Relaxation

Bibliography

Berg H, Viby-Mogensen J, Roed J, Mortensen CR, Engbaek J, Skovgaard LT, Krintel JJ
Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium
Acta Anaesthesiologica Scandinavica, Vol. 41, :1095-1103,
1997
"The study found residual paralysis (TOF ratio < 0.70) in 26% of the patients in the pancuronium group, when the intraoperative monitoring for neuromuscular block was performed manually. Residual paralysis with pancuronium was found to be a risk factor for post-operative pulmonary complications (POPC). The authors suggest that if the use of pancuronium instead of shorter-acting relaxants is continued due to economical reasons, this implies the obligatory use of objective monitoring of neuromuscular block."

Booij LHDJ
The use of muscle relaxants in the intensive care unit
Acta Anaesth Belg, Vol. 48, No. 1:35-44, 1997
"Indications for use of muscle relaxants in the ICU are to prevent extremely high airway pressures, to decrease oxygen consumption, to abolish tetanus, to cut epileptic status, to decrease ICP and to facilitate procedures. It is recommended to regularly monitor the degree of blockade. Often 1-2 responses to train of four stimulation is considered an adequate level. Continuous infusion of intermediate-acting drugs is often the preferred choice."

Kern SE, Johnson JO, Westenskow DR, Orr JA
An effectiveness study of a New Piezoelectric Sensor for Train-of-Four Measurement
Anesthesia and Analgesia, Vol. 78, :978-82, 1994
"A new type of sensor for NMT measurement is described. The sensor is made of piezoelectric polymer, which produces a voltage when bent. The voltage is measured with electrodes to measure the magnitude of muscle response to stimulation. The piezoelectric sensor is compared with mechanomyography (MMG). The sensor is not quite as accurate as MMG, but the limits of agreement are reasonable. The piezo sensor is more applicable to clinical practice than MMG."

Kopman AF, Mallhi MH, Neuman GG, Justo MD
Re-establishment of paralysis using mivacurium following apparent full recovery from mivacurium-induced neuromuscular block
Anaesthesia, Vol. 51, :41-44, 1996
"This paper studied a situation where neuromuscular block has recovered to TOF ratio of > 0.90, and subsequently a new dose is administered. There was a greater sensitivity to relaxants than would be assumed, indicating that there is a significant amount of residual block present even at such high TOF ratios. The authors suggest that the traditional safety limit of TOF ratio of 0.70-0.75 should thus be increased to as close to 1.0 as possible."

Martin L, Bratton S, O'Rourke P
Clinical uses and controversies of neuromuscular blocking agents in infants and children
Critical Care Medicine, Vol. 27, No. 7:1358-1368, 1999
"In the article, studies related to the following areas were reviewed: The developmental changes in neuromuscular transmission, the pharmacokinetics and pharmacodynamics of neuromuscular blocking agents (NMBA) in neonates, infants, children and adults and clinical experience with NMBAs in critical care settings. It was noticed that remarkable gaps in the knowledge of the pharmacokinetics and pharmacodynamics of NMBAs in pediatrics still exist. Routine use of NMBAs without NMT monitoring in critical care, changes in electrolyte balance and organ-specific drug metabolism may contribute to complications, such as prolonged weakness."

Rudis MI, Sikora CA. Angus E, Peterson E, Popovich J Jr, Hyzy R, Zarowitz BJ
A prospective, randomized, controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients.
Critical Care Medicine, Vol. 25, No. 4:575-583, 1997
"This study compared peripheral nerve stimulation controlled vs. clinical dosing of vecuronium. 77 mechanically ventilated patients were included in the study, and the stimulation group aimed at TOF count of 1, whereas the control group used standard clinical assessment. Despite no difference in clinical response, the stimulation group used significantly less vecuronium than the control group, and also the patients recovered faster from block and to returned to spontaneous ventilation sooner."

Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, Schein RM, Spevetz A, Stone JR
Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: An executive summary.
Critical Care Medicine, Vol. 23, No. 9:1601-1605, 1995
"The work of a task force put together to give recommendations on the use of neuromuscular blockade in the ICU is described. Pancuronium is the preferred agent for most patients, but should be avoided in patients with history of asthma or atopy. Vecuronium is the preferred agent in patients with cardiac disease of hemodynamic instability, and is preferably used by continuous infusion. Patient receiving neuromuscular blocking agents should be assessed for the degree of blockade."

Smith B
The role of electrical nerve stimulation in regional anesthesia
Current Anaesthesia and Critical Care, , No. 1:234-238, 1990
"Concerning nerve location, the following factors are considered in the article: Voltage and current, the type of needles used, pulse duration and frequency. Also the principle of electrical nerve location is presented."

Viby-Mogensen J, Jensen NH, Engboek J
Tactile and visual evaluation of the response to train-of-four nerve stimulation.
Anesthesiology, Vol. 63, :440-3, 1985
"This classical article assesses the physician's ability to evaluate the recovery of neuromuscular block by visual or tactile assessment. The results show that even for an experienced observer, correct estimation of the TOF ratio is impossible, i.e. quantitative monitoring of the muscle response to stimulation is needed."

Zarowitz B, Rudis M, Lai K, Petitta A, Lulek M
Retrospective pharmacoeconomic evaluation of dosing vecuronium by peripheral nerve stimulation versus standard clinical assessment in critically ill patients
Pharmacotherapy, Vol. 17, No. 2:327-332, 1997
"The health and economic outcomes of using TOF end points by peripheral nerve stimulation in dosing neuromuscular blocking agents during continuous infusion in a medical ICU were retrospectively analyzed. The results showed that individualizing vecuronium doses to TOF end points has both therapeutic and economic advantages. When considering costs of drugs, TOF monitoring, and ICU, the total cost/patient was 40% of that in the control group."

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