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Anesth Analg 2007;104:215
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000249795.54498.c9

LETTER TO THE EDITOR

Editor-in-Chief Steven L. Shafer

Does Fade with 100-Hz Tetanic Stimulation Reliably Detect Residual Neuromuscular Blockade?

Matthias Eikermann, MD

Division of Sleep Medicine, Sleep Disorders Program, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, meikermann{at}rics.bwh.harvard.edu

To the Editor:

In a study of 32 patients undergoing elective surgery, Capron et al. (1) compared the sensitivity different tests in detecting residual paralysis. Using the 100 Hz-tetanus test, the authors reported a fade of muscular contraction at a mechanomyographic train-of-four (TOF) ratio of ≥0.87 in 21 of the 32 patients (1). This is significant, as the adductor pollicis muscle does not fade during 100 Hz stimulation in the absence of neuromuscular blockade (2). The observation fade at 100 Hz tetanic stimulus at a TOF ratio of approximately 0.9 is consistent with other reports (3,4), and suggests that 100 Hz tetanic stimulation is a very sensitive method for detection of minimal neuromuscular blockade. It is also in agreement with our recent report (5) that the force of adductor pollicis muscle contraction can be decreased postoperatively with high frequency nerve stimulation, even with recovery of the TOF-ratio to 0.9–1. Detection of a minimal neuromuscular blockade is clinically important, because it can cause misdirected swallowing (6), and partial upper airway obstruction (7).

However, the authors conclude that the 100-Hz tetanus test is "unreliable," because a fade during 100-Hz tetanic stimulation was not always present, even at very low TOF-ratios of 0.14. (1) There might be some evidence (3,5) suggesting that assessment of a fade after high frequency nerve stimulation (i.e., between 50 and 100 Hz) provides a higher negative predictive value to exclude a residual paralysis compared with other available clinical tests such as double burst or TOF fade.

REFERENCES

  1. Capron F, Fortier LP, Racine S, Donati F. Tactile fade detection with hand or wrist stimulation using train-of-four, double-burst stimulation, 50-hertz tetanus, 100-hertz tetanus, and acceleromyography. Anesth Analg 2006;102:1578–84.[Abstract/Free Full Text]
  2. Cohen PJ, Heisterkamp DV, Skovsted P. The effect of general anaesthetics on the response to tetanic stimulus in man. Br J Anaesth 1970;42:543–7.[Abstract/Free Full Text]
  3. 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.[ISI][Medline]
  4. 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]
  5. Eikermann M, Hasselmann C, Beiderlinden M, Peters J. Force, Fatigue, and Contractile Behaviour of Skeletal Muscle after Clinical Recovery from Neuromuscular Blockade. Anesthesiology 2005;103:A1125.
  6. Sundman E, Witt H, Olsson R, et al. The incidence and mechanisms of pharyngeal and upper esophageal dysfunction in partially paralyzed humans: pharyngeal videoradiography and simultaneous manometry after atracurium. Anesthesiology 2000;92:977–84.[ISI][Medline]
  7. Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, de Greiff A, Peters J. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med 2006 Oct 5; [Epub ahead of print].



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Does Fade with 100-Hz Tetanic Stimulation Reliably Detect Residual Neuromuscular Blockade?
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press