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Mona Ring Gatke - One of the best experts on this subject based on the ideXlab platform.
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a retrospective observational study of Neuromuscular Monitoring practice in 30 430 cases from six danish hospitals
Anaesthesia, 2020Co-Authors: J L Thomsen, Ole Mathiesen, Daniel Hagipedersen, A K Staehrrye, Mona Ring GatkeAbstract:Timely application of objective Neuromuscular Monitoring can avoid residual Neuromuscular blockade. We assessed the frequency of objective Neuromuscular Monitoring with acceleromyography and the last recorded train-of-four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving Neuromuscular blocking agents, divided into non-depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a Neuromuscular blocking drug. Non-depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non-depolarising Neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non-depolarising drugs and from 3% to 79% for succinylcholine alone. The median (IQR [range]) of the last recorded train-of-four ratio before tracheal extubation was 0.97 (0.90-1.06 [0.01-2.20]) when non-depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95%CI 2.33-2.70) p < 0.001] and non-depolarising drugs [2.57 (95%CI 2.32-2.84) p < 0.001] as compared with cases where no Neuromuscular blockade drug was used. In conclusion, acceleromyography was almost always used in cases where non-depolarising Neuromuscular blocking drugs were used, but a train-of-four ratio of 0.9 was not always achieved. Monitoring was used in less than 30% of cases where succinylcholine was the sole drug used.
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A retrospective observational study of Neuromuscular Monitoring practice in 30,430 cases from six Danish hospitals.
Anaesthesia, 2020Co-Authors: J L Thomsen, A. K. Staehr-rye, Ole Mathiesen, Daniel Hägi-pedersen, Mona Ring GatkeAbstract:Timely application of objective Neuromuscular Monitoring can avoid residual Neuromuscular blockade. We assessed the frequency of objective Neuromuscular Monitoring with acceleromyography and the last recorded train-of-four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving Neuromuscular blocking agents, divided into non-depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a Neuromuscular blocking drug. Non-depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non-depolarising Neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non-depolarising drugs and from 3% to 79% for succinylcholine alone. The median (IQR [range]) of the last recorded train-of-four ratio before tracheal extubation was 0.97 (0.90-1.06 [0.01-2.20]) when non-depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95%CI 2.33-2.70) p
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Barriers and aids to routine Neuromuscular Monitoring and consistent reversal practice-A qualitative study.
Acta anaesthesiologica Scandinavica, 2020Co-Authors: Jakob Louis Demant Thomsen, Adrian Marty, Shin Wakatsuki, Alex Macario, Pedro Paulo Tanaka, Mona Ring Gatke, Doris OstergaardAbstract:Neuromuscular Monitoring is recommended whenever a Neuromuscular blocking agent is administered, but surveys have demonstrated inconsistent Monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine Neuromuscular Monitoring and consistent reversal practice. Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture. Interviews were conducted at five Danish and one US hospital. Data were analysed using template analysis. Danish anaesthetists used objective Neuromuscular Monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective Neuromuscular Monitoring, objective Neuromuscular Monitoring was generally not available and most had not used it. Danish anaesthetists used Neuromuscular Monitoring to assess readiness for extubation, whereas US residents used subjective Neuromuscular Monitoring, clinical tests like 5-second head lift and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and Monitoring use. Barriers to consistent and correct Neuromuscular Monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of Neuromuscular blocking agents and residual block, lack of standards and guidelines and departmental culture. Using qualitative methods, we found that though Danish anaesthetists generally apply objective Neuromuscular Monitoring routinely and residents at the US institution often apply subjective Neuromuscular Monitoring, barriers to consistent and correct use still exist. © 2020 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.
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barriers and aids to routine Neuromuscular Monitoring and consistent reversal practice a qualitative study
Acta Anaesthesiologica Scandinavica, 2020Co-Authors: Jakob Louis Demant Thomsen, Adrian Marty, Shin Wakatsuki, Alex Macario, Pedro Paulo Tanaka, Mona Ring Gatke, Doris OstergaardAbstract:BACKGROUND Neuromuscular Monitoring is recommended whenever a Neuromuscular blocking agent is administered, but surveys have demonstrated inconsistent Monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine Neuromuscular Monitoring and consistent reversal practice. METHODS Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture. Interviews were conducted at five Danish and one US hospital. Data were analysed using template analysis. RESULTS Danish anaesthetists used objective Neuromuscular Monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective Neuromuscular Monitoring, objective Neuromuscular Monitoring was generally not available and most had not used it. Danish anaesthetists used Neuromuscular Monitoring to assess readiness for extubation, whereas US residents used subjective Neuromuscular Monitoring, clinical tests like 5-second head lift and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and Monitoring use. Barriers to consistent and correct Neuromuscular Monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of Neuromuscular blocking agents and residual block, lack of standards and guidelines and departmental culture. CONCLUSION Using qualitative methods, we found that though Danish anaesthetists generally apply objective Neuromuscular Monitoring routinely and residents at the US institution often apply subjective Neuromuscular Monitoring, barriers to consistent and correct use still exist.
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Improving Neuromuscular Monitoring and Reducing Residual Neuromuscular Blockade With E-Learning: Protocol for the Multicenter Interrupted Time Series INVERT Study
JMIR research protocols, 2017Co-Authors: J L Thomsen, Doris Ostergaard, Ole Mathiesen, Daniel Hägi-pedersen, Lene Theil Skovgaard, J. Engbæk, Mona Ring GatkeAbstract:Muscle relaxants facilitate endotracheal intubation under general anesthesia and improve surgical conditions. Residual Neuromuscular blockade occurs when the patient is still partially paralyzed when awakened after surgery. The condition is associated with subjective discomfort and an increased risk of respiratory complications. Use of an objective Neuromuscular Monitoring device may prevent residual block. Despite this, many anesthetists refrain from using the device. Efforts to increase the use of objective Monitoring are time consuming and require the presence of expert personnel. A Neuromuscular Monitoring e-learning module might support consistent use of Neuromuscular Monitoring devices. The aim of the study is to assess the effect of a Neuromuscular Monitoring e-learning module on anesthesia staff's use of objective Neuromuscular Monitoring and the incidence of residual Neuromuscular blockade in surgical patients at 6 Danish teaching hospitals. In this interrupted time series study, we are collecting data repeatedly, in consecutive 3-week periods, before and after the intervention, and we will analyze the effect using segmented regression analysis. Anesthesia departments in the Zealand Region of Denmark are included, and data from all patients receiving a muscle relaxant are collected from the anesthesia information management system MetaVision. We will assess the effect of the module on all levels of potential effect: staff's knowledge and skills, patient care practice, and patient outcomes. The primary outcome is use of Neuromuscular Monitoring in patients according to the type of muscle relaxant received. Secondary outcomes include last recorded train-of-four value, administration of reversal agents, and time to discharge from the postanesthesia care unit as well as a multiple-choice test to assess knowledge. The e-learning module was developed based on a needs assessment process, including focus group interviews, surveys, and expert opinions. The e-learning module was implemented in 6 anesthesia departments on 21 November 2016. Currently, we are collecting postintervention data. The final dataset will include data from more than 10,000 anesthesia procedures. We expect to publish the results in late 2017 or early 2018. With a dataset consisting of thousands of general anesthesia procedures, the INVERT study will assess whether an e-learning module can increase anesthetists' use of Neuromuscular Monitoring. Clinicaltrials.gov NCT02925143; https://clinicaltrials.gov/ct2/show/NCT02925143 (Archived by WebCite® at http://www.webcitation.org/6s50iTV2x). ©Jakob Louis Demant Thomsen, Ole Mathiesen, Daniel Hägi-Pedersen, Lene Theil Skovgaard, Doris Østergaard, Jens Engbaek, Mona Ring Gätke. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 06.10.2017.
Thomas M Hemmerling - One of the best experts on this subject based on the ideXlab platform.
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Brief review: Neuromuscular Monitoring: an update for the clinician.
Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2007Co-Authors: Thomas M HemmerlingAbstract:To review established techniques and to provide an update on new methods for clinical Monitoring of Neuromuscular function relevant to anesthesia. A PubMed search of relevant article for the period 1985-2005 was undertaken, and bibliographies were scanned for additional sources. There is no substitute for objective Neuromuscular Monitoring; for research purposes, mechanomyography (MMG) is the gold standard; however, the most versatile method in the clinical setting is acceleromyography since it can be applied at various muscles and has a long track record of clinical utility. Kinemyography is valid to monitor recovery of Neuromuscular transmission at the adductor pollicis muscle (AP), whereas phonomyography is easy to apply to various muscles and shows promising agreement with MMG. Monitoring of the corrugator supercilii muscle (CS) may be used to determine the earliest time for tracheal intubation as it reflects laryngeal relaxation better than Monitoring at the AP. Recovery of Neuromuscular transmission is best monitored at the AP, since it is the last muscle to recover from Neuromuscular blockade (NMB). If train-of-four (TOF) stimulation is used, a TOF-ratio > 0.9 should be the target before awakening the patient. If surgery or the type of anesthesia necessitates NMB of a certain degree, e.g., TOF-ratio = 0.25, Monitoring of muscles which best reflect the degree of NMB at the surgical site is preferable. Objective methods should be used to monitor Neuromuscular function in clinical anesthesia. Acceleromyography offers the best compromise with respect to ease of use, practicality, versatility, precision and applicability at various muscles. The CS is the optimal muscle to determine the earliest time for intubation, e.g., for rapid sequence induction.
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brief review Neuromuscular Monitoring an update for the clinician
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2007Co-Authors: Thomas M HemmerlingAbstract:Purpose To review established techniques and to provide an update on new methods for clinical Monitoring of Neuromuscular function relevant to anesthesia.
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comparison of phonomyography kinemyography and mechanomyography for Neuromuscular Monitoring
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2006Co-Authors: Guillaume Trager, Guillaume Michaud, Stephane Deschamps, Thomas M HemmerlingAbstract:The gold standard of Neuromuscular Monitoring is mechanomyography (MMG). Phonomyography (PMG) and kinemyography (KMG) are new methods of Neuromuscular Monitoring. In this study, all three methods were compared to determine Neuromuscular blockade at the adductor pollicis muscle. In 14 patients, phonomyography was recorded via a microphone taped to the thenar region. A standard mechanomyographic device was applied to the same thumb, and attached to the force transducer. On the contralateral side, a NMT-Mechanosensore probe was attached to the thumb and forefinger (KMG). After induction of general anaesthesia, the ulnar nerves were stimulated supramaximally using superficial electrodes at the wrists using train-of-four (TOF) stimulation every 12 sec. Onset and recovery indices measured by the three methods after mivacurium 0.2 mg·kg-1 iv were compared using ANOVA-multiple group comparisons. Agreement between methods was determined using Lin’s concordance correlation coefficient. Onset time and peak effect measured via MMG and PMG were similar. Recovery times from Neuromuscular blockade (NMB) as measured via the three methods were not different. Agreement between PMG and MMG was excellent for onset and offset of NMB but unsatisfactory for peak effect. Agreement between MMG and KMG was satisfactory for TOF 0.25 and 0.50, and excellent for TOF 0.75 and 0.90 (onset and peak effect not determined for KMG). Agreement between PMG and KMG was satisfactory for TOF 0.25, 0.50 and 0.75, and excellent for TOF 0.90. Mechanomyography, PMG and KMG show satisfactory agreement for determination of recovery of NMB for clinical purposes.
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Comparison of phonomyography, kinemyography and mechanomyography for Neuromuscular Monitoring
Canadian Journal of Anesthesia, 2006Co-Authors: Guillaume Trager, Guillaume Michaud, Stephane Deschamps, Thomas M HemmerlingAbstract:Purpose The gold standard of Neuromuscular Monitoring is mechanomyography (MMG). Phonomyography (PMG) and kinemyography (KMG) are new methods of Neuromuscular Monitoring. In this study, all three methods were compared to determine Neuromuscular blockade at the adductor pollicis muscle. Methods In 14 patients, phonomyography was recorded via a microphone taped to the thenar region. A standard mechanomyographic device was applied to the same thumb, and attached to the force transducer. On the contralateral side, a NMT-Mechanosensorê probe was attached to the thumb and forefinger (KMG). After induction of general anaesthesia, the ulnar nerves were stimulated supramaximally using superficial electrodes at the wrists using train-of-four (TOF) stimulation every 12 sec. Onset and recovery indices measured by the three methods after mivacurium 0.2 mg·kg^-1 iv were compared using ANOVA-multiple group comparisons. Agreement between methods was determined using Lin’s concordance correlation coefficient. Results Onset time and peak effect measured via MMG and PMG were similar. Recovery times from Neuromuscular blockade (NMB) as measured via the three methods were not different. Agreement between PMG and MMG was excellent for onset and offset of NMB but unsatisfactory for peak effect. Agreement between MMG and KMG was satisfactory for TOF 0.25 and 0.50, and excellent for TOF 0.75 and 0.90 (onset and peak effect not determined for KMG). Agreement between PMG and KMG was satisfactory for TOF 0.25, 0.50 and 0.75, and excellent for TOF 0.90. Conclusion Mechanomyography, PMG and KMG show satisfactory agreement for determination of recovery of NMB for clinical purposes. Objectif La référence en monitorage neuromusculaire est la mécanomyographie (MMG). La phonomyographie (PMG) et la cinémyographie (CMG) sont de nouvelles méthodes. Nous comparons les trois méthodes pour qualifier le blocage neuromusculaire à ľadducteur du pouce. Méthode La phonomyographie a été enregistrée par un microphone fixé à la région thénar chez 14 patients. Un appareil de mécanographie standard, au même pouce, a été fixé au transducteur de force. Au côté opposé, une sonde de NMTMechanosensorê a été fixée au pouce et à ľindex (CMG). Après ľinduction de ľanesthésie, les nerfs cubitaux ont reçu une stimulation supramaximale, utilisant un train-de-quatre (TDQ) toutes les 12 sec, produite par des électrodes superficielles aux poignets. Les indices du début et de la fin du bloc, mesurés par les trois méthodes après ľadministration iv de 0,2 mg·kg^-1 de mivacurium, ont été comparés par une analyse ANOVA de groupes multiples. La concordance entre les méthodes a été déterminée par le coefficient de concordance et de corrélation de Lin. Résultats Les temps du début et de ľeffet maximal du blocage neuromusculaire (BNM) étaient similaires par MMG et PMG. Les temps de récupération du BNM ont été similaires avec les trois méthodes. La concordance entre la PMG et la MMG a été excellente pour le début et la fin du BNM, mais insatisfaisante pour ľeffet maximal. La concordance entre la MMG et la CMG a été satisfaisante pour les TDQ 0,25 et 0,50, et excellente pour les TDQ 0,75 et 0,90 (début et effet maximal non déterminés pour le CMG). La concordance entre la PMG et la CMG a été satisfaisante pour les TDQ 0,25, 0,50 et 0,75 et excellente pour le TDQ 0,90. Conclusion La MMG, la PMG et la CMG affichent une concordance satisfaisante pour la détermination de la récupération après un BNM réalisé pour des objectifs cliniques.
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Comparison of phonomyography, kinemyography and mechanomyography for Neuromuscular Monitoring.
Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2006Co-Authors: Guillaume Trager, Guillaume Michaud, Stephane Deschamps, Thomas M HemmerlingAbstract:The gold standard of Neuromuscular Monitoring is mechanomyography (MMG). Phonomyography (PMG) and kinemyography (KMG) are new methods of Neuromuscular Monitoring. In this study, all three methods were compared to determine Neuromuscular blockade at the adductor pollicis muscle. In 14 patients, phonomyography was recorded via a microphone taped to the thenar region. A standard mechanomyographic device was applied to the same thumb, and attached to the force transducer. On the contralateral side, a NMT-Mechanosensor(R) probe was attached to the thumb and forefinger (KMG). After induction of general anaesthesia, the ulnar nerves were stimulated supramaximally using superficial electrodes at the wrists using train-of-four (TOF) stimulation every 12 sec. Onset and recovery indices measured by the three methods after mivacurium 0.2 mg x kg(-1) iv were compared using ANOVA-multiple group comparisons. Agreement between methods was determined using Lin's concordance correlation coefficient. Onset time and peak effect measured via MMG and PMG were similar. Recovery times from Neuromuscular blockade (NMB) as measured via the three methods were not different. Agreement between PMG and MMG was excellent for onset and offset of NMB but unsatisfactory for peak effect. Agreement between MMG and KMG was satisfactory for TOF 0.25 and 0.50, and excellent for TOF 0.75 and 0.90 (onset and peak effect not determined for KMG). Agreement between PMG and KMG was satisfactory for TOF 0.25, 0.50 and 0.75, and excellent for TOF 0.90. Mechanomyography, PMG and KMG show satisfactory agreement for determination of recovery of NMB for clinical purposes.
Réka Nemes - One of the best experts on this subject based on the ideXlab platform.
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awake volunteer pain scores during Neuromuscular Monitoring
Anesthesia & Analgesia, 2020Co-Authors: Réka Nemes, Béla Fülesdi, Glenn S. Murphy, György Nagy, Ilana I. Logvinov, Ross J RenewAbstract:BACKGROUND There is a need for easy to use, reliable Neuromuscular monitors (NMMs). This multicenter, prospective, unblinded study compared the discomfort associated with neurostimulation in unmedicated healthy volunteers when using the new electromyography (EMG)-based TetraGraph and acceleromyography (AMG)-based TOF-Watch NMMs. The secondary aim was to compare the repeatability of the train-of-four (TOF) ratios (TOFRs) obtained with the 2 devices. METHODS The TOF measurements of 135 volunteers from 3 university hospitals were analyzed (age: 38.3 ± 12 years [mean ± standard deviation [SD]]; male/female ratio = 63:72). The left or right ulnar nerve was stimulated at the wrist in TOF mode with 20, 30, 40, and 50 mA stimulating current intensities with both devices in random order. The TOF-Watch used standard electrocardiography (ECG) electrodes (Red Dot; 3M Health Care) for nerve stimulation. The stimulating surface area of 1 ECG electrode is 113 mm. The piezoelectric probe was attached to the thumb, and a hand adapter was used to ensure consistency of AMG measurements. The TetraGraph uses proprietary surface strip electrodes for nerve stimulation and muscle action potential recording, whose stimulating surface area is roughly twice as big as that of standard ECG electrodes (228.5 mm). The volunteers were asked to rate the discomfort associated with neurostimulation on a 0-10 verbal numerical rating scale (VNRS) score anchored with 0 (no pain) and 10 (worst pain ever experienced). A linear mixed-effects model was used to evaluate the difference in VNRS scores between devices. P <.05 was accepted as the level of significance. RESULTS In the linear mixed-effects model, there were no differences in VNRS scores between devices at any of the stimulating current intensities, P = .38. The median (range) VNRS scores obtained with TOF-Watch and TetraGraph devices were 2 (0-7) vs 2 (0-8) at 20 mA, 3 (1-9) vs 3 (1-9) at 30 mA, 5 (1-10) vs 5 (1-10) at 40 mA, and 5 (1-10) vs 6 (1-10) at 50 mA stimulating current intensities. The mean of the 1469 TOFRs obtained with TetraGraph was 100.43% ± 7.74% (standard error = 0.2%). Due to technical difficulties, the repeatability of the TOFRs could not be determined. CONCLUSIONS Despite the different size and design of the stimulating electrodes, the 2 NMMs caused the same level of discomfort in unmedicated healthy volunteers.
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Awake Volunteer Pain Scores During Neuromuscular Monitoring
Anesthesia and analgesia, 2020Co-Authors: Réka Nemes, Béla Fülesdi, Glenn S. Murphy, György Nagy, Ilana I. Logvinov, J. Ross RenewAbstract:BACKGROUND There is a need for easy to use, reliable Neuromuscular monitors (NMMs). This multicenter, prospective, unblinded study compared the discomfort associated with neurostimulation in unmedicated healthy volunteers when using the new electromyography (EMG)-based TetraGraph and acceleromyography (AMG)-based TOF-Watch NMMs. The secondary aim was to compare the repeatability of the train-of-four (TOF) ratios (TOFRs) obtained with the 2 devices. METHODS The TOF measurements of 135 volunteers from 3 university hospitals were analyzed (age: 38.3 ± 12 years [mean ± standard deviation [SD]]; male/female ratio = 63:72). The left or right ulnar nerve was stimulated at the wrist in TOF mode with 20, 30, 40, and 50 mA stimulating current intensities with both devices in random order. The TOF-Watch used standard electrocardiography (ECG) electrodes (Red Dot; 3M Health Care) for nerve stimulation. The stimulating surface area of 1 ECG electrode is 113 mm. The piezoelectric probe was attached to the thumb, and a hand adapter was used to ensure consistency of AMG measurements. The TetraGraph uses proprietary surface strip electrodes for nerve stimulation and muscle action potential recording, whose stimulating surface area is roughly twice as big as that of standard ECG electrodes (228.5 mm). The volunteers were asked to rate the discomfort associated with neurostimulation on a 0-10 verbal numerical rating scale (VNRS) score anchored with 0 (no pain) and 10 (worst pain ever experienced). A linear mixed-effects model was used to evaluate the difference in VNRS scores between devices. P
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International survey of Neuromuscular Monitoring in two European countries: a questionnaire study among Hungarian and Romanian anaesthesiologists
Romanian journal of anaesthesia and intensive care, 2019Co-Authors: Adrienn Pongrácz, Réka Nemes, Caius Breazu, László Asztalos, Ileana Mitre, Edömér Tassonyi, Béla Fülesdi, Calin MitreAbstract:Background Accumulating evidence indicates that objective Neuromuscular Monitoring and pharmacological reversal of Neuromuscular block reduces the occurrence of residual muscle paralysis in the acute postoperative phase. However, objective Neuromuscular Monitoring is not a routine habit in anaesthesia. In order to change this situation, we wished to find out, as a first step to improvement, the current use of Neuromuscular monitors and the custom of anaesthetists for reversal of Neuromuscular block before tracheal extubation. Methods A ten-point questionnaire was available via the Surveymonkey website and the link was sent to 2202 Hungarian and Romanian anaesthetists by email. Results Three hundred and two (13.7%) of the 2202 registered anaesthetists responded. Less than 10% of them regularly use Neuromuscular monitors. They underestimated the occurrence of residual block; only 2.2% gave a correct answer. Neuromuscular monitors are available in 74% of hospitals but are scarcely used. One third of anaesthetists rarely or never use reversal; approximately 20% regularly reverse before extubation. The responders typically believe that clinical signs of residual block are reliable. Instead of Monitoring, they use the "timing methods" for tracheal extubation such as time elapsed from last dose, the duration of action of relaxant, the number of top-up doses, the cumulative dose, the return of adequate respiratory tidal volume and the ability to sustain a 5 s head lift. Conclusions We concluded that Neuromuscular Monitoring in these two European countries is suboptimal as is the reversal strategy. Given the fact that monitors are available in the hospitals, the mentality should be changed towards evidence based practice.
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Quantitative Neuromuscular Monitoring: Current Devices, New Technological Advances, and Use in Clinical Practice
Current Anesthesiology Reports, 2018Co-Authors: Hajime Iwasaki, Réka Nemes, Sorin J. Brull, J. Ross RenewAbstract:Purpose of Review The purpose of this review is to summarize various quantitative Neuromuscular Monitoring modalities and describe strategies to implement them into routine practice. We will contrast these objective modalities with unreliable clinical tests and subjective techniques that expose patients to unnecessary risk associated with postoperative residual weakness. Recent Findings As major specialty societies publish guidelines and consensus statements urging anesthesiologists to utilize quantitative monitors, clinicians must familiarize themselves with this equipment. Furthermore, new monitors are emerging as the industry tries to address the need for user-friendly, reliable monitors. Summary Clinical assessment is an unacceptable technique to guide Neuromuscular blockade management in patients receiving Neuromuscular blocking agents. The use of a peripheral nerve stimulator can provide some information regarding the level of Neuromuscular blockade in patients; however, it cannot reliably confirm adequate recovery. The use of objective, quantitative Monitoring is an essential practice that helps guide the administration of Neuromuscular blocking agents and excludes deleterious postoperative residual weakness.
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Quantitative Neuromuscular Monitoring: Current Devices, New Technological Advances, and Use in Clinical Practice
Current Anesthesiology Reports, 2018Co-Authors: Hajime Iwasaki, Réka Nemes, Sorin J. Brull, J. Ross RenewAbstract:The purpose of this review is to summarize various quantitative Neuromuscular Monitoring modalities and describe strategies to implement them into routine practice. We will contrast these objective modalities with unreliable clinical tests and subjective techniques that expose patients to unnecessary risk associated with postoperative residual weakness. As major specialty societies publish guidelines and consensus statements urging anesthesiologists to utilize quantitative monitors, clinicians must familiarize themselves with this equipment. Furthermore, new monitors are emerging as the industry tries to address the need for user-friendly, reliable monitors. Clinical assessment is an unacceptable technique to guide Neuromuscular blockade management in patients receiving Neuromuscular blocking agents. The use of a peripheral nerve stimulator can provide some information regarding the level of Neuromuscular blockade in patients; however, it cannot reliably confirm adequate recovery. The use of objective, quantitative Monitoring is an essential practice that helps guide the administration of Neuromuscular blocking agents and excludes deleterious postoperative residual weakness.
J L Thomsen - One of the best experts on this subject based on the ideXlab platform.
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A retrospective observational study of Neuromuscular Monitoring practice in 30,430 cases from six Danish hospitals.
Anaesthesia, 2020Co-Authors: J L Thomsen, A. K. Staehr-rye, Ole Mathiesen, Daniel Hägi-pedersen, Mona Ring GatkeAbstract:Timely application of objective Neuromuscular Monitoring can avoid residual Neuromuscular blockade. We assessed the frequency of objective Neuromuscular Monitoring with acceleromyography and the last recorded train-of-four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving Neuromuscular blocking agents, divided into non-depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a Neuromuscular blocking drug. Non-depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non-depolarising Neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non-depolarising drugs and from 3% to 79% for succinylcholine alone. The median (IQR [range]) of the last recorded train-of-four ratio before tracheal extubation was 0.97 (0.90-1.06 [0.01-2.20]) when non-depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95%CI 2.33-2.70) p
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a retrospective observational study of Neuromuscular Monitoring practice in 30 430 cases from six danish hospitals
Anaesthesia, 2020Co-Authors: J L Thomsen, Ole Mathiesen, Daniel Hagipedersen, A K Staehrrye, Mona Ring GatkeAbstract:Timely application of objective Neuromuscular Monitoring can avoid residual Neuromuscular blockade. We assessed the frequency of objective Neuromuscular Monitoring with acceleromyography and the last recorded train-of-four ratio in a cohort of Danish patients. We extracted data from all patients receiving general anaesthesia from November 2014 to November 2016 at six hospitals in the Zealand Region of Denmark. Acceleromyography was available in all operating rooms and data were recorded automatically. The primary outcome measure was acceleromyography use in patients receiving Neuromuscular blocking agents, divided into non-depolarising agents and succinylcholine only. The dataset included 76,743 cases, of which 30,430 received a Neuromuscular blocking drug. Non-depolarising drugs were used in 16,525 (54%) and succinylcholine as the sole drug in 13,905 (46%) cases. Acceleromyography was used in 14,463 (88%) patients who received a non-depolarising Neuromuscular blocking drug and in 4224 (30%) receiving succinylcholine alone. Acceleromyography use varied between the departments from 58% to 99% for non-depolarising drugs and from 3% to 79% for succinylcholine alone. The median (IQR [range]) of the last recorded train-of-four ratio before tracheal extubation was 0.97 (0.90-1.06 [0.01-2.20]) when non-depolarising drugs were used, and was less than 0.9 in 22% of cases. The OR for oxygen desaturation was higher with the use of succinylcholine [2.51 (95%CI 2.33-2.70) p < 0.001] and non-depolarising drugs [2.57 (95%CI 2.32-2.84) p < 0.001] as compared with cases where no Neuromuscular blockade drug was used. In conclusion, acceleromyography was almost always used in cases where non-depolarising Neuromuscular blocking drugs were used, but a train-of-four ratio of 0.9 was not always achieved. Monitoring was used in less than 30% of cases where succinylcholine was the sole drug used.
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Improving Neuromuscular Monitoring and Reducing Residual Neuromuscular Blockade With E-Learning: Protocol for the Multicenter Interrupted Time Series INVERT Study
JMIR research protocols, 2017Co-Authors: J L Thomsen, Doris Ostergaard, Ole Mathiesen, Daniel Hägi-pedersen, Lene Theil Skovgaard, J. Engbæk, Mona Ring GatkeAbstract:Muscle relaxants facilitate endotracheal intubation under general anesthesia and improve surgical conditions. Residual Neuromuscular blockade occurs when the patient is still partially paralyzed when awakened after surgery. The condition is associated with subjective discomfort and an increased risk of respiratory complications. Use of an objective Neuromuscular Monitoring device may prevent residual block. Despite this, many anesthetists refrain from using the device. Efforts to increase the use of objective Monitoring are time consuming and require the presence of expert personnel. A Neuromuscular Monitoring e-learning module might support consistent use of Neuromuscular Monitoring devices. The aim of the study is to assess the effect of a Neuromuscular Monitoring e-learning module on anesthesia staff's use of objective Neuromuscular Monitoring and the incidence of residual Neuromuscular blockade in surgical patients at 6 Danish teaching hospitals. In this interrupted time series study, we are collecting data repeatedly, in consecutive 3-week periods, before and after the intervention, and we will analyze the effect using segmented regression analysis. Anesthesia departments in the Zealand Region of Denmark are included, and data from all patients receiving a muscle relaxant are collected from the anesthesia information management system MetaVision. We will assess the effect of the module on all levels of potential effect: staff's knowledge and skills, patient care practice, and patient outcomes. The primary outcome is use of Neuromuscular Monitoring in patients according to the type of muscle relaxant received. Secondary outcomes include last recorded train-of-four value, administration of reversal agents, and time to discharge from the postanesthesia care unit as well as a multiple-choice test to assess knowledge. The e-learning module was developed based on a needs assessment process, including focus group interviews, surveys, and expert opinions. The e-learning module was implemented in 6 anesthesia departments on 21 November 2016. Currently, we are collecting postintervention data. The final dataset will include data from more than 10,000 anesthesia procedures. We expect to publish the results in late 2017 or early 2018. With a dataset consisting of thousands of general anesthesia procedures, the INVERT study will assess whether an e-learning module can increase anesthetists' use of Neuromuscular Monitoring. Clinicaltrials.gov NCT02925143; https://clinicaltrials.gov/ct2/show/NCT02925143 (Archived by WebCite® at http://www.webcitation.org/6s50iTV2x). ©Jakob Louis Demant Thomsen, Ole Mathiesen, Daniel Hägi-Pedersen, Lene Theil Skovgaard, Doris Østergaard, Jens Engbaek, Mona Ring Gätke. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 06.10.2017.
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improving Neuromuscular Monitoring and reducing residual Neuromuscular blockade with e learning protocol for the multicenter interrupted time series invert study
JMIR Research Protocols, 2017Co-Authors: J L Thomsen, Doris Ostergaard, Ole Mathiesen, Lene Theil Skovgaard, J. Engbæk, Daniel Hagipedersen, Mona Ring GatkeAbstract:Background: Muscle relaxants facilitate endotracheal intubation under general anesthesia and improve surgical conditions. Residual Neuromuscular blockade occurs when the patient is still partially paralyzed when awakened after surgery. The condition is associated with subjective discomfort and an increased risk of respiratory complications. Use of an objective Neuromuscular Monitoring device may prevent residual block. Despite this, many anesthetists refrain from using the device. Efforts to increase the use of objective Monitoring are time consuming and require the presence of expert personnel. A Neuromuscular Monitoring e-learning module might support consistent use of Neuromuscular Monitoring devices. Objective: The aim of the study is to assess the effect of a Neuromuscular Monitoring e-learning module on anesthesia staff’s use of objective Neuromuscular Monitoring and the incidence of residual Neuromuscular blockade in surgical patients at 6 Danish teaching hospitals. Methods: In this interrupted time series study, we are collecting data repeatedly, in consecutive 3-week periods, before and after the intervention, and we will analyze the effect using segmented regression analysis. Anesthesia departments in the Zealand Region of Denmark are included, and data from all patients receiving a muscle relaxant are collected from the anesthesia information management system MetaVision. We will assess the effect of the module on all levels of potential effect: staff’s knowledge and skills, patient care practice, and patient outcomes. The primary outcome is use of Neuromuscular Monitoring in patients according to the type of muscle relaxant received. Secondary outcomes include last recorded train-of-four value, administration of reversal agents, and time to discharge from the postanesthesia care unit as well as a multiple-choice test to assess knowledge. The e-learning module was developed based on a needs assessment process, including focus group interviews, surveys, and expert opinions. Results: The e-learning module was implemented in 6 anesthesia departments on 21 November 2016. Currently, we are collecting postintervention data. The final dataset will include data from more than 10,000 anesthesia procedures. We expect to publish the results in late 2017 or early 2018. Conclusions: With a dataset consisting of thousands of general anesthesia procedures, the INVERT study will assess whether an e-learning module can increase anesthetists’ use of Neuromuscular Monitoring. Trial Registration: Clinicaltrials.gov NCT02925143; https://clinicaltrials.gov/ct2/show/NCT02925143 (Archived by WebCite® at http://www.webcitation.org/6s50iTV2x) [JMIR Res Protoc 2017;6(10):e192]
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premature awakening and underuse of Neuromuscular Monitoring in a registry of patients with butyrylcholinesterase deficiency
BJA: British Journal of Anaesthesia, 2015Co-Authors: J L Thomsen, C V Nielsen, D F Palmqvist, Mona Ring GatkeAbstract:Background Patients with butyrylcholinesterase (BChE) deficiency can experience prolonged paralysis after receiving suxamethonium or mivacurium. We hypothesized that patients suspected of BChE deficiency had a higher risk of being awakened while paralysed and having respiratory complications if Neuromuscular Monitoring was not applied before awakening. Methods We retrospectively included patients referred to the Danish Cholinesterase Research Unit between 2004 and 2012 on suspicion of BChE deficiency. We collected data on genotype, BChE activity, Neuromuscular blocking agents administered, Neuromuscular Monitoring, and postoperative respiratory complications, defined as arterial oxygen desaturation Results We included 123 patients. Neuromuscular Monitoring was applied before awakening in 48 (39%) patients. A nerve stimulator was never used or only after attempted awakening in the remaining 75 (61%) patients. Premature awakening occurred in 75 (100%) and 14 (29%) of the unmonitored and monitored patients, respectively (P Conclusions Patients with BChE deficiency are at higher risk of being awakened while paralysed if Neuromuscular Monitoring is not applied or used; Neuromuscular Monitoring is recommended whenever a Neuromuscular blocking agent is administered.
J. Ross Renew - One of the best experts on this subject based on the ideXlab platform.
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Awake Volunteer Pain Scores During Neuromuscular Monitoring
Anesthesia and analgesia, 2020Co-Authors: Réka Nemes, Béla Fülesdi, Glenn S. Murphy, György Nagy, Ilana I. Logvinov, J. Ross RenewAbstract:BACKGROUND There is a need for easy to use, reliable Neuromuscular monitors (NMMs). This multicenter, prospective, unblinded study compared the discomfort associated with neurostimulation in unmedicated healthy volunteers when using the new electromyography (EMG)-based TetraGraph and acceleromyography (AMG)-based TOF-Watch NMMs. The secondary aim was to compare the repeatability of the train-of-four (TOF) ratios (TOFRs) obtained with the 2 devices. METHODS The TOF measurements of 135 volunteers from 3 university hospitals were analyzed (age: 38.3 ± 12 years [mean ± standard deviation [SD]]; male/female ratio = 63:72). The left or right ulnar nerve was stimulated at the wrist in TOF mode with 20, 30, 40, and 50 mA stimulating current intensities with both devices in random order. The TOF-Watch used standard electrocardiography (ECG) electrodes (Red Dot; 3M Health Care) for nerve stimulation. The stimulating surface area of 1 ECG electrode is 113 mm. The piezoelectric probe was attached to the thumb, and a hand adapter was used to ensure consistency of AMG measurements. The TetraGraph uses proprietary surface strip electrodes for nerve stimulation and muscle action potential recording, whose stimulating surface area is roughly twice as big as that of standard ECG electrodes (228.5 mm). The volunteers were asked to rate the discomfort associated with neurostimulation on a 0-10 verbal numerical rating scale (VNRS) score anchored with 0 (no pain) and 10 (worst pain ever experienced). A linear mixed-effects model was used to evaluate the difference in VNRS scores between devices. P
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Quantitative Neuromuscular Monitoring: Current Devices, New Technological Advances, and Use in Clinical Practice
Current Anesthesiology Reports, 2018Co-Authors: Hajime Iwasaki, Réka Nemes, Sorin J. Brull, J. Ross RenewAbstract:Purpose of Review The purpose of this review is to summarize various quantitative Neuromuscular Monitoring modalities and describe strategies to implement them into routine practice. We will contrast these objective modalities with unreliable clinical tests and subjective techniques that expose patients to unnecessary risk associated with postoperative residual weakness. Recent Findings As major specialty societies publish guidelines and consensus statements urging anesthesiologists to utilize quantitative monitors, clinicians must familiarize themselves with this equipment. Furthermore, new monitors are emerging as the industry tries to address the need for user-friendly, reliable monitors. Summary Clinical assessment is an unacceptable technique to guide Neuromuscular blockade management in patients receiving Neuromuscular blocking agents. The use of a peripheral nerve stimulator can provide some information regarding the level of Neuromuscular blockade in patients; however, it cannot reliably confirm adequate recovery. The use of objective, quantitative Monitoring is an essential practice that helps guide the administration of Neuromuscular blocking agents and excludes deleterious postoperative residual weakness.
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Quantitative Neuromuscular Monitoring: Current Devices, New Technological Advances, and Use in Clinical Practice
Current Anesthesiology Reports, 2018Co-Authors: Hajime Iwasaki, Réka Nemes, Sorin J. Brull, J. Ross RenewAbstract:The purpose of this review is to summarize various quantitative Neuromuscular Monitoring modalities and describe strategies to implement them into routine practice. We will contrast these objective modalities with unreliable clinical tests and subjective techniques that expose patients to unnecessary risk associated with postoperative residual weakness. As major specialty societies publish guidelines and consensus statements urging anesthesiologists to utilize quantitative monitors, clinicians must familiarize themselves with this equipment. Furthermore, new monitors are emerging as the industry tries to address the need for user-friendly, reliable monitors. Clinical assessment is an unacceptable technique to guide Neuromuscular blockade management in patients receiving Neuromuscular blocking agents. The use of a peripheral nerve stimulator can provide some information regarding the level of Neuromuscular blockade in patients; however, it cannot reliably confirm adequate recovery. The use of objective, quantitative Monitoring is an essential practice that helps guide the administration of Neuromuscular blocking agents and excludes deleterious postoperative residual weakness.
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The Effect of Quantitative Neuromuscular Monitoring on the Incidence of Residual Neuromuscular Blockade and Clinical Outcomes
Current Anesthesiology Reports, 2016Co-Authors: J. Ross Renew, Sorin J. BrullAbstract:Neuromuscular blocking agents (NMBAs) are useful perioperative medications. Despite this utility, their administration is associated with increased morbidity due to residual Neuromuscular blockade. Clinical testing prior to tracheal extubation is subjective, dependent on the patient’s cooperation, and not predictive of adequate respiratory function to prevent the occurrence of postoperative critical respiratory events. The use of peripheral nerve stimulators may improve detection of residual weakness; however, this technique does not reliably detect residual paralysis, as it requires the subjective (and imperfect) assessment of fade in response to train-of-four (TOF) stimulation. Quantitative Neuromuscular Monitoring can be accomplished through a variety of modalities and remains as the most effective and reproducible method of detecting residual paralysis after NMBA administration. In this review, we will discuss the various techniques that are used clinically to assess depth of block and adequacy of reversal, with a focus on quantitative (objective) Neuromuscular Monitoring.