Acceleromyography

4
Acceleromyography
4.1
Principles
- 126
4.2
The Accelograph and the TOF-Guard
- 127
4.3
TOF-Watch models
4.3.1
The TOF ratio algorithm
4.3.2
Calibration modes
4.3.3
Nerve localization in regional anesthesia procedures
4.4
TOF-Watch
4.4.1
Short set-up instructions
- 130
- 130
- 133
- 138
- 138
4.4.2
Brief overview
4.4.3
Scheme of buttons and display symbols
- 139
4.5
TOF-Watch- S
4.5.1
4.5.2
Brief overview
4.5.3
4.6
TOF-Watch- SX
4.6.1
4.6.2

Brief overview - 165
4.6.3
- 166
4.6.4
- 168
- 140
- 150
- 150
- 151
- 152
- 164
- 164
- 136
4
4.7
FAQS
4.7.1
Can acceleromyography also be used in infants?
179
- 179
4.7.2
Is neuromuscular monitoring painful for patients?
4.7.3
What to obs rv when attaching rOF -Watch nerve
4.7.4
Is calibration really n cessary?
4.7 .5
Can neuromuscular monitoring with the rOF -Watch
stimulators?
- 182
- 184
n rye stimulator prey nt residual blockade?

4.8
4.8.1
- 180
Acceleromyogr phy
10
r s
rch
- 190
193
Neuromuscular monitoring for scientific purposes: What

should an sth siologists g nerally look out for?
- 194
4.8.2
Particulars of performing accel romyography
4.8.3
Guidelines for measuring onset and time profile of

neuromuscular blockad
Concluding r m rks
R f renc s
- 202
- 198
- 200
- 197
126
Chapter 4 Acceleromyography
4.1
Principles
Thanks to acceleromyography (AMG), routine objective monitoring of neuromuscular blockade has become possible for the first time in clinical practice. Not only is this monitoring method much easier to apply than the other
two established quantitative neuromuscular monitoring methods, i.e., mechanomyography and electromyography, but acceleromyography is also clearly
more precise than the simple- qualitative nerve stimulators which only allow subjective assessment, but no objective measurement of the stimulatory
response. Surveys have shown that TOF-Guard acceleromyographs and their
successor models in the TOF-Watch" series are by far the most frequently
used nerve stimulators for clinical monitoring of neuromuscular blockade in
Germ any and many other countries a Fig.4.1 [1].
*
Applikation
customs
.
.
81 - 100%
61 80%
41 600/.
021 40%
0 - 20%
Never
20%
0%
..L-L.-_ _.J.-....l-_ _.....L.- . I: ' -_ _J..-....I-_
......1.._
TOF-Gu ard.
simple
Electromyograph NMT module
TOFWatch nerve stimulator (Relaxograph)
e.g. Datex AS-3
D Fig.4.1. Neuromuscular monitoring method s. The frequency with wh ich the indiv idual nerve
stimulators are used is presented [1]
127
4.2 . The Accelograph and the TOF-Guard
Acceleromyography is based on the principle that mechanical forces at

play on the surface of certain materials, such as crystals or ceramics, can
induce an electrical current. This is termed the piezoelectric effect. Modern
AMG-based nerve stimulators use a piezoelectric wafer made of ceramic
as the acceleration transducer. Acceleration of the transducer produces an
electrical charge. According to Newton's second law of motion, force equals
mass times acceleration (F=mxa). At constant mass, the acceleration measured and the voltage thereby generated can be used to derive the force of the
stimulated muscle.
Thus , acceleromyography can be performed on all muscles whose
movement or acceleration is easily measured after electrical stimulation
of its innervating nerve. Usually, the ulnar nerve is stimulated and the acceleration is subsequently measured with a piezoelectric sensor fixed to
the thumb. Th is method allows objective assessment of the degree of neuromuscular blockade at the adductor pollicis muscle. Alternatively, acceleromyography can also be applied to other muscle-nerve units . The flexor
hallucis brevis muscle and the posterior tibial nerve are primarily used as
the muscle-nerve unit of the lower extremity. For the facial region, the orbicularis oculi muscle and the corrugator supercilii muscle are the two test
muscles available. Both of these muscles are innervated by branches of the
facial nerve, allowing them to be stimulated by surface electrodes placed
near the eye.
4.2
The Accelograph and the TOF-Guard
The design of nerve stimulators based on the principle of acceleromyography was predicated on the invention of suitable acceleration transducers .
The year 1988 marked the development and validation of the first acceleration transducer especially designed for monitoring neuromuscular blockade
[2]. Concurrently, a novel concept for monitoring neuromuscular blockade
emerged [3, 4]. The first ready-for-market nerve stimulator based on acceleromyography was also introduced that very same year [5]. The device
was dubbed the Accelograph in line with the new measuring method on
which it was based. While not being very compact in design, the original Accelograph was relatively fast and easy to implement; including calibration, it
was operational within a few minutes. In 1989, Ueda et al. [5] were the first
128
Chapter 4 . Acceleromyography
to compare the Accelograph with the reference method, i.e., mechanomyography. According to these authors, both the single twitch stimulation and
the TOF response were identical on the two nerve stimulator models, the
AMG device proving much easier to handle. Contingent upon the anesthesiologist's good intentions, objective monitoring of neuromuscular blockade
was now possible in clinical practice.
Just a few years later, the TOF-Guard came out on the market - a truly
compact, portable and battery-operated device based on the principle of acceleromyography [6] (a Fig. 4.2). This was the first device to become available
for routine clinical use that not only met anesthesiologists' basic requirements, but also enabled a sufficiently accurate intraoperative assessment of
neuromuscular function .
Undoubtedly, this first model had its weaknesses in terms of both ergonomics and technique . The TOF-Guard was designed as an all-purpose
a Fig. 4.2. TOF-Guard nerve stimulator
129
4.2 . The Accelograph and the TOF-Guard
device for applications in clinical anesthesia, intensive care medicine and

research. Moreover, this nerve stimulator featured no less than 19 (!) different buttons, some programmed with multiple and/or freely programmable
functions . Not surprisingly, it was cumbersome to operate and rather unmanageable. During routine clinical use, the first generation of acceleration
transducers and their original cable designs were also subject to malfunction.
These problems were compounded by the fact that the model did not yet incorporate a technical solution for the inherent overshoot that occurred when
measuring the TOF ratio. This problem was the reason that the TOF-Guard
frequently measured TOF ratios greater than 100%, which occasionally led
to a certain amount of uncerta inty when interpreting the results. To improve
on these bugs, the TOF-Watch" series - representing a completely overhauled
and optimized version of compact acceleromyographs - was launched in
1997 (D Fig.4.3).
D Fig.4.3. TOF-Watch" nerve

stimulator
130
4.3
TOF-Watch'" models
The most notable change over its predecessor was the diversity of models
offered by the TOF-Watch" series. Instead of a single TOF-Guard model, the
new product family included three nerve stimulators : the TOF-Watch", TOFWatch" Sand TOF-Watch" SX - each featuring different application profiles.
These differences involved the calibration modes and the algorithms used
for calculating the TOF ratio. Common to all three TOF-Watch" models is
that they can also be used to localize nerves during locoregional anesthesia
procedures. The following sections will address these particulars and explain
which models are best suited for which applications.
4.3 .1 The TOF ratio algorithm

It has been frequently observed in clinical practice that acceleromyographic
TOF baseline values measured prior to NMBA injection exceeded 100%.
Suzuki et al. [7] investigated this phenomenon in a total of 120 patients. In
their study, the average baseline response after TOF stimulation was 111%,
across a range of 94-147% (aTab.4.1). This overshoot-type TOF response is
a unique characteristic of acceleromyography and is not observed with mechanomyography or electromyography to such an extent. The reason for this
phenomenon has not been explained fully, but is assumed to be caused by
the thumb not returning to its exact original position after stimulation of the
ulnar nerve. Therefore, successive stimulations keep producing subsequent
response values exceeding 100% until the thumb has finally returned to a
stable starting position. This theory is reinforced by the observation that the
phenomenon is significantly reduced by using a hand adapter to ensure that
the thumb returns to its baseline position after every stimulation.
Overshoot-type baseline responses after TOF stimulation cause problems
with interpreting neuromuscular recovery. Adequate neuromuscular recovery is strictly defined as a TOF ratio of 0.9, i.e., 90% of the baseline value.
At a baseline TOF ratio of 147% (as Suzuki et al. reported in the study cited
above), a TOF ratio measured as 90% however is barely 61% of baseline. In
this example, a recovery to 90% of baseline is thus not accomplished until
the TOF ratio equals 132%, i.e., 90% of 147%. Neuromuscular recovery will
be overestimated when the value of 90% is indicated on the display. That
131
4 .3 . TOFWatch- models
a Tab. 4.1. Proqress of T, response and TOF ratio over 30 minutes (modified after (7))
n=120
5tart
5mon
10mon
20min
30 min
%T,
100
121
(100-168)
131
(102- 188)
136
(100- 192)
136
(92-192)
1.10
(0.92-1.47 )
1.12
(0.97- 1.45)
1.12
(0.94-1. 45)
1.13
(0.95- 1.47)
TOFratio
1.11
(0.94-1.47)
Data are presented as mean [range] .
means that particularly moderate residual blockade, corresponding to a TOF

ratio between 60% and 90%, i.e. where severe functional impairment of the
upper airway can be expected, will not be detected properly under the above
circumstances.
Calibration does not solve the problem of overshoot -type TOF ratios
either, but only initially sets the T I response to 100%. The study by Suzuki et
al. showed however that TOF ratios > 1 were measured regularly despite calibration [7]. During a 30-minute stabilization phase prior to administration of
the NMBA, the average T I response rose continuously from an original 100%
to 136%(SD range: 92-192%). By contrast, the TOF ratio (i.e., the ratio of the
T4 to the T I response) remained very constant : from an initial 1.11 (SD range:
0.94-1.47), it was still only 1.13 (range 0.95-1.47) after 30 min (aTab.4.1).
The only explanation for why the ratio of the fourth to the first response remained largely constant is that all four responses to TOF stimulation increase
in equal measure during the stabilization phase.
Therefore, when acceleromyographic nerve stimulators are used in research studies, a 20- to 30-minute stabilization phase followed by re-calibration is required before injecting the NMBA. Moreover, the TOF recovery
should be stated as a percentage of the TOF ratio measured at baseline [8].
This will ensure that a recovery of the TOF ratio to 0.9 really equals 90%
of baseline. This procedure is called norrnalization. Because it is timeconsuming, this method is not suitable for clinical application and therefore
other solution s must be sought. Detailed analyses of the four single TOF
responses showed that, after acceleromyographic stimulation, a differential is
observed between the first and second TOF response, while the responses T2
up to and including T4 do not essentially differ (aFig.4.4). In light of these
132
facts, the factory-set algorithm for calculating the TOF ratio built into the
TOF-Watch and TOF-Watch" S models was modified as follows:
- When the second TOF response (T2 response) is greater than the first (T,
response) , the TOF ratio is not calculated as a ratio of TiT l' but automatically as a ratio of T4/ T 2'
- If the TOF ratio continues to be >100%, the monitor will only ever display
a value of 100%.
Thanks to these modifications, the two devices no longer produce excessive
TOF responses . However, this begs the question as to whether these changes
limit the assessment of neuromuscular recovery. In an initial study, Kopman
and Kopman [9] explored this concern. Their results showed that the newly
modified T4/T2 algorithm did not change the accuracy of the TOF ratio for
assessing neuromuscular recovery. While the change in TOF algorithm considerably simplified clinical application of the devices, it still did not adversely
affect their results. The two models, TOF-Watch and TOF-Watch S, are
therefore especially suited for clinical use, but should not be used for research
studies where original, unaltered data are desired. It should also be noted that
the TOP-Guard model is not equipped with this modified algorithm so that
---------- ----------- -----------
-----
---------- ----------_. -----------
-----
a Fig. 4.4. TOF-Watch

ponse [9]
algorithm: Marked difference between the first and second TOF res-
133
4.3 . TOF-Watch- models
it continues to produce TOF values markedly above the 1.0 level. Hence, caution is advised when using these older-generation acceleromyographic nerve
stimulators for interpreting recovery data. The TOF-Watch" SX model was
designed primarily for research studies and therefore does not work according to this new TiT 2 algorithm either. Before the actual measurement on this
device can start, the anesthesiologist must wait until both the T I response
and the TOF ratio have stabilized to constant readings. Once the TOFWatch" SX is calibrated and the baseline reading taken, the nerve stimulator
is operational.
The TOF-Watch- and TOF-Watch- 5 are equipped with an algorithm that

prevents the TOF ratio from exceeding 100%. This facilitates handling of the
devices without limiting their clinical accuracy in assessing neuromuscular
recovery.
4.3.2 Calibration modes
Simple- nerve stimulators are only useful for assessing the stimulatory response subjectively - be it tactilely or visually. Their high ease of operation is
contrasted by their limited accuracy.
As their name implies, quant itative nerve stimulators, on the other hand,
measure the objective response and are accordingly more accurate. To reliably perform quantitative measurements, however, several technical requirements must be met before the NMBA can be injected and the neuromuscular
block actually monitored. In this regard, it makes no fundamental difference
whether the respective device is used for neuromuscular monitoring in clinical practice or in research. In general, the following requirements deserve
mention:
- The stimulatory response must be stabilized
- The stimulation current must be sufficient for supramaximal stimulation
- The nerve stimulator must be calibrated.
As described above, the TOF-Watch" and TOF-Watch" S models feature a
special algorithm that obviates any time-consuming stabilization phase for
the TOF ratio, whereas with the TOF-Watch" SX model, there is a wait before
stabilization.
134
But, afterwards, the anesthesiologist just needs to ensure that an adequate stimulation current is applied throughout the entire surgical procedure and that the nerve stimulator has been calibrated. Both functions take
place at the same time during the actual calibration. During this process,
the twitch after a single stimulus (T 1) is measured and, if necessary, automatically amplified by an internal gain until it finally equals 100%. Particularly in small children, but also when monitoring muscles in the ocular
region, the twitch signal is often rather weak and needs to be amplified
accordingly to achieve a baseline value of 100%. When T 1 responses >100%
are elicited , the calibration function likewise ensures that the control value
is optimized to 100%, meaning that the T 1 response is reduced. It is imperative that this take place prior to NMBA injection. The gain determined
during calibration is then stored for the entire measurement. Since the same
gain factor is used for all of the patient's measured data, the interrelationship of the individual T 1 responses to each other and the TOF ratios does
not change. Indeed, this calibration is more like a metrological procedure
that keeps amplifying the response signal until a pre-set baseline value is
reached. That makes the measurement more stable and more reliable. This
fact was ultimately confirmed by the results of a recent study of Baillard
et al. [10] in which the authors observed considerable discordances in the
individual, directly successive TOF ratios when calibration of the acceleromyographs was omitted.
The various TOP-Watch models differ in terms of their calibration
functions: two different programs are available .
CAL 1. With the more simple calibration function (CAL 1), the T 1 response is
set to 100% after just a few single twitches. Unless the corresponding setting
is changed in the set-up menu, the stimulation is carried out automatically at
the pre-set default current of 50 rnA. In total, this calibration procedure takes
less than 10 s!
CAL 2. The second calibration function (CAL 2) detects both the supramaximal stimulation current and the control twitch height. Both measurements
are carried out automatically in just around 30 seconds! Stimulation is initiated at a current of 60 rnA and the T 1 response set to 100% after a few single
twitches . Next, the stimulation current is reduced in increments of 5 rnA for
as long as it takes the T I response to drop to below 90% of the baseline value
135
4.3 . rOF-Watch- models
(e.g. 35 rnA). The last stimulation current before the reduction in T 1 response
drops to values below 90% counts as the maximum current (here: 35 mA+5
mA=40 rnA). The supramaximal current is defined as 10% above this peak
value (and thus equals 44% in the example cited). Then, this supramaximal
current (i.e., 44%) is used for stimulation and the response is finally set to
100% (D Fig. 4.5). With this, the calibration procedure is concluded.
The two stimulation programs are easy to use and can be carried out during anesthesia induction with little extra effort of time. The TOF-Watch is
only equipped with the first, more simple stimulation mode. On this model,
the supramaximal current is not measured, but rather stimulation takes place
at the pre-set current; the default setting is 50 rnA.
With the TOF-Watch" Sand TOF-Watch" SX models , the user can
choose between the two calibration procedures. Pre-programmed functions on the models allow the second calibration function to be activated by
pressing the calibration button, i.e. initiating automatic measurement of the
supramaximal stimulation current as well as the control twitch height. This
calibration function is indicated in the display as CAL 2. In the setup
menu, the user can also optionally set these two models to run the first,
simple calibration mode or CAL 1. When activated, CAL 1 is indicated
in the display.
Although all TOF-Watch" nerve stimulators can essentially be used
without pre-calibration, their accuracy is not only diminished in detecting a
single twitch but also in the important TOF mode if not pre-calibrated.
Stability testing
Gain setting
n n nu
.1 0 %
--:;;------:i\-----:J\----~- ::;
StimulatO<)' ../'..
response
Transducer
9 ln 157
Transducer
gain 170
Transducer
gain 178
a Fig.4.5. Calibrationfunction (CAL 2) and sensitivity settings
136
The other three stimulation modes on TOF-Watch" nerve stimulators,

namely the DBS,the PTC and tetanic stimulation, are not affected by calibration because these stimulation modes do not measure the twitch, but only
enable its tactile or visual assessment.
TOF-Watch- neuromuscular transmission mon itors should always be

calibrated before starting the measurement. The calibration procedure
takes little extra time and improves the accuracy of the acquired data .
4.3.3
Nerve localization in regional anesthesia procedures
In addition to their original function as neuromuscular transmission monitors, the three TOF-Watch" models can also be used to localize nerves during
regional anesthesia procedures . For this purpose, they need a special stimulation cable. This cable contains a connection for a surface electrode as well as
a standard plug for the stimulation needle.
As soon as this cable is plugged in, the nerve stimulator switches to the
regional anesthesia function and the stimulation parameters are adjusted to
the new application. A mechanical barrier prevents the regional anesthesia
cable from being plugged into the wrong outlet. In the regional anesthesia
mode, the TOF-WatchO models stimulate with the following parameters:
- Square wave constant current
- Pulse width of 40 fIs
- Stimulation current between 0-6.0 mA and/or 0-0.24 fIC infinitely selectable (pre-set default 0 fIC set)
- Stimulation frequency 1 Hz (i.e., one stimulation per second)
Thus, the TOF-Watch" models similarly fulfill the requirements placed on
nerve stimulators used to localize peripheral motor nerves in regional anesthesia procedures [11]. Besides their application in neuromuscular moni toring, these devices can be used as fully fledged nerve stimulators during
regional anesthesia as well. This feature is a further improvement over the earlier TOF-Guard model, which was not equipped with this double function .
The different features provided by the three TOF-Watch" nerve stimulators (DTab.4.2) allow them to be classified according to the various areas of
application.
137
4 .3 . TOF-Watch- models
a Tab. 4.2. Features and functlonalltles of the various TOF-Watch" models

Model
TOF-Watch
TOF-Watch S
TOF Watch SX
Stimulation mode
Train-of-four (TO F)
Post-tetanic count (PTC)
Single twitch - 1 Hz
Single twitch - 0.1 Hz
Double-burst stimulation (DBS)3.3 or 3.2
Tetanus - SOor 100 Hz
. Slow TOF (TOFs)
TOF ratio algorithm
Always T.tT I
Current (0-60 mAl
Pulse w idth
Monophasic 200 ps
Monophasic 300 liS
C Iibration mode
CALl
CAL2
Manual transducer sensitivity
setting
TOF and /or TOFs alarm
Loudspeaker
Automatic power switch off
Surface temperature sensor
PC connection option
Nerve localization In reg ional
anesthesia
"SlowTOF and/or TOFs: TOFinterval infinitely selectable between 1-60 min

TOFalarm and/or TOFs alarm:TOF mon itor ing with alarm limits for the number ofTOF responses
(TOFcount) or the TOF ratio, the alarm limits are infinitely selectable
Manual transducer sensitivity setting : If no supramaximal stimulation current can be found, the
transducer sensitiv ity can be manually set from 0 to 600.
Pre-set default is a unit- less value of 157.
Automatic pow er switch off :The device switches off auto matically after 2 hours of no operat ion.
138
Key points - - - - - - - - - - - - - - - - - - - - - - - - ,
- Due to theirT.fT2 algorithm. the models TOF-Watch- and TOF-Watch- S
are suited for clinical applications exclusively. They should not be used
for research studies. The TOF-Watch- model fulfillsthe basic require ments placed on quantitative nerve stimulators and is completely ad equate for routine clinical applications.
- The most notable feature distinguishing these two models is their calibration mode. In addition to the standard calibration funct ion (CAL 1).
the TOF-Watch- S model can also determine the supra maximal current
during the calibrat ion procedure (CAL2).This feature prevents the st imulation current from becoming too strong and thereby prevents any
risk of direct muscle stimulation or the risk of insufficient. i.e. submaximal stimulation. Moreover. the TOF-Watch- S gives users the option to
define the TOF interval within a range of 1-60 minutes. This function
was specifically developed for applications on the ICU.
- The TOF-Watch- SX was designed as a nerve stimulator for research.
Accordingly, it is the only one of the three models that features a data
exchange option with a PC interface. When using th is model for clinical purposes. the anesthesiologist must wait for calibrat ion unt il the T.
response or the TOF ratio have stabilized .
- Furthermore. all three TOF-Watch- models can be employed to localize
peripheral motor nerves for regional anesthesia procedures.
4.4
TOF-Watch Gil
4.4.1
1. Place the electrodes on the distal course of the ulnar nerve, attach the acceleration transducer to the thumb.
. , Clean, degrease, and if necessary, shave the skin where the electrodes
are to be attached. The distal electrode should be connected to the
black (negative) clip. Fasten the acceleration transducer with its largest
flat side to the thumb.
2. Turn TOF-Watch" on by pressing the on-off button and holding it down
for 1 second (this will be acknowledged by a short beep)
139
4.4 . rOF-Watch-
The device can be switched on while the patient is awake.
3. Pre ss the calibration button; after not more than 10 single stimulations
at 1 Hz the device is calibrated and operational
Always calibrate after anesthesia induction, but before muscle relaxation!

Never calibrate if the patient is not yet anesthetized; calibration is equally
pointless if the patient is already relaxed.The suitable time point for calibrating is during test ventilation directly prior to NMBA injection.The stimulation
current strength on this device is pre-selected (50 rnA). Ifdesired, it can also
be freely selected between 0 rnAand 60 rnA.
4. Hold down the rOF button for at least 1 s, repetitive TOF stimulation
occurs in IS-second cycles
. Switch to the PTC mode if the aim is to
monitor deep neuromuscular blockade during the further procedure.
These three buttons are allthat is needed to quickly set up the rOF-Watch- for
objective ly monitoring the course of neuromuscular blockade!When neuromuscular monitoring is initiated intraoperatively on already relaxed patients,
the procedu re is the same as described above, but the calibration step is left
out; calibration here would be pointless. A pre-NMBA administration baseline
value can no longer be determined in this situation. Calibration here would
thus be pointless.
4.4.2
-
Brief overview
Calibration: Press CAL 1, i.e., automatically adjust gain to 100% control

twitch height; the stimulation current is set to default (50 rnA)
Stimulation modes: TOF, DBS (3.3 and 3.2), PTC, tetanic stimulation
(50 Hz and 100 Hz), single twitch (l Hz and 0.1 Hz)
Output in neuromuscular monitoring: Constant current, infinitely selec table between 0-60 rnA, default pre-set to 50 rnA, pulse width of 200 fls
Output in regional anesthesia: Constant current, infinitely selectable
between 0-6 rnA, default pre-set to 1.5 rnA, pulse width of 40 fls
The TOF-WatchO will automatically switch to the regional anesthesia
mode when the special stimulation cable is connected
140
4.4.3 Scheme of buttons and display symbols
Scheme of buttons and display symbols on the TOF-Watch

IDFig.4.6)
1. Stop / on-off button
2. Post-tetanic count (PTC) or tetanic stimulation button
3. Train-of-four (TOF) or double-burst stimulation lOBS) button
4. Secondary function button
S. Secondary function symbol
6. Calibration symbol
7. Device on / stopped symbol
8. Battery status symbol
9. Internal error symbol
10. Stimulation beep symbol
11. Acceleration transducer symbol
12. Resistance too high symbol
13. Needle electrode symbol
14. TImer / stimulation symbol
15. Stimulation mode indication
16. Frequency symbol
17. Microcoulomb symbol
18. Milliampere symbol
19. Value for TOFratio, twitch height, PTC or stimulation current
20. Percent symbol: used for TOF ratio or twitch height
21. rnA I~C) up button
22. Calibration button
23. mAI~C) down button
24. 1 Hz / 0.1 Hz stimulation button
All buttons except for the calibration button on the TOF-Watch" nerve
stimulator have a double function . Depending on the button, the secondary
function is activated in different ways:
The double function is depicted in the background on the three buttons
used for selecting the stimulation mode; the secondary function is activated by first pressing the double function button and directly thereafter
the corresponding stimulation mode button.
141
4.4 . TOFWatchO
a Fig. 4.6.TOF-Watcho: Schemeof buttons and display symbols
For the other double function buttons, the period of time that a button is
activated determines the selection of the function . The desired function
is selected by pressing this button for less than 1 s (short activation) or by
pressing the button for more than 1 sec (long activation).
The buttons and display symbols on the TOF-Watch" can be classified into
four categories according to their function :
142
1.
2.
3.
4.
Starting up the TOF-Watch"

Selecting the stimulation mode
Alarm functions
Settings
Starting up the r OF-WatchWhile the nerve stimulator can be switched on in the still awake patient, the
button for selecting calibration and/or stimulation mode may only be operated after induction of anesthesia (but before injection of the NMBA).
On-off button and /or stop-button
The function activated by this button is determined by how long it is pressed.
To switch the unit on and/or off, the button must be pressed for at least 1 s.
As soon as the device is switched on, the corresponding symbol appears in
the display
Long activa tion (> 1 s) of this button is required to switch the unit on
and/or off.
Short activation 1 s) toggles the ongoing stimulation to off and clears the
last twitch while the device continues to remain operational. For example,
if the stimulation was performed in th e TOF mode, the TOF stimulation
will be toggled off and the last TOF value cleared from the monitor. If the
nerve stimulator is used again at a later point in time, all the anesthesiologist has to do to activate the desired function is press the button with the
corresponding stimulation pattern. The original calibration parameters
remain stored in the memory. This function is especially relevant if the
nerve stimulator is not intended to be used intraoperatively for a longer
period of time.
As recommended, the TOF-Watch" can be calibrated at the onset of anesthesia and subsequently switched to the stand-by mode by briefly pressing
the on-off button. As the end of the surgery intervention nears, the neuro muscular recovery can be assessed based on the initial calibration parameters. Here, it should be noted that the device automatically switches itself off
after 2 h of non-use.
Press the on -off button for < 1 s (short activation) to switch the device to
stand-by.
4.4 . rOF-Watch-
143
Y Calibration button
On this model, the calibration routine takes 10 seconds at the most and is
not at all comparable with the calibration of a measuring instrument used
for research purposes. Here, the transducer gain in the response to a single
1-Hz stimulation is simply adjusted to 100%; this value then serves as the
reference value for the further quantitative measurements, i.e., single twitch
and TOE
To calibrate, this button must be pressed for at least 1 second . Calibration
of the nerve stimulator is successful when the corresponding symbol
is
indicated on the monitor.
Now, the device is operational and the NMBA can be injected.
The calibration procedure with the rOFWatch - takes no more than lO s.
The nerve stimulator can also be used without pre-calibration. In that case,
however, the results after single twitch and after TOF stimulation in particular, are less accurate. Operation without previous calibration is indicated by
the flashing symbol
Up and down rnA (lJC) buttons

This button is used to set the stimulation current. On the TOF-Watch- S
and TOF-Watch" SX models, the supramaximal current is measured and set
automatically during the calibration routine, whereas on the TOF-Watch" a
stimulation current of 50 rnA is factory-set in the set-up menu. If a different
stimulation current is required , it must be manually set by the user; here a
range of 0-60 rnA is available.
Functionally, this button features an up and down option for manually
adjusting the strength of the stimulation. The current is continuously stepped
up or down depending on which part of the button is pressed.
After short activation of this button 1 s), the display indicates the
stimulation current. Pressing again increases or decreases the current.
long activation of this button (> 1 s) continuously steps up and/or decreases the stimulation current; the current keeps increasing or decreasing
for as long as the up or down part of the button is pressed.
On th is rOF -Watch- model, the default stimulation current is SO mAo

Any settings other than this must be made manually.
144

The other four buttons on the TOF-Watch" are used for selecting the stimulation mode; without exception, all of them have a double function . With the
three stimulation buttons, a total of six stimulation modes can be selected.
The respective double function of the button is activated by pressing the
secondary function button. The twitch after TOF stimulation and/or after
single twitch (1 Hz or 0.1 Hz) can be objectively measured and the result
subsequently indicated in the display. The other three stimulation modes
featured are DBS, PTe and tetanic stimulation . None of these three stimulation patterns is suitable for objective monitoring. Therefore, they should be
assessed subjectively, i.e., either tactilely or visually, with the TOF-Watch"
nerve stimulator.
Secondary function button
The three stimulation buttons on the TOF-Watch" have the double functions
as listed below:
TOF stimulation and DBS button
PTe and tetanic stimulation button
I-Hz single twitch and/or O.I-Hz-single twitch button.
The secondary function of these buttons is activated by first pressing the
secondary function button for less than 1 s and then activating the corresponding stimulation button . Along with the selected stimulation mode, the
symbol for the secondary funct ion . appears in the display. If none of the
three double function stimulation buttons is selected within 5 s, the device
automatically toggles to the stimulation mode that was previously activated.
The secondary function of a stimu lation button is selected by pressing the

secondary funct ion button for < 1 s and then pressing the corresponding
stimulation button.
Pressing the secondar y function button for > 1 s (long activation), switches
the acoustic stimulation sig!,lalon/off and the corresponding symbol is indicated in the display for 1 s 18 If the acoustic stimulation signal is switched on,
a short beep can be heard each time the nerve stimulator TOF-Watch" performs a stimulation . Therefore, when the device is used in clinical practice,
145
4.4 . rOF-Watch"
the recommended setting is to have the acoustic stimulation signal switched

off. If the signal is not switched off, the corresponding setting can be made
in the set-up menu.
rOF or DBS button

This is one of the three buttons with a double function. The TOF is the primary and the DBSthe secondary function.
Short activation starts a single TOF stimulation. Pressing the
button for longer than 1 s, starts a repetitive TOF stimulation that occurs in
IS-second cycles. Once all 4 TOF responses are detected, the display indicates the TOF ratio in percent (%). When less than four TOF responses are
detected or if the first twitch is less than 20%, only the number of responses
is displayed (without the % symbol).
The following should be noted :
- Stimulatory responses below the threshold of 3% control twitch height are
not counted as independent TOF responses.
- The use of DBS and TOF is automatically excluded for 12 s after the last
TOE
Short activation 1 s) ofTOF button starts a single rOF stimulation ;

long activation (> 1 s) of th e button starts a repetitive rOF stimulation.
DBS mode. To start a DBS, first press the secondary function button for
< 1 s and then the corresponding stimulation button. The twitch is assessed
by visual or tactile evaluation. Alongside the selected stimulation mode, the
display only shows the selected current. Compared to the TOF mode, the
DBS cannot be used as a continuous stimulation mode, but only on-demand
as a single stimulation .
Another DBS or a TOF stimulation cannot be started until 20 s after the
last DBS stimulation.
The TOF-Watch" is equipped with the two DBS modes, i.e. DBS 3.2 or
DBS 3.3. The corresponding setting can be made in the set-up menu. The
default is pre-set to the DBS 3.2 mode.
In the DBS mode. the response can only be assessed by tactile or visual evalu ation. The display shows the stimulation strength in m illiamperes (mA) on ly.
146
Post-tetanic count (PTe) or tetanic stimulation button
This button also has a double function. PTC is the primar y function and
tetanic stimulation is the secondary function.
PTe mode. In this stimulation mode, the TOF-Watch" device starts by
performing 15 single stimulations at a frequency of 1 Hz. Since the PTC
can only be used during deep blockade, the device automatic ally stops the
PTC stimul ation and switches to the TOF-mode if after the first 15 single
stimulations the patient responds to more than five consecutive stimulations. Only if fewer than 5 of the original 15 stimulatory responses are
detected, i.e. an appropriately deep neuromuscular block has been attained,
will a 5-second long tetanic stimulation of 50 Hz follow. After a pause of
3 seconds, the next 15 single stimulations will follow; the number of detected responses is indicated as PTC on the display. After 12 seconds, the
display clears and the TOF-Watch" automati cally enters the continuous
TOF stimulation mode. The next PTC cannot be started until after another
2 minutes! The PTC mode can only be used in deep neuromuscular blockade; If the block is not sufficiently deep, the unit automatically switches
back to TOF stimulation.
Tetanic stimulation. Activation of the secondary function starts a tetanic
stimulation of 50 Hz or 100 Hz that lasts 5 seconds. The desired stimulation
frequency can be programmed in the set-up menu (see below). The default
setting is a 100-Hz stimulation. The response after tetanic stimulation has to
be evaluated visually or tactilely, the display only shows the selected stimulation frequency of 50 Hz or 100 Hz. Like the PTC mode, the TOF-Watch"
excludes the use of another tetanic stimulation for 2 min.
1 Hz I 0.1 Hz stimulation button
This button also features a double function that can be used to trigger a
single twitch. A I-Hz stimulation is the primary function and a D.I-Hz
stimulation the secondary function. Short activation 1 s) starts a single
stimulation; long activation (> 1 s) starts repetitive single stimulations. The
display shows the twitch height of the last response calculated from a control value and indicated in percent. To use this function, the nerve stimulator must be calibrated before the NMBA is injected and the corresponding
control value must have been measured. Without initial calibration, the
147
4.4 . rOF-Watch "
TOF-Watch " compares the response with an internal reference control. The
response is also indicated in percent. In this case, the calibration symbol
in the display flashes to indicate that no calibration was performed. In this
stimulation mode, too, the accuracy of findings of an uncalibrated measurement is markedly limited.
Alarms
In this context, there is a difference between information about the current
nerve stimulator functions and error signals. The former includes the previou sly presented symbols for:
- Secondary function
- Calibration
- Switch on
- Stimulation beep symbol
Therefore, we will now only discuss the error signals along with the re maining display for timer function, stimulation signal and stimulation
current.
.,.
.: ~ :. Optical stimulation signal and timer
When the center dot in the timer symbol is flashing, the TOF-Watch" is currently performing a stimulation. This signal appears during all six stimulation patterns.
During repetitive stimulation, the timer symbol indicates the time to next
stimulation.
<:.
Stimulation units
The TOF -Watch" can show the strength of the electrical stimulation in both
milliamperes [rnA) and microcoulomb [flC). For routine monitoring, the
stimulation strength is indicated in milliamperes. The pre-installed default
current is therefore set to a milliampere display. Occasionally, for use in regional anesthesia, the electric charge is indicated in flC.
~C
Microcoulomb is the unit of electric charge and measures the quantity of

electricity.
rnA Milliampere is the unit for current.
148
Error signals
Whenever an error is detected, the stimulation is suspended. The flashing

symbol alerts the user to the error. Attention beeps will sound unless the
acoustic stimulation signal has been switched off in the set-up menu. The
TOF-Watch features the following error alerts:
Battery status symbol: This symbol only appears on the display, if the
battery is low and/or empty. This means the battery should be replaced.
Internal error symbol: This symbol is displayed whenever a technical

problem is detected . When this symbol is displayed, the device should be
taken to the technical services department or the responsible service company.
t Acceleration transducer symbol

When this symbol is flashing, either no acceleration transducer is present or
the signal is too weak. As the case may be, the acceleration transducer should
be attached either at the test muscle (normally thumb) or its position/fixation
checked.
If the acceleration transducer symbol flashes during calibration, the acceleration transducer signal is either too low or unstable. If this happens, the
stimulation current should be increased manually.
Three different error signals alert the user to problems with the stimula tion electrodes and/or any of the cables.
~J-E) A flashing surface electrode symbol indicates a missing or bad electrode connection .
-E) This flashing symbol means that the skin resistance is too high. Clean
the skin where the stimulation electrodes are attached and shave away any
excessive hair growth. Poor quality of the stimulation electrodes may be
another cause.
-E) 7 If these two symbols are flashing simultaneously, check the connection between the stimulation cables and the two electrodes. Usually, a cable
is not connected .
149
4.4 . rOF-Watch"
Settings
This fourth and last section deals with the repeatedly mentioned set-up
menu. In the set-up menu, the basic settings of the TOF-Watch" nerve stimulator can be pre-programmed and remain stored in memory even when the
battery is removed. This menu is used to customize some of the parameters
and to permanently store the settings. It is recommendable to define standard
Set-up parameter.
Set-up Display
sudace electrode flashing (stimulation units)

mA:
Surfaceelectrode stimulation strength in milli-amperes,
~:
Surfaceelectrode stimulation strength in micro-coulomb,
5urface electrode flashing (stimulationsize)
50 rnA:
Default surfaceelectrode stimulation strength can be

adjusted between 0 and 60 mA/12 ~.
....
....
:==~~
Needle electrode flashing (stimulationunits)

~C:
rnA:
Needlestimulation strength shown in micro-coulomb.

Needlestimulation strength shown in milli-amperes,
Needle electrode flashing (stimulation size)
0.0 IJC:
Default needle electrode stimulation strength can be

adjusted between 0.0 and 6.0 mAlO.24 1Jc.
Loudspeaker flashing
0:
1:
Stimulation beep off.

Stimulation beep on.
DB53.2 is used
DB533 is used
o db5
085 flashing
3.2:
33 :
100Hz(or 50 Hz) flashing

100 Hz tetanic stimulation.
100 Hz:
50 Hz:
50 Hz tetanic stimulation.
a Fig.4.7.rOF-Watch" set-up parameters.Thestandard settings are printed in bold and shown

in the display.
150
settings for these parameters and only make changes as agreed. Otherwise ,
use of the nerve stimulator could easily lead to malfunctions, misunderstandings or misinterpretations.
The set-up mode can only be accessed when the TOF-Watch" is switched
on, but in the suspended mode , i.e., not during stimulation. The set-up menu
is operated by pressing one of the two rnA (flC) up and down buttons and the
calibration button.
To enter the set-up menu , press both rnA (flC) up and down buttons simultaneously.
- To modify the setting of the displayed parameter, now press either the
mA(flC) up or down button.
- To store the modified setting, again press both rnA (flC) up and down
buttons simultaneously.
- Within the activated set-up menu, press the calibration (CAL) button to
activate the individual parameters.
4.5
TOF-Watch l8l S
4.5.1
1. Place the electrodes on the distal course of the ulnar nerve, attach the ac-
celeration tran sducer to the thumb .
f)
Clean, degrease, and ifnecessary, shave the area where the electrodes
black(negative) clip. Fasten the acceleration transducer with its largest
2. Turn TOF-Watch" on by pressing the on -off button and holding it down

for 1 second (this will be acknowledged by a short beep).
f)
The devicecan already be switchedon whilethe patient isawake.
3. Press the calibration button: The calibration function CAL 2 automatically sets the supramaximal current. Within a maximum of 30 seconds,
the device is calibrated and operational.
151
4 .5 . TOF-Watch- S
Always calibrate after anesthesia induction. but before muscle relaxation!

pointless if the patient is already relaxed. The suitable time point for calibrating is during test ventilation directly prior to NMBA injection.
occurs in IS-second cycles. Switch to the PTC mode if the aim is to
These three buttons are all that is needed to quickly set up the TOF-Watch- S
for objectively monitoring the course of neuromuscular blockade!When neuromuscular monitoring is initiated intraoperatively on already relaxed patients.
the procedure is the same as described above. but the calibration step is left
out. A pre-NMBA administration baseline value can no longer be determined in
this situation. Calibration here would thus be pointless.
4.5.2 Brief overview

-
Calibration: Press CAL 1, i.e., automatically adjust gain to 100% control

twitch height; the stimulation current is set to default (50 rnA). Press
CAL 2, i.e., automatically adjust gain to 100% control twitch height; the
supramaximal current is set automatically. Stimulation modes: TOF,
TOFs (slow TOF) , DBS (3.3 und 3.2), PTC, single twitch (l Hz and
0.1 Hz)
Output in neuromuscular monitoring : Constant current, infinitely selectable between 0-60 rnA, default is pre-set to measure supramaximal current, pulse width between 200 f.ls and 300 f.ls
between 0-6 rnA, default pre-set to 1.5 rnA, pulse width of 40 f.ls.
The TOF-Watch" will automatically switch to the regional anesthesia
mode when the special stimulation cable is connected.
152
Scheme of buttons and display symbols on the TOF-Watch e S

(D Fig. 4.8)
1. Stop / on-off button
2. Post-tetanic count (PTC) or double-burst stimulation (DBS) button
3. Train-of-four (TOF) or slow train -of-four (TOFs)
5. Secondary function symbol
6. Calibration symbol
7. Device on / stopped symbol
8. Battery status symbol
9. Internal error symbol
14. Timer / stimulation symbol
19. Value for TOF ratio, twitch height, PTC or stimulation current
20. Percent symbol : used forTOF ratio or twitch height
21. rnA (IJC) up button
22. Calibration button
23. mA(IJC) down button
24. 1 Hz / 0.1 Hz stimulation button
153
4.5 .TOFWatch S
a Fig. 4.8. TOF-Watch"; Scheme of buttons and displaysymbols
154
All buttons on the TOF-Watch' S nerve stimulator have a double function .

Depending on the button, the secondary function is activated in different
ways:
- The double function is depicted in the background on five buttons; the
secondary function is activated by first pressing the double funct ion
button and directly thereafter the corresponding stimulation mode
button.
- For the other double function buttons, the period of time that a button is
pressing the button for more than 1 sec (long activation).
The buttons and display symbols on the TOF-Watch' can be classified into
four categories according to their function .
1. Starting up the TOF-Watch S
2. Selecting the stimulation mod e
3. Alarm functions
4. Settings
Starting up the TOF-Watch 8 S
While the nerve stimulator can be switched on in the awake patient, the button for selecting calibration may only be operated after induction of anesthesia (but before injection of the NMBA). The same applies to the selection of
the stimulation mode.
On-off button and/or stop -button
The function activated by this button is determined by how long it is pressed.
As soon as the device is switched on, the corresponding symbol appears in
the display.
Long activation (> 1 s) of this button is required to switch the unit on

and/or off.
Short activation 1 s) toggles the ongoing stimulation to off and clears the
last twitch while the device continues to remain operational. For example, if
the stimulation was performed in the TOF mode, the TOF stimulation will
155
4.5 . TOF -Watche 5
be toggled off and the last TOF value will be cleared. If the nerve stimulator is used again at a later point in time, all the anesthesiologist has to do
to activate the desired function is press the button with the corresponding
stimulation pattern. The original calibration parameters remain stored in
the memory. This function is especially relevant if the nerve stimulator is
not intended to be used intraoperatively for a longer period of time. As
recommended, the TOF-Watch" S can be calibrated at the onset of anesthesia, and subsequently switched to the stand -by mode by briefly pressing the
on-off button. As the end of the surgery intervention nears, the neuromuscular recovery can be assessed based on the initial calibration parameters.
Here, it should be noted that the device automatically switches itself off after
2 h of non -use.
Pressthe on -off button for < 1 s (short act ivat ion ) to swi tch the dev ice to
stand -by.
Calibration button
On this model, the calibration routine takes a maximum of 30 seconds at the

most. In the pre-set default CAL 2 function, the TOF-Watch S automatically determines the supramaximal current and simultaneously calibrates the
device. Alternatively, the CAL 1 calibration function can be selected in the
set-up menu. In this case, calibration only lasts 10 seconds, but, in return , the
supramaximal current is no longer measured, instead stimulation is carried
out at a preset current of 50 rnA.
To calibrate, this button must be pressed for at least 1 second. Calibration of the nerve stimulator is successful when the corresponding symbol is
Now, the device is operation al and the NMBA can be injected.
The nerve stimulator can also be used without pre-calibration . In that
case, however, the results after single twitch and after TOF stimulation in
particular, are less accurate. Operation without previous calibration is indicated by the flashing symbol.
The secondary function on this button can be used to display the sensitivity of the acceleration transducer and change it as needed .
This function will be explained in more detail in the Settings section.
On the TOF-Watch e 5, the calibration procedure (CAL 2) takes approx. 30 s,

the supramaximal current is measured automatically.
156
Up and down rnA
(~C)
buttons
These buttons are used to manually set the stimulation current. On the
TOF-Watch Sand 'I'Ol--Watch" SX models, the supramaximal current is
measured and set automatically during the calibration routine. Whereas, if a
different stimulation current is required, it must be manually set by the user;
here a range of 0-60 rnA is available.
Functionally, this button features an up and down option for manually
adjusting the strength of the stimulation.
The current is continuously stepped up or down depending on which
part of the button is pressed.
Long activation of the button continuously steps up and/or decreases the
stimulation current; the current keeps increasing or decreasing for as long as
the up or down part of the button is pressed.
On this rOF-Watch- model, the stimulation current is pre -selected. Any set tings other than this must be made manually

The other four buttons on the TOF-Watch" S are used for selecting the stimulation mode ; without exception, all of them have a double function . With the
three stimulation buttons, a total of six stimulation modes can be selected.
The respective double function is activated by pressing the secondary function button.
The twitch after TOF stimulation and/or after single twitch (l Hz or
0.1 Hz) is measured objectively and the result indicated in the display.
The other stimulation modes featured are PTC, DBS and tetanic stimulation . None of these stimulation patterns are suitable for objective monitoring.
Therefore, they should be assessed subjectively, i.e., either tactilely or visually,
with the 'I'Ol'-Watch" S nerve stimulator.
The three stimulation buttons on the TOF-Watch" S have the double functions as listed below:
157
4.5 . TOF-Watche S
TOF stimulation and TOFs button

PTC and DBS
I-Hz single twitch andlor a.l -Hz-single twitch button.
secondary function button for < 1 s and then activating the corresponding
stimulation button.
Along with the selected stimulation mode, the symbol for the secondary funct ion . appears in the display. If none of the three double function
stimulation buttons is selected within S seconds, the device automatically
toggles to the stimulation mode that was previously activated.
The secondary function button also features a double function that can
be used to change the impulse duration . This function will be explained in
more detail in the Settings section.
The secondary function of a stimulation button is selected by pressing the

secondary function button for < 1 s and then pressing the corresponding
stimulation button.
Pressing the secondary function button for > 1 s (long activation), switches
the acoustic stimulation signal onloff and the corresponding symbol is indicated in the display for 1 s. If the acoustic stimulation signal is switched on,
a short beep can be heard each time the nerve stimulator TOF-Watch" performs a stimulation . Therefore, when the device is used in clinical practice,
the recommended setting is to have the acoustic stimulation signal switched
off. If the signal is not switched off, the corresponding setting can be made
in the set-up menu .
TOFor TOFs button
This is one of the three buttons with a double function. The TOF is the primary and the slow-train-of-four (TOFs) the secondary function .
TOF mode. Short activation starts a single TOF stimulation. Pressing the
IS-second cycles. Once all four TOF responses are detected, the display indicates the TOF ratio in percent (%). When less than four TOF responses are
158
detected or if the first twitch is less than 20%, only the number of responses
is displayed (without the % symbol).
The following should be noted :
TOE
Short activation 1 s) ofTOF button starts a single TOF stimulation;

long activation (> 1 s) of the button starts a repetitive TOF stimulation.
TOFs mode. To switch to the TOFs mode, first press the secondary function button for < 1 s and then the corresponding stimulation button. The
time between two TOF stimulations can now be set to within an interval
of 1-60 minutes. The pre-set default is an interval of 3 minutes. The set-up
menu can be used to change other settings.
PTe or DBS
This button also has a double function . PTC is the primary function and DBS
the secondar y function .
PTe mode. When the PTC mode is activated, the TOF-Watch" S starts by
performing 15 single stimul ations at a frequency of 1 Hz. Since the PTC
can only be used during deep blockade, the device automatically stops the
PTC stimulation and switches to the TOF mode if after the first 15 single
stimulations the patient responds to more than five consecutive stimulations. Only if fewer than 5 of the original 15 stimulatory responses are
detected , i.e. an appropriately deep neuromuscular block has been attained,
will a 5-second long tetanic stimulation of 50 Hz follow. After a pause of
3 seconds, the next 15 single stimulations will follow; the number of detected responses is indicated as PTC on the display. After 12 second s, the
display clears and the TOF-Watch" S automatically enters the continuous
TOF stimulation mode . The next PTC cannot be started until after another
2 minutes.
The PTe mode can only be used in deep neuromuscular blockade. If the
block is not sufficiently deep, the unit automatically switches back to rOF
stimulation.
159
4.5 . TOF-Watche 5
DBS mode. To start a DBS, first press the secondary function button for
< 1 s and then the corresponding stimulation button. The twitch is assessed
by visual or tactile evaluation . The display only shows the selected current.
Compared with the TOF mode , the DBS cannot be used as a continuous
stimulation mode , but only on -demand as a single stimulation. Another
DBS or a TOF stimulation cannot be started until 20 s after the last DBS
stimulation.
The TOF-Watch" S is equipped with the two DBS modes, i.e, DBS 3.2 or
DBS 3.3. The corresponding settings can be made in the set-up menu . The
default is pre-set to the DBS 3.2 mode.
In the DBSmode. the response can only be assessedby tactile or visual evalu ation. The display shows the stimulation strength in rnA only.
, Hz / 0.' Hz stimulation button

single twitch. A I-Hz stimulation is the primary function and a OJ-Hz
stimulation the secondary function . Short activation 1 s) starts a single
stimulation; long activation (> 1 s) starts repetitive single stimulations. The
display shows the twitch height of the last response calculated from a control value and indicated in percent. To use this function, the nerve stimulator must be calibrated before the NMBA is injected and the corresponding
TOF-Watch" compares the response with an internal reference control. The
Alarms
nerve stimulator functions and error signals. The former includes the preinstalled symbols for the secondary function, calibration, the power button
und the stimulation beep symbol. Therefore, we will now only discuss the
remaining display for timer function, stimulation signal and the display for
the stimulation current.
160
.,.
.: ~:. Optical stimulation signaland timer

When the center dot in the timer symbol is flashing, the TOF-Watch is currently performing a stimulation. This signal appears during all six stimula tion patterns.
C. During repetitive stimulation, the symbol indicates the time to the next
stimulation.
Stimulation units
The TOF-Watch" can show the strength of the electrical stimulation in both
milliamperes [rrtA] and microcoulomb [Ile]. For routine monitoring, the
current is therefore set to a milliampere display. Occasionally, for use in regional anesthesia, the electric charge is indicated in 1lC.
IJC Microcoulomb is the unit of electric charge and measures the quantity of
electricity.
Errorsignals
Whenever an error is detected, the stimulation is suspended.
The flashing symbol alerts the user to the error.
Attention beeps will sound unless the acoustic stimulation signal has
been switched off in the set-up menu . The 'I'Oli-Watch" S features the following error alerts:
EI
Battery status symbol: Th is symbol only appears on the display, if the

battery is low liil or empty 13. This mean s the battery should be replaced.
Internal errorsymbol: This symbol is displayed whenever a technical problem is detected. When this symbol is displayed, the device should be taken to
th e technical services department or the responsible service company.
......-=t
Acceleration transducer symbol

When this symbol is flashing, either no acceleration tran sducer is present or
be attached either at the test muscle (normally thumb) or its positionlfixation
checked. Moreover, this error signal can also be triggered if the stimulation
current is too weak.
161
4.5 . TOFWatch- S
Three different error signals alert the user to problems with the stimulation
electrodes and/or any of the cables:
-1f-E) A flashing surface electrode symbol indicates a missing or bad electrode connection.
-E> This flashing symbol means that the skin resistance is too high. Clean
the skin where the stimulation electrodes are attached and shave away any
excessive hair growth. Poor quality of the stimulation electrodes may be
another cause.
-E> 7
If these two symbols are flashing simultaneously, check the connection between the stimulation cables and the two electrodes. Usually, a
cable is not connected. This symbol also indicates that the resistance is too
high.
Settings
This fourth and last section deals with the repeatedly mentioned set-up menu.
In the set-up menu, the basic settings of the TOF-Watch- S nerve stimulator
can be pre-programmed and remain stored in memor y even when the battery is removed. This menu is used to customize some of the parameters and
to permanently store the settings. It is recommended to define standard settings for these parameters and only make changes as agreed. Otherwise, use
of the nerve stimulator could easily lead to malfunctions , misunderstandings
or misinterpretations.
In addition , the following settings are stored as secondar y function of the
calibration button and the secondar y function button :
The secondary function on this button can be used to display acceleration tran sducer sensitivity for 5 s. During this period, sensitivity can be increased/d ecreased by pressing mA(flC) up or down.
This function can be used to optimize twitch height percentage manually.
This can make sense when the calibration function did not produce a 100%
contro l response.
Sensitivity can be adjusted between 1 and 512, where 512 represents
the most sensitive setting. The sensitivity setting 157 is the default sensitivity.
162
Ch pter 4 . Accele romyogr phy
After successful calibration, do not change the sensitivity as this will

invalidate any previous calibration of the device. By contrast, any change
made at this point will not affect the default setting selected in set-up
menu.
The secondary function on this button can be used to toggle stimulation
pulse width between 200 and 300 ps. This makes sense if, previously, 200
fls at 60 rnA was not sufficient to produce supramaximal stimulation. In
this case too, any previous calibration will be invalidated. By contrast, any
change made at this point will not affect the default setting selected in set-up
menu.
The set-up mode can only be accessed when the TOF-WatchO S is
switched on. The set-up menu is operated by pressing one of the two rnA
(flC) up and down buttons and the calibration button. To enter the set-up
menu, press both rnA (flC) up and down buttons Simultaneously. To modify the setting of the displayed parameter, now press either the mA{flC) up
or down button. To store the modified setting, again press both rnA (flC)
up and down buttons simultaneously. Within the activated set-up menu ,
press the calibration (CAL) button to activate the individual parameters
(a Fig.4.9).
To enter the set-up menu, press both mA (~C) up and down buttons
simultaneously. Press the calibration button to select the individual
parameters.
163
4.5 . TOF-WatchOS
S -up 0 sp
ra: s nlJ51Jing (TOF S te
l ion Ii e)
TOF S repetitlon time n be djusted between 1 nd
60 minu .
3I:
rode + sti
ation nlJ51Jing (stitraJlatitln IItIits)
Surfac:e eledrodestI ulJtIon sttength In m loa peres.
Surfac:e eledrode mu tIon sttength In miaoalulomb. 0
SutfDQI ectrode .. stitraJlation nlJ51Jing (plJs.

200 liS:
De u surf ~ stImulJ on pulse
h)
han be selected
to2ooor3~
SutfDQI
50
~c:
rnA:
1:
arode + stifrIJation noshing (stitraJlatitln size)

Oef ult surfl~ electTod stimulatlon strength an be
adjusted between0 nd 60 rnA (0 nd 1 2118~ .
I.
oM + stimulation flashing(stimtJation urits)
Needle stlmu Ionstrength shown In mlcro<oulomb.
Needle stI u
n strength shown In mUll mperes.
D
o
aion)
Determ
of sup
1m threshold, folIawed I
alib tlon of tllInsducer se Ivlly It threshold + 1~
[
(
6OmAorl21181).
0
I bratlon c:A transducer sensitivity t user set
'--
amenVch rge.
a Fig.4.9.rOF-Watch" S set-up parameters
..
lo..-J
164
4.6
TOF-Watchlil SX
4.6.1
1. Place the electrodes on the distal course of the ulnar nerve, att ach the acceleration transducer to the thumb.
Clean, degrease, and if necessary, shave the area where the electrodes
black (negative) clip. Fasten the acceleration transducer with its largest
2. Turn TOF-Watch" on by pressing the on-off button and holding it down

for 1 second (this will be acknowledged by a short beep).
The device can be switched on while the patient is awake.
3. Press the calibration button: The calibration function CAL 2 automatically measures the supramaximal current. W ithin a maximum of 30 seconds, the device is calibrated and operational.
Alwayscalibrate after anesthesia induction, but before muscle relaxation!

pointless if the patient is already relaxed. The suitable time point for calibrat ing is during test ventilation directly prior to NMBA injection .
occurs in IS-second cycles . Switch to the PTC mode if the aim is to
These three buttons are all that is needed to quickly set up the rOF-Watch- SX
for objectively monitoring the course of neuromuscular blockade!
When neuromuscular monitoring is initiated intraoperatively on already
relaxed patients, the procedure is the same as descr ibed above, but the
calibration step is left out ; calibration here would be pointless .
165
4.6 . TOF-Watch- SX
4.6.2
-
Brief overview
Calibration: Press CAL I, i.e., automatically adjust gain to 100% control
twitch height; the stimulation current is set to default (50 rnA). Press CAL
2, i.e., automatically adjust gain so that the T1 response is 100% control
twitch height; the supramaximal current is measured automatically.
Stimulation modes: TOF, TOFs (Slow-TOp), PTC, single twitch (l Hz
and 0.1 Hz) , moreover, the user-programmable button (P button) can be
programmed to produce either DBS (3.3 or 3.2) or tetanic stimulation (50
Hz or 100 Hz) .
Output in neuromuscular monitoring: Constant current, infinitely selectable between 0-60 rnA, the default is pre-set to mea sure supramaximal
current, pulse width between 200 Ils and 300 Ils.
between 0-6 rnA, default pre -set to 1.5 rnA, pulse width of 40 Ils.
The TOF-WatchO will automatically switch to the regional anesthesia
mode when the special stimulation cable is connected.
166
4.6.3
Scheme of buttons and display symbols on the TOF-Watch SX

(D Fig. 4.10)
1. Stop l on-off button
2. Post-tetanic count (PTC) or pre-programmed stimulation button
3. Train-of-four (TOF) or slow train -of-four (TOFs) button
5. Secondary function symbol
6.
7.
8.
g.
Calibration symbol
Device on I stopped symbol
8attery status symbol
Internal error symbol

14. Timer I stimulation symbol
19. Value forTOF ratio, twitch height, PTC or stimulation current
20. Percent symbol : used for TOF ratio or twitch height
21.
22.
23.
24.
rnA ( ~C ) up button
Calibration button
rnA ( ~C ) down button
25. Temperature button

26. Microsecond (us) symbol
27. Degree Celsius (OC) symbol
167
4 .6
. TOFWatch e
SX
a Fig. 4.1 O.TOF-Watch " SX: Scheme of buttons and display symbols
168
All buttons on the TOF-Watch SX nerve stimulator have a double function.

Depend ing on the button, the secondary function is activated in different
ways:
- The double function is depicted in the background on six buttons; the secondary function is activated by first pressing the double function button
and directly thereafter the corresponding stimulation mode button.
- For the other double function buttons, the period of time that a button is
pressing the button for more than 1 sec (long activation) .
The buttons and display symbols on the 'I'Olt-Watch" can be classified into
four categories according to their function.
1. Starting up the TOF-Watch" SX
2. Selecting the stimulation mode
3. Alarm functions
4. Settings
Starting up the TOF-Watch 8 SX

While the nerve stimulator can be switched on in the still awake patient , the
button for the selecting calibration mode may only be operated after indu ction of anesthesia (but before injection of the NMBA). The same applies to
the selection of the stimulat ion mode.
On-off button and /or stop -button
The function activated by this button is determ ined by how long it is pressed.
As soon as the device is switched on, the corresponding symbol
appears
in the display.
Long activation (> 1 s) of this bu tton is required to switch the unit on

and/or off.
Short activation 1 s) toggles the ongoing stimulation off and clears the
last twitch while the device continues to rema in operational. For example,
169
4.6 . TOF-Watch- SX
if the stimulation was performed in the TOF mode, the TOF stimulation
will be toggled off and the last TOF value cleared . If the nerve stimulator
is used again at a later point in time, all the anesthesiologist has to do to
activate the desired function is press the button with the corresponding
stimulation pattern. The original calibration parameters remain stored in
the memory. This function is especially relevant if the nerve stimulator is
not intended to be used intraoperatively for a longer period of time . As recommended, the TOF- Watch" SX can be calibrated at the onset of anesthesia
and subsequently switched to the stand-by mode by briefly pressing the on off button. As the end of the surgery intervention nears, the neuromuscular
recovery can be assessed based on the initial calibration parameters. Here,
it should be noted that the device automatically switches itself off after 2 h
of non-use.
Pressthe on -off button for < 1 s (short activation) to switch the device
to stand-by.
Calibration button
On this model, the calibration routine takes 30 seconds at the most. In the
pre-set default CAL 2 function, the TOF-Watch" SX automatically determines the supramaximal current and simultaneously calibrates the device.
Alternatively, the CAL 1 calibration function can be selected in th e set-up
menu. In this case, calibration only takes 10 s, but, in return, the supramaximal current is no longer measured, instead stimulation is carried out at a
preset current of 50 rnA.
To calibrate, this button must be pressed for at least 1 second . Calibration
of the nerve stimulator is successful when the corresponding symbol
is
Now, the device is operational and the NMBA can be injected .
The nerve stimulator can also be used without pre-calibration. In that
case, however, the results after single twitch and after TOF stimulation in
particular, are less accurate . Operation without previous calibration is indi cated by the flashing symbol ~ .
The secondary function on this button can be used to display the sensitivity of the acceleration transducer and change it as needed.
This function will be explained in more detail in the Settings section.
170
On the TOF-Watch- SX, the calibration procedure (Cal 2) takes no more than
30 s, the supramaximal current is measured automatically.
Up and down rnA (IlC) buttons
These buttons are used to manually set the stimulation current. On the
TOF-Watch" Sand TOF-Watch" SX models, the supramaximal current is
measured and set automatically during the calibration routine. Whereas, if a
different stimulation current is required, it must be manually set by the user;
here a range of 0-60 rnA is available. Functionally, this button features an up
and down option for manually adjusting the strength of the stimulation. The
current is continuous ly stepped up or down depending on which part of the
button is pressed.
Long activation of this button (> 1 s) continuous ly steps up and/or decreases the stimulation current; the current keeps increasing or decreasing
for as long as the up or down part of the button is pressed.
On this TOF-Watch- model. the supramaximal stimulation current

is determined automatically. Any settings other than this must be
made manually.
The secondary function on this button can be used to activate the TOF alarm.
This function will be described in more detail in the Alarms- section.
Four of the remaining buttons on the TOF-Watch" SX are used for selecting
the stimulation mode. Without exception, all of them have a double function. With the three stimulation buttons, a total of five pre-set stimulation
modes can be selected. Additionally, another stimulation mode, either DBS
or tetanus, can be freely programmed with the user-programmable button .
The respective double function is activated by pressing the secondary function button.
The twitch after TOF stimulation and/or after single twitch (1 Hz or
0.1 Hz) is objectively measured and the result indicate d in the display.
171
4.6 .TOFWatch" SX
In addition, the PTC, DBS and the tetanic stimulation modes are available. None of these stimulation patterns are suitable for objective monitoring.
Therefore, they should be assessed subjectively, i.e., either tactilely or visually,
with the TOF-Watch" SX nerve stimulator. The display only shows the mode
selected and the stimulation strength.
The three stimulation buttons on the TOF-Watch" SX have the double functions as listed below:
TOF stimulation and slow (TOFs) button
PTC and user-programmable button
I-Hz single twitch and/or Ol-Hz-single twitch button.
secondary function button- for less than I s and then activating the corresponding stimulation button.
Along with the selected stimulation mode, the symbol for the secondary funct ion . appears in the display. If none of the three double function
stimulation buttons is selected within 5 s, the device automatically toggles to
the stimulation mode that was previously activated.
The secondary function button also features a double function that can
be used to change the impulse duration. This function will be explained in
more detail in the Settings- section.
The secondary function of a stimulation button is selected by pressing the

secondary function button for < 1 s.
Pressing the secondary function button for > I s (long activation), switches
the acoustic stimulation signal on/off and the corresponding symbol is indicated in the display for I s. If the acoustic stimulation signal is switched
on, a short beep can be heard each time the nerve stimulator TOF- Watch"
performs a stimulation. Therefore, when the device is used in clinical practice, the recommended setting is to have the acoustic stimulation signal
switched off.
If the signal is not switched off, the corresponding setting can be made in
the set-up menu .
172
Train-of-four (TOF) or slow train-of-four (TOFs) button

This is one of the three buttons with a double function . The TOF is the primary and the slow train-of-four (TOFs) the secondary function.
TOF mode. Short activation starts a single TOF stimulation . Pressing the
IS-second cycles.
Once all four TOF responses are detected, the display indicates the TOF
ratio in percent (%). When less than four TOF responses are detected or if
the first twitch is less than 20%, only the number of responses is displayed
(without the % symbol).
The following should be noted:
TOE
Short activation 1 s) of rOF button starts a single rOF stimulation;

Long activation (> 1 s) of the button starts a repetitive rOF stimulation.
Slow TOF mode. To switch to the Slow-TOF mode, first press the secondary
function button for < 1 s and then the corresponding stimulation button.
The time between two TOF stimulations can now be set to within an interval
of 1-60 minutes. The pre-set default is an interval of 3 minutes. The set-up
menu can be used to change other settings.
Post -tetanic count (PTe) or user-programmable button
This button also has a double function . PTe is the primary function; the secondary can be used to either select DBS (3.2 or 3.3), tetanic stimulation (50
Hz or 100 Hz) or no function . This button is not assigned a secondary function as a pre-set default. The set-up menu can be used to assign the desired
stimulation mode to the button.
PTe mode. When the PTe mode is activated, the TOF-Watch' SX device
starts by performing IS single stimulations at a frequency of 1 Hz. Since
the PTe can only be used during deep blockade, the device automatically
stops the PTe stimulation and switches to the TOF-mode if after the first
173
4.6 . TOF-Watch- SX
15 single stimulations the patient responds to more than five consecutive

stimulations. Only if fewer than five of the original 15 stimulatory responses are detected, i.e, an appropriately deep neuromuscular block has
been attained, will a 5-second long tetanic stimulation of 50 Hz follow.
After a pause of 3 seconds, the next 15 single stimulations will follow; the
number of detected responses is indicated as PTC on the display. After 12
seconds, the display clears and the TOF-Watch" automatically enters the
continuous TOF stimulation mode . The next PTC cannot be started until
after another 2 minutes.
The PTe mode can only be activated in deep neuromuscular blockade.

If the block is not sufficiently deep, the unit automatically switches back
to TOF stimulation.
DBS mode or tetanic stimulation. It is not until the user-programmable

button has been assigned the corresponding function, either DBS or tetanic
stimulation, in the set-up menu, that these modes can be accessed. This
button is not assigned a secondary function as a pre-set default. To assign
a function, first press the secondary function button for < 1 s and then the
corresponding stimulation button . The twitch is assessed by visual or tactile
evaluation after both DBS and tetanic stimulation. The display only shows
the selected current and the stimulation mode. Compared to the TOF mode,
the DBS cannot be used as a continuous stimulation mode, but only ondemand as a single stimulation. Another DBS cannot be started until 20 s
after the last DBS stimulation.
The 'I'Of-Watch" SX is equipped with the two DBS modes, i.e, DBS 3.2 or
DBS 3.3. The corresponding setting can be made in the set-up menu.
If the user-programmable button has been assigned with the tetanic
stimulation function, tetanic stimulation will be carried out for 5 s at 50
Hz or 100 Hz; the desired stimulation frequency can be set in the set-up
menu . The response after tetanic stimulation has to be evaluated visually
or tactilely. The display only shows the selected stimulation frequency of 50
Hz or 100 Hz and the stimulation mode. Like with the PTC mode, in this
mode, the TOF-Watch SX excludes the use of another tetanic stimulation
for 2 minutes.
174
Both in the DBSmode and after tetanic stimulation, the response has to be
evaluated visually or tactilely. The display only shows the stimulation mode
and the stimulation strength.

single twitch. A I-Hz stimulation is the primary function and a D.I-Hz
stimulation the secondary function . Short activation Is) starts a single
stimulation; long activation (> I s) starts repetitive single stimulations. The
display shows the twitch height of the last response calculated from a control value and indicated in percent. To use this function , the nerve stimulator must be calibrated before the NMBA is injected and the corresponding
TOF-Watch" compares the response with an internal reference control. The
Alarms
nerve stimulator functions and error signals. The former includes the pre-in stalled symbols for the secondary function, calibration, the power button und
the stimulation beep symbol. So now, the TOF alarm function, the temperature button, the remaining displays for timer function and for the stimulation
signal as well as the display for the stimulation current.
TOF alarm function
The secondary function on this button can be used to silence or activate

the TOF alarm function . As soon as the number of TOF responses drops
below the number of responses previously set in the set-up menu, an
acoustic alarm signal beeps. On the display, the loudspeaker symbol and
the transducer symbol are flashing. By default, this function is not activated.
175
4.6 . rOF-Watch- SX
Temperature button
When pressed, the surface temperature measured by the temperature sensor
is shown. If the temperature drops below 32C (measured on the surface of
the extremities!), an attention beep will sound and the temperature display
(0C) flashes. Pressing the temperature button causes the flashing to stop. The
temperature display will flash in a similar fashion if the temperature sensor
becomes disconnected .
:~: Optical stimulation signal and timer

When the center dot in the timer symbol is flashing, the TOF-Watch" is currently performing a stimulation. This signal appears during all six stimulation patterns. During repetitive stimulation , the symbol .". indicates the time
to next stimulation.
Stimulation units
The TOF-Watch" can show the strength of the electrical stimulation in both
milliamperes [rnA) and microcoulomb [fiC)o For routine monitoring, the
current is therefore set to a milliampere display. Occasionally, for use in regional anesthesia, the electric charge is indicated in fie.
IJC Microcoulomb is the unit of electric charge and measures the quantity
of electricity.
Error signals
Whenever an error is detected, the stimulation is suspended . The flashing
symbol alerts the user to the error. Attention beeps will sound unless the
acoustic stimulation signal has been switched off in the set-up menu. The
TOF-Watch" features the following error alerts:
EI
Battery status symbol : This symbol only appears on the display, if the
battery is low ~ and/or empty 13. This means the battery should be replaced.
Internal error symbol : This symbol is displayed whenever a technical problem is detected. When this symbol is displayed, the device should be taken to
the technical services department or the responsible service company.
176
Acceleration transducer symbol

When this symbol is flashing, either no acceleration transducer is present or
be attached either at the test muscle (normally thumb) or its position/fixation
checked. Moreover, this error signal can also be due to a too weak stimulation current.
Three different error signals alert the user to problems with the stimulation electrodes and/or any of the cables.
-+) A flashing surface electrode symbol indicates a missing or bad electrode connection.
-) This flashing symbol means that the skin resistance is too high. Clean the
skin where the stimulation electrodes are attached and shave away any excessive hair growth. Poor quality of the stimulation electrodes may be another
cause.
-)..., If these two symbols are flashing simultaneously, check the connection
between the stimulation cables and the two electrodes. Usually, a cable is not
connected. Resistance too high symbol.
;....-c::::::I
Settings
This fourth and last section deals with the repeatedly mentioned set-up
menu . In the set-up menu, the basic settings of the TOF-Watch" nerve stimulator can be pre-programmed and remain stored in memory even when the
battery is removed. This menu is used to customize some of the parameters
and to permanently store the settings. It is recommended to define standard
settings for these parameters and only make changes as agreed. Otherwise,
use of the nerve stimulator could easily lead to malfunctions, misunderstandings or misinterpretations.
In addition, the following two settings are stored as a secondary function
of the calibration button and of secondary function button:
The secondary function on this button can be used to display acceleration transducer sensitivity for 5 s. During this period, sensitivity can
be increased/decreased by pressing mA (flC) up or down. This func tion can be used to optimize twitch height percentage manually. This can
make sense when the calibration function did not produce a 100% control
response.
177
4.6 . TOF-Watch- SX
The sensitivity can be adjusted between 1 and 512, where 512 represents the most sensitive setting. Sensitivity setting 157 is the default sensitivity.
After successful calibration, do not change sensitivity because this will
invalidate any previous calibration of the device. By contrast, any changes
made at this point would not affect the default setting selected in set-up
menu.
The secondary function on this button can be used to toggle stimulation pulse width between 200 and 300 fls. This makes sense if, previously,
200 fls at 60 rnA was not sufficient to produce supramaximal stimulation. In
this case too, any previous calibration will be invalidated. By contrast, any
changes made at this point would not affect the default setting selected in
set-up menu .
The set-up mode can only be accessed when the TOF-Watch" SX is
switched on. The set-up menu is operated by pressing one of the two rnA
(flC) up and down button and the calibration button .
To enter the set-up menu, press both rnA (flC) up and down buttons
simultaneously. To modify the setting of the displayed parameter, now press
either the mA(flC) up or down button . To store the modified setting, again
press both rnA (flC) up and down buttons simultaneously. Within the activated set-up menu, press the calibration (CAL) button to activate the individual parameters (D Fig. 4.11).
To enter the set-up menu, press both mA (!leI up and down buttons
simultaneously. Pressthe calibration button to select the individual
parameters.
178
Set.up param tt>r.
ra: 5 n0511ing (fOF5 rtpf1ition time)

TOFS repetition time n be adjusted belW~n I nd
60 minutes.
3I:
Surfaa tltarode + 51ilTlJfotionnoshing(51itrXJlotion unia)

rnA:
Surfaaelectrodestil1lulation st~ngth in l1IiUi-ampertS.
IJC:
Surfaa electrodestil1lU lion st~ngth in lIiclO-COUloI'Ib.
SurfrJa earod+ 51itrXJlotion n05hing (pUlf . 11)

200 uS:
Default sulfa stil1lulatlon pulsewidth can be selected
t0 200or 3~
SurfrJa
SOmA:
NtMft
~C:
rnA:
aroa + 51ilTlJlotionnOll1ing (j/ itrXJlotion lizt)

Oet ult sulf ceelectrodestlmulation stlength can be
adjusted btlW~n 0 and 60 mA (0 nd 121 18llC).
tarodt + 5limulotion f105hing (5rimrJoo'on uBa )

Needle stimu ionstltngth shownIn l1Iicro<oulomb.
Needle stimu ionstltngth shownin lIiU i.... mperes,
NtMf, tarodt + 5rimulotion flo5hing (5rimrJorion size)
0.0 IJC:
Det ult need elealOdestil1lulation st~ngth can be

adjusted
een 0.0 and 6.0 mAl014 1JC.
p no5hing (P buttonfuncrion)
no functloo assigned to P button
OIlS 33:
OIlS 31 :
50 Hz:
100Hz
Lo + loud
1-4:
3 lOO'lb:
OIlS 3J stil1lulatlon assignedto Pbutton

OIlS 31 stil1lulatlon assignedto P button
50 Hz ltUInicstiR.I ion assigned to P button
100 Hz let nicstlllU tion assignedto P button
II + tromducer noshing ([ow TOF of111m)
Imt TOF I rm not actlile
TOF I rmwill sound If the number of TOF
~ponses a~ below the numberof set responses.
Imt TOF alarmwill sound If the TOF ratio is below
set percentage.
a Fig. 4.11. TOF-Watch" SX set-up parameters
Setup Disp
rTiiFl
rr..
D
o
179
4 .7 FAQS
4.7
FAQS
The following section will address several of the questions that frequently
arise in connection with the application of neuromuscular monitoring and
acceleromyography.
4.7.1
Can acceleromyography also be used in infants?
The pharmacokinetics and pharmacodynamics of NMBAs vary markedly

between neonates and infants compared to older children and adults. The
most important of the reasons for this include the fact that their body compartments differ in composition, their organ development is still immature
and that the ACh receptor is still in transition from the fetal to the adult
form .
Therefore, particularly in these tiny patients, neuromuscular monitoring
makes sense to ensure safe application of NMBAs. Another aspect is that the
usual clinical tests are obviated in this patient cohort. For example, babies
will very rarely lift their head for 5 seconds when asked, even if a residual
blockade is no longer present!
Driessen et al. [12] investigated whether acceleromyography is also safe
to use in neonates and small infants. They included a total of 22 babies in
their study; the average age was 3 months and the average weight 4 kg. In all
22 patients, the authors were able to calibrate the TOF-Guard nerve stimula tor successfully. In 13 patients, however, the transducer signal gain factor had
to be increased manually to maintain a baseline value of 100%. Once this was
achieved though, the course of neuromuscular blockade was easily recorded
after 0.3 mg/kg rocuronium; the T1 response recovered to 101 (15)% and
recovery of the TOF ratio was 92 [12].
On the current TOF-Watch Sand TOF-Watch SX models, the secondary function on the calibration button can be used to manually modify the
sensitivity of the transducer signal gain factor. In this pediatric patient group,
TOF-Watch" nerve stimulators can also be used to objectively monitor the
course of neuromuscular blockade - an option that should lead to enhanced
safety when administering NMBAs to neonates and infants.
180
4.7.2 Is neuromuscular monitoring painful
for patients?
Neuromuscular monitoring is recommended to be continuous. When neuromuscular monitoring is performed continuously, a suitable time point for
reinjection ofNMBAs can be determined intraoperatively and the progress of
neuromuscular recovery followed over a longer period. In conjunction with
clinical signs, this strategy allows a more reliable assessment of neuromuscular blockade than when neuromuscular monitoring is used only as an isolated test at the end of the surgery. Moreover, more accurate measurements
and results are obtained with quantitative nerve stimulators if they have been
pre-calibrated. The above statement is valid for acceleromyographs as well as
for the neuromuscular transmission (NMT) module. For this reason, quantitative neuromuscular monitoring should be applied continuously throughout
the entire procedure.
Occasionally, the concern is expressed that continuous intraoperative
monitoring of neuromuscular blockade may be associated with postoperative
skin irritation around the stimulation site or myalgia of the test muscle for
patients. Neuromuscular monitoring is a noninvasive monitoring method
that is regarded as safe and generally risk-free for patients. The literature
contains at least two publications that address the subject of erythema at the
stimulation site and myalgia of the test muscle.
Nakamura et al. [13] reported on three patients who developed skin
erythema after neuromuscular monitoring. The surgical interventions lasted
4 h 50 min, 8 h 20 min and 8 h 50 min, respectively. All patients were monitored by electromyography (Relaxograph). In two patients, carbon-coated
EeG electrodes were used and in one patient, electrodes especially designed
for neuromuscular monitoring which were also carbon-coated. In all three
observed cases, the erythema completely resolved within a few days without
additional treatment; none of the affected patients suffered any late sequelae.
All three cases showed loss or damage of the carbon when the electrodes
were detached. The authors of this case report considered this to be the cause
for the erythema. Obviously, it is not recommended to use damaged electrodes . Irrespective of this report, it is very important that the electrodes are
sufficiently coated with electrode gel to guarantee optimal conduction of the
stimulation current.
181
4.7 FAQS
It is very important to ensure that the stimulation electrodes are not

damaged and are sufficiently coated with gel.
A report published in 2007 addressed, among others, the question of skin tolerability and muscle pain after the continuous application of neuromuscular
monitoring [14]. This prospective study enrolled a total of 220 patients. The
duration of anesthesia was 120 min (60 min). All patients received continuous monitoring of their neuromuscular blockade with the TOF-Watch"
S throughout the entire intervention. Stimulation was administered at a constant current of 50 mAoThe following parameters were evaluated during the
first 24 hours after surgery:
- Local irritation around the stimulation site
- Redness around the stimulation site
- Contact dermatitis around the stimulation site
- Muscle ache of the test muscle
In none of the patients investigated did the authors detect any anomalies at
the stimulation site or at the target muscle, thereby confirming that neuromuscular monitoring is simple and easy to perform, and harmless for the
patient.
Several authors have proposed using neuromuscular monitoring in
the postanesthesia care unit to check the patient's neuromuscular recovery
[10]. Within this context, they asked whether neuromuscular monitoring
was painful and/or caused discomfort when administered postoperatively
to awake patients. To answer this question, Saitoh et al. investigated the
pain sensation patients subjectively experience at different stimulation
currents [15]. Based on their results, the authors concluded that a stimulation strength of 30 mA represents the best compromise between the
requirements placed on neuromuscular monitoring techniques and patient
discomfort. This conclusion can be interpreted to imply that conscious
patients regularly experience discomfort at stimulation currents above
30 mA, whereas stimulation currents less than 30 mA are usually insufficient to obtain a reproducible measurement. Overall, however, there are
numerous other arguments that speak against the concept of neuromuscular monitoring in conscious patient s in postanesthesia care units . The
major ones are listed below:
182
Even when subjected to low currents 30 rnA), patients have frequently

been observed to exhibit involuntar y defensive movements that could
falsify the measurement.
If neuromuscular monitoring is not admini stered until the patient is in
the postanesthesia care unit, the measurement must be taken without
calibration. This limits the accuracy of the acquired data.
The question concern ing whether neuromu scular recovery is adequate
should not wait to be addressed until patients are awake in the postanesthesia care unit, but rather while they are still in the operating room, prior
to extubation . Notwithstanding the above, it is paramount that every residual block be detected in a timely fashion and treated with the appropriate
measures.
The results of a survey on German customs for administering NMBAs and

neuromuscular monitoring have shown that, in Germany, no clinical relevance is attached to the concept of neuromuscular monitoring on the awake
patient in recovery rooms.
The question of adequate neuromuscular recovery should not wait

until patients awaken in the recovery room, but while they are still in
the operating room, prior to extubation.
4.7.3 What to observe when attaching TOF-Watch 8

nerve stimulators?
This chapter deals with specific questions such as whether the polarity of the
stimulation electrodes affects the measurement, how to properly attach the
acceleration transducer, how to position the patient's arm and whether the
thumb should move freely or not.
The question as to whether stimulation electrode polarity affects the
stimulatory response was pursued by Brull and Silverman [16]. These author s
established that the polarity of the electrodes indeed influenced amplitude
and that, in most cases, the amplitude of the evoked response was greater
when the negative electrode of the stimulation cable (black terminal) was
connected to the distal electrode. Based on this evidence, it is recommended
to consider electrode polarity when setting up neuromuscular monitoring
183
4.7 FAQS
and to confirm the consistency of the baseline evoked response. Subject to

inter-disciplinary discussion, the negative end of the cable (black) should be
attached to the distal electrode (a Fig.4.12) . Such a standardized procedure
is important in research because it contributes to making the results comparable. This recommendation should be given equal consideration in clinical
practice, since the negative-to-distal electrode configuration ensures the
greatest probability that the optimal stimulatory response will be obtained
at the pre-set current. Moreover, the recommendations for the stimulation
electrodes detailed in ~ Chapter2 should also be observed.
The negative connection on the TOF-Watch- stimulation cable (black) shou ld

be attached to the distal stimulation electrode.
a Fig. 4.12.Polarityof
the stimulation cable.The
negativestimulation cable
(black) isconnected to the
distal electrode
184
When connecting the acceleration transducer, the following should be observed: The acceleration transducer must be taped with its largest flat side to
the inner side of the thumb . It is best to fasten the cable in such a way that no
drag is exerted on the transducer. It is additionally important to note that the
more distal the transducer is placed on the thumb, the stronger the acceleration signal. This technique also makes the measurement less susceptible to
artifacts and disturbances.
Finally, the best position in which the arm should be placed needs to be
discussed and whether the thumb should move freely or not. Not only is the
acceleration of the transducer influenced by the force development of the
stimulated muscle, but also by the direction of gravity, its starting position
and the elastic components of the test muscle being examined. To produce
reliable measurements, the patient's hand should therefore be fixed in the supinated position. Moreover, the thumb should strictly be allowed to move in
a horizontal direction in order to keep the influence of gravity constant.
For the reasons mentioned above, it was originally demanded that the
thumb be allowed to move freely. Meanwhile, the recommendation for research studies, at least, is to measure with a preload. The use of a preload
indeed makes sense for clinical applications of acceleromyography, too. In
clinical practice, intraoperative repositioning of patients is not uncommon,
e.g. lowering their head or turning them on their side. Without a preload,
the starting position of the thumb can also shift in relation to the patient's
position and thereby influence the twitch measured by acceleromyography.
The advantage of preloading primarily lies in the fact that it ensures that the
thumb always returns back to its exact original position and thereby prevents
the measurement from being confounded by intraoperative repositioning
of the patient. Against this background, the TOF-Watch hand adapter was
developed as a special accessory similar to the clamp on the NMT module
( a Fig.4.13).
4.7.4 Is calibration really necessary?
All that is needed to calibrate TOF-Watch" nerve stimulators is a press of the

corresponding button. Depending on the program, the calibration procedure
itself takes approx. 10 seconds (CAL 1), but no longer than 30 seconds (CAL
2) and runs automatically.
185
4.7 FAQS
a Fig. 4.13. rOF-Watch" hand
adapter
And, there is much more behind the question concerning the necessity
for calibration than the few seconds time required to make the device operational. Calibration is performed prior to NMBA injection. This means that
neuromuscular monitoring should be initiated during anesthesia induction,
when calibration of the nerve stimulator is intended . In most cases, however
the neuromuscular monitor is not used until the surgery is underway and/or
at the end of the surgery and, consequently, can no longer be calibrated. On
the heels of the question of calibration follows the next: How should TOFWatch" nerve stimulators be employed - continuously throughout the entire
surgery or only as an isolated test, e.g. at the end of the operation? The extent
to which the type of application affects the accuracy of the findings obtained
with the TOF-Watch" nerve stimulators was investigated in the following
studies performed by the author's own working group.
First, we examined which test is best suited to assess neuromuscular
recovery at the end of the surgical procedure when used in isolation [17].
With this objective, 40 patients scheduled to undergo abdominal surgery
186
were enrolled. Neuromuscular blockade was continuously monitored by

mechanomyography on one hand. Upon skin closure, a DBS, an acceleromyographic TOF and a 100-Hz tetanus were applied in direct succession to
the other hand. The twitches after DBS and tetanus were evaluated tactilely,
whereas the TOF ratio was measured objectively with a TOF-Watch nerve
stimulator. The measurement was performed without calibration; the stimulation strength was manually set to 50 rnA. The results are summarized in
a Tab.4.3. Of the 40 patients investigated, 31 had a residual blockade. Above
a mechanomyographically measured TOF ratio of 0.5, no more fade could be
detected after DBS. As a result, the residual blockade that actually existed was
not diagnosed in 22 of 31 patients .
By comparison, several patients still showed marked fade after tetanic
stimulation despite adequate neuromuscular recovery. With the TOF-Watch"
nerve stimulator, however, residual blockade was not detected in only 9 of 31
patients , whereas 8 of the 9 patients had at least a TOF ratio > 0.75. Even by
this minimalistic approach, i.e., a single TOF stimulation at the end of the
operation without initial calibration, neuromuscular recovery was evaluated
correctly in the overwhelming proportion of patients (aTab. 4.3). In this test,
the probability of actually detecting residual blockade was 47% compared
with 29% for DBS [17]. When the TOli-Watch" nerve stimulator was used,
albeit without calibration, but throughout the entire recovery phase and not
just for a single TOF stimulation at the end of the operation, this probability
rose to as high as 72% [18]. Neither DBS nor tetanic stimulation were able to
achieve comparable values [17, 18].
Even when pre -calibration is omitted and TOF only measured byacceleromyography at the end of the operation, this method is still better suited to
detect residual blockade than subjectively assessed fade after DBSor tetanus.
Conversely, if acceleromyographic monitoring is carried out continuously

right from the beginning of surgery, the probability of this method actually
detecting incomplete neuromuscular recovery goes up to 97%. However,
previous calibration of the device is a prerequisite for this [19]. Thus, acceleromyography can help to reliably detect patients who do not need to be
reversed at the end of the operation. When the device is used properly, even
low levels of residual blockade can be diagnosed with certainty. This is a feat
that subjective neuromuscular monitoring cannot achieve.
187
4.7 FAQS
a Tab. 4.3. Isolated AMG, lOG-Hztetanus or DBSfor detecting residual blockade

(mod ified after (17))
Patient
MMGTOF
AMGTOF ratio
lOG-Hz tetanus,
D8S
rano
>0.9
No fade
No fade
0.06
0.16
0.18
0.20
0.24
0.2B
0.39
0.44
0.47
10
0.48
11
0.50
12
0.52
13
0.57
14
0.60
15
0.60
16
0.63
17
0.66
18
0.67
19
0.72
20
0.73
21
0.76
22
0.76
188
a Tab. 4.3. Conrinued

Patient
MMGTOF
ratio
23
0.79
24
0.79
2S
0.80
26
0.81
27
0.82
28
0.84
29
0.85
30
0.86
31
0.87
32
0.90
33
0.90
34
0.91
3S
0.91
36
0.92
37
0.93
38
0.94
39
0.94
40
1.00
AMGTOFratio
>0.9
1OO-Hz tetanus,
No fade
DBS
No fade
Neuromuscular recovery was measured by mechanomyography (MMG) in 40 patients. At the

end of the intervention, neuromuscular recovery were assessedon the contralateral arm by
a double-burst stimulation (DBS), a single acceleromyographic (AMG) TOF stimulation and
a 1OO-Hz tetanus; the results of this study were subsequently compared with the reference
value obtained by MMG. The MMG values of the 40 patients are listed in ascending order.
Dark blue :Test revealed residual blockade; Light blue :Test showed complete neuromuscular
recovery.
189
4 .7 FAQS
When initially calibrated. rOF -Watch- nerve stimulators can rule out even
low-grade residual blockade reliably. This way, patients who no longer need
to be reversed can be detected with certainty.
One thing to be noted, however, is that all this evidence about the accuracy
of TOF-Watch" nerve stimulators is based on the assumption that the acceleration transducer is actually connected and the nerve stimulator is truly
measuring by acceleromyography. In contrast, if, as seen occasionally, the
TOF-Watch" nerve stimulator is used without the acceleration transducer, i.e.
the corresponding nerve is stimulated and the subsequent twitch assessed by
tactile or visual evaluation only, then the device produces an accuracy comparable to that of a simple nerve stimulator.
Concurrent with the discussion about the probability with which neuromuscular mon itoring is capable of detecting the limits of neuromuscular
recovery, one should not forget that continuous monitoring of the neuromuscular blockade can provide even further clinically relevant information .
Indeed , more knowledge is gained about the pharmacology of the NMBA
used; an aspect that is especially pertinent for doctors training for further
specialization.
Likewise, each individual patient's reaction to the respective drug can be
analyzed - evidence that is certainly valuable, even for the experienced
specialist, and enables judicious and safe administration ofNMBAs. Such
information cannot be gathered without quantitative neuromuscular monitoring that is continuous.
Even if the benefits of continuous monitoring are very difficult to document
in randomized, controlled and prospective studies (if at all), this type of information nevertheless goes into the decision-making as to whether a patient
has already recovered from their neuromuscular block sufficiently enough
to be extubated safely or if reversal should be administered before extubating. Such evidence is consequently of clinical relevance. Hence, continuous
neuromuscular monitoring conveys substantially more information than
just drawing an arbitrary line in the sand for sufficient neuromuscular
recovery.
190
4.7 .S Can neuromuscular monitoring with the

TOF-Watch 8 nerve stimulator prevent residual
blockade?
Residual blockades corresponding to a TOF ratio of 0.5-0.9 can lead to a

reduction in vital capacity, upper airway obstruction, pharyngeal dysfunction
and impairment of the hypoxic respiratory response, among other immediate
sequelae. It has moreover been proven that residual blockade is an independent risk factor for postoperative pulmonary complications [20]. Although
residual blockade poses a potential risk for patients in the immediate postoperative phase, anesthesiologists cannot rule them out reliably by their mere
senses nor with the aid of sirnple nerve stimulators.
Even under clinical conditions, acceleromyography can objectively measure neuromuscular recovery and reliably detect minimal partial neuromuscular blockade. Whether this method is actually able to lower the incidence
of residual blockade, however, not only depends on the functionality of
neuromuscular monitoring, but also on other determinants like whether the
method is even employed at all and what therapeutic measures follow on
the diagnosis of incomplete neuromuscular recovery. That said, successful management of neuromuscular blockade is ultimately reliant on a well
thought-through overall strategy.
Citing examples from their own hospital, Baillard et al. [21] showed how
appropriate management lowered the incidence of residual blockade down
to 3% from formerly 62%. Within a quality assurance project, the authors
surveyed the incidence of residual neuromuscular blockade in their postanesthesia care units (PACU). To this aim, a total of 435 patients were studied
over a 3-month period. The large majority underwent abdominal surgery.
The sobering result is well known: 62% of them did not meet the criteria of
adequate neuromuscular recovery, i.e., a TOF ratio >0.9!
The same internal survey additionally examined how frequently neuromuscular monitoring was used intraoperatively and finally how frequently
patients were reversed. A mere 2% of the 435 patients received neuromuscular monitoring and just 6% of the cases were reversed. This was in the
year 1995. The authors established a causal relationship between the high
incidence of incomplete neuromuscular recovery and the rather reticent use
of monitoring and reversal strategies. As a response to the findings from this
first survey, they implemented the following measures:
191
4.7 FAQS
All operating rooms were equipped with objective neuromuscular monitoring devices (TOF-Guard, and later TOF-Watch"), with one nerve
stimulator per workplace
Anesthesiologists and anesthesiology nurses were educated about the
causes and sequelae of residual blockade
Anesthesiologists and anesthesiology nurses were educated on the subject
of neuromuscular monitoring and the pharmacology ofNMBA and their
antagonists
Anesthesiologists and anesthesiology nurses were instructed in the operation of the newly purchased nerve stimulators
The effectivenessof this quality assurance project was reviewed by means
of regular surveys over the ensuing years
The effects of the measures introduced are summarized in a Fig.4.14. The

incidence of residual blockade declined continuously from a former high
of 62% in the year 1995 to just 3% by 2004! At the same time, the number
of patients whose neuromuscular blockade was monitored intraoperatively
rose from an original 2% to 60% by 2004. In parallel to the increase in the
100
80
VI
C 60
.!!!
40
20
0
_
1995
2000
2002
2004
n=435
n=130
n=101
n=218
a Fig. 4.14. Blacksquares: Incidence of residual neuromuscular blockade. Blue bars: Number of
patients (%) receiving intraoperative monitoring and/or reversal (adapted from [21])
192
frequency of neuromuscular monitoring, the number of patients who were

reversed went up to 42% from an initial 6%.
Neuromuscular monitoring exposed residual blockade that were subsequently treated with antagonists.
Based on the data gathered, the authors identified the following independent predictors for the occurrence of incomplete neuromuscular
recovery :
_ Omitting the use of neuromu scular monitoring was identified as the most
important independent predictor for postoperative residual blockade.
- Absence of reversal also markedly elevated the risk of a residual block.
- The duration of surgery was a similarly important determinant in this
context. The shorter the duration of surgery, the greater was the probability that the patient did not completely recover from the neuromu scular
block at the end of the operation .
Another aspect this survey looked at were the factors influencing the individual anesthesiologist's actual decision to reverse the neuromuscular blockade
at the end of surgery. The intraoperative use of neuromuscular monitoring
and the time interval between the last NMBA injection and the end of surgery indeed impacted decision-making on reversal:
- The use of neuromuscular monitoring had a crucial impact on the
anesthesiologist's willingness to reverse. When neuromuscular blockade
was mon itored intraoperatively, the probability that the patient was
reversed at the end of the surgical procedure was also markedly greater.
Nevertheless, even neuromuscular monitoring often did not prevent the
occurrence of residual blockade. This finding may be primarily due to the
patient cohort. A large portion of the patients were undergoing abdominal surgery, which meant that deep neuromuscular blockade frequently
had to be maintained until the peritoneum was closed. The incidence
of residual blockade was accordingly high. Most of the time, however,
the anesthesiologists only discovered these residual blockade thanks to
neuromuscular monitoring, but were therefore that much more willing to

administer reversal agents.
The time between the last NMBA injection and the end of surgery similarly influenced their decision to reverse: The shorter this period , the greater was the probability that an anesthesiologist would decide to reverse
their patient.
193
4.8 Acceleromyography in research
One by-product of the availability of neuromuscular monitoring: The amount

of NMBAs used for reinjection dropped by around 35% in each of the operating rooms. It was perfectly clear that the intraoperative use of neuromuscular
monitoring enabled a more targeted use of NMBA reinjection. The result
was that a reduction in NMBA consumption was observed over the entire
9-year period. The long-term savings gained by the reduced consumption of
NMBAs certainly offset the investment costs spent on purchasing the neuromuscular transmission monitors instead.
The survey of Baillard et al. clearly illustrates that neuromuscular mon itoring
and on -demand reversal can in fact prevent postoperative residual blockad e.
This finding not only applies within the scope of pre-designed study protocols. but also in rout ine clinical operations.
4.8
Acceleromyography in research
With the objective of improve the quality of research studies and facilitate the
comparability of research results, a group of international experts convened
for the first time in 1996 to define research standards for pharmacodynamic
studies on NMBAs. Within this framework, the experts unified pharmacodynamic end points, among others, and presented the Copenhagen Score" - a
system for assessing intubating conditions. Moreover, these guidelines established which monitoring methods are suited for research studies on neuromuscular blockade and how these measuring methods are used properly
[22). These recommendations were broadly accepted and have significantly
impacted research in this field.
Back then, the method of acceleromyography had not been considered
for research , since it was originally developed for clinical monitoring of
neuromuscular blockade. As the first research guidelines in this sector were
finalized in 1996, few studies were available that had compared this new
method with established ones like mechanomyography and electromyography. Consequently, back then, it would have been premature to also recommend acceleromyography for research . In the meantime, innumerable
comparative studies have been published on acceleromyography. Indeed,
mechanomyographs and electromyographs are hardly commercially marketed anymore, a development which has promoted the use of accelero-
194
myographs in research studies . Therefore, these research guidelines , newly

revised and updated in the year 2007, reassessed the merits of this monitoring method. The new research guidelines accepted acceleromyography in
principle for pharmacodynam ic studies and defined how it is to be used in
research [8].
The following section will recount the particular aspects to be observed
when using acceleromyography for research purposes. However, before any
researcher starts planning a scientific study on the action of NMBAs, they
should studiously read the Good Clinical Research Practice Guidelines.
The recommendations contained therein will help prevent serious method ological errors , likely improve the quality of the acquired data and certainly
up the probability that the paper will get published.
4.8.1
Neuromuscular monitoring for scientific purposes:

What should anesthesiologists generally look out for?
When neuromuscular monitoring is intended for scientific purposes, this

list of standard recommendations should be observed - irrespective of the
monitoring method employed.
Stimulation electrodes
To ensure optimal cond uction of the stim ulation current, it is recommended to meticulously clean and degrease as well as slightly roughe n and,
if appropriate, shave the area of the skin where the stimulation electro des
are to be attached . Additionally, the stimu lation electrodes should have a
contact area of 7- 11 mm in diameter and be positioned 2.5-4 cm apart
( . Chapter 2.2).
Stimulation patterns
Among others determinants, the stimulatory response depends on the stimulation frequency. It has been shown that supposedly comparable stimulation
patterns, such as a 0.1-Hz single twitch stimulation every 10 seconds and a
2-Hz TOF stimulation every 12 seconds lead to different pharmacodynamic
outcomes. Furthermore, the time to stability of baseline values influences
195
4.8 . Acceleromyography in research
both the neuromuscular blockade's duration of onset and its duration of action . Increasing the stimulation frequency should thus lead to a shortening of
the onset time and extend the duration of action.
In order to avoid repetitive nerve stimulations and/or direct muscle
stimulation , the individual stimulation pulse should last 300 fis at most. The
pre-defined default current is usually set at 200 fis. The response to PTC
stimulation varies depending on the duration and frequency of the tetanic
stimulation as well as on the interval between tetanus and the onset of a
single twitch.
These variables should therefore be kept constant and be adequately described in the methods section of the publication.
Temperature
Just as body temperature influences the pharmacodynamics and pharmacokinetics of NMBAs, fluctuations in skin temperature occurring around the
target nerve-muscle unit can affect the stimulatory response. Therefore, body
temperature and skin temperature at the stimulation site should be monitored and maintained at > 35C for the body and> 32C on the skin.
Supramaximal stimulation
Always ensure that each patient is stimulated with a supramaximal current.

The respective stimulation strength and the way it is to be determined should
be described in the methods section ( ~ Chapter 2.1).
Calibration
The nerve stimulator used should be calibrated before injecting the NMBA in
order to ensure that reliable and reproducible data are produced. Calibration
involves setting the transducer gain so that the twitch after single stimulation
and/or the T1 response to TOF stimulation equals 100%. This shifts the acceleration signal into the optimal measuring range and reduces background
noise to a minimum. Later, this baseline value serves as a reference value
throughout the entire measurement. The calibration procedure differs from
nerve stimulator to nerve stimulator and should also be detailed in the paper's methods section.
196
For example, on the TOF-WatchOSX,the CAL 2 mode determines the

supramaximal stimu lation strength while it is performing the calibration
( . Chapter 4.3.2).
Signal stabilization
Lastly, a stable baseline value should be obtained before the NMBA is injected and the actual monitoring started. To this end, the stimulatory response obtained over a period of several minutes should not deviate from the
baseline value by more than S%. The stimulation frequency influences the
time needed to maintain a stable baseline value. The higher the stimulation
frequency, the faster the stimulatory response will stabilize.
The following procedure is recommended to coordinate calibration, supramaximal stimulation and signal stabilization when starting the measure ment (D Fig. 4.15):
_ After switching on the nerve stimulator, first apply a couple of stimulations (single twitch stimulations of TOF)
Next, a SO-Hztetanus for S s
Calibrate the stimulatory response
Determine the supramaximal stimulation strength
Onset of stimulation using the stimulation mode and stimulation frequenc y to be applied during the study (typically TOF, every 12 s)
- When the twitch remains stable for 2-S min S% deviation), the NMBA
can be injected and the actual measurement started; otherwise recalibrate.
Immobilization
All neuromuscular monitoring methods react sensitively to movement. For
that reason, the target extremity should be immobilized to prevent motion
artifacts.
Intu bation conditions

Since they can be influenced by the depth of anesthesia, intubating conditions
should be assessed separately, i.e. independently of the examinations on the
time-action profile of the neuromuscular blockade under investigation. This is
the sole way to ensure that intubation is performed under real-life conditions.
197
4.8 . Acceleromyography in research
50 Hz Tetanus for 5 s (only for use with Ml\I G and
r - - - - - - - --
MG )
Ca libration
Supramaximal stimulation ( 1.0 Hz )
Recalibratio n (if needed )
Stable response 1:1 "ting 2-5 min '!

' - - - - - Nil
Yes
lnject I MBA
a Fig. 4.15. Flow chart for determining supramaximal stimulation strength, calibration and
signal stabilization (modified after [8]).
4.8.2
Particulars of performing acceleromyography
Unlike its use in clinical practice, the procedure for performing acceleromyography differs in several ways when used for research purposes.
Choice of materials
Not all commercially available acceleromyographs are suited for research

studies. For example, the latest TOF-Watch" and TOF-Watch" S models are
equipped with a special TOF ratio algorithm ( ~Chapter 4.3.1). This algorithm
always ensures that whenever the second TOF response (T2) turns out to be
greater than the first (Tl), the TOF ratio is not calculated from the ratio of
T4/Ti' but from the ratio T 4/T2 Moreover, no TOF ratios >1 are indicated on
either of the two models.
Even though these two modifications presumably have no vital clinical
implications, nerve stimulators equipped with them should still not be used
in scientific studies. Currently, neither the TOF-Guard nor the TOF-Watch"
SX are implemented with these modifications; as a result, the prevailing
opinion is that these two models may be used for research purposes.
198
Preload
Originally, it was demanded that the thumb be allowed to move freely as

prerequisite for acceleromyographic measurement of neuromuscular blockade at the adductor pollicis muscle. Meanwhile, evidence is gathering that
the use of an appropriate preload markedly reduces the variability of the
stimulatory response and the susceptibility of the method to motion artifacts. Therefore, it is recommended to use a preload of 75-150 g in research
studies. The TOF-Watch" hand adapter is suited for this purpose. Of course,
any other method can be used that ensures a constant preload. Whichever
method is employed, it should be described and the preload given in grams
(g) or newton (N).
Normalization
Now, in the meantime, acceleromyography has been satisfactorily compared with mechanomyography and electromyography, i.e., the two reference
methods . Evidence has shown that acceleromyography frequently produces
slightly higher recovery values than its comparators. Therefore, AMG values
cannot be directly equated with the comparators' measurements. For this
reason, some authors have proposed to normalize- the neuromuscular recovery values measured by acceleromyography, i.e. by first comparing them
with the baseline value, and not to assume adequate neuromuscular recovery
until this normalized value equals a TOF ratio of at least 0.9 (j- Chaptera.s.f ).
Nevertheless, further study is pending before this method can truly be recommended.
Given the above, studies should always indicate the time to achieving
an uncorrected, i.e., non-normalized, TOF ratio of 0.9. It is also advisable to
indicate the time it took acceleromyography to measure an uncorrected TOF
ratio of 1.0.
4.8.3 Guidelines for measuring onset and time profile

of neuromuscular blockade
The stimulation mode influences onset time. Data gathered by a variety

stimulation modes will therefore not be directly intercomparable . The O.l-Hz
single twitch or the TOF stimulation are typically used, while the minimum
200
Intense or deep neuromuscular block
For a certain amount of time after injection of the NMBA, single twitch
stimulations or TOF stimulations will fail to produce a detectable response.
The best mode for monitoring this phase is the PTC mode. The block here is
defined as intense according to the PTC response, i.e. when even PTC stimulation fails to produce a single detectable response.
Deep neuromuscular blockade
Next followsthe phase of the deep neuromuscular blockade. This phase starts
with the occurrence of the first PTC response and ends with the reemergence
of the first TOF response.
Moderate neuromuscular blockade
The phase of moderate neuromuscular blockade is defined as the period

from the occurrence of the first TOF response to the reemergence of the
fourth TOF response.
Neuromuscular recovery
The neuromuscular recovery starts with the occurrence of the fourth TOF
response and ends once the TOF ratio baseline value is achieved.
Additional time intervals of note include Duration 25 and Duration
TOF 0.9. These cover the period from start ofNMBA injection up to a 25%
recovery of the T 1 response and/or a recovery of the TOF ratio to 0.9. The
first interval indicates the duration of surgical relaxation; the second interval defines the total action time of the investigated drug. Irrespective of the
measuring method, the first of three successive measured values above the
respective limit of 25% and/or 0.9 should be evaluated.
Concluding remarks
This textbook has presented the anatomical, metabolic and pharmacolog ical principles of neuromuscular monitoring by starting with an explanation
of the action of acetylcholine at the synaptic junction and the effects of
neuromuscular blocking agents at the neuromuscular endplate. The further
detailed description of the underlying concept of neuromuscular monitoring
covered the discovery of muscle relaxants and a history of nerve stimulation.
201
Concluding remarks
The mechanisms of action of established depolarizing and non-depolarizing

neuromuscular blocking agents (NMBAs) have been elucidated and those of
a new class of selective relaxant binding agents like sugammadex introduced.
The key test muscles stimulation sites and stimulation patterns were analyzed
in terms of their relevance for anesthesia. Extensive evidence from innumerable clinical study reports has been cited to support the proposed approach
towards neuromuscular monitoring device-guided anesthesia.
The reasons why neuromuscular monitoring is so relevant to modern
clinical practice have been argued in a logical and structured fashion and
underpinned by substantiated data. It could be demonstrated that neuromuscular monitoring is indicated for the timing of anesthesia induction, for
intraoperative and postoperative control, for the timing of extubation, in
effect, for perioperative monitoring that extends to the patient's recovery on
the postanesthesia care unit.
The various methods employed to objectively measure the depth of
neuromuscular blockade by mechanomyography, electromyography, kinemyography and be acceleromyography in particular were discussed and the
data supporting the effectiveness of devices such as the TOF-Watch" series of
neuromuscular monitors laid out, always with reference to a body of pertinent literature.
The final and extensive chapter on the features and operation of modern
neuromuscular monitoring devices serves as a manual in the use of these
simple and effective instruments. The reader learns how to place stimulation
electrodes, properly select the stimulation mode and interpret the findings
obtained with neuromuscular monitors.
At the end of each subsection, the key points are summarized succinctly
for the reader. The general conclusion of each of these sections and of the
entire book is that neuromuscular monitoring is critical for the judicious
use of neuromuscular monitoring agents and, in combination with pharmacological reversal, is fundamental to every successful strategy for managing
postoperative residual blockade.
The near future can be predicted to see the concept of device-supported
neuromuscular monitoring becoming an indispensible element of safe and
effective anesthesia in both clinical practice and research. This compendium of all the essential information needed to monitor neuromuscular
function hopes to prove a useful guide to anesthesiologists in clinical practice
and research throughout the world.
202
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4

The Accelograph and the TOF-Guard

The TOF ratio algorithm

Nerve localization in regional anesthesia procedures

Short set-up instructions

Scheme of buttons and display symbols

Short set-up instructions

Scheme of buttons and display symbols

Short set-up instructions

Scheme of buttons and display symbols

Scheme of buttons and display symbols

Can acceleromyography also be used in infants?

Is neuromuscular monitoring painful for patients?

What to obs rv when attaching rOF -Watch nerve

Is calibration really n cessary?

Can neuromuscular monitoring with the rOF -Watch

n rye stimulator prey nt residual blockade?

Neuromuscular monitoring for scientific purposes: What

Particulars of performing accel romyography

Guidelines for measuring onset and time profile of

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4.2 . The Accelograph and the TOF-Guard