Kalsotra Sidhant, Rice-Weimer Julie, Tobias Joseph D
Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
Department of Anesthesiology and Pain Medicine, The Ohio State University, Columbus, OH, USA.
Saudi J Anaesth. 2023 Jul-Sep;17(3):378-382. doi: 10.4103/sja.sja_160_23. Epub 2023 Jun 22.
Train-of-four (TOF) monitoring is essential in optimizing perioperative outcomes as a means to assess the depth of neuromuscular blockade and confirm recovery following the administration of neuromuscular blocking agents (NMBAs). Quantitative TOF monitoring has been limited in infants and children primarily due to lack of effective equipment. The current study evaluates a novel electromyography (EMG)-based TOF monitor with a recently developed pediatric-sized self-adhesive sensor in infants and children.
Consented pediatric patients undergoing inpatient surgery requiring the administration of NMBAs were enrolled. The EMG electrode was placed along the ulnar nerve on the volar aspect of the distal forearm. The muscle action potentials from the adductor pollicis muscle were recorded throughout surgery at 20-second intervals. Data from the monitor's built-in memory card were later retrieved and analyzed.
The final study cohort included 51 patients who ranged in age from 0.2 to 7.9 years and in weight from 4.2 to 36.0 kilograms. Thirty patients weighed less than 15 kgs. Supramaximal stimulus current intensity (mA) at a pulse width of 200 μsec was 30 mA in 8%; 40 mA in 29%; 50 mA in 16%; and 60 mA in 20% of the patients. Supramaximal stimulus current intensity (mA) at a pulse width of 300 μsec was 50 mA in 4%; 60 mA in 24%. The muscle action potential baseline amplitude was 8.7 ± 3.3 mV and recovered to 7.2 ± 3.7 mV after antagonism of neuromuscular blockade. The average baseline TOF ratio was 100 ± 3% and recovered to 98 ± 7% after antagonism of neuromuscular blockade. No technical issues were noted with application of the sensor or subsequent use of the monitor.
Neuromuscular monitoring can be performed intraoperatively in pediatric patients who are less than 8 years of age using a novel commercially available EMG-based monitor with a recently developed pediatric sensor. The novel sensor allows use of an EMG-based monitor in infants and children in whom acceleromyography or subjective (visual) observation of the TOF response may not be feasible. Automatic detection of neuromuscular stimulating parameters (supramaximal current intensity level, baseline amplitude of the muscle action potential) was feasible in pediatric patients of all sizes including those weighing less than 15 kilograms or when there was limited access to the extremity being monitored.
四个成串刺激（TOF）监测对于优化围手术期结局至关重要，它是评估神经肌肉阻滞深度及确认给予神经肌肉阻滞剂（NMBAs）后恢复情况的一种手段。定量TOF监测在婴幼儿和儿童中一直受到限制，主要原因是缺乏有效的设备。本研究评估了一种新型的基于肌电图（EMG）的TOF监测仪，其配备了最近开发的适合儿童尺寸的自粘式传感器，用于婴幼儿和儿童。
纳入同意接受需要给予NMBAs的住院手术的儿科患者。将EMG电极沿尺神经置于前臂远端掌侧。在整个手术过程中，每隔20秒记录一次拇收肌的肌肉动作电位。随后从监测仪的内置存储卡中检索并分析数据。
最终研究队列包括51例患者，年龄从0.2岁至7.9岁，体重从4.2千克至36.0千克。30例患者体重小于15千克。在脉冲宽度为200微秒时，超最大刺激电流强度（毫安）在8%的患者中为30毫安；29%的患者中为40毫安；16%的患者中为50毫安；20%的患者中为60毫安。在脉冲宽度为300微秒时，超最大刺激电流强度（毫安）在4%的患者中为50毫安；24%的患者中为60毫安。肌肉动作电位基线幅度为8.7±3.3毫伏，在拮抗神经肌肉阻滞后恢复至7.2±3.7毫伏。平均基线TOF比值为100±3%，在拮抗神经肌肉阻滞后恢复至98±7%。在传感器应用或监测仪后续使用过程中未发现技术问题。
使用一种新型的市售基于EMG的监测仪及最近开发的儿科传感器，可在8岁以下的儿科患者术中进行神经肌肉监测。这种新型传感器使得基于EMG的监测仪能够用于那些加速度肌电图或对TOF反应进行主观（视觉）观察可能不可行的婴幼儿和儿童。在所有体型的儿科患者中，包括体重小于15千克的患者或监测肢体接触受限的情况下，自动检测神经肌肉刺激参数（超最大电流强度水平、肌肉动作电位基线幅度）是可行的。
