer, Hans D.; Sorbello, Massimiliano; Jankovic, Radmilo; Kranke, Peter. Peri-operative management of neuromuscular blockade: A guideline from the European Society of Anaesthesiology and Intensive Care. European Journal of Anaesthesiology 40(2):p 82-94, February 2023. | DOI: 10.1097/EJA.0000000000001769

Stephan R. Thilen, Wade A. Weigel, Michael M. Todd, Richard P. Dutton, Cynthia A. Lien, Stuart A. Grant, Joseph W. Szokol, Lars I. Eriksson, Myron Yaster, Mark D. Grant, Madhulika Agarkar, Anne M. Marbella, Jaime F. Blanck, Karen B. Domino; 2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade: A Report by the American Society of Anesthesiologists Task Force on Neuromuscular Blockade. Anesthesiology 2023; 138:13–41 doi: https://doi.org/10.1097/ALN.0000000000004379

Fuchs-Buder, Thomas; De Robertis, Edoardo; Thilen, Stephan R.; Champeau, Michael W.. Joint Letter to the Editor from the American Society of Anesthesiologists and the European Society of Anaesthesiology and Intensive Care on Management of Neuromuscular Blockade. European Journal of Anaesthesiology ():10.1097/EJA.0000000000001867, June 02, 2023. | DOI: 10.1097/EJA.0000000000001867

Iwasaki et al- A comparison between the Adductor Pollicis Muscle Using TOF-Watch SX and the Abductor Digit Minimi Muscle Using TetraGraph in Rocuronium-Induced Neuromuscular Block: A prospective Observational Study, Anesth Analg, 2022 Aug 1;135(2):370-375. Doi: 10.1213/ ANE.0000000000005897. Epub 2022 Jan 21  

J Klucka et al, Residual neuromuscular block in paediatric anaesthesia, BJA 2019 

Cha, Y.M., Faulk, D.J. Management of Neuromuscular Block in Pediatric Patients — Safety Implications. Curr Anesthesiol Rep 12, 439–450 (2022). https://doi.org/10.1007/s40140-022-00537-x

Debra J. Faulk, MD, A Survey of the Society for Pediatric Anesthesia on the Use, Monitoring, and Antagonism of Neuromuscular Blockade, Anesthesia and Analgesia 2021 

Luc E. Vanlinthout et al, Neurophysiological Assessment of Prolonged Recovery From Neuromuscular Blockade in the Neonatal Intensive Care Unit