Electromyography for Continuous Quantitative Neuromuscular Monitoring: Innovation Brief

Idea: Quantitative continuous neuromuscular monitoring.

Current state:
Most general anesthesia cases and many ICU patients requiring endotracheal intubation receive neuromuscular (NM) blocking agents to optimize surgical conditions and support mechanical ventilation. Qualitative NM monitoring utilizing intermittent train of four assessment is commonly used to dose NM blocking drugs and to ensure adequate recovery. Nonetheless, residual NM weakness is a persistent issue that can delay recovery or result in pulmonary complications. Presumably, quantitative NM monitoring can help in appropriate NM monitoring by providing objective and continuous assessment, thereby facilitating appropriate dosing of NM blocking and reversal agents. Also, highly effective NM function assessment devices, like electromyograph, are not routinely available beyond research setting. Novel devices have made mechanomyography, acceleromyography, and electromyography accessible in clinical settings, enabling quantitative and continuous NM monitoring.¹

Innovation:
TwitchView is an electromyography (EMG) based train of four monitoring which enables continuous quantitative NM monitoring in routine clinical care.

Figure TwitchView Monitor courtesy of Blink Device Company, Seattle, WA, USA.

Evidence:
Acceleromyography frequently underestimated train-of-four count in comparison with electromyography with TwitchView.²

Potential Impact:
Quantitative EMG based continuous train of four monitoring is better than current NM monitoring practice. However, impacts on outcomes like reduction in residual neuromuscular weakness, appropriate use of neuromuscular blockers and reversal agents, faster recovery, reduced pulmonary complications are not studied well. Also, we need to evaluate implementation barriers in clinical setting for routine use.

Average Cost:
$20 per use.

Key words:
General anesthesia, monitoring, neuromuscular, qualitative, quantitative, residual muscle weakness.

Refernces:

1. Bowdle A, Bussey L, Michaelsen K. Counting train-of-four twitch response: comparison of palpation to mechanomyography, acceleromyography, and electromyography. Br J Anaesth. 2020;124(6):712-717.

2. Bowdle A, Bussey L, Michaelsen K, et al. A comparison of a prototype electromyograph vs. a mechanomyograph and an acceleromygraph for assessment of neuromuscular blockade. Anesthesia. 2020;75(2):187-195.