Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%² train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

raise-head

Ability to lift the head

handshake
Firm handshake
minute-ventilation

Sufficient minute ventilation of an intubated patient

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent

Normal vital capacity possible with
TOFR = 0.6²

60percent

Quantitative neuromuscular monitoring to accurately assess neuromuscular block

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Electromyography (EMG) is the gold standard for measuring  neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•
TOF

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC

PTC**
Tetanic stimulation is a continuous 5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

NMT-hand


*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of block
Complete block
Deep block
Moderate block
Shallow block
Shallow/minimal block
Minimal block
Minimal block
Quantitative
measurement
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR: 0.2–0.5
TOFR: 0.5–0.7
TOFR: 0.7–0.9
Neostigmine
(μg/kg)
Not effective
Not effective
Not effective
50–70
40
20
10
Sugammadex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407

Optimal dose and injection
time of reversal agent¹

Path 1408

Increased likelihood of complete neuromuscular
recovery⁵

Path 1406
Enhanced patient
experience⁶
Path 1409
Cost-effective patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

Not all products or features are available in all markets. Full product technical specification is available upon request. Contact a GE HealthCare Representative for more information. Please visit www.gehealthcare.com/promotional-locations. Data subject to change.
© 2023 GE HealthCare
GE is a trademark of General Electric Company used under trademark license. All other trademarks are property of their respective owners.
Reproduction in any form is forbidden without prior written permission from GE HealthCare. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

JB02095XX-JB27114XX 12/2023

Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%² train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

raise-head

Ability to lift the head

handshake
Firm handshake
minute-ventilation

Sufficient minute ventilation of an intubated patient

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent

Normal vital capacity
possible with TOFR = 0.6²

60percent

Quantitative neuromuscular monitoring to accurately assess neuromuscular block

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Electromyography (EMG) is the gold standard for measuring
neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•
TOF

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC

PTC**
Tetanic stimulation is a continuous 5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

NMT-hand


*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of block
Complete block
Deep block
Moderate block
Shallow block
Shallow/minimal block
Minimal block
Minimal block
Quantitative
measurement
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR: 0.2–0.5
TOFR: 0.5–0.7
TOFR: 0.7–0.9
Neostigmine
(μg/kg)
Not effective
Not effective
Not effective
50–70
40
20
10
Sugammadex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407

Optimal dose and injection time of
reversal agent¹

Path 1408

Increased likelihood of complete neuromuscular
recovery⁵

Path 1406
Enhanced patient
experience⁶
Path 1409
Cost-effective patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

Not all products or features are available in all markets. Full product technical specification is available upon request. Contact a GE HealthCare Representative for more information. Please visit www.gehealthcare.com/promotional-locations. Data subject to change.
© 2023 GE HealthCare
GE is a trademark of General Electric Company used under trademark license. All other trademarks are property of their respective owners.
Reproduction in any form is forbidden without prior written permission from GE HealthCare. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

JB02095XX-JB27114XX 12/2023

Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%² train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

raise-head

Ability to lift the head

handshake
Firm handshake
minute-ventilation

Sufficient minute ventilation of an intubated patient

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent

Normal vital capacity
possible with TOFR = 0.6²

60percent

Quantitative neuromuscular monitoring to accurately assess neuromuscular block

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Electromyography (EMG) is the gold standard
for measuring neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•
TOF

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC

PTC**
Tetanic stimulation is a continuous 5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

NMT-hand


*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of block
Complete block
Deep block
Moderate block
Shallow block
Shallow/minimal block
Minimal block
Minimal block
Quantitative
measurement
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR: 0.2–0.5
TOFR: 0.5–0.7
TOFR: 0.7–0.9
Neostigmine
(μg/kg)
Not effective
Not effective
Not effective
50–70
40
20
10
Sugammadex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407

Optimal dose
and injection time of reversal agent¹

Path 1408
Increased likelihood
of complete neuromuscular
recovery⁵
Path 1406
Enhanced
patient
experience⁶
Path 1409
Cost-effective
patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

Not all products or features are available in all markets. Full product technical specification is available upon request. Contact a GE HealthCare Representative for more information. Please visit www.gehealthcare.com/promotional-locations.
Data subject to change.
© 2023 GE HealthCare
GE is a trademark of General Electric Company used under trademark license. All other trademarks are property of their respective owners.
Reproduction in any form is forbidden without prior written permission from GE HealthCare. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

JB02095XX-JB27114XX 12/2023

Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%²  train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

raise-head

Ability to lift the head

handshake
Firm handshake
minute-ventilation

Sufficient minute ventilation of an intubated patient

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent

Normal vital capacity
possible with TOFR = 0.6²

60percent

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC**
Tetanic stimulation is a continuous 5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

Electromyography (EMG) is the gold standard for measuring neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Quantitative neuromuscular monitoring to accurately assess neuromuscular block


*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

NMT-hand PTC TOF

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of block
Complete block
Deep block
Moderate block
Shallow block
Shallow/minimal block
Minimal block
Minimal block
Quantitative
measurement
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR: 0.2–0.5
TOFR: 0.5–0.7
TOFR: 0.7–0.9
Neostigmine
(μg/kg)
Not effective
Not effective
Not effective
50–70
40
20
10
Sugammadex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407

Optimal dose
and injection time of reversal agent¹

Path 1408
Increased likelihood
of complete neuromuscular
recovery⁵
Path 1406
Enhanced
patient
experience⁶
Path 1409
Cost-effective
patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

Not all products or features are available in all markets. Full product technical specification is available upon request. Contact a GE HealthCare Representative for more information. Please visit www.gehealthcare.com/promotional-locations.
Data subject to change.
© 2023 GE HealthCare
GE is a trademark of General Electric Company used under trademark license. All other trademarks are property of their respective owners.
Reproduction in any form is forbidden without prior written permission from GE HealthCare. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

JB02095XX-JB27114XX 12/2023

Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%2  train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

raise-head

Ability to lift the head

handshake
Firm handshake

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent
minute-ventilation

Sufficient minute ventilation of an intubated patient

Normal vital capacity
possible with TOFR = 0.6²

60percent

Quantitative neuromuscular monitoring to accurately assess neuromuscular block

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Electromyography (EMG) is the gold standard for measuring neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•
TOF PTC

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC**
Tetanic stimulation is a continuous
5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

NMT-hand

*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of block
Complete block
Deep block
Moderate block
Shallow block
Shallow/
minimal block
Minimal block
Minimal block
Quantitative
measurement
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR: 0.2–0.5
TOFR: 0.5–0.7
TOFR: 0.7–0.9
Neostigmine
(μg/kg)
Not effective
Not effective
Not effective
50–70
40
20
10
Sugammadex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407

Optimal dose and injection time of reversal agent¹

Path 1408

Increased likelihood of
complete neuromuscular
recovery⁵

Path 1406
Enhanced patient
experience⁶
Path 1409
Cost-effective patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

Not all products or features are available in all markets. Full product technical specification is available upon request. Contact a GE HealthCare Representative for more information. Please visit www.gehealthcare.com/promotional-locations.
Data subject to change.
© 2023 GE HealthCare
GE is a trademark of General Electric Company used under trademark license. All other trademarks are property of their respective owners.
Reproduction in any form is forbidden without prior written permission from GE HealthCare. Nothing in this material should be used to diagnose or treat any disease or condition. Readers must consult a healthcare professional.

JB02095XX-JB27114XX 12/2023

Quantitative neuromuscular monitoring and the reduction of residual neuromuscular block¹

Under-recognized post operative residual paralysis2,5,6

of cases do not reach 90%2  train-of-four (TOF) ratio extubation threshold, leading to insufficient neuromuscular recovery¹

40-83%

90percert
Possible post operative risks
•
Respiratory events
•
Reintubation
•
Increased length of stay
•
Patient distress
•

May lead to increased mortality

Unreliable visual and tactile assessment of neuromuscular function1,2

no-lightbulb
•

Subjective and healthcare provider dependent evaluation

•

Neuromuscular block with TOF > 40% canʼt be reliably detected even by experienced anaesthetists²

Evaluations that lead to misinterpretation of adequate recovery²

Ability to lift the head

raise-head
Firm handshake
handshake

Patients can lift the head and hold firm handshake for five seconds with TOFR = 0.33²

33percent
minute-ventilation

Sufficient minute ventilation
of an intubated patient

Normal vital capacity
possible with TOFR = 0.6²

60percent

Quantitative neuromuscular monitoring to accurately assess neuromuscular block

One of the only suitable methods

•

To titrate adequate levels of neuromuscular block

•

To guide optimal dose and timing of reversal agent

Path 2

Recommended by
ESAIC, ASA & APSF

Electromyography (EMG) is the gold standard for measuring neuromuscular block¹

Offers advantages versus other technologies

•

Captures the first clean signal at the neuromuscular junction

•
TOF

TOF*
Four stimulation pulses are generated at 0.5 sec intervals. The response is measured after each stimulus, and the ratio of the fourth to the first response of the TOF sequence is calculated, resulting in TOF%.

PTC

PTC**
Tetanic stimulation is a continuous
5 sec stimulation. After tetanic stimulation, single twitch stimulations are generated. The number of detected responses is counted and expressed as PTC. The fewer the responses, the deeper the relaxation.

NMT-hand

*TOFC = number of elicited contractions
TOFR = ratio of 4th to 1st twitch response

**PTC is used if there is no response to TOF or a single twitch (i.e. in profound non-depolarising block)

Quantitative neuromuscular monitoring to support reversal agent choice and dose decision2,4

•

With TOF <90 residual neuromuscular block is present and has to be reversed by either waiting or by administering reversal drugs

•

Correct choice of dose, timing and reversal drug are crucial for achieving complete neuromuscular recovery and allow safe extubation

Depth of
block
Complete
block
Deep
block
Moderate
block
Shallow
block
Shallow/
minimal
block
Minimal
block
Minimal
block
Quantitative
measure-ment
PTC = 0
PTC ≥ 1
TOFC = 1–3

TOFC = 4
TOFR < 0.2

TOFR:
0.2–0.5
TOFR:
0.5–0.7
TOFR:
0.7–0.9
Neostig-mine
(μg/kg)
Not
effective
Not
effective
Not
effective
50–70
40
20
10
Sugam-madex
(mga/kg)
16
4
2
1*–2
0.75*–2
0.25*–2
0.25*–2
Line 7 Line 7 Line 7 Line 7 Line 7 Line 7
Outcomes
Path 1407
Path 1408

Optimal dose and injection time of reversal agent¹

Increased likelihood of complete neuromuscular
recovery⁵

Path 1406
Path 1409
Enhanced patient
experience⁶
Cost-effective patient
throughput²

*These doses have been determined in dose-finding studies, and have not been tested in comparative clinical trials. They are not recommended by the manufacturer. Please note that the use of low-dose sugammadex has been questioned, since elderly patients are at greater risk for recurarisation and residual muscle paralysis when low-dose sugammadex is administered.

Naguib M, Brull SJ, Kopman AF, Hunter JM, Fulesdi B, Arkes HR, Elstein A, Todd MM, Johnson KB. Consensus Statement on Perioperative Use of Neuromuscular Monitoring. Anesth Analg 2018;127:71-80.

1.

Blobner M, Eikermann E, Lewald H. Safe and Efficient Anesthesia: The Role of Quantitative Neuromuscular Monitoring. Advances in Patient Safety.

2.

Viby-Mogensen J, Jensen NH, Engbaek J, Ording H, Skovgaard LT, Chraemmer-Jorgensen B. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440-443.

3.

Sasakawa T, Miyasaka K, Sawa T, Iida H. Postoperative Recurarization After Sugammadex Administration Due to the Lack of Appropriate Neuromuscular Monitoring: The Japanese Experience’. APSF Newsletter. 2020:42-43.

4.

Todd M, Hindman B, King B. The Implementation of Quantitative Electromyographic Neuromuscular Monitoring in an Academic Anesthesia Department. Anesth Analg 2014:119 Number 2:323-331.

5.

Benoît Plaud, Bertrand Debaene, François Donati, Jean Marty. Residual Paralysis after Emergence from Anesthesia, Anesthesiology 2010;1013-1022.

6.

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JB02095XX-JB27114XX 12/2023