title: Impaired neuromuscular transmission after recovery of the train-of-four ratio.
abstract: BACKGROUND
  Residual neuromuscular blockade may increase the risk of development of post-operative pulmonary complications, but is difficult to detect clinically. It was speculated that patients may have impaired neuromuscular transmission after surgery of long duration, despite the recovery of the train-of-four (TOF) ratio.
  
  
  METHODS
  The muscle force (mechanomyography), motor compound muscle action potential amplitude and fatigue of the adductor pollicis (AP) muscle were assessed after recovery of the TOF ratio to 0.9. Thirteen patients receiving repetitive administration of neuromuscular blocking agents (NMBAs) during surgery (median, 5.3 h; interquartile range, 3.4-6 h) were studied post-operatively in the intensive care unit. At the time of the measurements, patients were scheduled for extubation and the AP TOF ratio amounted to a mean (standard deviation, SD) of 0.94 (0.05). Six healthy volunteers of similar age, weight and gender were studied for comparison. Force-frequency curves were generated by stimulation (10-80 Hz) of the ulnar nerve, and the AP electromyogram (EMG) amplitude was measured, in parallel, before and after evoked muscle fatigue.
  
  
  RESULTS
  The maximum AP force at a stimulation frequency of 20-80 Hz was significantly lower in patients than in controls [40 N (16 N) vs. 65 N (18 N) at 80 Hz]. In patients, but not in controls, the EMG amplitude decreased with increasing nerve stimulation frequency, and a tetanic fade of both force and EMG, amounting to 0.41 (0.33) (EMG) and 0.61 (0.35) (mechanomyography) at 80 Hz, was observed. Force after fatiguing contractions did not differ between the groups.
  
  
  CONCLUSIONS
  After repetitive administration of NMBAs during surgery, even with recovery of the TOF ratio to 0.9 or more, muscle weakness from impaired neuromuscular transmission can occur. The clinician should consider that post-operative recovery of the TOF ratio to 0.9 does not exclude an impairment of neuromuscular transmission.
authors.affiliation: Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany. meikermann@rics.bwh.harward.edu
authors.forename: M
authors.initials: M
authors.lastname: Eikermann
authors.forename: M
authors.initials: M
authors.lastname: Gerwig
authors.forename: C
authors.initials: C
authors.lastname: Hasselmann
authors.forename: G
authors.initials: G
authors.lastname: Fiedler
authors.forename: J
authors.initials: J
authors.lastname: Peters
mesh_terms: D000200:Action Potentials; D000328:Adult; D004558:Electric Stimulation; D004576:Electromyography / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D009119:Muscle Contraction / Q000502:physiology*; D019148:Neuromuscular Blockade / Q000009:adverse effects*; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage / Q000009:adverse effects*; D009469:Neuromuscular Junction / Q000187:drug effects* / Q000503:physiopathology; D012044:Regression Analysis; D009435:Synaptic Transmission / Q000187:drug effects* / Q000502:physiology
chemical_list: D009466:Neuromuscular Blocking Agents