train-of-four

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train-of-four

a test for measuring the level of neuromuscular blockade: four consecutive stimuli are delivered along the path of a nerve and the response of the muscle is measured in order to evaluate stimuli that are blocked versus those that are delivered. Four equal muscle contractions will result if there is no neuromuscular blockade, but if nondepolarizing blockade is present, there will be a loss of twitch height and number, which will indicate the degree of blockade. This test is commonly used in intensive care units. See illustration.

Ulnar nerve placement for train-of-four stimulation of the ulnar nerve. Electrodes are positioned in a direct line along the lateral side of the wrist. The thumb adducts to stimulation. From McQuillan et al., 2002.

train-of-four

TOF

A monitoring protocol for counting the number of contractions produced by peripheral nerve stimulators in patients who have received neuromuscular blocking agents (NMBAs) such as Pavulon and vecuronium. When NMBAs are used, staff may be unable to use normal assessment techniques of neurological function.

Patient care

In TOF, electrodes are placed on the patient's wrist, and the number of thumb twitches is counted. After the NMBA infusion is begun, thumb twitches are measured every 30 min for 2 hr to ensure the appropriate level of paralysis has been reached. The absence of contractions indicates that too much NMBA is being given; 1 to 2 twitches indicate the appropriate level of drug is being administered, and 3 to 4 twitches indicate the need to increase the infusion rate. Once the desired level is reached, response to peripheral nerve stimulation is measured every 4 hr.

Patients retain sensory nerve function and awareness of their surroundings, so analgesics and sedatives are usually administered concurrently. Whether TOF augments clinical assessment of neuromuscular blockade is controversial; it may be more useful with some neuromuscular blocking agents (e.g., vecuronium) than others.

References in periodicals archive ?

While the facial nerve might be considered the most convenient location for train-of-four stimulation, anaesthetists need to be aware of the potential confounding effect of recent Botox injections in the assessment of neuromuscular blockade.

Assessing neuromuscular function in patients who have received Botox injections

It took two minutes for the train-of-four count to reach zero.

Normal rocuronium sensitivity after titrated intraoperative sugammadex

One hour later, after confirming no residual paralysis on the train-of-four monitor, she was given neostigmine 2.5 mg and glycopyrrolate 0.4 mg.

The use of sugammadex to reverse rocuronium in a patient with myotonic dystrophy

Neuromuscular monitoring (TOF guard, Organon, Netherlands) showed a train-of-four ratio of 0.4.

Should serum calcium levels be measured preoperatively in all multiparous, lactating females?

One report documents a prolonged paralysis of 50 minutes after 1 mg/kg intravenous dose of suxamethonium and the recovery was characterised by fade on the train-of-four, indicating a phase 2 block (1).