It is a must in daily anesthesia practice provided that you have all the equipments. We do not use it routinely in our center.

It 's true, not all centers have the equipment, and should persuade administrators that this leads, patient safety and cost savings for the hospital.

I almost never use a nerve stimulator. When I employ muscle relaxants (which is infrequently), I utilize continuous infusions, generally with cisatracurium. I have a defined endpoint, generally surgical satisfaction, titrate to that endpoint, and discontinue the infusion when the muscle relaxant is no longer required. In my experience, the degree of relaxation required to maintain surgical satisfaction is compatible with rapid reversibility on discontinuation of the infusion.

Are they actually routinely required for all patients? Probably not. Is there any level one evidence that it should be used all patients? It is required only in a selected patient population, such a morbidly obese patient or a patient of myasthenia gravis where you wish to minimise use of NDMR. It may be required in surgeries where a deep or intense block is desirable.

I'm not entirely in agreement, With Souvik and Jeff, there are several articles that talk about the PORC (post operative residual curarization) and others relate to the evidence based medicine, see: Anesthesiology. 2003 May, 98 (5) :1037-9.

Evidence-based practice and neuromuscular monitoring: it's time for routine quantitative assessment. Eriksson LI.

Other items on the usefulness of monitoring especially in general surgery and laparoscopic, and i replay and the PORC and to the safety of the patient? What do you think?

My research interest is in pharmacokinetic control, so I view clinical problems through that lens. If you want to know how to achieve constant depth of sedation with a mixture of propofol and remifentanil via a PCA pump by pressing the button at precisely timed intervals, I've done that (25 times) and published it. Scheduled intermittent boluses are fine, but too much work for the average clinician. Substituting a TOF for a stopwatch is no improvement. Stopwatches run like, well, clockwork, TOF is subject to considerable measurement error. A far more reliable process is continuous infusion of a drug with reliable pharmacokinetics.

Having determined a method to maintain a relatively constant drug level, the question is what observation to use to close the loop. I've never met a surgeon who knew he had inadequate relaxation change his mind when presented with a TOF value. "You have a single sensor, and my fingers have millions, and they all say the patient is rigid". Thus, I titrate to a clinical endpoint (a quiet surgeon), and discontinue the muscle relaxants when the clinical need ends. I rarely employ muscle relaxants for intubation (I prefer to adequately anesthetize my patients prior to intubating them), and only use reversal agents when I have a demonstrable need for them. Never forget that the only reason we have muscle relaxants is that indigenous people discovered their utility for killing wild animals.

This discussion needs facts.

1. Omission of quantitative measurement of neuromuscular block is unequivocally associated with increased risk of residual block in the recovery room.

2. It is of limited use to present the surgeon with a TOF value, since the relatively NMB-resistant diaphragm will be active with a TOF of zero. For this purpose, it is mandatory to employ post-tetanic count measurement, which enables clinicians to quantify different levels of block below the TOF threshold.

3. The measurement variation of a correctly employed accelerograph is an order of magnitude smaller than the individual NMB response and elimination variations.

4. Several drugs markedly affect the NMB response. Try for example to observe NMB response in patients on valproate.

Suggested reading for the weekend: Miller´s Anesthesia, Chapter 47: Neuromuscular Monitoring - by my fellow countryman Jørgen Viby-Mogensen.

I do not use it for all cases who have been given muscle relaxants. However, I routinely use a TOF monitoring in cases of MEP monitoring and use of sugammadex, and also use a PTC monitoring in cases of profound block in surgeries such as robot surgeries and some laparoscopic surgeries.

I have to admit to a big change in practice in recent years after having done some research in this area and become more aware of the issues.

The " human monitor" using clinical signs like head lift for 5 seconds, grip strength etc are not sensitive enough and often don't detect significant blockade. Many of these "tests" also require the patient to be conscious. Even subjectiveTOF monitoring is not helpful above 0.4- when we can no longer appreciate the fade. Only objective monitors eg EMG, KMG or AMG with a mechanical sensor are truly useful. These are commercially available and. Not very expensive by medical equipment standards with minimal disposable cost - a few ECG electrodes.

If you start to monitor your patients you we will be surprised at the high level of post op residual blockade they have. This has been by several authors( and my group will have something in this space soon.

Does it matter? Well Erikson showed aspiration at levels of block as high as 0.8 in awake volunteers, so withou the addition of sedatives - which can only make it worse, it does.while rare, Aspiration is equal to failed intubation as a cause of death in the British audit project 4, and ask in France. It is responsible for 10-15% of airway related litigation in the USA?

So I think it is important. Since I started routinely monitoring, I have been surprised at how often I would have sent my extibated patient to recovery unreversed. It is especially important in those with other comorbidities eg obesity, sleep apnea and delayed gastric emptying.

Try it you will be surprised.

Dear Stephanie, I agree with you;

I changed the way I work and with the TOF and PTC I've seen smaller events related to PORC.

How do you know you don't have residual blockade if you don't look for it?

As stated by several people here, our (finger tip) sensitivity in dedecting residual blockade is not sufficient in the context of preventing morbidity/mortality. I agree with Jeff as for the onset of NMBAs: you can give as much as you need and in my experience many times you don't need full blockade (TOFR=0) to achieve what the surgeons require. Also, many times NMBAs aren't needed at all. True. BUT, that wasn't the question. There is a nice editorial and article about the deceiving safety of reversing NMBAs, but not monitoring it: Reversal with Sugammadex in the Absence of Monitoring Did Not Preclude Residual Neuromuscular Block. Kotake et al. Anesthesia & Analgesia: August 2013 - Volume 117 - Issue 2 - p 345–351

Who wants to go a bit deeper into this subject and look at the comparison between AMG and EMG should have a look at pages 373-379 of the same issue.

Of course , the use of TOF and PTC in necessary for the administration dose of reversal.

Infact, the dose of reversal must be calibrated on the TOF and PTC response.

TOF monitors are generally available at every institution (at least academic institution) and are very cheap and easy to use. I agree with previous authors though that there is a large amount of obervational error in estimating the fade or TOF ratio. I have worked with accelerometers like TOF-watch which, if calibrated correctly with full tetanus, can be very accurate. However, the set-up can be tedious. Therefore, TOF ratio is the best bang for the buck. The initial cost of the stimulator is minimal, ekg buttons double as sensors, and even one prevented instance of residual neuromuscular block justifies the cost...let alone the value to the patient. In summary, TOF may not be exact but for the effort required, it is one of the easist and cheapest patient safety iniatives we can employ.

At our setup at Aga Khan university hospital,we are not doing objective NMJ monitoring as a routine with the exception of patients with neumuscular disease like MG scheduled for thymectomy in which we do TOF monitoring..We donot have any problem in the PACU of the residual NMB .The muscle relaxants that we are routinely using are of intermediate duration like Atracurium and Rocuronium.We routinely extubate the patients on the basis of adequacy of tidal volume (ETCO2 correlation),RSBI of less than 100 especially if the patient is under deep plan of anesthesia.This is our institutional practice for routine general surgical patients .

tidal volume is useless as an indicator of residual relaxation.

F Donati. Residual paralysis: a real problem or did we invent a new disease? Can J Anesth 2013; 60:714-29

I agree with the comment given by Dr Cansoni regarding the optimal dose of reversal agent if the NMJ monitoring is done.Regarding Dr Felsby comment on uselessness of spontaneous Tidal volume as a measure of residual NMB seems to be theoretically right but practically its doing fine on the basis of factual clinical practice at our institution as evident by our experience at our PACU .Clinical monitoring should not be discouraged at the expence of only NMT monitoring in isolation.

Practically, I use TOF monitoring during the surgical procedure followed up with a 10 sec Tetanic response at the end of the case prior to 'waking' looking for any evidence of fade. The aim being to time dosing of NDMR to avoid/ minimise the need for reversal agents.