title: Intraoperative neuromuscular monitoring site and residual paralysis.
abstract: BACKGROUND
  Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis.
  
  
  METHODS
  This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates.
  
  
  RESULTS
  150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8-8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1-14.5).
  
  
  CONCLUSIONS
  Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.
authors.affiliation: Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington 98104, USA. sthilen@uw.edu
authors.forename: Stephan R
authors.initials: SR
authors.lastname: Thilen
authors.forename: Bradley E
authors.initials: BE
authors.lastname: Hansen
authors.forename: Ramesh
authors.initials: R
authors.lastname: Ramaiah
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Kent
authors.forename: Miriam M
authors.initials: MM
authors.lastname: Treggiari
authors.forename: Sanjay M
authors.initials: SM
authors.lastname: Bhananker
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D019148:Neuromuscular Blockade / Q000009:adverse effects* / Q000379:methods; D061886:Neuromuscular Monitoring / Q000379:methods*; D009801:Oculomotor Muscles / Q000502:physiology; D010243:Paralysis / Q000175:diagnosis* / Q000209:etiology* / Q000503:physiopathology; D011446:Prospective Studies