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An Ipsilateral Comparison of Acceleromyography and Electromyography During Recovery from Nondepolarizing Neuromuscular Block Under General Anesthesia in Humans

Liang, Sophie S. BSc (Adv.)*; Stewart, Paul A. MBBS, FANZCA; Phillips, Stephanie BMed, FANZCA, FRCA

doi: 10.1213/ANE.0b013e3182937fc4
Technology, Computing, and Simulation: Research Report

BACKGROUND: Residual neuromuscular block is defined as a mechanomyography (MMG) or electromyography (EMG) train-of-four (TOF) ratio <0.90, and is common in patients receiving neuromuscular blocking drugs. Objective neuromuscular monitoring is the only reliable way to detect and exclude residual neuromuscular block. Acceleromyography (AMG) is commercially available and easy to use in the clinical setting. However, AMG is not interchangeable with MMG or EMG. Currently, it is unclear what value must be reached by AMG TOF ratio to reliably exclude residual neuromuscular block.

METHODS: During spontaneous recovery from neuromuscular block, we monitored TOF ratio on the same arm using AMG at the adductor pollicis and EMG at the first dorsal interosseus. AMG and EMG TOF ratios were compared by the Bland–Altman analysis for repeated measurements. The precision of each device was assessed by the repeatability coefficient. A small repeatability coefficient indicates high precision of the device. The agreement between the devices was assessed by the bias and the 95% limits of agreement. Small bias and narrow limits of agreement indicate strong agreement. We defined clinically acceptable agreement between AMG and EMG as a bias <0.025 and limits of agreement within −0.050 to 0.050, provided that the control comparison between EMG and itself can fulfill these criteria.

RESULTS: In 26 patients, 261 comparisons between AMG and EMG were made. The repeatability coefficient of AMG and EMG were 0.094 (95% confidence interval [CI], 0.088–0.100) and 0.051 (95% CI, 0.048–0.055), respectively. The bias between AMG and EMG TOF ratio was 0.176 (95% CI, 0.162–0.190), with limits of agreement −0.045 to 0.396 (95% CI, −0.067 to 0.419).

CONCLUSIONS: AMG is less precise than EMG and overestimates EMG TOF ratio by at least 0.15. The lack of agreement cannot be attributed to instrumental imprecision or the baseline difference between successive measurements during spontaneous recovery of neuromuscular function. Residual neuromuscular block cannot be excluded on reaching an AMG TOF ratio of 1.00.

Published ahead of print July 2, 2013.

From the *Concord Clinical School, Sydney Medical School, University of Sydney; and Sydney Adventist Hospital Clinical School, Sydney Medical School, University of Sydney, Wahroonga, New South Wales, Australia.

Accepted for publication March 1, 2013.

Published ahead of print July 2, 2013.

Funding: This study was supported by the Jackson Rees Research Grant from the Australian Society of Anaesthetists and the Australasian Research Institute. The AMG device was loaned by Dräger (Mt. Waverly, Victoria, NSW, Australia). The EMG device loaned by GE Healthcare (Sydney-Rydalmere, NSW, Australia).

The authors declare no conflicts of interest.

This report was previously presented, in part, at the 2012 Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists.

Reprints will not be available from the authors.

Address correspondence to Paul A. Stewart, MBBS, FANZCA, Department of Anaesthesia, Sydney Adventist Hospital, 185 Fox Valley Rd., Wahroonga NSW 2076, Australia. Address e-mail to

© 2013 International Anesthesia Research Society