RGB Medical Devices - Monitor NMT Multiparamétrico

Demiri M, Colegrave N, Motamed C, Billard V. Comparison of the four-train measurement with a new TOF Cuff® device versus TOF Watch® accelerometer. Anaesth Crit Care Pain Med. 2020 Dec;39(6):891-892

Comparison of the four-train measurement with a new TOF Cuff® device versus TOF Watch® accelerometer

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF monitor and the TOF-Watch SX monitor (monitoring using acceleromyography). The study was carried out with 35 patients and the measurements were carried out simultaneously with both monitors on contralateral arms. Induction was performed with Atracurium (30 patients) and Rocuronium (5 patients) and a reverter was used in 25 patients (the type of reverter is not specified). During recovery from neuromuscular blockade, significant differences were observed between devices for both deep blockade (recovery of train-of-four responses 1, 2, 3, 4 and T4/T1 > 10%) and moderate blockade (delay in recovery until reaching T4/T1 > 70%, T4/T1 > 75%). For T4/T1 > 90%, Bland-Altman analysis showed a bias of -9.3 minutes with an upper/lower limit of agreement of [31.9; 13.2] minutes

Meney L. A mixed methods systems approach to the implementation of new neuromuscular blockade monitoring technology to anesthetic practice during laparoscopic colorectal surgery. 6th International Conference and Exhibition on Anesthesia and Surgery, 2017

A mixed methods systems approach to the implementation of new neuromuscular blockade monitoring technology to anesthetic practice during laparoscopic colorectal surgery

This document corresponds to the presentation at a conference of the results of the evaluation of the use of TOFCUFF at the Ninewells hospital. To this end, interviews were carried out with 2 anesthesiologists and 2 surgeons before and after the implementation of the TOFCUFF. It could not be evaluated whether the use of lower intra-abdominal pressures reduces the patient's postoperative pain. Anesthetists reported that the benefits outweighed the drawbacks of using the TOFcuff. The surgeons found it reassuring to have an accurate indicator of the patient's level of paralysis and were able to operate with lower laparoscopic pressures without affecting their field of vision. The conclusion is that incorporating TOFcuff into routine practice would improve confidence in anesthetists' decisions regarding reversal of neuromuscular blockade, allow them to comply with AAGBI guidelines, and improve laparoscopic surgical performance.

Meney L, Fioratou E, Hilton-Christie S. An evaluation of the introduction of new neuromuscular monitoring technology to anaesthetic practice during laparoscopic colorectal surgery. Ninewells Hospital & Medical School.

An evaluation of the introduction of new neuromuscular monitoring technology to anaesthetic practice during laparoscopic colorectal surgery

This document is a poster for a presentation of the same work described in the previous reference and the results are similar. In this case, it is indicated that the interview was carried out with 3 anesthesiologists and 2 surgeons and the conclusions are similar, but the advantages and disadvantages of using the TOFCUFF are described. Advantages: Easy application, Muscle relaxant bolus timer, Low pressure operation (8-10 mmHg) without affecting the field of vision, Auto-Pilot mode, Guided choice of the type and dose of the reverter, Accurate monitoring of residual paralysis and Completion of the Auto-Pilot with the patient completely recovered. Disadvantages: Delay in medication administration, Impedance issues in 3 cases (2 of them resolved), Blood pressure not recorded regularly enough for dual use, Use of separate monitor, Distracting monitor sounds (can be muted), and Monitor disconnected from patient before going to recovery.

Veiga Ruiz G, García Cayuela J, Orozco Montes J, Parreño Caparrós M, García Rojo B. Aguayo Albasini JL. Monitorización intraoperatoria del bloqueo neuromuscular y la presión arterial con un solo dispositivo (TOF-Cuff): estudio comparativo con la mecanomiografía y la presión arterial invasiva. Rev Esp Anestesiol Reanim. 2017 Dec; 560-567

Intraoperative Monitoring of Neuromuscular Blockade and Blood Pressure with a Single Device (TOF-Cuff): Comparative Study with Mechanomyography and Invasive Blood Pressure

This article is based on clinical research carried out to validate the compression myography method for measuring neuromuscular transmission and non-invasive pressure, so the results obtained were already known. For neuromuscular transmission, an observational study was carried out with 32 patients compared with mechanomyography in opposite arms. When comparing a TOF-ratio > 0.9 quantified by TOF-Cuff with a TOF-ratio > 0.7 in the MMG, it had a specificity of 91% and a positive predictive value of 84%. The 90% TOF Ratio measurement occurred at different times with both methods (3.5 minutes before with compressmyography). The conclusions of the article are that the method has been shown to be valid and safe in the monitoring of TNM and in the measurement of PNI, with no patient presenting adverse events, skin lesions or residual pain.

Suzuki H, Ootaki K, Kawamae K. Comparison of the TOF-Cuff® and TOF-Watch SX® During Spontaneous Recovery From Neuromuscular Blockade. ASA October 2017; A2316

Comparison of the TOF-Cuff® and TOF-Watch SX® During Spontaneous Recovery From Neuromuscular Blockade

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF method and the TOF-Watch monitor (monitoring using acceleromyography). The study was carried out with 22 patients and the measurements were carried out simultaneously with both monitors. The time to reach a certain TOF value is significantly shorter with the TOF-CUFF method (TOF > 0.7: 45.4 vs. 50.9 min, TOF > 0.9: 51.7 vs. 58.0 min). The conclusions of the study are that a faster recovery from neuromuscular blockade and greater repeatability is obtained with the TOF-CUFF method than with the TOF-Watch, probably due to differences in the measurement methods used or differences in the muscles measured. The authors' conclusion is that more studies are needed in a larger number of patients and various conditions to confirm the accuracy and usefulness of the TOF-CUFF method.

Hagiwara H, Kazuma S, Wakasugi K, Kubo M, Yamakage M. Comparison of the Accuracy Between the TOF-Cuff® Neuromuscular Transmission Monitor and the TOF-Watch SX™. ASA October 2017; A4062

Comparison of the Accuracy Between the TOF-Cuff® Neuromuscular Transmission Monitor and the TOF-Watch SX

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF method and the TOF-Watch monitor (monitoring using acceleromyography). The study was carried out with 15 patients and the measurements were carried out simultaneously with both monitors. The results obtained with the statistical design indicate that the TOF ratio with the administration of rocuronium at the time of induction of anesthesia showed that the TOF-CUFF measurements were significantly correlated with those of TOF-Watch (correlation coefficient = 0.98, p <0.0001). In the case of sugammadex administration at the time of extubation, TOF-CUFF measurements were also significantly correlated with TOF-Watch measurements (correlation coefficient = 0.91, p < 0.0001). The conclusions of the study are that the measurement of the TOF ratio with the TOF-CUFF method correlates with the measurement obtained with the TOF-Watch SX in the period of induction of anesthesia and in the period of reversal of neuromuscular blockade, and the results suggest that the TOF-CUFF method can evaluate neuromuscular blockade more easily

Markle A, Horn K, Dullenkopf A. TOF-Cuff vs TOF-Scan for relaxometry during general anaesthesia. ESA June 2018

TOF-Cuff vs TOF-Scan for relaxometry during general anaesthesia

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF method and the TOF-Scan monitor (monitoring using acceleromyography). The study was carried out with 56 patients and the measurements were carried out simultaneously with both monitors on contralateral arms. The compared values were the time to achieve complete neuromuscular blockade (T0), the time to achieve recovery of TOFc=2 (T2) and the time to achieve recovery of TOFr≥90% (T90). T0 value was recorded in all patients, while T2 and T90 values were recorded in 19 patients. The results obtained indicate that the time until T0 was 139 ± 50 s (TOF-Cuff) and 149 ± 47 s (TOF-Scan), the time until T2 was 49 ± 14 min (TOF-Cuff) and 54 ± 13 min (TOF-Scan) and, finally, the time to T90 was 73 ± 12 min (TOF-Cuff) and 79 ± 10 min (TOF-Scan). The conclusions of the study are that the results obtained for both methods differ statistically, but it does not necessarily imply that they differ clinically, so more studies are needed to evaluate the usefulness of TOF-Cuff, both in general and in different groups of patients and situations. clinics

Kameyama Y, Arai A, Goto M, Iwasawa Y, Niikura R, Suzuki T. Comparative accuracy of new neuromuscular monitoring -TOF cuff, when compared with TOF watch. JSA May 2018; P01-18-02

Comparative accuracy of new neuromuscular monitoring -TOF cuff, when compared with TOF watch

Adachi T, Murata Y. Comparison of the neuromuscular monitoring between acceleromyography and cuff method. JSA May 2018; P01-18-03

Comparison of the neuromuscular monitoring between acceleromyography and cuff method

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF method and acceleromyography). The study was conducted with 20 patients and measurements were performed simultaneously with both monitors on opposite arms. The results obtain a strong correlation with a Pearson correlation coefficient of 0.871 and a Spearman correlation coefficient of 0.818. They indicate that there may be discrepancies in the PTC.

Kameyama Y, Takagi S, Seto K, Kajiwara I, Goto M, Kitajima O, Suzuki T. Efficiency of the TOF-Cuff for the evaluation of rocuronium-induced neuromuscular block and its reversal with sugammadex: a comparative study vs. acceleromyography. Journal of Anesthesia. 2018 Nov

Efficiency of the TOF-Cuff for the evaluation of rocuronium-induced neuromuscular block and its reversal with sugammadex: a comparative study vs. Acceleromyography

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOF-CUFF method and the TOF-Watch monitor (monitoring using acceleromyography). The study was carried out with 20 patients and the measurements were carried out simultaneously with both monitors on contralateral arms. The variables measured from the time of Rocuronium administration were the time to maximum depression of T1 and the time to spontaneous recovery of post-tetanic count (PTC) and TOF. Additionally, the time was measured from the injection of Sugammadex to measuring a TOFr > 90%. Regression analyzes revealed no statistically significant differences in the mean onset of Rocuronium-induced neuromuscular blockade [127.8 (27.2) s, 123.5 (30.5) s], time to recovery of the first PTC response [23.9 (8.0) min , 25.4 (8.6) min], the time to recovery of the first TOF response [37.2 (8.8) min, 38.9 (11.1) min] and the time to adequate reversal with Sugammadex [139.2 (30.6) s, 151.8 ( 31.5) s] between the TOF-CUFF and the TOF-Watch. The conclusion of the study is that the TOF-CUFF is clinically applicable for the evaluation of the depth of neuromuscular blockade and the recovery of neuromuscular function.

Kazuma S, Wakasugi K, Hagiwara H, Yamakage M. Comparative Study of TOF-Cuff, a New Neuromuscular Blockade Monitor, and TOF-Watch, an Acceleromyography. Anesth Analg. 2019 Jul;129(1):e16-e19

Comparative Study of TOF-Cuff, a New Neuromuscular Blockade Monitor, and TOF-Watch, an Acceleromyography

This article summarizes the results of a prospective observational study to compare neuromuscular transmission monitoring with the TOFCUFF and the TOF-Watch monitor. The study was conducted with 55 patients and measurements were performed simultaneously with both monitors on the contralateral arms. The neuromuscular blockade was reversed with Sugammadex. Repeated measurements were performed for each patient by analyzing sample pairs at five time points (0 seconds, 30 seconds, 1 minute, 1.5 minutes, and 2 minutes) in the induction phase and the recovery phase. Additionally, 20 randomly selected patients were examined for symptoms of residual paralysis within 5 minutes after extubation. The study provides the data from the statistical analysis and concludes that when all TOF Ratio values in the recovery phase are considered, the values measured by both monitors are comparable. However, when only values of TOFr>0.7 are considered for comparison, there is a greater difference and the TOFCUFF monitor overestimates the TOF Ratio value compared to the TOF-Watch monitor (the publication indicates that it underestimates the values, but it seems like a drafting error), so he considers that the TOFCUFF monitor may not be sufficient to evaluate residual paralysis in all patients

Dullenkopf A, Horn K, Steurer MP, Hess F, Welter J. Placement of TOF-Cuff® on the lower leg for neuromuscular and blood pressure monitoring during anesthetic induction for shoulder surgeries. J Anesth. 2020 Feb;34(1):79-85

Placement of TOF-Cuff® on the lower leg for neuromuscular and blood pressure monitoring during anesthetic induction for shoulder surgeries

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOFCUFF monitor and the TOF-Scan monitor (monitoring using acceleromyography). The study was carried out with 20 patients and the measurements were carried out simultaneously with both monitors, with the TOFCUFF bracelet placed on the leg and the TOF-Scan sensor placed on the wrist. The compared values were the time elapsed until reaching complete neuromuscular blockade (T0) and the mean pressure value measured by the TOFCUFF was also compared with the mean pressure value measured with the standard monitor used during the intervention. The results obtained indicate that the time until T0 was 174.4 ± 42.7 s (TOFCUFF) and 150.8 ± 43.7 s (TOF-Scan). The bias was –15.9 s (95% confidence interval: −37.5s to 5.6s) with 95% limits of agreement of –95.2s to 63.3s. 25% of patients had some technical problem with the TOFCUFF measurements. For mean arterial pressure, the mean difference was 1.4 mmHg (95% confidence interval: 2.4mmHg to 5.2mmHg) with 95% limits of agreement of –22.7mmHg to 25.5mmHg. None of the patients suffered any type of injury in the measurement areas. The conclusions of the study are that the results obtained for both monitors show a relatively low correlation in the case of neuromuscular transmission, which they attribute mainly to the different areas of placement of the sensors, while the correlation of blood pressure measurements was high. . The failure rate of measurements with the TOFCUFF was too high, although this is probably attributed to the fact that the size of the cuff used was not the most appropriate for placement on the leg.

Markle A, Graf N, Horn K, Welter JE, Dullenkopf A. Neuromuscular monitoring using TOF-Cuff® versus TOF-Scan®: an observational study under clinical anesthesia conditions. Minerva Anestesiol. 2020 Jul;86(7):704-711

Neuromuscular monitoring using TOF-Cuff® versus TOF-Scan®: an observational study under clinical anesthesia conditions

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOFCUFF monitor and the TOF-Scan monitor (monitoring using acceleromyography). The study was carried out with 20 patients and the measurements were carried out simultaneously with both monitors. The main value compared was the total recovery time (time in minutes from Atracurium injection to a TOFr = 90%). Secondary values compared were the time to complete neuromuscular blockade at induction (TOFr = 0%) and the time to onset of recovery (TOFc = 2). The results obtained indicate that the mean recovery time to obtain a TOFr of 90% was 79.6 ± 13.6 min for TOF-Scan and 70.8 ± 12.8 min for TOFCUFF (P < 0.001; mean bias 8. 9 min, 95% CI: 5.8-12.0). The mean time to obtain 0% TOFr at induction was 164.6 ± 38.8 s for TOF-Scan and 145.5 ± 44.6 s for TOFCUFF (P < 0.001; mean bias 19.1 s, CI 95%: 10.0-28.2). The mean time to obtain a TOFc of 2 was 52.8 ± 12.5 min for TOF-Scan and 45.5 ± 11.1 min for TOFCUFF (P < 0.001; mean bias 7.3 min, CI 95 %: 4.3-10.2). The conclusion of the study is that the TOFCUFF consistently recorded the compared values before the TOF-Scan, although there were large intra-individual variations found with both devices. They consider that this difference could be significant in a clinical setting

Chau I, Horn K, Dullenkopf A. Neuromuscular monitoring during modified rapid sequence induction: A comparison of TOF-Cuff® and TOF-Scan®. Australas Emerg Care. 2020 Dec;23(4):217-220

Neuromuscular monitoring during modified rapid sequence induction: A comparison of TOF-Cuff® and TOF-Scan®

Markle A, Horn K, Welter J, Dullenkopf A. An observational study comparing the performance of TOF-Cuff with TOF-Scan monitoring during anaesthetic induction in clinical routine. Anaesthesiol Intensive Ther. 2020;52(3):181-186

An observational study comparing the performance of TOF-Cuff with TOF-Scan monitoring during anaesthetic induction in clinical routine

This article summarizes the results of a prospective observational study to compare monitoring of neuromuscular transmission with the TOFCUFF monitor and the TOF-Scan monitor (monitoring using acceleromyography). The study was carried out with 25 non-obese patients (BMI < 30 kg/m2) and 25 obese patients (BMI > 30 kg/m2) and measurements were performed every 15 s simultaneously with both monitors located on contralateral arms. The main value compared was the time elapsed to achieve complete neuromuscular blockade at induction (TOFr = 0%), after induction with Atracurium (0.5 mg/kg). In nonobese patients, the bias was -3 ± 21.2 s (limits of agreement -44.7 to 38.4; P = 0.702). In obese patients, the bias was -20 ± 35.0 s (limits of agreement -88.6 to 48.6; P = 0.0139). The conclusion of the study is that a significant systematic difference was found in the time to reach a TOF Ratio of 0% when using the two devices in obese patients, but there was a large overall variability in the measurements, so both devices cannot be compared. use interchangeably

Sunnen M, Schläpfer M, Biro P. Automated Quantitative Relaxometry for Deep Neuromuscular Blockade in Robot-Assisted Prostatectomy. Rom J Anaesth Intensive Care. 2020 Jul;27(1):29-34

Automated Quantitative Relaxometry for Deep Neuromuscular Blockade in Robot-Assisted Prostatectomy

This article describes the results of a study with 20 patients to adapt rocuronium dosing to maintain BNM at deep levels during pneumoperitoneum for robotic-assisted prostatectomy. For this purpose, the TOFCUFF was used and the fractions of time with intense block (PTC 0), adequately deep block (PTC 1 to 3) and not sufficiently deep block (PTC > 3) were quantified. Optimal deep block (PTC 1-3) was achieved for 110 ± 38 min (50 ± 15%). Intense blockage was found for 60 ± 45 min (27 ± 18%) of the total PP time. PTC values > 3 lasted 60 ± 45 min (23 ± 17%). The conclusion is that the deep NMB technique controlled by repetitive bolus doses achieved its objective in 77% of the PP time. In the case of automated quantitative relaxometry, an optimized rocuronium dosing strategy should be applied to maintain a high level of safety and adequate operating conditions without risking unnecessary prolongation of NMB in the post-pneumoperitoneum period.

Sugimura S, Khanh HV, Kawashima S, Nakajima Y, Kinoshita H. Electrocardiogram Cream Reduces Skin-Electrode Impedance Upon Neuromuscular Monitoring Using TOF-Cuff®. Cureus. 2023 Sep 4;15(9):e44670

Electrocardiogram Cream Reduces Skin-Electrode Impedance Upon Neuromuscular Monitoring Using TOF-Cuff®

This article analyzed whether the use of water or cream/gel for ECG electrodes applied between the patient's skin and the cuff electrodes allows the impedance between the electrodes and the patient's skin to be reduced to the range allowed by the monitor. The origin of the study was the high impedance when the cuff is placed on the patient's lower leg. For this, an in vitro study was carried out using non-living materials and a prospective observational clinical study with eight patients over 70 years of age who underwent elective surgery. Application of water and ECG cream/gel similarly reduced impedance values in the in vitro study. Application of ECG cream/gel between the patient's skin surface and the cuff electrodes decreased impedance in the study surgical patients (median 8,600 (6,450 to 9,775) to 2,000 (1,600 to 2,600) (P = 0.012 )). The bottom line is that applying ECG cream/gel between the patient's skin surface and the cuff electrodes can facilitate measurements with the NMT/BP monitor.

Radkowski P, Ruść J, Kęska M. Evaluation of Neuromuscular Blockade: A Comparative Study of TOF-Cuff® on the Lower Leg and TOF-Scan® on the Ulnar Nerve During Mivacurium Anesthesia. Med Sci Monit. 2024 Oct 14;30:e945227

Evaluation of Neuromuscular Blockade: A Comparative Study of TOF-Cuff® on the Lower Leg and TOF-Scan® on the Ulnar Nerve During Mivacurium Anesthesia

This study compared neuromuscular blockade monitoring between the TOF-Cuff placed on the leg and the TOF-Scan on the ulnar nerve during mivacurium anesthesia. An observational clinical trial was conducted with 26 patients. Parameters such as onset time, recovery, and blood pressure were evaluated. Onset time and relaxation time did not differ significantly. The time from the last dose of mivacurium to a TOF index > 90 was shorter in the leg than in the hand (median 20 [5-28, 0-65] min vs 30 [20-35, 0-60] min, p = 0.025). The difference between the pressure measurements was: 11.6 (-41 to 45, 2-19) for SBP and -8 (-28 to 26, -15 to -4) for DBP at baseline (p = 0.0495); 5 (-53 to 55, -2 to 9) for SBP and -11 (-45 to 29, -19 to -5) (p = 0.0017) for DBP during the block. The results showed that the onset time and systolic blood pressure were similar between both methods, but the recovery time was faster with the TOF-Cuff on the leg. These findings highlight differences in muscle response depending on the measurement site, suggesting that the TOF-Cuff may be a useful alternative in certain clinical settings.

Radkowski P, Ruść J, Kęska M, Sztaba K. Comparing Neuromuscular Blockade Measurement Between Upper Arm (TOF Cuff®) and Eyelid (TOF Scan®) Using Mivacurium during General Anesthesia. Med Sci Monit. 2024 May 2;30:e943630

Comparing Neuromuscular Blockade Measurement Between Upper Arm (TOF Cuff®) and Eyelid (TOF Scan®) Using Mivacurium during General Anesthesia

This study compared neuromuscular blockade monitoring using TOF-Cuff on the upper arm and TOF-Scan on the corrugator superciliari muscle during general anesthesia with mivacurium. An observational clinical trial was conducted with 36 patients. The results showed that the onset and recovery time were faster in the corrugator superciliari muscle. TOF-Scan is a viable alternative when the upper arm is unavailable, although it requires adjustments in timing to match the results of the TOF-Cuff. It was concluded that both devices are useful for monitoring, but TOF-Scan needs further validation for wider application.

Radkowski P, Ruść J, Kęska M. Comparison of measurements obtained with TOF-Cuff placed on the arm and the TOF-Scan on the adductor pollicis muscle during general anaesthesia using mivacurium: a prospective observational clinical trial. Sci Rep. 2024 Nov 8;14(1):27180

Comparison of measurements obtained with TOF-Cuff placed on the arm and the TOF-Scan on the adductor pollicis muscle during general anaesthesia using mivacurium: a prospective observational clinical trial

This study compared neuromuscular blockade measures between TOF-Cuff on the arm and TOF-Scan on the adductor pollicis during mivacurium anesthesia. An observational clinical trial was conducted with 25 patients. Both devices showed similar onset and recovery times, with a significant positive correlation. The time from the last relaxant dose to TOFR > 0.9 was not significantly shorter for the hand muscle than for the brachialis muscle (median 20 min [10–55 min] vs. 20 min [15–50 min]. The median (IQR, range) difference between paired measurements (TOF-Scan – TOF-Cuff) was 5 min (–5 min to 10 min, −20 min to 30 min). It is concluded that both methods are useful and comparable, but that interpretations need to be adjusted when using TOF-Scan instead of TOF-Cuff due to differences in muscle tenderness depending on the anatomical location.

Schepens T, Cammu G. Neuromuscular blockade: what was, is and will be. Acta Anaesthesiol Belg. 2014;65(4):151-9

Neuromuscular blockade: what was, is and will be

This article reviews the status of monitoring and reversal of neuromuscular blockade and the different associated aspects.

Brull SJ, Kopman AF. Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities. Anesthesiology. 2017 Jan;126(1):173-190

Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities

This article reviews the status of monitoring and reversal of neuromuscular blockade focusing on residual neuromuscular blockade. Indicates that evaluation of neuromuscular function with a quantitative monitor is mandatory and that objective measurement (a train-of-four ratio greater than 0.90) is the only method to determine the appropriate timing of tracheal extubation and ensure muscle function normal and patient safety.

Duţu M, Ivaşcu R, Tudorache O, Morlova D, Stanca A, Negoiţă S, Corneci D. Neuromuscular monitoring: an update. Rom J Anaesth Intensive Care. 2018 Apr;25(1):55-60

Neuromuscular monitoring: an update

This article is a literature review document in relation to all relevant aspects of monitoring neuromuscular transmission: describing the fundamental principles of the currently available methods, describing the response of different muscles to muscle relaxants, and reviewing the used reversers. The conclusion of the article is the recommendation to implement monitoring of neuromuscular transmission when using muscle relaxants.

Naguib M, Brull SJ, Hunter JM, Kopman AF, Fülesdi B, Johnson KB, Arkes HR. Anesthesiologists' Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey. Anesth Analg. 2019 Jun;128(6):1118-1126

Anesthesiologists' Overconfidence in Their Perceived Knowledge of Neuromuscular Monitoring and Its Relevance to All Aspects of Medical Practice: An International Survey

This article describes the results of a survey of anesthesiologists around the world on the use of muscle relaxants. The anesthesiologists surveyed expressed overconfidence in their knowledge and ability to manage the use of muscle relaxants. This overconfidence may be partially responsible for the lack of adoption of routine perioperative neuromuscular monitoring.

Motamed C. Intraoperative Monitoring of Neuromuscular Blockade. Life (Basel). 2023 May 15;13(5):1184

Intraoperative Monitoring of Neuromuscular Blockade

This article describes the current situation of neuromuscular monitoring based on the review of the referenced bibliography. Based on the recommendations of current clinical practice guidelines, it concludes that quantitative neuromuscular monitoring should be used in the operating room, since it can allow the rational use of muscle relaxants and avoid some of the main complications related to residual neuromuscular blockade.

Boon M, Martini C, Hellinga M, Bevers R, Aarts L, Dahan A. Influence of variations in arterial PCO2 on surgical conditions during laparoscopic retroperitoneal surgery. Br J Anaesth. 2016;117(1):59-65

Influence of variations in arterial PCO2 on surgical conditions during laparoscopic retroperitoneal surgery

This article studies the effect of changes in arterial carbon dioxide concentrations on surgical conditions in patients undergoing laparoscopic surgery under general anesthesia and deep neuromuscular blockade. They use the TOFCUFF monitor to monitor neuromuscular transmission.

Cardia L, Arena A, Giacoppo C, Capua P, Crea B, Micalizzi S, Siliotti R, Mondello E. Clinical evaluation after laparoscopic surgery using TOF-CUFF monitoring for deep neuromuscular block: Low vs Standard pneumoperitoneum pressure. SIAARTI National Congress. 2016

Clinical evaluation after laparoscopic surgery using TOF-CUFF monitoring for deep neuromuscular block: Low vs Standard pneumoperitoneum pressure

This document is a poster for a presentation made at the congress of the Italian society of anesthesiology. The objective is to perform a clinical evaluation after laparoscopic surgery using standard or low pressure and with deep neuromuscular blockade monitored with TOFCUFF. The study was conducted with 22 patients and reversal was induced with sugammadex.

Boon M, Martini C, Yang HK, et al. Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery. PLoS One. 2018;13(5).

Impact of high- versus low-dose neuromuscular blocking agent administration on unplanned 30-day readmission rates in retroperitoneal laparoscopic surgery

This article performs a retrospective analysis to compare unplanned 30-day readmissions in patients receiving high-dose versus low-dose rocuronium during general anesthesia for laparoscopic retroperitoneal surgery.

Biro P, Paul G, Dahan A, Brull SJ. Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring. Anesth Analg. 2019 Jun;128(6):1361-1363

Proposal for a Revised Classification of the Depth of Neuromuscular Block and Suggestions for Further Development in Neuromuscular Monitoring

This article is a multi-expert consensus document that recommends two changes related to neuromuscular blockade monitoring. The first change refers to improving the classification of neuromuscular block levels and dividing deep block (PTC≥1 and TOFCunt=0) into deep block (PTC≥4 and TOFCunt=0) and severe block (PTC=1-3 ). The second change refers to improvements in the screen presentation

Ishida Y, Nakazawa K, Okada T, Tsuzuki Y, Kobayashi T, Yamada R, Uchino H. Anesthetic management of a morbidly obese patient with endometrial cancer during robot-assisted laparoscopic surgery. JA Clin Rep. 2021 Apr 5;7(1):30

Anesthetic management of a morbidly obese patient with endometrial cancer during robot-assisted laparoscopic surgery

This article describes a clinical case about the anesthetic management of a patient with morbid obesity and endometrial cancer during robotic-assisted laparoscopic surgery.

Veiga G. Monitorización Intraoperatoria del Bloqueo Neuromuscular y la Presión Arterial con un solo Dispositivo (Tof-Cuff): Estudio Comparativo con la Mecanomiografía y la Presión Arterial Invasiva. Universidad de Murcia

Monitorización Intraoperatoria del Bloqueo Neuromuscular y la Presión Arterial con un solo Dispositivo (Tof-Cuff): Estudio Comparativo con la Mecanomiografía y la Presión Arterial Invasiva

The thesis is based on clinical research carried out to validate the compressionomyography method for measuring neuromuscular transmission and non-invasive pressure, so the results obtained were already known. For neuromuscular transmission, an observational study was carried out with 32 patients compared with mechanomyography in opposite arms. When comparing a TOF-ratio > 0.9 quantified by TOF-Cuff with a TOF-ratio > 0.7 in the MMG, it had a specificity of 91% and a positive predictive value of 84%. The 90% TOF Ratio measurement occurred at different times with both methods (3.5 minutes before with compressmyography). The conclusions of the article are that the method has been shown to be valid and safe in monitoring TNM and measuring PNI, with no patient presenting adverse events, skin lesions or residual pain.

Meney L. A mixed methods systems approach to the implementation of new neuromuscular blockade monitoring technology to anesthetic practice during laparoscopic colorectal surgery. 6

A mixed methods systems approach to the implementation of new neuromuscular blockade monitoring technology to anesthetic practice during laparoscopic colorectal surgery

This document is the final dissertation of the work carried out by a medical student to evaluate the use of TOFCUFF at Ninewells hospital. The document describes in detail the work carried out with all its details, which allows a better understanding of the results described in the two application studies by the same author that have been previously referenced.

Souza R. The importance of using the Train-of-Four (TOF) in the COVID-19 ICUs

The importance of using the Train-of-Four (TOF) in the COVID-19 ICUs

This document describes the need to monitor neuromuscular transmission in the ICU with patients requiring mechanical ventilation for many days to precisely regulate the dosing of muscle relaxants. The document highlights the ease of use of the monitor compared to monitors placed on the thumb

Biro P. Keine Angst vor Operationen. Costa Blanca Nachrichten. N. 2070, 20.

Keine Angst vor Operationen

This work is a general presentation on the tasks of the anesthesiologist in the operating room, but the monitoring of neuromuscular transmission is not specifically mentioned.

Bolhuis LC. Development and validation of a Machine Learning Based Pharmacodynamic Model Of Rocuronium induced neuromuscular block during general anesthesia. Leiden University ; Delft University of Technology ; Erasmus University Rotterdam. 2023

Development and validation of a Machine Learning Based Pharmacodynamic Model Of Rocuronium induced neuromuscular block during general anesthesia

This study aimed to develop an automated data logger to record neuromuscular transmission (NMT) measurements and rocuronium infusion data during surgery and, as a secondary objective, to analyze new machine learning (ML) models and compare them with PKPD models. traditional. In 2023, a prospective observational study was conducted with 42 patients and data was collected from the TOF-Cuff and GE NMT monitors to evaluate the response of the model in different neuromuscular junctions. In terms of model performance, the machine learning models showed suboptimal results when applied to the GE NMT monitor data, indicated by high RMSE and low R² values. In contrast, the basic and optimized PKPD models exhibited better predictive capabilities.

Veiga G, Gonzalez A, Corral J. Clinical investigation report: Monitoring of the neuromuscular blockade and the arterial pressure with one single device: Comparison of TOF-CUFF versus mechanomyography for the evaluation of neuromuscular blockade level and comparison of the TOF-CUFF versus invasive arterial pressure, for the monitoring of non invasive arterial pressure.

Monitoring of the neuromuscular blockade and the arterial pressure with one single device: Comparison of TOF-CUFF versus mechanomyography for the evaluation of neuromuscular blockade level and comparison of the TOF-CUFF versus invasive arterial pressure, for the monitoring of non invasive arterial pressure

Once the muscle relaxant is delivered, basic neuromuscular blockade is achieved when the response to the fourth TOF stimulation pulse disappears. The NMT monitor detects this blockage with a specificity of 97% and a positive predictive value of 92%, which can be considered a very good result. The next phase is reached when the block is deep and there is no response to any of the 4 TOF stimulation pulses. The NMT monitor detects this blockage with a specificity of 91% and a positive predictive value of 93%, which is still a very good result). Once the intervention is completed, extubation of the patient requires that the level of relaxation be low enough to avoid postoperative complications. The measurement of values with %TOF > 90 using the NMT monitor has obtained a specificity of 91% and a positive predictive value of 84%, which constitutes a good result, in line with the results of the methods currently used in clinical practice. to monitor neuromuscular blockade. No patient presented any type of adverse event related to the use of the NMT monitor cuff, which, together with its easy handling and the good results obtained in this clinical investigation, allows us to affirm that the compression method used by the NMT monitor is an optimal tool for monitoring neuromuscular blockade.

Silva L, Ramírez C, Julián S, Callicó F. Clinical investigation report: Observational study of the neuromuscular blockade monitoring with the TOF-CUFF monitor versus CARESCAPE B450 monitor

Clinical investigation report: Observational study of the neuromuscular blockade monitoring with the TOF-CUFF monitor versus CARESCAPE B450 monitor

The main objective of this clinical study was to establish a comparison between neuromuscular blockade measurements with the TOF-CUFF monitor versus electromyography. The results obtained suggest a good correlation between both methods during different phases of the patient's neuromuscular blockade. The results of this study have a similar range of results compared to other independent studies in which comparisons were made between other accepted measurement methods versus EMG, such as acceleromyography and kinemiography. The TOF-CUFF monitor uses the same pressure cuff to measure neuromuscular blockade and blood pressure. No interference was found between both measurements. Taking into account all this data and the researchers' experience in the configuration and analysis of both monitors, their conclusion is that the TOF-CUFF monitor allows for more stable and consistent monitoring. Dual use of the cuff to monitor non-invasive blood pressure and neuromuscular blockade would result in a greater number of patients routinely monitored for neuromuscular blockade in daily practice. The ease of use of the TOF-CUFF monitor could have a positive impact on patient safety and compliance with current practice guidelines. The study shows that monitoring neuromuscular blockade with the TOF-CUFF monitor is reliable, correlates well with an already established method, and can make it easier for anesthesiologists to monitor neuromuscular blockade in clinical practice.

Dr. Rodrigo Souza da Silva - Anesthesiologist - CRM: 31841 PR

The importance of using the Train-of-Four (TOF) in the COVID-19 ICUs

The use of Neuromuscular Blockade (NMB) during mechanical ventilation in patients with Acute Respiratory Distress Syndrome (ARDS) improves (1) ventilatory support, (2) reduces mortality and has been used for many years in Intensive Care Units (ICUs).

In the context of the COVID-19 pandemic, several patients are in need of mechanical ventilation and use of NMB for prolonged periods, often exceeding 10 days. This use is different from the indications in the usual ARDS, to which we were accustomed, in which the need for NMB was kept for short periods, usually 24 to 48 hours. This created a difficulty in the proper dosage and management of these drugs. In addition, this prolonged use in so many patients has led to a shortage of these drugs worldwide.

The use of Neuromuscular Block monitors, such as Train-of-Four (TOF), is a well- established practice in anesthesiology during general anesthesia, with its indications, limitations and mechanisms well described and accepted by the entire medical community. This monitoring is necessary because the ideal dose is extremely variable among different people due to several factors such as age, sex, muscle mass and pre-existing diseases. In general anesthesia, in addition to the need to maintain the patient with an adequate level of NMB, we need to reverse this block at the end of the procedure for the possibility of safe extubation of the patient.

Now, in this new context, the use of TOF in the ICU allows the precise dosage of drugs, enabling better management of patients in addition to their more rational use, leading to savings in resources.

The introduction of a new routine is accompanied by several challenges and possibilities for process failures. The TOF monitors which are available today in Brazil work through loose electrodes associated with an accelerometer attached to the region to be stimulated, usually the thumb. This method, although well established, has the problem of being affected by many factors, such as the position of the hand/arm, the electrodes, the accelerometer, objects limiting the movement of the finger, etc. in addition to impacting the routine of the ICU, both for the medical and nursing staff.

The TOF-cuff works through a non-invasive pressure cuff, equipment widely used in any ICU and therefore, does not cause any kind of estrangement to the team, greatly facilitating its introduction into the care routine. In addition, it can be easily switched between patients, without the need for additional material, such as electrodes.

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