KNRS ------], 7 [ ], and this ], and this 9 , Paik Institute Paik 8 2 Review such surgical conditions. In addition, owing to issues such such issues to addition, owing In conditions. surgical such in AMG- (TOF)ratio of train-of-four as overestimation EMG-basedbased neuromuscular equipment, the trends we review this article, In in the spotlight. is back methods for the residual neuromuscular blockade. The The blockade. neuromuscular methods residual for the developed1958 in nerve was peripheral first stimulator (MMG)- and electro mechanomyography and thereafter, devel (EMG)-based methods were measuring myography and complicated bulky these devices were oped. However, so they did not become use, to widely 1988, accel used. In [ introduced first (AMG) was eromyography device based on this principle started be to widely used became portable to and easier as the equipment clinically, AMG-based neuromuscular decades, the following In use. gold stan “clinical as regarded was monitoringequipment to owing however, and widely distributed. Recently, dard” as laparoscopy techniques such in surgical developments de has monitoring surgery, neuromuscular robotic and arm in is difficult the patient's to access because creased 133 - - - - - ]. 6 – 4 eISSN 2383-7977 1,2 • Delayed emergence from ; ; Neuromuscular block Neuromuscular Electromyography; anesthesia; from emergence Delayed ], which first first ], which 3 [ Department of and Pain Medicine, Busan Paik Hospital, Medicine, Busan Paik and Pain Department of Anesthesiology ing agents; Neuromuscular monitoring. Neuromuscular agents; ing performed. Acceleromyography (AMG)-based neuromuscular monitoring was regarded as as regarded was monitoring neuromuscular (AMG)-based Acceleromyography performed. and posture patient’s to issues related However, applied. widely and standard” gold “clinical monitoring neuromuscular with AMG-based associated ratio train-of-four of overestimation re is monitoring neuromuscular (EMG)-based electromyography Recently, increased. have AMG- both weaknesses. AMG’s However, overcomes it since attention, renewed ceiving Ulti followed. are certain when considerations useful are systems EMG-based based and as im is not system monitoring of choice the outcomes, good patient’s assure the to mately, patients. in such implemented be always should which itself, portant monitoring as the Keywords: The latest trend in neuromuscular monitoring: monitoring: neuromuscular trend in The latest electromyography return of the Lee Wonjin 1 Korea Inje University College of Medicine, Busan, for Clinical Research, be must monitoring neuromuscular blockade, neuromuscular residual of risk the reduce To Anesth Pain Med 2021;16:133-137 Med Pain Anesth https://doi.org/10.17085/apm.21014 pISSN 1975-5171 ], while the second was a study on on ], while the second a study was 2 [ ] selected the two most relevant articles ] selected the two relevant most INTRODUCTION 1 [ February 14, 2021 14, February February 21, 2021 21, February The development of neuromuscular blockers and rever and blockers neuromuscular of development The A 2015 review A 2015 review This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits which (http://creativecommons.org/licenses/by-nc/4.0) License Non-Commercial Attribution Commons Creative the of terms the under Access article is an Open This distributed cited. is properly work original the provided in any medium, reproduction and distribution, use, non-commercial unrestricted 2021 Anesthesiologists, Society of Korean © the Copyright residual neuromuscular blockade remain a problem [ a problem remain blockade neuromuscular residual muscular blockers and the use of neuromuscular reversal reversal and the use of neuromuscular blockers muscular mortality and to due complications postoperative agents, increased postoperative complications and mortality due mortality and due complications postoperative increased develop Despite blockade. neuromuscular residual to neuro of action of duration the of reduction as such ments these evidences, the use of neuromuscular blockers could could blockers the use of neuromuscular these evidences, an facilitates that as a double-edged sword be interpreted with associated surgery,and esthesia simultaneously is but of curare from 1942 from of curare the risk 1954 of surgery from and anesthesia Considering blockers. the risk of neuromuscular reported among 20 anesthesiology fields, and in the field of neuro anesthesiology 20 fields, among use on the clinical a report was the first blockers, muscular E-mail: [email protected] E-mail: Korea 82-51-890-6520 Tel: 82-51-898-4216 Fax: Pain Medicine, Busan Paik Hospital, Hospital, Busan Paik Medicine, Pain Research, Clinical for Institute Paik 75 Medicine, of College University Inje Busan 47392, Busanjin-gu, Bokji-ro, Corresponding author author Corresponding M.D. Lee, Wonjin and Anesthesiology of Department Accepted Received Received sal agents resulted in that of neuromuscular monitoring monitoring of neuromuscular in that resulted agents sal Anesth Pain Med of recent neuromuscular monitoring equipment use AMG-BASED EQUIPMENT through a comparison between the most widely distribut- ed AMG-based and recently developed EMG-based equip- Since AMG-based equipment measures muscle acceler- ment. ation, it is very sensitive to movement. Therefore, the im- mobilization of all related muscles and structures except ACCELEROMYOGRAPHY AND for the muscle to be measured is essential (for example, ELECTROMYOGRAPHY immobilizing the arm and 2nd–5th finger during ulnar nerve stimulation) for accurate measurement [10]. In addi- Neuromuscular monitoring equipment measures the tion, the muscles to be measured (for example, the adduc- muscle’s contractile “force” following electrical nerve stim- tor pollicis during ulnar nerve stimulation) should be able ulation. Therefore, the classical standard neuromuscular to move freely. If the movement of the target muscle is re- monitoring equipment was MMG-based, which directly stricted by the surgical cloth or by fixing the arm to the measured contractile “force,” and different types of neuro- body, an accurate measurement cannot be obtained [10]. muscular monitoring equipment are compared with it to According to a Danish survey, 75% of respondents experi- determine their reliability [10]. However, since MMG- enced difficulties > 1 out of four times when using a neu- based equipment is bulky and difficult to set up, it is not romuscular monitor, and 41% considered that these were used for clinical purposes. caused by TOF fluctuation [13]. Therefore, for accurate The AMG-based method measures muscle acceleration AMG-based equipment use, removing obstacles that hin- based on the fact that, according to Newton's second law of der the target muscle movement and avoiding movement motion “Force = mass × acceleration,” force and accelera- of the surgical participant, which affects the measurement, tion are proportional [9]. AMG-based measurements were are two important points. correlated well with MMG-based measurements, and Additionally, AMG-based equipment tends to overesti- showed reliable results [11,12]; thus, it is widely used. Until mate TOF ratio more than MMG- or EMG-based methods, the recent EMG-based devices were released around 2018, with a reported TOF ratio 10–20% higher than with the oth- most clinical neuromuscular monitoring equipment avail- er methods [19–21]. To avoid this, when using AMG-based able was AMG-based. In particular, the TOF-Watch (Orga- equipment it is recommended to “normalize” the TOF ratio non, Ireland) series is widely used worldwide, amounting according to the baseline value. For example, if the base- for 91% of all neuromuscular monitoring devices according line TOF ratio is 1.1 on the AMG-based equipment, all to a 2017 Danish survey [13]. measured TOF ratios should be divided by 1.1. If the TOF The EMG-based method measures the compound mus- ratio on the monitor is 0.9, the normalized value is 0.9/1.1 cle action potential (CMAP) and focuses on the fact that = 0.82, which means that recovery has not yet been the CMAP is proportional to the muscle’s contractile force. achieved. However, in the clinical field, it is difficult to nor- The EMG-based method was also correlated well with the malize each measurement, so for convenience, when using MMG-based method [14,15], but some reports found mi- AMG-based equipment, TOF is generally considered to be nor dissimilarities [9,16,17]. However, recently neuromus- 10% higher, and the criterion for neuromuscular recovery cular monitoring consensus concluded that the EMG- is not > 0.9, but rather > 1.0 [22,23]. based methods are reliable enough to be exchangeable There are some considerations when using TOF-Watch, with MMG [18]. Until 2018, only one EMG-based equip- the most widespread AMG-based equipment. There are ment, the Datex-Ohmeda NMT module (GE Healthcare, three versions of TOF-Watch: TOF-Watch, TOF-Watch S, UK) was clinically available, so it was not commonly used. and TOF-Watch SX. The first two display values up to only Recently, the TwichView (Blink Device Company, USA) 1.0, even when measured TOF ratios are > 1.0, so they are and TetraGraph (Senzime AB, Sweden) have been released not recommended for research requiring accurate mea- and the use of EMG-based monitoring has been increas- surements because normalization is impossible [10]. ing. Since the accelerometer in TOF-Watch recognizes only unidirectional (front-back) acceleration [24], accurate measurements can only be performed when the sensor di- rection matches the muscle movement. TOF-scan (Drager

134 www.anesth-pain-med.org KNRS - ] ------]. 28 ,

29 135 27 [ Conclusion ). Bowdle et al. Table 1 Table ( discomfort assessment of neuromuscular block neuromuscular assessment of ade with EMG in comparison count count of-four Two devices caused the same level of of level same the caused devices Two EMG most closely resemble MMG MMG resemble closely most EMG TOF underestimated frequently AMG train- the overestimate may E-NMT The % ]. 59 27

, ] evaluated whether TetraGraph would re TetraGraph whether ] evaluated 26 [ 30 [ Result mA) mA) mA) mA) (AMG) 20 30 40 50 (AMG vs. (AMG EMG) (MMG) ( ( ( ( (EMG vs. (EMG MMG) (EMG) 9 . 2 3 5 6 7 8 67 63 % of E-NMT data were were E-NMT data % of Recent research has focused on the increasing use of re focused has the increasing on research Recent EMG-based devices are released summary,In recently : : : : . . . . % of TwichView data, TwichView % of 2 3 5 5 4 14 0 0 0 palpation (kappa): palpation data. 30 data. with palpation identical expected to continue to increase in use of their ac because increase to expected continue to of and the solution the issues to measurement curate AMG-based equipment: the need overesti normalize to limitation usage and the perioperative values TOF mated posture. the patient's by trode. Furthermore, overestimation, a major problem of of problem a major overestimation, Furthermore, trode. be used can which without in EMG, an issue is not AMG, normalization EMG-based equipment cent correlated was TwichView from ratio TOF the that reported with with MMG-based than AMG-basedmore equipment accu and sensitive more were TOFs that and equipment, with equip AMG than with MMG-based equipment rate and the between study TwitchView a comparative In ment. EMG de previous the only NMT module, Datex-Ohmeda [ counts TOF reliable showed more TwitchView vice, et al. Nemes duringduce pain nerve the larger to owing stimulation they but electrode, nerve of the area stimulation contact TOF- to compared scores in pain showed no difference Watch. Median score (EMG:AMG): score Median Mean difference: Mean with agreement Substantial E-NMT > for TwichView 70 ------]. 24 Latest trend in NM monitoring in NM trend Latest Comparison target Comparison TOF count TOF (VNRS) score Pain TOF ratio TOF count TOF ]. Conversely, ]. Conversely, 13 [ ], and accurate measure ], and accurate 25 [ Comparison groups Comparison AMG (Stimpod™) AMG (TwichView™) EMG Palpation (TwichView™) EMG (E-NMT module) EMG (TOF-Watch™) AMG (Tetragraph™) EMG MMG (Stimpod™) AMG (TwichView™) EMG Palpation MMG 5 43 46 135 Study Study population (n) population ] ] ] ] ]. Therefore, new EMG-based monitoring new EMG-based monitoring ]. Therefore, 28 27 29 30 [ [ [ [ 18 The Study of the Recently Launched Electromyography-based Devices Electromyography-based Launched Recently the of Study The Study In recent years, the use of laparoscopic and robotic sur and robotic the use of laparoscopic years, recent In RETURN OF THE ELECTROMYOGRAPHY RETURN OF THE www.anesth-pain-med.org TOF: train-of-four, EMG: electromyography, MMG: mechanomyography, AMG: acceleromyography, VNRS: verbal numeric rating scale. TwichView™ TwichView™ scale. rating numeric verbal VNRS: acceleromyography, AMG: mechanomyography, MMG: electromyography, EMG: train-of-four, TOF: Xavant of trademark the is Stimpod™ AB (Sweden). Senzime of trademark is the Tetragraph™ (USA). Company Blink Device of trademark is the (USA). Healthcare GE of is a product E-NMT module (Ireland). Organon of trademark is the TOF-Watch™ Africa). (South Technology Nemes et al. al. et Nemes Bussey et al. Bussey al. et Bowdle et al. al. et Bowdle Bowdle et al. al. et Bowdle complex lines, now they only require one integrated elec one integrated they require only now lines, complex 1. Table creased owing to this recent surgical trend. Another ad trend. surgical this recent to owing creased EMG de while previous models is that, of current vantage and connecting electrodes five attaching vices required stricted [ in been gradually developed has its usage and equipment EMG-based equipment has been be af to EMG-based less reported has equipment position the arm’s fected by is re movement muscle if the target even is possible ment during surgery. Sixteen percent of respondents to a survey to of respondents during surgery. percent Sixteen arm position patient's the to due difficulties reported AMG-based when using equipment ment. Although the patient's arm can be accessible for for beaccessible arm can patient's the Although ment. monitoring during induction anesthesia neuromuscular performed be properly monitoring cannot or recovery, tached to their bodies. In such postures, accurate mea accurate postures, such In tached bodies. their to be performed cannot withsurements AMG-basedequip gery has increased. Accordingly, to secure free movement movement free secure to gery Accordingly, increased. has at often arms are the patient's the patient, around space Technologies, Canada), which compensates for this prob compensates which Canada), Technologies, in all acceleration measure to a 3D-accelerometer lem by [ measurements accurate more enables directions Anesth Pain Med

ELECTROMYOGRAPHY OR CONFLICTS OF INTEREST ACCELEROMYOGRAPHY? No potential conflict of interest relevant to this article Since 2010, international guidelines require neuromus- was reported. cular monitoring when using neuromuscular blockers [31]. In Korea, in order to improve the quality of anesthesia, the DATA AVAILABILITY STATEMENT National Health Insurance Service initiated the Anesthetic Quality Evaluation in 2018. Neuromuscular monitoring has Not applicable. been included in this evaluation, and numerous medical institutions have started to pay attention to neuromuscular ORCID monitoring. Until now, the Korean Neuromuscular Re- search Society conducted several surveys on neuromuscu- Wonjin Lee, https://orcid.org/0000-0002-6240-7370 lar monitoring use, but the rates of neuromuscular moni- toring equipment use were low: 16.7% (2008), 24.7% (2013), REFERENCES and 39.7% (2018) [32,33]. Currently, the use of neuromus- cular monitoring is expected to be increased due to the 1. Barash P, Bieterman K, Hersey D. Game changers: the 20 most Anesthetic Quality Evaluation, but the use rate is still ex- important anesthesia articles ever published. Anesth Analg pected to be low. 2015; 120: 663-70. The best neuromuscular monitoring device is that with 2. Griffith HR, Johnson GE. The use of curare in general anesthe- high measurement accuracy and that is easy to use. The re- sia. Anesthesiology 1942; 3: 418-20. cently released EMG-based equipment not only provide 3. Beecher HK, Todd DP. A study of the deaths associated with more reliable measurements than AMG-based equipment anesthesia and surgery: based on a study of 599, 548 anesthe- [27,28], but also increase the usability by means of a dis- sias in ten institutions 1948-1952, inclusive. Ann Surg 1954; posable integrated electrode. Consequently, we expect that 140: 2-35. EMG-based equipment will eventually replace AMG-based 4. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, equipment in the neuromuscular monitoring equipment Uribe JV, Nguyen NT, et al. Intermediate acting non-depolariz- market. However, AMG-based equipment, which is cur- ing neuromuscular blocking agents and risk of postoperative rently widely used, can be as good a device as EMG-based respiratory complications: prospective propensity score equipment if properly used. For proper and accurate AMG- matched cohort study. BMJ 2012; 345: e6329. based equipment use, anesthesiologists need to pay atten- 5. Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft tion to immobilization of the related structure and secure A, Hollmann M, et al. POPULAR Contributors. Post-anaesthe- free movement of the target muscle, and keep in mind that sia pulmonary complications after use of muscle relaxants the reported TOF ratio is overestimated. Ultimately, the (POPULAR): a multicentre, prospective observational study. choice of monitoring system is not as important as the Lancet Respir Med 2019; 7: 129-40. monitoring itself, which should be always implemented. 6. Saager L, Maiese EM, Bash LD, Meyer TA, Minkowitz H, Grou- dine S, et al. Incidence, risk factors, and consequences of resid- CONCLUSION ual neuromuscular block in the United States: the prospective, observational, multicenter RECITE-US study. J Clin Anesth Neuromuscular monitoring must be performed to re- 2019; 55: 33-41. duce the risk of residual neuromuscular blockade. When 7. Christie TH, Churchill-Davidson HC. The St. Thomas's Hospi- using AMG-based neuromuscular monitoring devices, it is tal nerve stimulator in the diagnosis of prolonged apnoea. necessary to consider immobilization of the measurement Lancet 1958; 1: 776. site and free movement of the target muscle, and be aware 8. Jensen E, Viby-Mogensen J, Bang U. The accelograph: a new that the TOF ratio is overestimated. Newly developed neuromuscular transmission monitor. Acta Anaesthesiol EMG-based devices are recommended because they pro- Scand 1988; 32: 49-52. vide accurate measurements and have few limitations. 9. Viby-Mogensen J, Jensen E, Werner M, Nielsen HK. Measure- ment of acceleration: a new method of monitoring neuromus-

136 www.anesth-pain-med.org KNRS ------

137 . s10877-020- 187-95.

/

. .

. Influence of muscle temperature and fore temperature of muscle . Influence . . ative residual neuromuscular block and neuromuscular moni and neuromuscular block neuromuscular residual ative 2010; 5: 70-4. Med Pain Anesth toring. in and antagonists agents blocking use of neuromuscular rent 2019; 14: 441-8 Med Korea: a 2018 survey. Pain Anesth ed volunteers. J Anesth Clin Res 2018; 9: 848 Clin Anesth J Res ed volunteers. a vs. electromyograph et al. A comparison of a prototype for assessment and an acceleromyograph mechanomyograph 2020; 75: Anaesthesia blockade. of neuromuscular comparison twitch of response: train-of-four et al. Counting and acceleromyography, mechanomyography, to palpation 2020; 124: 712-7. Br J Anaesth electromyography. electctromyo monitor monitoring with the twitchview of-four and manual the GE NMT to electromyograph compared graph 2020 doi: 10.1007 Comput J Clin Monit palpation. of print]. ahead 00615-7. [Epub moni during neuromuscular scores pain volunteer JR. Awake 2020; 130: 941-8 Analg Anesth toring. the recommenda are what blockade: of neuromuscular ment Rep Anesthesiol Curr tions in the USA countries? and other 2020; 10: 90-8 of acceleromyography improved with preload and normaliza and with preload improved acceleromyography of Anesthesiology tion? A comparison with mechanomyography. 2009; 110: 1261-70 anes Miller's editors. blockade. of neuromuscular tagonism) 2015. p. Elsevier. Philadelphia, RD, Miller 8th ed. In: thesia. 995-1027.e5. TOF- and the Comparison M, et al. Deshur of the TOFscan function. Anes of neuromuscular during recovery SX Watch thesiology 2018; 129: 880-8. Br J in the hand. arm electromyography position on evoked 1994; 72: 407-10. Anaesth neu of a new electromyography-based assessment formance discomfort and subjective monitor in unmedicat romuscular Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, TD, SB, Shear Greenberg MJ, JW, Avram Szokol GS, Murphy Nemes R, Nagy G, Murphy GS, Logvinov II, Fülesdi B, Renew B, Renew Fülesdi II, Logvinov GS, Murphy G, R, Nagy Nemes Kim JS, Han JW, Lee JH, Choi JM, Kim HJ, Sung TY, et al. Cur TY, Sung JW, Lee HJ, Kim JM, Choi JH, Han JS, Kim Bussey L, Jelacic S, Togashi K, Hulvershorn J, Bowdle A. Train- J, K, Hulvershorn Togashi L,Bussey S, Jelacic Nemes R, Diószeghy B, Pongrácz A, Tassonyi E, Fülesdi B. Per E, Fülesdi A, B, Pongrácz Tassonyi R, Diószeghy Nemes Bowdle A, Bussey L, Michaelsen K, Jelacic S, Nair B, Togashi K, B, Togashi Bowdle A, Nair L, Bussey K, S, Michaelsen Jelacic K, B, Togashi Bowdle A, Nair L, Bussey K, S, Michaelsen Jelacic Smith DC, Booth JV Nemes R, Renew JR. Clinical practice guideline for the manage guideline JR. R, practice Clinical Renew Nemes Claudius C, Skovgaard LT, Viby-Mogensen J. Is the performance Is J. Viby-Mogensen LT, C,Claudius Skovgaard

...... 33 27. 28. 29 30 31 A survey of postoper HS. Yang Lee YK, KS, Kim Lee32. Seo SS, HJ, 22 (an Reversal RD. Eriksson LI, Miller De Boer HD, GS, 23. Murphy 24. 25. 26 ------

.

1998; 14:

t . ecording of ecording

Latest trend in NM monitoring in NM trend Latest 26: 204-11.

Stockholm re Stockholm

. wart PA, Phillips S. An ipsilateral comparison of comparison of An ipsilateral S. Phillips wart PA,

from nondepolarizing neuromuscular block under general an under general block nondepolarizing neuromuscular from 2013; 117: 373-9. Analg Anesth in humans. esthesia four fade ratio. Acta Anaesthesiol Scand 2005; 49: 1575-6 Anaesthesiol Acta fade ratio. four during recovery electromyography and acceleromyography 2006; 96: 44-7 tion of acceleromyographic train-of-four ratio by baseline val by ratio train-of-four tion of acceleromyographic Br J Anaesth block. neuromuscular residual ue for detecting HR, et al. Consensus statement on perioperative use of neuro on perioperative HR, et al. Consensus statement 2018; 127: 71-80. Analg Anesth monitoring. muscular cle and the mechanomyogram of the adductor pollicis of the adductor com and the mechanomyogram cle Anesthesiology 1988; 68: 604-7. pared. nomyography in cat and man. Dan Med Bull 1996; 43: 301-16. Bull Med Dan and man. in cat nomyography mus interosseous dorsal of the first electromyogram tegrated relaxants during anesthesia. Anesthesiology 1965; during anesthesia. relaxants comparisonA with mecha during anaesthesia. tromyography spontaneous and evoked muscle activity. The clinical value of value clinical activity. The muscle and evoked spontaneous use of muscle the rational to as an aid recording continuous Relaxograph during anaesthesia and atracurium-induced neu and atracurium-induced during anaesthesia Relaxograph 1986; 58: 1447-52 Br J Anaesth blockade. romuscular in Denmark: Acta an online-based survey practice. of current Scand 2017; 61: 619-26. Anaesthesiol 19-27. blockade monitoring of neuromuscular jective neuromuscular en HS, Severinsen IK,en HS, for neuro equipment Schmidt MB. New monitoring: a comparison of the TOF- transmission muscular Compu 2000. J Clin Monit with the Myograph Guard Belg 2002; 53: 85. Belg omyography and acceleromyography for the assessment of ro the assessment for and acceleromyography omyography Anaesthesiol Acta block. induced neuromuscular curonium Meeting. Good clinical research practice in pharmacodynamic in pharmacodynamic practice Good research clinical Meeting. II: the agents blocking of neuromuscular studies Scand 2007; 51: 789-808. Anaesthesiol Acta vision. khur RK, Viby-Mogensen J; 8th International Neuromuscular Neuromuscular RK, J; 8th International khur Viby-Mogensen cular function. Acta Anaesthesiol Scand 1988; 32: 45-8. Anaesthesiol function. Acta cular Fuchs-Buder T, Claudius C, Skovgaard LT, Eriksson LI, Mira LT, C, Claudius Skovgaard T, Fuchs-Buder Naguib M, Brull SJ, Kopman AF, Hunter JM, Fülesdi B, Arkes B, Arkes Fülesdi JM, Hunter AF, Kopman M, Brull SJ, Naguib Liang SS, Ste SS, Liang Suzuki T, Fukano N, Kitajima O, Saeki S, Ogawa S. Normaliza S. Ogawa S, Saeki O, Kitajima N, Fukano T, Suzuki Söderström CM, Eskildsen KZ, Gätke MR, Staehr-Rye AK. Ob MR,KZ, Staehr-Rye Eskildsen CM, Söderström Gätke Kirkegaard-Nielsen H, Helbo-Hansen HS, Lindholm P, Peders Lindholm P, HS, Helbo-Hansen H, Kirkegaard-Nielsen Engbaek J. Monitoring of neuromuscular transmission by elec by transmission neuromuscular of Monitoring J. Engbaek Katz RL.Katz r Comparison of electrical and mechanical Carter JA, Arnold R, Yate PM, Flynn PJ. Assessment of the Datex of the Datex Assessment PJ. Flynn PM, JA,Carter Arnold R, Yate Kopman AF. The dose-effect relationship of metocurine: the in dose-effect The relationship AF. Kopman Kopman AF. Normalization of the acceleromyographic train-of- of the acceleromyographic Normalization AF. Kopman

. . . . www.anesth-pain-med.org 21. 20 19 18. 17. 16. 15. 14 13. 12 11. Pieters A, De Wolff M, Vanlinthout L. A comparison of mechan M, Vanlinthout A,11. Pieters De Wolff 10.