title: Clinical analysis of the flexor hallucis brevis as an alternative site for monitoring neuromuscular block from mivacurium.
abstract: OBJECTIVE
  To compare the flexor hallucis brevis, which is responsible for flexion of the great toe, to the adductor pollicis as a site for monitoring the onset and recovery from neuromuscular block after an intubating dose of mivacurium chloride.
  
  
  METHODS
  Prospective patient-controlled study.
  
  
  METHODS
  University teaching hospital.
  
  
  METHODS
  10 ASA physical status I and II adults (age 18 to 55 years, 6 women, 4 men) scheduled for elective procedures requiring muscle relaxation for tracheal intubation.
  
  
  RESULTS
  Patients were monitored at the adductor pollicis and the flexor hallucis brevis during the onset and recovery of neuromuscular block, which was administered to facilitate tracheal intubation. All subjects were given mivacurium 0.2 mg/kg over 30 seconds. Their train-of-four (TOF) response was continually monitored at both sites until the patient recovered from the intubating dose to a TOF ratio of 0.75. The time to onset of neuromuscular block, recovery of the first TOF response, and recovery to a TOF ratio of 0.75 were compared between the two monitoring sites using the Wilcoxon signed rank test. Following administration of the intubating dose of mivacurium, the loss of all twitch response occurred 1.2 minutes sooner at the adductor pollicis than at the flexor hallucis brevis (p < 0.02). Reappearance of the first twitch occurred 0.49 minutes slower at the adductor pollicis, although this difference was not statistically significant. The time to recovery to a TOF ratio of 0.75 at the adductor pollicis was slower by 2.83 minutes (p = 0.046).
  
  
  CONCLUSIONS
  Due to its lag behind the adductor pollicis, the flexor hallucis brevis is not a good indicator of when to intubate the trachea during the onset of neuromuscular block; however, its faster recovery may make it useful for monitoring deep neuromuscular block intraoperatively or during recovery when the adductor pollicis TOF response still shows complete blockade.
authors.affiliation: Department of Anesthesiology, University of Utah Health Sciences Center, Salt Lake City 84132, USA.
authors.forename: S E
authors.initials: SE
authors.lastname: Kern
authors.forename: J O
authors.initials: JO
authors.lastname: Johnson
authors.forename: J A
authors.initials: JA
authors.lastname: Orr
authors.forename: D R
authors.initials: DR
authors.lastname: Westenskow
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D007546:Isoquinolines / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D000077590:Mivacurium; D008991:Monitoring, Physiologic / Q000379:methods*; D018482:Muscle, Skeletal / Q000187:drug effects*; D003473:Neuromuscular Nondepolarizing Agents / Q000627:therapeutic use*; D011446:Prospective Studies
chemical_list: D007546:Isoquinolines; D003473:Neuromuscular Nondepolarizing Agents; D000077590:Mivacurium