NMM

PATTERNS OF SIMULATION

OBJECTIVES OF NM
MONITORING

Single-Twitch Stimulation

MONITORING MECHANISMS

Tetanic Stimulation

Mechanomyography

To evaluate the degree of neuromuscular

blockade during and after anesthesia
Monitoring onset of NM Blockade.
Assessing patients recovery from blockade to
minimize risk of residual paralysis.

SENSITIVITIES OF MUSCLE
GROUPS TO NDMRS
Train-of-Four Stimulation

In order from most resistant to most sensitive

1. Vocal cords
2. Diaphragm
3. Orbicularis Oculi
4. Abdominal rectus
5. Adductor pollicis
6. Masseter
7. Pharyngeal muscles
8. Extraocular muscles
FEATURE

TETANU
S
Current
Supramaxi Supra or
Supra or
strength
mal
submaxima submaxima
l
l
Frequency/Des 0.1 1 Hz 2 Hz four 30 50 Hz
cription
stimuli
for 5 sec

Prerelaxant
Control
Pain on
stimulation
Sensitivity of
manual
detection
(visual/tactile)
Alteration of
subsequent
responses
Interval
between
successive
stimuli
Receptor
occupancy
detection
Sensitivity for
detection of
subtle block

ST

TOF

DBS

Supra or
submaxima
l
30 Hz for 5
sec, 3 sec
later ST at
1 Hz

Needed
-

-/+

++

++

Accelerography
Double-Burst Stimulation

PTC

Supra or
submaxima
l
3 impulses
at 50 Hz
repeated
after 750
msec
Not needed Not needed Not needed

Post-Tetanic Count Stimulation

Electromyograhy

Non deploarizing NM Blockade

Kinemyography

Not needed

Application of NMJ monitoring

Not
sensitive

Not
Sensitive
sensitive at
TOF ratio
of 0.4-0.7
Not altered Not altered Altered
(posttetanic
facilitation)
5 sec
12 sec
6 min

75-90%

70 90%

70 90%

Highly
sensitive

Sensitive
TOF RATIO

0.70 0.75
Not altered Altetred

12 15 sec 6 min

70 90%

>90% also

0.85 0.90
> 0.90

Not
sensitive

Monitoring of Not useful

profound block

Sensitive

Sensitive

Sensitive

Not
applicable

Not useful

Not useful

Not useful

Useful

SIGNS AND SYMPTOMS

Diplopia and viaual disturbances
Decreased hand grip
Inability to maintain opposition of the incisor teeth
Tongue depressor test negative
Inability to sit up without assisstance
Severe facial weakness
Speaking a major effort
Overall weakness and tiredness
Diplopia and viaual disturbances
Generalised fatigue
Excludes clinically important residual neuromuscular blockade

CLINICAL
OBJECTIVE

SITE

TWITCH
MODALITY

TARGET
RESPONSE

Fast onset/tracheal Orbicularis oculi

intubation

Single twitch or
train-of-four

0 twitches

Profound blockade Adductor pollicis

Orbicularis oculi

Post tetanic count

Train-of-four

Relaxant
dependant

Adequacy of
relaxation
(abdominal
surgery)

Adductor pollicis

Train-of-four
count

One to two
twitches present

Predicting
reversible block
(when no TOF
response present)

Adductor pollicis

Post tetanic count

Relaxant
dependant

Detecting
reversible block

Adductor pollicis

Train-of-four
count

At least two
twitche spresent

Detecting
adequate
neuromuscular
function

Adductor pollicis

Double-burst
stimulus

No fade present

Phonomyography