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The assessment of return of neuromuscular function following the administration of non depolarising-muscle-relaxants being a combination of clinical assessment and use of a peripheral nerve-stimulator

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"Red to head". Placement of the +ve (red) electrode proximally normally elicits the greatest neuromuscular response. refl.in/9z

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Alternative sites for peripheral nerve stimulation are facial and posterior tibial nerves. refl.in/5o

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Clinical signs suggestive of return of neuromuscular function include: Sustained head lift for 5 seconds; Sustained leg lift for 5 seconds; Sustained handgrip for 5 seconds; Sustained “tongue depressor test”; Maximum inspiratory pressure 40 to 50 cm H2O or greater. refl.in/fe refl.in/fg

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Although sustained head life for 5 seconds does not rule out significant residual neuromuscular blockade. refl.in/fd
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Depolarising muscle relaxants ( suxamethonium) result in consistently reduced amplitude twitches, but not fade, during a train-of-four stimulation.

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Double burst stimulation was developed as a more reliable method than TOF for determining the TOF ratio manually without the use of use of acceleromyography. An absence of tactile difference between contractions correlates with a TOF ratio of greater than 0.5-0.6. refl.in/9q refl.in/91 refl.in/dbs. This is not sufficient to guarantee absence of residual neuromuscular blockade however.

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Pharyngeal function (and risk of aspiration) is not normalized until an adductor pollicis TOF ratio of >0.90 is reached. refl.in/ff refl.in/fe

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To achieve rapid reversal (within 10min) to a TOF ratio of 0.7 in more than 90% of patients, three & preferably four responses should be present at the time of neostigmine injection refl.in/9y

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The safety and reliability of a variety of nerve stimulators were tested here. journals.lww.com/ejanaest...

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