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.
References 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: 10.1109/EMBC.2012.6345893