• Maëlle Le Merrer, Denis Frasca, Maxime Dupuis, Bertrand Debaene, and Matthieu Boisson.
• From the Service d'anesthésie-réanimation, CHU de Poitiers (MLM, DF, MD, BD, MB), Université de Poitiers, UFR Médecine-Pharmacie, Poitiers (DF, BD, MB), Inserm U1246, SPHERE, Methods in Patients-Centered Outcomes and Health Research, Nantes (DF) and Inserm U1070, Pôle Biologie Santé, Poitiers, France (MB).
• Eur J Anaesthesiol. 2020 Jan 1; 37 (1): 38-43.

BackgroundNeuromuscular blockade (NMB) monitoring is essential to avoid residual NMB. While the adductor pollicis is the recommended site for monitoring recovery, it is not always accessible. The flexor hallucis brevis could be an interesting alternative.ObjectiveThe aim of our study was to compare NMB onset and recovery at both sites.DesignProspective observational study.SettingOperating rooms at the University Hospital of Poitiers, France.PatientsSixty patients scheduled for surgery under general anaesthesia with neuromuscular blocking agents were enrolled from January 2016 to September 2017. Data from 56 patients were finally analysed. Among these, 11 patients received pharmacological reversal with neostigmine and atropine before emergence from anaesthesia.InterventionAfter atracurium injection, NMB onset and recovery at the adductor pollicis and flexor hallucis brevis were monitored simultaneously.Main Outcome MeasuresThe time to NMB onset, defined as a train-of-four (TOF) count equal to 0, and the times to NMB recovery: TOF = 1, TOF = 4, T4/T1 ratio = 0.75 and T4/T1 ratio more than 0.90.ResultsNMB onset was significantly slower at the flexor hallucis brevis with a mean onset time of 4.4 ± 1.5 versus 3.7 ± 1.2 min at adductor pollicis (P = 0.0001). Recovery to TOF = 1 was significantly slower at flexor hallucis brevis. No difference was found for TOF = 4. The full recovery of NMB (T4/T1 > 0.90) was significantly faster at flexor hallucis brevis with a mean time to recovery of 59.5 ± 9.9 versus 64.5 ± 10.7 min at adductor pollicis (P < 0.0001), a difference of 4.9 min between both sites. This difference was not present after pharmacological reversal with a mean time to recovery of 53.0 ± 12.2 min at flexor hallucis brevis versus 54.0 ± 12.4 min at adductor pollicis (P = 0.28). However, NMB onset and recovery did not follow the same pattern in individual patients.ConclusionFlexor hallucis brevis could be an interesting alternative site for NMB monitoring when the adductor pollicis is not accessible. However, in the absence of pharmacological reversal, monitoring at the hallucis brevis muscle should be used with caution for the detection of residual paralysis.Trial RegistrationClinicalTrials.gov (NCT02825121).

22 keywords...

hide…