• Andrew Bowdle, Logan Bussey, Kelly Michaelsen, Srdjan Jelacic, Bala Nair, Kei Togashi, and Justin Hulvershorn.
• Department of Anaesthesiology, University of Washington, Seattle, WA, USA. Electronic address: bowdle@u.washington.edu.
• Br J Anaesth. 2020 Jun 1; 124 (6): 712-717.

BackgroundTrain-of-four twitch monitoring can be performed using palpation of thumb movement, or by the use of a more objective quantitative monitor, such as mechanomyography, acceleromyography, or electromyography. The relative performance of palpation and quantitative monitoring for determination of the train-of-four ratio has been studied extensively, but the relative performance of palpation and quantitative monitors for counting train-of-four twitch responses has not been completely described.MethodsWe compared train-of-four counts by palpation to mechanomyography, acceleromyography (Stimpod™), and electromyography (TwitchView Monitor™) in anaesthetised patients using 1691 pairs of measurements obtained from 46 subjects.ResultsThere was substantial agreement between palpation and electromyography (kappa = 0.80), mechanomyography (kappa = 0.67), or acceleromyography (kappa = 0.63). Electromyography with TwitchView and mechanomyography most closely resembled palpation, whereas acceleromyography with StimPod often underestimated train-of-four count. With palpation as the comparator, acceleromyography was more likely to measure a lower train-of-four count, with 36% of counts less than palpation, and 3% more than palpation. For mechanomyography, 31% of train-of-four counts were greater than palpation, and 9% were less. For electromyography, 15% of train-of-four counts were greater than palpation, and 12% were less. The agreement between acceleromyography and electromyography was fair (kappa = 0.38). For acceleromyography, 39% of train-of-four counts were less than electromyography, and 5% were more.ConclusionsAcceleromyography with the StimPod frequently underestimated train-of-four count in comparison with electromyography with TwitchView.Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.

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