Skip Navigation LinksHome > April 1997 - Volume 86 - Issue 4 > Relationship of the Train‐of‐four Fade Ratio to Clinical Sig...
Anesthesiology:
Clinical Investigation

Relationship of the Train‐of‐four Fade Ratio to Clinical Signs and Symptoms of Residual Paralysis in Awake Volunteers

Kopman, Aaron F. MD; Yee, Pamela S. BA; Neuman, George G. MD

Free Access
Article Outline
Collapse Box

Author Information

Collapse Box

Abstract

Background:: Recovery of the train‐of‐four (TOF) ratio to a value > 0.70 is synonymous with adequate return of neuromuscular function, but there is little information available concerning the subjective experience that accompanies residual neuromuscular block wherein the TOF ratio is in the range of 0.70 to 0.90.
Methods:: Ten American Society of Anesthesiologists' (ASA) physical status 1 volunteers were studied. Control measurements included grip strength in kilograms and ability to perform a 5‐s head‐ and leg‐lift. In addition, a standard wooden tongue depressor was placed between each subject's incisor teeth, and he or she was told not to let the investigator remove it. All subjects were easily able to retain the device despite vigorous attempts to dislodge it. Neuromuscular function was monitored with a Datex(TM) (Datex Medical Instrumentation, Inc., Tewksbury, MA) 221 electromyographic (EMG) monitor. TOF stimulation was given every 20 s, and the measured TOF fade ratio was continuously recorded. A 5 mg/kg bolus of mivacurium was then administered, and an infusion at 2 mg [center dot] kg sup ‐1 [center dot] min sup ‐1 was begun. The infusion was continued until the TOF ratio decreased to < 0.70 and was adjusted to keep it in the range of 0.65 to 0.75. Signs and symptoms of weakness were recorded when the TOF ratio had been stable +/‐ 0.03 for at least 10 min during an interval when there were no adjustments in the infusion. All tests noted previously were repeated at this time. The TOF ratio was then allowed to recover to 0.85–0.90. When stable at this level, all tests were repeated, and the infusion was discontinued. TOF measurements were continued until a ratio of 1.0 was attained and until a final set of observations was recorded.
Results:: The TOF ratio in all subjects was reduced to < 0.70. No volunteers required intervention to maintain a patent airway, and the hemoglobin oxygen saturation while breathing air was greater or equal to 96% at all times. TOF ratios less or equal to 0.90 were accompanied by diplopia and difficulty in tracking moving objects in all subjects. The ability to strongly appose the incisor teeth did not return until the TOF ratio (on average) exceeded 0.85. A sustained 5‐s head‐lift was not achieved until the TOF ratio averaged 0.60 (range, 0.45–0.75). At a TOF ratio of 0.70, grip strength averaged 59% of control (range, 50–75%). With certain exceptions (vision, ability to clench the teeth tightly), there was wide variation in symptomatology between patients for any given TOF ratio. It is impossible to give reliable TOF break‐points at which symptoms and signs will be present or absent.
Conclusions:: All subjects had significant signs and symptoms of residual block at a TOF ratio of 0.70; none considered themselves remotely “street ready” at this time. The authors believe that satisfactory recovery of neuromuscular function after mivacurium‐induced neuromuscular block requires return of the TOF ratio to a value > 0.90 and ideally to unity.
In the mid‐1970s, Ali et al. [1] demonstrated that when the train‐of‐four (TOF) ratio had spontaneously recovered to a value of 0.60, vital capacity, inspiratory force, and peak expiratory flow rate were at clinically acceptable values. Brand et al. [2] confirmed that at a TOF ratio of 0.70, all patients had sustained eye opening, hand grasp, tongue protrusion, and 9 of 10 could maintain head‐lift. Based in large part on these studies, many anesthesiologists have come to consider recovery of the train‐of‐four ratio greater or equal to 0.70 as synonymous with adequate return of neuromuscular function. This standard has stood as a reasonable measure of patient safety, however, there is little information available concerning the subjective experience that accompanies residual neuromuscular block wherein the TOF ratio is 0.70–0.90. This issue was of little consequence 20 years ago when few patients were discharged from the hospital within hours of surgery. In today's era of ambulatory surgery where rapid return of cognitive function is normal, a new look at standards of neuromuscular recovery seems warranted.
Past attempts to study this association shortly after relaxant administration [3,4] are difficult to interpret because the relationship between single twitch (T1) and the TOF ratio measured during recovery does not necessarily apply during onset. [5] The degree of fade at a given amount of initial twitch depression is significantly less during onset than during spontaneous offset of action. [6] After a bolus of pancuronium sufficient to abolish the fourth response to TOF stimulation, peak effects on T1 occur in about 6.5 min. but maximum TOF fade takes almost 30 min to develop. [7]
Any attempt to correlate signs and symptoms or residual paresis with the TOF ratio of the adductor pollicis is complicated by an additional factor. Blood flow to different muscle groups varies widely. [8] After an intravenous bolus of a neuromuscular blocking drug, plasma concentrations at a muscle of high perfusion may be decreasing at a time when the peak effect in a muscle of low perfusion may not be evident. We therefore decided to study this issue in unpremedicated awake volunteers who were administered mivacurium by infusion in an attempt to approximate steady state conditions.
Back to Top | Article Outline

Methods and Materials

Ten healthy American Society of Anesthesiologists' (ASA) physical status 1 volunteers (eight male, two female) aged 23–33 years were recruited to participate in this study. All subjects were free from neuromuscular disease and within 15% of ideal body weight. Patients in whom difficulty performing orotracheal intubation may be anticipated were excluded from the protocol. Institutional review was obtained before this project began, and all participants gave informed consent. Subjects were unpremedicated and had fasted for at least 8 hours before drug administration.
Subjects were placed in a modified supine position with the head raised slightly and the knees flexed 15–20 degrees. Patients breathed room air. A pulse oximeter continuously recorded hemoglobin oxygen saturation (SpO2). The neuromuscular function of the adductor pollicis or first interosseous muscle was monitored with a Datex(TM) 221 NMT monitor using surface electrodes. Once an adequate evoked response (> 10 mV peak to peak) and a stable baseline were achieved, further increases in evoked amplitude were not sought. Delivered current ranged from 45 to 60 mA with a pulse width of 100 ms. We intentionally did not attempt to reach supramaximal levels of stimulation in our subjects. All our volunteers were unpremedicated; TOFs were repeated every 20 s, and the shortest period of observation approached 90 min. Visual Analogue Scale (VAS) pain scores associated with supramaximal TOF stimulation average 5.0 or more. [9,10] We did not believe it was practical to ask our subjects to submit to such a protocol. Brull et al. [11] and Silverman et al. [12] have demonstrated that provided all four responses to TOF stimulation can be elicited and that the pulse delivered exceeds the initial threshold to stimulation (ITS) by at least 10 mA, the TOF ratio is constant over a wide range of stimulating currents. The test hand was immobilized, and approximately 200–300 g of resting tension was applied to the thumb.
Before the administration of mivacurium, each subject was asked to carry out a variety of tasks, which served as control values. Hand‐grip strength in kilograms (average of three attempts) was measured with a Jaymar(TM) (J. A. Preston Corporation, Jackson, MI) dynamometer. Each subject also was asked to perform a 5‐s head‐lift and a 5‐s leg‐lift. In addition, a standard wooden tongue depressor was placed between each subject's incisor teeth, and he or she was told not to let the investigator pull it out of his or her mouth. All subjects were easily able to retain the device despite rather vigorous attempts to dislodge it.
Once the subject had become acclimated to the nerve stimulator, a single bolus of mivacurium, 5 mg/kg, was administered, and an infusion at 2 mg [center dot] kg sup ‐1 [center dot] min sup ‐1 was begun. The mivacurium infusion was continued until the TOF ratio decreased to < 0.70 and was adjusted as necessary to keep it 0.65–0.75. Signs and symptoms of weakness were recorded when the TOF ratio had been stable +/‐ 0.03 for at least 10 min during an interval when there were no adjustments in the infusion rate. All tests noted previously were repeated at this time. In addition, subjects were asked to sip water from a cup via a straw and to note if any difficulty with this task was encountered. They were also encouraged to verbalize any thoughts or sensations as they occurred and to comment on their ability to talk and smile and on their general feeling of well‐being. The infusion rate was then decreased, and the TOF ratio was allowed to recover to 0.85–0.90. Once the TOF ratio was stable at this level, all tests were repeated, and the infusion was discontinued. TOF measurements were continued until a TOF ratio of 1.0 was attained and until a final set of observations was recorded. At this point, obvious signs of weakness usually were absent, but it was common for subjects to note that in some manner they still felt a little “off‐center.” All subjects were told to report to the investigators the time interval (if any) between discharge from the experiment and the moment when they felt back “normal.”
Grip strength at TOF ratios of 0.70, 0.90, and control were compared for differences using a Kruska‐Wallis one‐way analysis of variance (ANOVA; P < 0.05 = significant.).
Back to Top | Article Outline

Results

Table 1
Table 1
Image Tools
The TOF ratio was reduced to a level < 0.70 (as measured at the adductor pollicis muscle) in all subjects. During the initial onset of neuromuscular block, it was difficult to titrate the TOF ratio to exactly the range desired, and there usually was some initial “overshoot” to levels less than the target ratio (0.65–0.70; Table 1). Signs and symptoms referenced to this range of TOF ratios occurred after a stable level of blockade at that level had been achieved. Twitch height (T1 in each TOF) never decreased by more than 10% in any subject and was usually maintained at control levels despite decreases in the TOF ratio. No volunteer required intervention by the investigators to maintain a patent airway, and the SpO2 was maintained at greater or equal to 96% in all subjects at all times. Infusion rates required for maintenance of a TOF of 0.70 ranged from 1.15 to 3.0 mg [center dot] kg sup ‐1 [center dot] min sup ‐1 (mean, 1.8). Infusion times averaged 100 +/‐ 16.5 (SD) min (range, 80–140).
All of the subjects rapidly acclimated to peripheral nerve stimulation at pulses averaging 5–6 micro C (10 mA x 0.10 ms sup (dagger) = 1 micro C); no one complained of pain or showed obvious distress from this aspect of the protocol.
Back to Top | Article Outline
Observations during Onset of Train‐of‐four Fade
Train‐of‐four fade was slow to develop. It took on average 25 min (range, 15–35 min) for the TOF ratio to decrease to < 0.90 and 30 min (range, 20–50 min) to decrease to less or equal to 0.70. Pronounced symptoms of neuromuscular weakness appeared shortly after the initial dose of relaxant. For example, 16 min after the infusion had begun (cumulative dosage of mivacurium, 0.04 mg/kg) subject 6 was unable to perform a head‐lift, could not approximate his incisor teeth, and was having difficulty swallowing. His TOF ratio was 1.00. Therefore, TOF ratios measured at the adductor pollicis during the onset of block may markedly underestimate the extent of weakness in the muscles of the neck and jaw.
Back to Top | Article Outline
Observations during Steady State Train‐of‐four Depression
Vision.
Train‐of‐four ratios of 0.90 were accompanied by significant visual disturbances in all subjects. Below this level of recovery, every subject complained of diplopia and difficulty in tracking moving objects, and these symptoms often persisted despite full return of the TOF ratio. Seven subjects believe that their vision was abnormal at a time when the TOF ratio had recovered to 1.00. One subject stated “I don't have double vision anymore, but things just don't look right. It's sort of like the sensation of putting on a new pair of glasses that you are not used to.” These seven subjects reported that it took between 45 and 90 min after return of the TOF ratio to a value of 1.00 before they believed that vision had completely recovered to normal.
Back to Top | Article Outline
Masseter Strength.
Before mivacurium administration, all subjects could easily prevent a wooden tongue depressor clenched between their incisor teeth from being pulled out by even a vigorous effort. This ability did not return on average until the TOF ratio exceeded 0.86 (Table 1), although one subject was able to prevent extraction of the tongue depressor at a TOF of 0.68. In the majority of subjects, however, at the latter value only weak opposition to removal of the tongue depressor could be mounted. Although resistance increased from this level on, the point at which the tongue depressor could not be dislodged was unambiguous.
Back to Top | Article Outline
Head‐lift and Leg‐lift.
Once the TOF ratio achieved a value greater or equal to 0.60, sustained head‐ and leg‐lift usually were present (Table 1). Three subjects were able to accomplish head‐lift at TOF ratios of 0.48 to 0.55, and all subjects were able to achieve a 5‐s head‐ and leg‐lift at a TOF ration of 0.75.
Back to Top | Article Outline
Grip Strength.
Table 2
Table 2
Image Tools
At a TOF ratio of 0.70, grip strength was decreased in all subjects, but there was considerable individual variation (Table 2). At a TOF ratio of 0.70, grip strength averaged 57% of the control, with a range of 43–77%. This strength increased to 83% of the control (range, 70–105%) at a TOF ratio of 0.90. Both of these values were different from each other and from control with P < 0.01.
Back to Top | Article Outline
Miscellaneous Observations.
With certain notable exceptions (vision, ability to clench the teeth tightly), there was variation in symptoms between subjects for any given TOF ratio. In some subjects, head‐lift and leg‐lift returned simultaneously; in others, the leg‐lift was never lost. In addition, subjects often reported that symptoms may wax and wane at a time when the TOF ratio was stable. It is impossible to give definitive TOF break‐points at which most symptoms and signs will be present or absent.
At TOF ratios < 0.75, all subjects were uncomfortable. Most reported that speaking required great effort and that swallowing was becoming difficult. Most found it impossible to sip water through a straw because they could not maintain a tight seal with their lips. Finally, all subjects at this level of block had the same “flat” expression. We believe that this was a reflection of significant involvement of the facial muscles.
Back to Top | Article Outline

Discussion

Our results support the finding of other investigators [5–7] that TOF fade is slow to develop. Observations made shortly after the administration of small precurarizing or priming doses of nondepolarizing relaxants, which attempt to correlate signs and symptoms of partial paralysis with recorded TOF ratios, [3,4] are unlikely to be applicable to the clinical situation that occurs during spontaneous or anticholinesterase‐induced recovery of neuromuscular function. Thus, very little of the currently available information on the subjective effects or residual block experienced at TOF ratios in the range of 0.70–1.00 should be accepted uncritically. Priming doses of nondepolarizing relaxants have been cited as producing easily detectable detrimental effects of the mechanisms of swallowing as measured electromyographically (EMG) 3–6 min after drug administration. [13] For example, Isono et al. [14] found that 0.02 mg/kg of pancuronium resulted in ptosis, blurred vision, a 66% depression in the EMG activity of the suprahyoid muscles, and difficulty in swallowing in five of eight subjects studied. At this time, grip strength was minimally affected, and the TOF ratio measured at the adductor pollicis was > 0.80. For reasons outlined previously, we do not believe that the magnitude of TOF fade measured in peripheral muscles at this time is relevant to the clinical circumstances during return of neuromuscular function at the end of anesthesia.
It is now well established that return of the TOF ratio to an excess of 0.70 represents almost complete return of mechanical respiratory reserve and the ability to satisfactorily maintain a patent airway. [1,2] Although statistically significant decreases in the forced vital capacity, forced expiratory volume in 1 s (FEV1), and peak expiratory flow rate can be demonstrated at this level of recovery, these changes are probably of no clinical importance. [15] Ali's pioneering work on this subject was done in a era in which early patient discharge from the hospital was uncommon. In addition, rapid recovery of cognitive function was less easily accomplished 20 yr ago. Diethyl ether and methoxyflurane were still widely used anesthetic agents, and halothane was considered a drug of low blood solubility. Thus, the issue of a patient's perceptions of residual weakness immediately after surgery was not a pressing one. Today, in an environment wherein patients may be discharged from the hospital within 2–3 h of leaving the operating room, the problem of lingering paresis takes on greater relevance.
In addition, there has been a slow accumulation of information suggesting that nondepolarizing neuromuscular blocking drugs may have undesirable effects at TOF ratios as high as 0.90. There is convincing evidence that even partial neuromuscular block (TOF, 0.70) impairs the ventilatory response to hypoxia, suggesting an effect of nondepolarizing relaxants on carotid body hypoxic chemosensitivity. [16].
Eriksson et al. [17] also demonstrated that TOF ratios <0.90 are associated with functional impairment of the muscles of the pharynx and upper esophagus and therefore a potentially decreased ability to protect the airway against regurgitation and aspiration.
It is widely accepted that the ability to sustain a 5‐s head‐lift is associated with sufficient strength in otherwise healthy subjects to protect the airway against obstruction and aspiration of oral contents. [18] There is less agreement on the correlation between a sustained head‐lift and the TOF fade ratio at the adductor pollicis muscle. El Mikatti et al. [15] found that seven of seven subjects were able to sustain a head‐lift at a TOF ratio of 0.50 measured on EMG. Dupuis et al. [19] reported similar results (six of seven) using mechanomyography, but they found that when EMG monitoring was used that the TOF ratio had to attain a value of 0.70 before all subjects had a sustained head‐lift. Sharpe et al. [20] using EMG found that head‐lift was uniformly maintained at a TOF ratio greater or equal to 0.60. However, Engbaek et al. [21] (also using EMG) concluded that the TOF ratio had to recover to 0.80 before all patients could sustain head‐lift for 5 s, and head‐lift could not be sustained for any patient at a TOF ratio of 0.50. Our observations are in general agreement with those of Engbaek and suggest that the ability to sustain a head‐lift usually first occurs at a TOF ratio of 0.45–0.75 and that finer distinctions are probably not possible. One of our subjects, an extremely fit man aged 23 years could not maintain a 5‐s head‐lift until the TOF ratio was 0.75, and a 10‐s head‐lift required a TOF ratio of 0.85. This same subject had no difficulty maintaining a 10‐s leg‐lift at a TOF ratio of 0.68. The ability to perform a 5‐s head‐lift is not necessarily a precise end‐point. Several of the subjects when finally able to perform a 5‐s head‐lift were obviously distressed by the effort required and clearly could not have sustained a 10‐s head‐lift.
In a 1989 editorial, Miller suggested that there was a need for more sensitive indices of the adequacy of reversal of neuromuscular blockade. [22] An unexpected result of our investigation was the identification of a simple clinical test of neuromuscular function that is more sensitive than the 5‐s head‐lift. None of our subjects could perform the “tongue depressor test” adequately at a TOF ratio < 0.70, and the value at which it was usually accomplished was > 0.85. We believe the tongue depressor test may also prove more useful than the head‐lift test in situations where active patient cooperation is not feasible. For example, during emergence from anesthesia, inability to manually force open a patient's jaw to remove a bite block or oral airway probably indicates a TOF ratio well in excess of that which is required to perform a simple head‐lift. The question of masseter sensitivity to nondepolarizing neuromuscular blocking drugs is an area of some interest. We are aware of only one pertinent investigation in adults. Smith et al. [23] found the masseter to be only slightly more sensitive than the adductor pollicis to pancuronium with ED90 values of 0.38 and 0.43 mg/kg, respectively. These authors hypothesized that return of adductor pollicis function may not imply complete masseter muscle recovery, however, the relative durations of action in these two muscles was not actually measured.
Although several of our subjects complained of difficulty in swallowing at TOF ratios in the range of 0.45 to 0.60, this was not a prominent symptom once the TOF ratio exceeded 0.75. Our subjects' subjective reports do not provide support for the observations of Eriksson et al. [17] We also were surprised by the prominence of symptoms relating to paralysis of the muscles of facial expression. After nondepolarizing‐induced block, return of neuromuscular function in the muscles of the face has been uniformly reported to occur earlier than at the adductor pollicis. Although we find it difficult to reconcile the reports of our volunteers with the objective measurements of orbicularis oculi function reported by others, they were nonetheless real to our subjects. [24–26] All volunteers reported that their faces felt “numb” at a time when head‐lift was easily performed.
We recognize that a difficulty with the present investigation is our inability to quantitate the subjective reports of our subjects. Nevertheless, our results are not compatible with the popular belief that a TOF ratio of 0.70 (as measured at the adductor pollicis muscle) signifies satisfactory return of neuromuscular function. At a TOF ratio of this magnitude, none of our volunteers found airway maintenance a problem. All agreed, however, that they were not “street ready.” Although symptoms varied from subject to subject, TOFs in the range of 0.70–0.75 were associated with all of the following symptoms: diplopia and various visual disturbances, decreased grip strength, inability to maintain incisor teeth apposition, inability to sit up without assistance, severe facial weakness including an inability to make an airtight seal around a drinking straw with the lips, speaking described as a major effort, and overall weakness and tiredness. All of the aforementioned symptoms may be present despite the ability to perform a 5‐s head‐lift. Once the TOF ratio reached a value of 0.85–0.90, the major remaining symptoms were visual problems and a generalized fatigue. At a TOF ratio of 0.90–1.00, diplopia usually started to abate, although a TOF ratio of 1.00 did not guarantee full return of function of the extraocular muscles. Several subjects reported that diplopia persisted for periods in excess of 1 h after termination of the mivacurium infusion.
Another potential criticism of our methodology is that not all investigators are convinced that stimulating currents of ITS + 10 mA produce reliable measurements of the TOF ratio. Helbo‐Hansen et al. [27] suggested that delivered currents (at 0.2 ms) have to exceed ITS by at least 25 mA before TOF accuracy (the difference between TOF ratios at lesser currents and the TOF ratio at 58 mA) can be assured. They concluded that the accuracy of TOF monitoring is unacceptable at currents < ITS + 25 mA. Because ITS in their series averaged 20 mA, they in effect recommend that currents of < 45 mA should not be used. A pulse of 45 mA with a duration of 0.20 ms represents a delivered charge of 9.0 micro C. This raises a major dilemma. The maximum output of the Datex NMT monitor is only 7.0 micro C! If the conclusions of Helbo‐Hansen et al. [27] are accepted, then the entire world database of information collected with the Datex unit would have to be discarded. We do not believe that this is reasonable.
Finally, can our results using mivacurium as the test drug be extrapolated to other relaxants? There are remarkably few data to suggest that for any given level of T1 recovery that real differences in TOF fade actually exist between commonly used nondepolarizing blockers. The opposite is true. McCoy et al. [28] in a study of atracurium, vecuronium, rocuronium, and mivacurium found that at 90% recovery of T1 that the average TOF ratio for all four agents was 0.59, with a range of 0.53–0.61 (n = 10 per group, NS). Hence, we believe that our data are likely to be applicable to relaxants other than mivacurium.
We conclude that any definition of “satisfactory” recovery of neuromuscular function after the administration of a nondepolarizing neuromuscular blocking drug should be context‐sensitive. In a subject recovering from intraabdominal surgery and receiving opioids in amounts sufficient to control postoperative pain, diplopia or diminished grip strength is unlikely to be of major concern. Visual disturbances and facial weakness may be disquieting to the patient who has otherwise fully recovered from the effects of anesthesia and is attempting to ambulate or sip liquids through a straw. Thus we believe that “adequate” recovery of neuromuscular function in the outpatient setting requires return of the TOF ratio to a value greater or equal to 0.90 and ideally to unity.
Back to Top | Article Outline

References

1. Ali HH, Wilson RS, Savarese JJ, Kitz, RJ: The effect of tubocurarine on indirectly elicited train-of-four muscle response and respiratory measurements in humans. Br J Anaesth 1975; 47:570-4.

2. Brand JB, Cullen DJ, Wilson NE, Ali HH: Spontaneous recovery from nondepolarizing neuromuscular blockade: Correlation between clinical and evoked responses. Anesth Analg 1977; 56:55-8.

3. Howardy-Hansen P, Moller J, Hansen B: Pretreatment with atracurium: The influence on neuromuscular transmission and pulmonary function. Acta Anaesthesiol Scand 1987; 31:642-4.

4. Engbaek J, Howardy-Hansen P, Ording J, Viby-Mogensen J: Precurarization with vecuronium and pancuronium in awake, healthy volunteers: The influence on neuromuscular transmission and pulmonary function. Acta Anaesthesiol Scand 1985; 29:117-20.

5. Turner GA, Williams JD, Baker DJ: Train-of-four fade during onset and recovery of neuromuscular blockade: A study in non-anaesthetized subjects. Br J Anaesth 1989; 62:279-86.

6. Pearce AC, Casson WR, Jones RM: Factors affecting train-of-four fade. Br J Anaesth 1985; 57:602-6.

7. Graham GG, Morris R, Pybus DA, Torda TA, Woodey R: Relationship of train-of-four ratio to twitch depression during pancuronium induced neuromuscular blockade. Anesthesiology 1986; 65:579-83.

8. Ibebunjo C, Donati F: Sensitivities of different muscles to relaxant drugs. In: Goldhill DR, Flynn PJ, eds., Bailliere's Clinical Anaesthesiology (Vol 8, No 2). Philadelphia: Bailliere Tindall, 1994, pp 369-94.

9. Connelly NR, Silverman DG, O'Connor TZ, Brull SJ: Subjective responses to train-of-four and double burst stimulation in awake patients. Anesth Analg 1990; 70:650-3.

10. Brull SJ, Silverman DG: Pulse width, stimulus intensity, electrode placement, and polarity during assessment of neuromuscular block. Anesthesiology 1995; 83:702-9.

11. Brull SJ, Ehrenwerth J, Silverman DG: Stimulation with sub-maximal current for train-of-four stimulation. Anesthesiology 1990; 72:629-32.

12. Silverman DG, Connelly NR, O'Conner TZ, Garcia R, Brull SJ: Accelographic train-of-four at near threshold currents. Anesthesiology 1992; 76:34-8.

13. D'Honneur G, Gall O, Gerard A, Rimaniol JM, Lambert Y, Duvaldestin P: Priming doses of atracurium and vecuronium depress swallowing in humans. Anesthesiology 1992; 77:1070-3.

14. Isono S, Ide T, Kochi T, Mizuguchi T, Nishino T: Effects of partial paralysis on the swallowing reflex in conscious humans. Anesthesiology 1991; 75:980-4.

15. El Mikatti N, Wilson A, Pollard BJ, Healy TEJ: Pulmonary function and head lift during spontaneous recovery from pipecuronium neuromuscular block. Br J Anaesth 1995; 74:16-9.

16. Eriksson L: Reduced hypoxic chemosensitivity in partially paralysed man. A new property of muscle relaxants. Acta Anaesthesiol Scand 1996; 40:520-3.

17. Eriksson LI, Nilsson L, Witt H, Olsson R, Ekberg O, Kuylenstierna R: Videoradiographical computerized manometry in assessment of pharyngeal function in partially paralysed humans. Anesthesiology 1995; 83:A886.

18. Pavlin EG, Holle RH, Schoene RB: Recovery of airway protection compared with ventilation in humans after paralysis with curare. Anesthiology 1989; 70:381-5.

19. Dupuis JY, Martin R, Tetrault JP: Clinical, electrical and mechanical correlations during recovery from neuromuscular blockade with vecuronium. Can J Anaesth 1990; 37:192-6.

20. Sharpe MD, Lam AM, Nicholas FJ, Chung DC, Merchant R, Alyafi W. Beauchamp R: Correlation between integrated evoked EMG and respiratory function following atracurium administration in unanaesthetized humans. Can J Anaesth 1990; 37:307-12.

21. Engbaek J, Ostergaard D, Viby-Mogensen J, Skovgaard LT: Clinical recovery and train-of-four measured mechanically and electromyographically following atracurium. Anesthesiology 1989; 71:391-5.

22. Miller RD: How should residual neuromuscular blockade be detected? Anesthesiology 1989; 70:379-80.

23. Smith CE, Donati F, Bevan DR: Differential effects of pancuronium on masseter and adductor pollicis muscles in humans. Anesthesiology 1989; 71:57-61.

24. Caffrey RR, Warren ML, Becker KE: Neuromuscular blockade monitoring comparing the orbicularis ocule and adductor pollicis muscles. Anesthiology 1986; 65:95-7.

25. Donati F, Meistelman, Plaud B: Vecuronium neuromuscular blockade at the diaphragm, the orbicularis oculi, and the adductor pollicis muscle. Anesthiology 1990; 73:870-5.

26. Sharpe MD, Moote CA, Lam AM, Manninen PH: Comparison of integrated evoked EMG between the hypothenar and facial muscle groups following atracurium and vecuronium administration. Can J Anaesth 1991; 38:318-23.

27. Helbo-Hansen HS, Connolly FM, Mirakhur RK, Loan PB: Nondepolarizing neuromuscular blocking drugs and train-of-four fade. Can J Anaesth 1995; 42:213-6.

28. McCoy EP, Connolly FM, Mirakhur RK, Loan PB: Nondepolarizing neuromuscular blocking drugs and train-of-four fade. Can J Anaesth 1995; 42:213-6.

Cited By:

This article has been cited 119 time(s).

Canadian Journal of Anesthesia-Journal Canadien D Anesthesie
Neuromuscular monitoring, residual blockade, and reversal: Time for re-evaluation of our clinical practice
Plaud, B
Canadian Journal of Anesthesia-Journal Canadien D Anesthesie, 60(7): 634-640.
10.1007/s12630-013-9952-4
CrossRef
Acta Anaesthesiologica Scandinavica
Modified double burst stimulation at varying stimulating currents
Saitoh, Y; Fujii, Y; Makita, K; Tanaka, H; Amaha, K
Acta Anaesthesiologica Scandinavica, 42(7): 851-857.

American Journal of Health-System Pharmacy
Monitoring and reversal of neuromuscular block
Bevan, DR
American Journal of Health-System Pharmacy, 56(): S10-S13.

British Journal of Anaesthesia
Editorial I - Postoperative residual curarization and evidence-based anaesthesia
Viby-Mogensen, J
British Journal of Anaesthesia, 84(3): 301-303.

Annales Francaises D Anesthesie Et De Reanimation
What are the safety rules for the reversal of the neuromuscular blockade?
Baurain, MJ
Annales Francaises D Anesthesie Et De Reanimation, 19(): 398S-402S.

Acta Anaesthesiologica Scandinavica
Does discontinuation of desflurane at the time of neostigmine administration speed recovery from cisatracurium block compared to that with a propofol-based technique?
Kirkegaard-Nielsen, H; Caldwell, JE; Abengochea, A; Berry, PD; Heier, T
Acta Anaesthesiologica Scandinavica, 45(5): 618-623.

Journal of Pharmacokinetics and Pharmacodynamics
A pharmacokinetic-pharmacodynamic model for neuromuscular blocking agents to predict train-of-four twitches
Eleveld, DJ; De Haes, A; Proost, JH; Wierda, JMKH
Journal of Pharmacokinetics and Pharmacodynamics, 30(2): 105-118.

Anesthesia and Analgesia
Spontaneous recovery profile of rapacuronium during desflurane, sevoflurane, or propofol anesthesia for outpatient laparoscopy
Zhou, TJ; Coloma, M; White, PF; Tang, J; Webb, T; Forestner, JE; Greilich, NB; Duffy, LL
Anesthesia and Analgesia, 91(3): 596-600.

Anesthesia and Analgesia
Precurarization and priming: A theoretical analysis of safety and timing
Kopman, AF; Khan, NA; Neuman, GG
Anesthesia and Analgesia, 93(5): 1253-1256.

Anesthesia and Analgesia
Tactile assessment for the reversibility of rocuronium-induced neuromuscular blockage during propofol or sevoflurane anesthesia
Kim, KS; Cheong, MA; Lee, HJ; Lee, JM
Anesthesia and Analgesia, 99(4): 1080-1085.
10.1213/01.ane.0000130616.57678.80
CrossRef
Journal of the Chinese Medical Association
Priming with Rocuronium to Accelerate the Onset Time of Cisatracurium During Intubation
Lin, SP; Chang, KY; Chen, YJ; Lin, SM; Chang, WK; Chan, KH; Ting, CK
Journal of the Chinese Medical Association, 72(1): 15-19.

Journal of Critical Care
Neuromuscular monitoring: Old issues, new controversies
Kopman, AF
Journal of Critical Care, 24(1): 11-20.
10.1016/j.jcrc.2008.02.008
CrossRef
Anesthesia and Analgesia
The problem with long-acting muscle relaxants? They cost more!
Caldwell, JE
Anesthesia and Analgesia, 85(3): 473-475.

Minerva Anestesiologica
Residual neuromuscular blockade: incidence, assessment, and relevance in the postoperative period
Murphy, GS
Minerva Anestesiologica, 72(3): 97-109.

Annales Francaises D Anesthesie Et De Reanimation
Monitoring of neuromuscular block and prevention of residual paralysis
Fuchs-Buder, T; Meistelman, C
Annales Francaises D Anesthesie Et De Reanimation, 28(): S46-S50.

Anesthesia and Analgesia
Residual Neuromuscular Block: Lessons Unlearned. Part I: Definitions, Incidence, and Adverse Physiologic Effects of Residual Neuromuscular Block
Murphy, GS; Brull, SJ
Anesthesia and Analgesia, 111(1): 120-128.
10.1213/ANE.0b013e3181da832d
CrossRef
Anesthesia and Analgesia
The clinical neuromuscular pharmacology of cisatracurium versus vecuronium during outpatient anesthesia
Stevens, JB; Walker, SC; Fontenot, JP
Anesthesia and Analgesia, 85(6): 1278-1283.

British Journal of Anaesthesia
Assessing paralysis
Norman, J
British Journal of Anaesthesia, 82(3): 321-322.

Anesthesia and Analgesia
The effects of residual neuromuscular blockade and volatile anesthetics on the control of ventilation
Eriksson, LI
Anesthesia and Analgesia, 89(1): 243-251.

Anesthesiology
Comparison of neuromuscular response of the masseter and adductor pollicis muscle to rocuronium-induced block
de Rossi, L; Preussler, NP; Fussel, U; Klein, U
Anesthesiology, 89(): U852.

Anaesthesia
Dosage of neostigmine for reversal of rocuronium block from two levels of spontaneous recovery
McCourt, KC; Mirakhur, RK; Kerr, CM
Anaesthesia, 54(7): 651-655.

Anaesthesia
A comparison of antagonism of rocuronium-induced neuromuscular blockade during sevoflurane and isoflurane anaesthesia
Sutcliffe, DG; Murphy, CM; Maslow, A; Uppington, J; Shorten, GD
Anaesthesia, 55(): 960-964.

Anaesthesia and Intensive Care
Early and late reversal of rocuronium with pyridostigmine during sevoflurane anaesthesia in children
Oh, AY; Kim, SD; Kim, CS
Anaesthesia and Intensive Care, 32(5): 649-652.

Journal of Clinical Anesthesia
Antagonism of profound cisatracurium and rocuronium block: the role of objective assessment of neuromuscular function
Kopman, AF; Kopman, DJ; Ng, J; Zank, LM
Journal of Clinical Anesthesia, 17(1): 30-35.
10.1016/j.jclinane.2004.03.009
CrossRef
Annals Academy of Medicine Singapore
Multimodal antiemetic therapy and emetic risk profiling
Ho, KY; Chiu, JW
Annals Academy of Medicine Singapore, 34(2): 196-205.

Anasthesiologie & Intensivmedizin
Neuromuscular blockade and its monitoring
Diefenbach, C
Anasthesiologie & Intensivmedizin, 46(): 233-244.

Formulary
Sugammadex A selective relaxant binding agent for neuromuscular block reversal
Kovac, AL
Formulary, 44(1): 13-+.

Anaesthesist
Neuromuscular monitoring
Fuchs-Buder, T
Anaesthesist, 47(8): 629-637.

British Journal of Anaesthesia
Use of cisatracurium during fast-track cardiac surgery
Ouattara, A; Richard, L; Charriere, JM; Lanquetot, H; Corbi, P; Debaene, B
British Journal of Anaesthesia, 86(1): 130-132.

Anesthesia and Analgesia
Unmasked residual neuromuscular block after administration of vecuronium for days
Fine, GF; Brandom, BW; Yellon, RF
Anesthesia and Analgesia, 93(2): 345-347.

British Journal of Anaesthesia
Commentary - Ali HH, Utting JE, Gray C. Stimulus frequency in the detection of neuromuscular block in humans. British Journal of Anaesthesia 1970; 42 : 967-978
Norman, J
British Journal of Anaesthesia, 80(4): 528-529.

Acta Anaesthesiologica Scandinavica
Knowledge of residual curarization: an Italian survey
Di Marco, P; Della Rocca, G; Iannuccelli, F; Pompei, L; Reale, C; Pietropaoli, P
Acta Anaesthesiologica Scandinavica, 54(3): 307-312.
10.1111/j.1399-6576.2009.02131.x
CrossRef
Anesthesia and Analgesia
The impact of choice of muscle relaxant on postoperative recovery time: A retrospective study
Ballantyne, JC; Chang, YC
Anesthesia and Analgesia, 85(3): 476-482.

Anesthesia and Analgesia
The effects of antagonizing residual neuromuscular blockade by neostigmine and glycopyrrolate on nausea and vomiting after ambulatory surgery
Joshi, GP; Garg, SA; Hailey, A; Yu, SY
Anesthesia and Analgesia, 89(3): 628-631.

British Journal of Anaesthesia
Tactile evaluation of fade of the train-of-four and double-burst stimulation using the anaesthetist's non-dominant hand
Saitoh, Y; Narumi, Y; Fujii, Y; Ueki, M
British Journal of Anaesthesia, 83(2): 275-278.

British Journal of Anaesthesia
Target controlled infusion of rocuronium: analysis of effect data to select a pharmacokinetic model
Vermeyen, KM; Hoffmann, VL; Saldien, V
British Journal of Anaesthesia, 90(2): 183-188.
10.1093/bja/aeg043
CrossRef
Anesthesia and Analgesia
Recovery of neuromuscular function after cardiac surgery: Pancuronium versus rocuronium
Murphy, GS; Szokol, JW; Marymont, JH; Vender, JS; Avram, MJ; Rosengart, TK; Alwawi, EA
Anesthesia and Analgesia, 96(5): 1301-1307.
10.1213/01.ANE.0000057602.27031.C8
CrossRef
Acta Medica Mediterranea
Antagonization Action of the Neostigmine in the Inversion of the Neuromuscular Block Induced By Rocuronio and Vecuronio
Baglieri, MG; Russo, FVE; Messina, A; Azzolina, R
Acta Medica Mediterranea, 25(2): 105-106.

Anaesthesia and Intensive Care
An audit of residual neuromuscular block in Australasia - Reply
Yip, PC; Hannam, JA; Cameron, AJD; Campbell, D
Anaesthesia and Intensive Care, 38(3): 593.

Anesthesia and Analgesia
The nature of spontaneous recovery from mivacurium-induced neuromuscular block
Lien, CA; Belmont, MR; Abalos, A; Hass, D; Savarese, JJ
Anesthesia and Analgesia, 88(3): 648-653.

British Journal of Anaesthesia
Assessment of a simple artificial neural network for predicting residual neuromuscular block
Laffey, JG; Tobin, E; Boylan, JF; McShane, AJ
British Journal of Anaesthesia, 90(1): 48-52.
10.1093/bja/aeg015
CrossRef
Anesthesia and Analgesia
Different F-wave recovery after neuromuscular blockade with pancuronium and mivacurium
Dueck, MH; Paul, M; Sagawe, P; Oberthuer, A; Wedekind, C; Boerner, U
Anesthesia and Analgesia, 99(5): 1402-1407.
10.1213/01.ANE.0000135407.11545.36
CrossRef
Anesthesia and Analgesia
Residual neuromuscular block: Rediscovering the obvious
Brull, SJ; Naguib, M; Miller, RD
Anesthesia and Analgesia, 107(1): 11-14.
10.1213/ane.0b013e3181753266
CrossRef
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Neuromuscular monitoring: useless, optional or mandatory?
Donati, F
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 45(5): R106-R111.

American Journal of Health-System Pharmacy
Neuromuscular blockers in surgery and intensive care, part 2
McManus, MC
American Journal of Health-System Pharmacy, 58(): 2381-2395.

Anaesthesia
Prospective randomised double-blind comparative study of rocuronium and pancuronium in adult patients scheduled for elective 'fast-track' cardiac surgery involving hypothermic cardiopulmonary bypass
Thomas, R; Smith, D; Strike, P
Anaesthesia, 58(3): 265-271.

Acta Anaesthesiologica Scandinavica
Does repetition of post-tetanic count every 3 min during profound relaxation affect accelerographic recovery of atracurium blockade?
Motamed, C; Kirov, K; Combes, X; Duvaldestin, P
Acta Anaesthesiologica Scandinavica, 49(6): 811-814.
10.1111/j.1399-6576.2005.00688.x
CrossRef
Cochrane Database of Systematic Reviews
Sugammadex, a selective reversal medication for preventing postoperative residual neuromuscular blockade
Abrishami, A; Ho, J; Wong, J; Yin, L; Chung, F
Cochrane Database of Systematic Reviews, (4): -.
ARTN CD007362
CrossRef
Acta Anaesthesiologica Scandinavica
Post-operative recovery after laparoscopic cholecystectomy
Viby-Mogensen, J
Acta Anaesthesiologica Scandinavica, 51(9): 1280-U1.
10.1111/j.1399-6576.2007.01420.x
CrossRef
Veterinary Anaesthesia and Analgesia
Comparison between acceleromyography and visual assessment of train-of-four for monitoring neuromuscular blockade in horses undergoing surgery
Martin-Flores, M; Campoy, L; Ludders, JW; Erb, HN; Gleed, RD
Veterinary Anaesthesia and Analgesia, 35(3): 220-227.
10.1111/j.1467-2995.2007.00380.x
CrossRef
Journal of Clinical Anesthesia
Sugammadex: the first selective binding reversal agent for neuromuscular block
Kovac, AL
Journal of Clinical Anesthesia, 21(6): 444-453.
10.1016/j.jclinane.2009.05.002
CrossRef
Anesthesia and Analgesia
Residual Neuromuscular Block: Lessons Unlearned. Part II: Methods to Reduce the Risk of Residual Weakness
Brull, SJ; Murphy, GS
Anesthesia and Analgesia, 111(1): 129-140.
10.1213/ANE.0b013e3181da8312
CrossRef
Annales Francaises D Anesthesie Et De Reanimation
Auditing the choice of anaesthetic agents
Benhamou, D; Laurent, S; Mercier, FJ; Preaux, N
Annales Francaises D Anesthesie Et De Reanimation, 19(2): 86-92.

British Journal of Anaesthesia
Neuromuscular monitoring and postoperative residual curarization: a meta-analysis
Naguib, M; Kopman, AF; Ensor, JE
British Journal of Anaesthesia, 98(3): 302-316.
10.1093/bja/ael386
CrossRef
Anaesthesia
The undesirable effects of neuromuscular blocking drugs
Claudius, C; Garvey, LH; Viby-Mogensen, J
Anaesthesia, 64(): 10-21.

Journal of Clinical Anesthesia
Effect of maintenance bolus on the recovery profile of a short-acting nondepolarizing muscle relaxant
Chen, XG; Tang, J; White, PF; Wender, RH; Sloninsky, A; Naruse, R; Kariger, R; Webb, T; Norel, E
Journal of Clinical Anesthesia, 14(7): 500-504.
PII S0952-8180(02)00427-0
CrossRef
Anaesthesia
Effect of milrinone on vecuronium-induced neuromuscular block
Nakajima, H; Hattori, H; Aoki, K; Katayama, T; Saitoh, Y; Murakawa, M
Anaesthesia, 58(7): 643-646.

Anaesthesia
Reversal of vecuronium with neostigmine in patients with diabetes mellitus
Saitoh, Y; Hattori, H; Sanbe, N; Nakajima, H; Akatu, M; Murakawa, M
Anaesthesia, 59(8): 750-754.

Acta Anaesthesiologica Scandinavica
Acceleromyography vs. electromyography: an ipsilateral comparison of the indirectly evoked neuromuscular response to train-of-four stimulation
Kopman, AF; Chin, W; Cyriac, J
Acta Anaesthesiologica Scandinavica, 49(3): 316-322.
10.1111/j.1399-6576.2004.00643.x
CrossRef
British Journal of Anaesthesia
Normalization of acceleromyographic train-of-four ratio by baseline value for detecting residual neuromuscular block
Suzuki, T; Fukano, N; Kitajima, O; Saeki, S; Ogawa, S
British Journal of Anaesthesia, 96(1): 44-47.
10.1093/bja/aei273
CrossRef
Anesthesia and Analgesia
Sugammadex: Another milestone in clinical neuromuscular pharmacology
Naguib, M
Anesthesia and Analgesia, 104(3): 575-581.
10.1213/01.ane.0000244594.63318.fc
CrossRef
Journal of Clinical Anesthesia
The effect of cisatracurium and rocuronium on cisatracurium precurarization and the priming principle
Mak, PH; Irwin, MG
Journal of Clinical Anesthesia, 16(2): 83-87.
10.1016/j.jclinane.2003.05.004
CrossRef
Minerva Anestesiologica
Of anesthesia standards in ambulatory surgery: questions and controversies, certainties and prospects
Gullo, A; Tufano, R
Minerva Anestesiologica, 72(): 1-11.

Anesthesia and Analgesia
Neuromuscular Monitoring: What Evidence Do We Need to Be Convinced?
Donati, F
Anesthesia and Analgesia, 111(1): 6-8.
10.1213/ANE.0b013e3181cdb093
CrossRef
Anesthesia and Analgesia
Visual evaluation of residual curarization in anesthetized patients using one hundred-hertz, five-second tetanic stimulation at the adductor pollicis muscle
Baurain, MJ; Hennart, DA; Godschalx, A; Huybrechts, I; Nasrallah, G; d'Hollander, AA; Cantraine, F
Anesthesia and Analgesia, 87(1): 185-189.

Anaesthesist
Neuromuscular monitoring
Fuchs-Buder, T; Mencke, T
Anaesthesist, 50(2): 129-138.

Anesthesia and Analgesia
Residual paralysis induced by either vecuronium or rocuronium after reversal with pyridostigmine
Kim, KS; Lew, SH; Cho, HY; Cheong, MA
Anesthesia and Analgesia, 95(6): 1656-1660.
10.1213/01.ANE.0000037150.20930.D5
CrossRef
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Neuromuscular effects of rapacuronium in pediatric patients during nitrous oxide-halothane anesthesia: comparison with mivacurium
Brandom, BW; Margolis, JO; Bikhazi, GB; Ross, AK; Ginsberg, B; Dear, GD; Kenaan, CA; Eck, JB; Woelfel, SK; Lloyd, ME
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 47(2): 143-149.

Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Fast-tracking in ambulatory anesthesia
Song, DJ; Chung, F
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 48(7): 622-+.

European Journal of Anaesthesiology
Use of reversal agents in day care procedures (with special reference to postoperative nausea and vomiting)
Fuchs-Buder, T; Mencke, T
European Journal of Anaesthesiology, 18(): 53-59.

Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Neuromuscular blockade can be assessed accelero- graphically over the vastus medialis muscle in patients positioned prone
Saitoh, Y; Nakajima, H; Hattori, H; Aoki, K; Katayama, T; Murakawa, M
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 50(4): 342-347.

Lancet
Perioperative management and monitoring in anaesthesia
Buhre, W; Rossaint, R
Lancet, 362(): 1839-1846.

Anesthesia and Analgesia
Postanesthesia care unit recovery times and neuromuscular blocking drugs: A prospective study of orthopedic surgical patients randomized to receive pancuronium or rocuronium
Murphy, GS; Szokol, JW; Franklin, M; Marymont, JH; Avram, MJ; Vender, JS
Anesthesia and Analgesia, 98(1): 193-200.
10.1213/01.ANE.0000095040.36648.F7
CrossRef
Anasthesiologie & Intensivmedizin
neuromuscular blocking drugs - Pharmacology and therapeutic strategies
Motsch, J; Bottiger, BW; Bock, M
Anasthesiologie & Intensivmedizin, 42(4): 237-251.

Journal of Critical Care
Clinical limitations of acetylcholinesterase antagonists
Caldwell, JE
Journal of Critical Care, 24(1): 21-28.
10.1016/j.jcrc.2008.08.003
CrossRef
Anaesthesia and Intensive Care
Monitoring neuromuscular transmission
Torda, TA
Anaesthesia and Intensive Care, 30(2): 123-133.

Advances in Modelling and Clinical Application of Intravenous Anaesthesia
Effect sites of neuromuscular blocking agents and the monitoring of clinical muscle relaxation
Meistelman, C
Advances in Modelling and Clinical Application of Intravenous Anaesthesia, 523(): 227-238.

Pediatric Anesthesia
Sevoflurane increases fade of neuromuscular response to TOF stimulation following rocuronium administration in children. A PK/PD analysis
Woloszczuk-Gebicka, B; Wyska, E; Grabowski, T
Pediatric Anesthesia, 17(7): 637-646.
10.1111/j.1460-9592.2006.02181.x
CrossRef
Annales Francaises D Anesthesie Et De Reanimation
Incidence and complications of post operative residual paralysis
Baillard, C
Annales Francaises D Anesthesie Et De Reanimation, 28(): S41-S45.

Journal of Pharmacokinetics and Pharmacodynamics
Simulation of the reversal of neuromuscular block by sequestration of the free molecules of the muscle relaxant
Nigrovic, V; Bhatt, SB; Amann, A
Journal of Pharmacokinetics and Pharmacodynamics, 34(6): 771-788.
10.1007/s10928-007-9068-y
CrossRef
Journal of Clinical Anesthesia
Acceleromyography as a guide to anesthetic management: A case report
Kopman, AF; Sinha, N
Journal of Clinical Anesthesia, 15(2): 145-148.
10.1016/S0952-8180(03)00518-4
CrossRef
Journal of Clinical Anesthesia
Visual evaluation of fade in response to facial nerve stimulation at the eyelid
Hattori, H; Saitoh, Y; Nakajima, H; Sanbe, N; Akatu, M; Murakawa, M
Journal of Clinical Anesthesia, 17(4): 276-280.
10.1016/j.clinane.2004.08.009
CrossRef
Anesthesia and Analgesia
Tactile fade detection with hand or wrist stimulation using train-of-four, double-burst stimulation, 50-Hertz tetanus, 100-Hertz tetanus, and acceleromyography
Capron, F; Fortier, LP; Racine, S; Donati, F
Anesthesia and Analgesia, 102(5): 1578-1584.
10.1213/01.ane.0000204288.24395.38
CrossRef
Anaesthesia
Recovery from neuromuscular blockade: a survey of practice
Grayling, M; Sweeney, BP
Anaesthesia, 62(8): 806-809.
10.1111/j.1365-2044.2007.05101.x
CrossRef
Annales Francaises D Anesthesie Et De Reanimation
Residual curarization and pharyngeal muscles: Remain vigilant!
d'Hollander, AA; Bourgain, JL
Annales Francaises D Anesthesie Et De Reanimation, 28(): 868-877.
10.1016/j.annfar.2009.07.090
CrossRef
British Journal of Anaesthesia
Undiagnosed myasthenia gravis unmasked by neuromuscular blockade
Dunsire, MF; Clarke, SG; Stedmon, JJ
British Journal of Anaesthesia, 86(5): 727-730.

Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Edrophonium effectively antagonizes neuromuscular block at the laryngeal adductors induced by rapacuronium, rocuronium and cisatracurium, but not mivacurium
Suzuki, T; Lien, CA; Belmont, MR; Tjan, J; Savarese, JJ
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 50(9): 879-885.

Annales Francaises D Anesthesie Et De Reanimation
Residual neuromuscular blockade
Beaussier, M; Boughaba, MA
Annales Francaises D Anesthesie Et De Reanimation, 24(): 1266-1274.
10.1016/j.annfar.2005.06.006
CrossRef
Journal of Clinical Anesthesia
Anesthesia for laparoscopy: a review
Gerges, FJ; Kanazi, GE; Jabbour-Khoury, SI
Journal of Clinical Anesthesia, 18(1): 67-78.
10.1016/j.jclinnane.2005.01.013
CrossRef
Anesthesia and Analgesia
Randomized, dose-finding, Phase II study of the selective relaxant binding drug, sugammadex, capable of safely reversing profound rocuronium-induced neuromuscular block
Groudine, SB; Soto, R; Lien, C; Drover, D; Roberts, K
Anesthesia and Analgesia, 104(3): 555-562.
10.1213/01.ane.00002601358.46070.c3
CrossRef
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Priming with rocuronium accelerates neuromuscular block in children: a prospective randomized study
Bock, M; Haselmann, L; Bottiger, BW; Motsch, J
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 54(7): 538-543.

Anaesthesia
Antagonism of non-depolarising neuromuscular block: current practice
Kopman, AF; Eikermann, M
Anaesthesia, 64(): 22-30.

Anaesthesia
Clinical implications of sugammadex
Caldwell, JE; Miller, RD
Anaesthesia, 64(): 66-72.

Pain
Postoperative recovery evaluated with a new, tactile scale (TaS) in children undergoing ophthalmic surgery
Westerling, D
Pain, 83(2): 297-301.

British Journal of Anaesthesia
Residual curarization in the recovery room after vecuronium
Baillard, C; Gehan, G; Reboul-Marty, J; Larmignat, P; Samama, CM; Cupa, M
British Journal of Anaesthesia, 84(3): 394-395.

Anesthesia and Analgesia
Recovery from neuromuscular block and its assessment
Bevan, DR
Anesthesia and Analgesia, 90(5): S7-S13.

Journal of Clinical Anesthesia
A cross-over, post-electroconvulsive therapy comparison of clinical recovery from rocuronium versus succinylcholine
Turkkal, DC; Gokmen, N; Yildiz, A; Iyilikci, L; Gokel, E; Sagduyu, K; Gunerli, A
Journal of Clinical Anesthesia, 20(8): 589-593.
10.1016/j.jclinane.2008.06.006
CrossRef
Neuroscience Letters
Vecuronium suppresses transmission at the rat phrenic neuromuscular junction by inhibiting presynaptic L-type calcium channels
Ji, F; Han, JL; Liu, BJ; Wang, HN; Shen, G; Tao, J
Neuroscience Letters, 533(): 1-6.
10.1016/j.neulet.2012.11.030
CrossRef
Anesthesiology
Antagonism of Low Degrees of Atracurium-induced Neuromuscular Blockade: Dose–Effect Relationship for Neostigmine
Fuchs-Buder, T; Meistelman, C; Alla, F; Grandjean, A; Wuthrich, Y; Donati, F
Anesthesiology, 112(1): 34-40.
10.1097/ALN.0b013e3181c53863
PDF (540) | CrossRef
Anesthesiology
Can Acceleromyography Detect Low Levels of Residual Paralysis?: A Probability Approach to Detect a Mechanomyographic Train-of-four Ratio of 0.9
Capron, F; Alla, F; Hottier, C; Meistelman, C; Fuchs-Buder, T
Anesthesiology, 100(5): 1119-1124.

PDF (218)
Anesthesiology
Is the Performance of Acceleromyography Improved with Preload and Normalization?: A Comparison with Mechanomyography
Claudius, C; Skovgaard, LT; Viby-Mogensen, J
Anesthesiology, 110(6): 1261-1270.
10.1097/ALN.0b013e3181a4f239
PDF (626) | CrossRef
Anesthesiology
Preanesthetic Train-of-four Fade Predicts the Atracurium Requirement of Myasthenia Gravis Patients
Mann, R; Blobner, M; Jelen-Esselborn, S; Busley, R; Werner, C
Anesthesiology, 93(2): 346-350.

PDF (150)
American Journal of Therapeutics
Reversal of Neuromuscular Block With a Selective Relaxant-Binding Agent: Sugammadex
Ren, WH; Jahr, JS
American Journal of Therapeutics, 16(4): 295-299.
10.1097/MJT.0b013e31817fe2d7
PDF (91) | CrossRef
Anesthesiology
Efficacy of Tactile-guided Reversal from Cisatracurium-induced Neuromuscular Block
Kirkegaard, H; Heier, T; Caldwell, JE
Anesthesiology, 96(1): 45-50.

PDF (423)
Anesthesiology
Single Acceleromyographic Train-of-Four, 100-Hertz Tetanus or Double-Burst Stimulation: Which Test Performs Better to Detect Residual Paralysis?
Samet, A; Capron, F; Alla, F; Meistelman, C; Fuchs-Buder, T
Anesthesiology, 102(1): 51-56.

PDF (214)
Anesthesiology
Reversal of Rocuronium-induced Neuromuscular Blockade with Sugammadex in Pediatric and Adult Surgical Patients
Stoddart, PA; van Kuijk, JH; Hermens, Y; Mirakhur, RK; Plaud, B; Meretoja, O; Hofmockel, R; Raft, J
Anesthesiology, 110(2): 284-294.
10.1097/ALN.0b013e318194caaa
PDF (762) | CrossRef
Anesthesiology
The Relationship between Acceleromyographic Train-of-four Fade and Single Twitch Depression
Kopman, AF; Klewicka, MM; Neuman, GG
Anesthesiology, 96(3): 583-587.

PDF (232)
Anesthesiology
Indicators of Recovery of Neuromuscular Function: Time for Change?
Brull, SJ
Anesthesiology, 86(4): 755-757.

PDF (2290)
Anesthesiology
The Continuing Search for a Succinylcholine Replacement
Caldwell, JE
Anesthesiology, 100(4): 763-764.

PDF (171)
Anesthesiology
Sugammadex: A Revolutionary Approach to Neuromuscular Antagonism
Kopman, AF
Anesthesiology, 104(4): 631-633.

PDF (204)
Anesthesiology
Residual Paralysis after Emergence from Anesthesia
Plaud, B; Debaene, B; Donati, F; Marty, J
Anesthesiology, 112(4): 1013-1022.
10.1097/ALN.0b013e3181cded07
PDF (1466) | CrossRef
Anesthesiology
Evidence-based Practice and Neuromuscular Monitoring: It's Time for Routine Quantitative Assessment
Eriksson, LI
Anesthesiology, 98(5): 1037-1039.

PDF (175)
Anesthesiology
Residual Paralysis in the PACU after a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action
Debaene, B; Plaud, B; Dilly, M; Donati, F
Anesthesiology, 98(5): 1042-1048.

PDF (330)
Anesthesiology
Criteria of Adequate Clinical Recovery from Neuromuscular Block
Raja, SN; Ali, HH
Anesthesiology, 98(5): 1278-1280.

PDF (122)
Anesthesiology
Accelerometry of Adductor Pollicis Muscle Predicts Recovery of Respiratory Function from Neuromuscular Blockade
Eikermann, M; Groeben, H; Hüsing, J; Peters, J
Anesthesiology, 98(6): 1333-1337.

PDF (219)
Anesthesiology
Acceleromyography for Use in Scientific and Clinical Practice: A Systematic Review of the Evidence
Claudius, C; Viby-Mogensen, J
Anesthesiology, 108(6): 1117-1140.
10.1097/ALN.0b013e318173f62f
PDF (738) | CrossRef
Anesthesiology
Temporal Relation between Acoustic and Force Responses at the Adductor Pollicis during Nondepolarizing Neuromuscular Block
Bellemare, F; Couture, J; Donati, F; Plaud, B
Anesthesiology, 93(3): 646-652.

PDF (202)
Anesthesiology
First Human Exposure of Org 25969, a Novel Agent to Reverse the Action of Rocuronium Bromide
Gijsenbergh, F; Ramael, S; Houwing, N; van Iersel, T
Anesthesiology, 103(4): 695-703.

PDF (924)
European Journal of Anaesthesiology (EJA)
Postoperative residual curarization with cisatracurium and rocuronium infusions
Cammu, G; de Baerdemaeker, L; den Blauwen, N; de Mey, J; Struys, M; Mortier, E
European Journal of Anaesthesiology (EJA), 19(2): 129-134.

Back to Top | Article Outline
Keywords:
Monitoring: neuromuscular function, train‐of‐four; Neuromuscular relaxants: mivacurium chloride; Postoperative period: neuromuscular recovery, post‐anesthesia care unit, testing.

© 1997 American Society of Anesthesiologists, Inc.

Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.
Login

Article Tools

Images

Share

Search for Similar Articles
You may search for similar articles that contain these same keywords or you may modify the keyword list to augment your search.