| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
 
|
|
|
||
|
|
Anesth Analg 2006;102:1578-1584 © 2006 International Anesthesia Research Society doi: 10.1213/01.ane.0000204288.24395.38
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
Residual neuromuscular blockade can be evaluated using acceleromyography, tactile assessment of train-of-four (TOF), double-burst stimulation (DBS), 50-Hz tetanus, or 100-Hz tetanus. Nerve stimulation can be at the hand or the wrist. We compared all these tests at both sites of stimulation. Rocuronium was given to 32 patients under sevoflurane anesthesia. The mechanomyographic adductor pollicis TOF ratio was measured at one extremity. In the other, stimulation was at the hand or the wrist, by random allocation, and the acceleromyographic TOF ratio was measured. During recovery, a blinded observer estimated tactile fade. The TOF fade became undetectable when mechanomyographic TOF ratio was (mean ± sd) 0.31 ± 0.15. For DBS, this threshold was 0.76 ± 0.11. For 50-Hz tetanus, it was 0.31 ± 0.15. For 100-Hz tetanus, it was 0.88 ± 0.18, with a range of 0.14–1.00. These tactile responses were the same for hand and wrist stimulation. When acceleromyographic TOF ratio reached 1.0, the mechanomyographic TOF ratio was 0.89 ± 0.06. With stimulation in the hand, acceleromyographic TOF ratio >1.0 was less frequent than at the wrist. To exclude residual paralysis, TOF, DBS, and 50-Hz tetanus are inadequate, 100-Hz tetanus is unreliable, and acceleromyography performs best.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
It is widely accepted that to avoid residual neuromuscular blockade, a mechanomyographic adductor pollicis train-of-four (TOF) ratio of 0.9 or more is normally required (1–3). Unfortunately, the visual or tactile detection of TOF fade is not possible when the TOF ratio is in the range 0.4–0.9, which implies that this test cannot exclude residual paralysis (4). Fade after double-burst stimulation (DBS) can be detected up to a TOF ratio of 0.6–0.7 (5); that is not enough to exclude residual paralysis. Fade after tetanic stimulation has not been evaluated extensively. In one study (6), detection of 50-Hz tetanic fade was found to be no better than detection of TOF fade reported in other studies. In another investigation (7), the threshold for fade detection after a 100-Hz tetanus was reported to be 0.8–0.9, but no comparison was made with other modes of stimulation. Furthermore, the usefulness of such a test is uncertain in the presence of volatile anesthetics, because fade can be observed with these drugs in the absence of neuromuscular blockade (8). Because it is impractical to use mechanomyography routinely, it has been recommended to use acceleromyography (9). Unfortunately, the acceleromyographic TOF ratio often exceeds 1.0 (10), and it is difficult to exclude a mechanomyographic TOF value <0.9.
One possible reason for the failure of observers to detect fade is movement of many muscles of the hand and forearm after stimulation of the ulnar nerve at the wrist. The individual assessing the contraction of the thumb might be distracted by simultaneous movement of the wrist or hypothenar eminence. Recently, it was found that stimulation over the adductor pollicis in the hand yielded similar acceleromyographic results to stimulation of the ulnar nerve at the wrist, without significant movement of digits other than the thumb (11). The ability to detect fade was not evaluated in that study.
Therefore, the purpose of the present study was to evaluate, in the same patient, all the currently available tests: the TOF ratio obtained with acceleromyography and the tactile evaluation of TOF, DBS, 50-Hz tetanic, and 100-Hz tetanic fade. These tests were compared with the mechanomyographic TOF ratio under sevoflurane anesthesia. Stimulation electrodes were applied either over the ulnar nerve at the wrist or over the adductor pollicis on both sides of the hand to evaluate the influence of this new site of stimulation on the performance of the different tests.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The protocol was approved by the research ethics committee at Hôpital Maisonneuve-Rosemont. Thirty-two adult patients, ASA physical status I-III, scheduled for elective surgical procedures under general anesthesia with tracheal intubation, were studied after giving their written informed consent. Exclusion criteria included neuromuscular, hepatic, or renal disease, suspected difficult tracheal intubation, body mass index
32 kg/m2, pregnancy, being on medication that influences neuromuscular function, or a history of allergic reaction to drugs used in the study. Monitoring included electrocardiography, noninvasive arterial blood pressure, pulse oximetry, capnography, and a temperature probe. Anesthesia was induced with 2–3 µg/kg of fentanyl, 2–2.5 mg/kg of propofol, and 0.6 mg/kg of rocuronium, and tracheal intubation was performed. Anesthesia was maintained with sevoflurane (1.5%–3% expired fraction) with air/oxygen (50%/50%), and intermittent doses of fentanyl (1–2 µg/kg). Additional doses of rocuronium 0.2 mg/kg were given if required. Central temperature was maintained to more than 35°C using a warming blanket covering the upper body and both arms. The patients' lungs were ventilated, and the end-tidal partial pressure for carbon-dioxide (Pco2) was maintained between 32 and 36 mm Hg.
Mechanomyography of the adductor pollicis was applied at random to the patient's dominant or nondominant hand, whereas the other upper extremity was reserved to test the various stimulation modalities. The hand and forearm used for mechanomyography were immobilized firmly. A TOF-Watch SX® nerve stimulator (Organon Ltd., Swords, Ireland) was used for supramaximal TOF stimulation (4 pulses of 0.2 ms in duration at a frequency of 2 Hz every 15 s) on the ulnar nerve at the wrist. The forearm and hand were immobilized, and the isometric force of contraction of the adductor pollicis was measured with a Cobe (Maxxim Medical, Athens, TX) transducer and recorded on paper. The ratio of the fourth to the first twitch (mechanomyographic TOF ratio) was measured.
On the contralateral extremity, the position of the stimulating electrodes was randomized to either the wrist, over the ulnar nerve, or the hand, on the skin overlying the dorsal and palmar aspects of the adductor pollicis (Fig. 1) (11). The hand and the fingers were immobilized with tape, leaving only the thumb free. During recovery, when the mechanomyographic TOF ratio had recovered to at least 0.2, the following occurred:
|
- An acceleromyographic TOF ratio was recorded using a TOF-Watch SX® accelerometer (Organon Ltd.) for stimulation and measurement of the TOF ratio using a probe taped to the volar aspect of the distal phalanx of the thumb. The stimulating current was set at 50 mA, and the accelerometer functioned in the uncalibrated mode.
- Then, 15 s later, fade after supramaximal TOF stimulation (4 pulses of 0.2 ms in duration at a frequency of 2 Hz) was assessed by an observer unaware of the degree of muscle relaxation.
- After a 15-s pause, the same individual assessed tactile fade after DBS3,3 (3 pulses at 50 Hz, a 750-ms pause, and 3 pulses at 50 Hz).
- Finally, after another 15-s pause, fade after a 5-s tetanic stimulation at either 50-Hz or 100-Hz tetanus delivered by a Digi Stim III stimulator (Neurotechnology, Houston, TX) was assessed. The frequency of stimulation was unknown to the observer.
- The sequence of 1 to 4 was repeated with a different observer after at least 3 min and when the mechanomyographic TOF ratio had recovered to a value >0.1 than in the previous assessment. If the tetanic stimulation was at 50 Hz previously, 100 Hz was applied and vice versa. This was repeated until the mechanomyographic TOF ratio reached a value >0.9.
The observers were anesthesiologists, anesthesia residents, and anesthesia assistants who were familiar with neuromuscular monitoring and used it frequently.
For each series of measurements, the acceleromyographic TOF ratio was compared with the corresponding mechanomyographic TOF ratio. Also, the presence or absence of detected fade was correlated with the mechanomyographic TOF ratio. The acceleromyographic fade was considered to be present whenever the TOF ratio was <1.0 because acceleromyographic TOF ratio often exceeds corresponding mechanomyographic values, and a threshold of 1.0 is recommended for acceleromyography to exclude residual paralysis (12). In addition, threshold for fade detection, defined as the highest mechanomyographic TOF ratio at which fade was last detected, was obtained for each patient and for each mode of stimulation. Logistic regression analysis (7) was used to determine the relationship between probability of fade detection and actual mechanomyographic TOF ratio.
Patient characteristics were compared using the Student's t-test and were expressed as mean ± sd and range; P < 0.05 was considered to indicate statistically significant differences. To investigate the agreement between mechanomyography and acceleromyography in the assessment of neuromuscular recovery, a Bland and Altman analysis was performed (13). For each test, the median ± quartile was calculated for the threshold of disappearance of the fade.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Data from all 32 patients could be analyzed without any dropouts. Demographic data are shown in Table 1. There were no significant differences with respect to age, weight, height, sex distribution, and assignment to right or left extremity between the patients assigned to stimulation at the wrist and stimulation at the hand. There were no statistically significant differences attributable to hand dominance or assignment of left or right extremity for testing.
|
A total of 339 assessments were made by 10 anesthesiologists, 6 anesthesia residents, and 11 anesthesia assistants. The percent of patients in whom fade was detected for each clinical test as a function of mechanomyographic TOF ratio is shown in Table 2.
|
There was good correlation between acceleromyographic and mechanomyographic TOF ratios, and the agreement was better with stimulation in the hand than at the wrist. When the ulnar nerve was stimulated at the wrist, bias was 5.3%, with 95% confidence limits between –21% and 31%. With stimulation at the hand, bias was less (0.5%; P < 0.001 compared with wrist stimulation), with 95% confidence limits between –19.8% and 20.7% (Fig. 2). There were fewer instances of acceleromyographic TOF ratios more than 1.0 when hand stimulation was used (Fig. 3). The acceleromyographic TOF ratio exceeded 1.0 at the last measurement in 13 of 32 patients. Of these 13, 9 had stimulation at the wrist, whereas 4 had stimulation at the hand.
|
|
The mean mechanomyographic TOF ratio when acceleromyographic TOF ratio first exceeded 1.0 was 0.89 ± 0.06. This threshold did not depend on the site of stimulation but was more variable with stimulation at the wrist (Fig. 4). The tactile TOF fade became undetectable at a mean mechanomyographic TOF ratio of 0.31 ± 0.15. The corresponding threshold was significantly higher for DBS fade (0.76 ± 0.11). Tetanic stimulation at 50 Hz and 100 Hz demonstrated no fade at a mechanomyographic TOF ratio of 0.31 ± 0.15 and 0.88 ± 0.18, respectively. For 50-Hz tetanus, 14 of the 32 patients did not show any fade at the first assessment (0.13–0.4). For 100-Hz tetanus, 21 of the 32 patients still had a fade at the last assessment when the mechanomyographic TOF ratio was 0.87. For each of these tests, the mechanomyographic threshold at which fade became undetectable was similar whether stimulation was at the wrist or the hand (Fig. 4).
|
The probability of detecting fade by tactile means after TOF, DBS, 50-Hz tetanus, and 100-Hz tetanus at a mechanomyographic TOF ratio of 0.9, derived from the logistic regression analysis, was 1%, 11%, 3%, and 66%, respectively (Fig. 5). If acceleromyographic fade is defined as a TOF value <1.0, then the probability to detect a mechanomyographic TOF ratio of 0.9 was 72%.
|
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This study compared the most popular clinical tests (tactile TOF, DBS, 50-Hz tetanus, and 100-Hz tetanus) with acceleromyography to detect residual paralysis caused by rocuronium in the presence of a volatile anesthetic, sevoflurane. Tactile detection of fade after 50-Hz tetanus is no better than after TOF and occurs, on average, when mechanomyographic TOF ratio is approximately 0.3. With DBS, the detection threshold is increased to 0.7, but DBS fade is rarely detected when the mechanomyographic TOF ratio approaches 0.9. Fade after 100-Hz tetanus is detected up to a mechanomyographic TOF ratio of 0.9, on average, but there is a large interpatient variability. The acceleromyographic TOF ratio, even in the uncalibrated mode, remains the most accurate test to reliably detect residual paralysis.
Tactile detection of fade is no better with stimulation in the hand than with stimulation at the wrist, irrespective of the stimulation mode used. Stimulation at the hand was proposed as an alternative to stimulating at the wrist and was shown not to produce direct muscle stimulation (11). Most likely, small terminal branches of the nerve are stimulated preferentially because current intensity and duration are insufficient to cause direct muscle stimulation. When electrical stimulation is applied directly over the hand, there is less movement of digits other than the thumb (11). This implies that the reason why fade may be missed with TOF stimulation is not the distraction produced by the movement of other fingers. However, the acceleromyographic TOF ratio exceeded 1.0 less often with hand stimulation than with wrist stimulation, which indicates that stimulation over the hand might provide more reliable acceleromyographic values during recovery than stimulation over the wrist.
In the present study, tactile evaluation of fade and acceleromyographic TOF were compared with the mechanomyographic value obtained in the other extremity. The assumption here is that neuromuscular blockade was the same in both extremities. Several studies have used a similar design, and there is no evidence that, on average, there is a difference in response between extremities because of the position of the IV access, hand dominance, or other factors (14,15). However, it is possible that some of the discrepancy measured between mechanomyographic and acceleromyographic TOF ratio might have been due to individual differences between arms. Measuring mechanomyography in the same extremity as acceleromyographic and assessment of fade is impractical because it would require setting up and dismantling mechanomyographic equipment frequently.
We chose to apply either 50-Hz or 100-Hz tetanus whenever a tactile evaluation was performed, but not both, because 2 consecutive tetanic stimulations could affect the result of the second tetanus. The time interval chosen between 2 consecutive measurements (3–10 min) is more than that required for the neuromuscular function to return to its pretetanic value (1–2 min) (16,17).
The individuals who were asked to evaluate fade were anesthesiologists, anesthesia technicians, or residents. All of them used neuromuscular monitoring routinely, and most were aware of the limitations of tactile detection of fade. Thresholds for detection of TOF and DBS fade in this study are consistent with previous investigations. On average, TOF fade was no longer detected when mechanomyographic TOF ratio exceeded 0.31. This compares well with a threshold of 
0.4 in 25 of 37 patients (68%) in Drenck et al.'s study (5). Tactile detection of fade when the measured mechanomyographic TOF ratio was 0.31–0.4 was reported to be 25%–80% (4,5,18–21). It was 35% in the present study. In the range of 0.41–0.5, fade was reported in only 24%–40% of cases (5,18–21) compared with 22% here. It seems that visual and tactile detections yield similar results (22). The threshold for DBS fade seems to be marginally higher in the present study (0.71) than in previous investigations. Drenck et al. (5) reported that for most patients, DBS fade threshold was in the 0.51–0.6 range. A DBS fade was reported in 40%–55% of patients when mechanomyographic TOF ratio was 0.61–0.7 (5,18–21,23), with one study reporting 0% (24). The similarity of the results across studies suggests that experience and awareness of the limitations of conventional monitoring do not alter one's ability to detect fade significantly.
The 50-Hz tetanus is probably the least useful clinical test. Half the patients had no detectable fade for a mechanomyographic TOF ratio 0.3. The results are similar to those of Dupuis et al. (6), who tested only 50-Hz tetanus in patients under isoflurane anesthesia. Therefore, this test should be abandoned for detecting residual paralysis. Only two previous studies have dealt with assessment of fade using 100-Hz tetanus. Baurain et al. (7) detected fade in all cases when the mechanomyographic TOF value was <0.85. This finding was not reproduced by Samet et al. (24), who reported no fade at mechanomyographic TOF values as low as 0.47. Both studies report many patients who still displayed fade when mechanomyographic TOF fade was >0.9. The findings of the present study agree with both studies with respect to the large proportion (64%) of fade detected when mechanomyographic TOF is >0.9. However, absence of fade was detected, even when TOF ratio was low, and the 100-Hz tetanus test in the present study seems to be very unreliable, confirming Samet et al.'s findings (24). In 14 of the 32 patients, detectable fade disappeared when the mechanomyographic TOF ratio was <0.9 (range, 0.14–0.89).
There are two important differences between this investigation and the other two studies. First, visual evaluation was made in both previous studies (7,24), whereas tactile assessment was made here. It is possible that, although visual and tactile assessments of TOF response are essentially the same, visual and tactile evaluations of tetanic stimulation are different. Second, both previous studies were conducted without a volatile anesthetic, whereas we used sevoflurane. High-frequency stimulation is associated with fade, even in the absence of a neuromuscular blocking drug (8). This fade is most likely accentuated by very small degrees of neuromuscular block. In the present study, both sensitivity and specificity of 100-Hz tetanus were poor because fade could be detected in some patients with a mechanomyographic TOF ratio >0.9, whereas in some other individuals, it was not detected with a significantly measured mechanomyographic TOF fade (0.14 in one patient). Samet et al. (24), using a noninhaled anesthetic, also found large variations in the threshold for reappearance of detectable 100-Hz tetanic fade. Thus, it seems that the background anesthetic is not the only factor that could explain the unreliability of the 100-Hz tetanus.
The most reliable test to detect residual paralysis, defined as a mechanomyographic TOF >0.9, is acceleromyography. Stimulation in the hand with acceleromyography was superior to stimulation at the wrist. There was less bias (0.5%) than with stimulation at the wrist (5.3%), and the bias was more apparent when mechanomyographic TOF ratio recovered to >0.9, i.e., in the range where the measurement is most useful. Limits of agreement were also narrower for hand stimulation. Measurements for acceleromyographic TOF exceeding 1.0 were less frequent with stimulation in the hand, which indicates that stimulation in the hand might be preferred if recovery is assessed by acceleromyography. This was not observed in a previous study on hand stimulation (11) because few measurements were made at high TOF ratios. For both sites of stimulation, the threshold at which an acceleromyographic value of 1.0, as recommended by Capron et al. (12), was close to a mechanomyographic TOF value of 0.9. Acceleromyography requires specialized equipment and is not available on every nerve stimulator. However, the additional information it provides makes it valuable.
In conclusion, during recovery from neuromuscular blockade under sevoflurane anesthesia, tactile evaluation of 50-Hz fade is no more sensitive than TOF fade. Neither of these tests can be used to exclude residual paralysis. Detection of DBS fade is more sensitive, but it cannot exclude residual paralysis. Fade after a 100-Hz tetanus is unreliable; it can be present when recovery is complete and can be absent when there is residual paralysis. For all these clinical tests, stimulation at the hand yields the same results as stimulation at the wrist. The acceleromyographic TOF, even uncalibrated, remains the most accurate test to exclude a residual paralysis when using an acceleromyographic TOF ratio of 1.0 as a threshold. Applying stimulation in the hand yields more accurate information than stimulation at the wrist when acceleromyography is used.
|
Footnotes |
|---|
Accepted for publication December 21, 2005.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
- Eriksson LI, Sato M, Severinghaus JW. Effect of a vecuronium-induced partial neuromuscular block on hypoxic ventilatory response. Anesthesiology 1993;78:693–9.[Web of Science][Medline]
- Eriksson LI, Sundman E, Olsson R, et al. Functional assessment of the pharynx at rest and during swallowing in partially paralyzed humans: simultaneous videomanometry and mechanomyography of awake human volunteers. Anesthesiology 1997;87:1035–43.[Web of Science][Medline]
- Kopman AF, Yee PS, Neuman GG. Relationship of the train-of-four fade ratio to clinical signs and symptoms of residual paralysis in awake volunteers. Anesthesiology 1997;86:765–71.[Web of Science][Medline]
- Viby-Mogensen J, Jensen NH, Englbaek J, et al. Tactile and visual evaluation of the response to train-of-four nerve stimulation. Anesthesiology 1985;63:440–3.[Web of Science][Medline]
- Drenck NE, Ueda N, Olsen NV, et al. Manual evaluation of residual curarization using double burst stimulation: a comparison with train-of-four. Anesthesiology 1989;70:578–81.[Web of Science][Medline]
- Dupuis JY, Martin R, Tessonnier JM, Tetrault JP. Clinical assessment of the muscular response to tetanic nerve stimulation. Can J Anaesth 1990;37:397–400.
- Baurain MJ, Hennart DA, Godschalx A, et al. Visual evaluation of residual curarization in anesthetized patients using one hundred-hertz, five-second tetanic stimulation at the adductor pollicis muscle. Anesth Analg 1998;87:185–9.
[Abstract/Free Full Text] - Miller RD, Eger EI II, Way WL, et al. Comparative neuromuscular effects of Forane and halothane alone and in combination with d-tubocurarine in man. Anesthesiology 1971;35:38–42.[Medline]
- Eriksson LI. Evidence-based practice and neuromuscular monitoring: it's time for routine quantitative assessment. Anesthesiology 2003;98:1037–9.[Web of Science][Medline]
- Kopman AF, Klewicka MM, Neuman GG. The relationship between acceleromyographic train-of-four fade and single twitch depression. Anesthesiology 2002;96:583–7.[Web of Science][Medline]
- Nepveu ME, Donati F, Fortier LP. Train-of-four stimulation for adductor pollicis neuromuscular monitoring can be applied at the wrist or over the hand. Anesth Analg 2005;100:149–54.
[Abstract/Free Full Text] - Capron F, Alla F, Hottier C, et al. Can acceleromyography detect low levels of residual paralysis: a probability approach to detect a mechanomyographic train-of-four ratio of 0.9. Anesthesiology 2004;100:1119–24.[Web of Science][Medline]
- Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307–10.[Web of Science][Medline]
- Curran MJ, Donati F, Bevan DR. Onset and recovery of atracurium and suxamethonium-induced neuromuscular blockade with simultaneous train-of-four and single twitch stimulation. Br J Anaesth 1987;59:989–94.
[Abstract/Free Full Text] - Merle JC, Jurczyk M, d'Honneur G, et al. Onset of neuromuscular block is the same if the ipsilateral or contralateral limb to the injection site is used for monitoring. Br J Anaesth 1995; 74: 333–4.
[Abstract/Free Full Text] - Baurain MJ, Hoton F, Dernovoi BS, D'Hollander AA. Influence and relative sensitivities of 50-Hz and 100-Hz tetanic stimuli on subsequent tetanic fade ratios in patients receiving vecuronium. Anesth Analg 1996;82:139–42.[Abstract]
- Silverman DG, Brull SJ. The effect of a tetanic stimulus on the response to subsequent tetanic stimulation. Anesth Analg 1993;76:1284–7.[Medline]
- Gill SS, Donati F, Bevan DR. Clinical evaluation of double-burst stimulation: its relationship to train-of-four stimulation. Anaesthesia 1990;45:543–8.[Medline]
- Saitoh Y, Nakazawa K, Makita K, et al. Evaluation of residual neuromuscular block using train-of-four and double burst stimulation at the index finger. Anesth Analg 1997;84:1354–8.[Abstract]
- Saitoh Y, Koitabashi Y, Makita K, et al. Train-of-four and double burst stimulation fade at the great toe and thumb. Can J Anaesth 1997;44:390–5.[Web of Science][Medline]
- Saitoh Y, Narumi Y, Fujii Y, Ueki M. Tactile evaluation of fade of the train-of-four and double-burst stimulation using the anaesthetist's non-dominant hand. Br J Anaesth 1999;83:275–8.
[Abstract/Free Full Text] - Brull SJ, Silverman DG. Visual and tactile assessment of neuromuscular fade. Anesth Analg 1993;77:352–5.[Web of Science][Medline]
- Saitoh Y, Nakazawa K, Makita K, et al. Evaluation of residual neuromuscular blockade using modified double burst stimulation. Acta Anaesthesiol Scand 1997;41:741–5.[Web of Science][Medline]
- Samet A, Capron F, Alla F, et al. Single acceleromyographic train-of-four, 100-hertz tetanus or double-burst stimulation: which test performs better to detect residual paralysis? Anesthesiology 2005;102:51–6.[Web of Science][Medline]
This article has been cited by other articles:
|
|
 |
|
  M. Eikermann Does Fade with 100-Hz Tetanic Stimulation Reliably Detect Residual Neuromuscular Blockade? Anesth. Analg., January 1, 2007; 104(1): 215 - 215. [Full Text] [PDF]
|
|
|
|
|
|
F. Donati Does Fade with 100-Hz Tetanic Stimulation Reliably Detect Residual Neuromuscular Blockade? Anesth. Analg., January 1, 2007; 104(1): 215 - 216. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
