Accuracy and Precision of Three Acceleromyographs, Three Electromyographs, and a Mechanomyograph Measuring the Train-of-four Ratio in the Absence of Neuromuscular Blocking Drugs.

Background: The accuracy and precision of currently available, widely used acceleromyograph and electromyograph neuromuscular blockade monitors have not been well studied. In addition, the normalization of the train-of-four ratio from acceleromyography (train-of-four ratio [T4/T1] divided by the baseline train-of-four ratio) has not been validated in comparison to mechanomyography.
Methods: Enrolled patients had surgery under general anesthesia with a supraglottic airway and without any neuromuscular blocking drugs. Three acceleromyograph monitors, three electromyograph monitors, and a mechanomyograph built in the authors' laboratory were tested. Most patients had an electromyograph and the mechanomyograph on one arm and a third monitor on the contralateral arm. Train-of-four ratios were collected every 12 to 20 s for the duration of the anesthetic. At least 1,000 train-of-four ratios were recorded for each device. Gauge repeatability and reproducibility analysis was performed.
Results: Twenty-eight patients were enrolled. In total, 9,498 train-of-four ratio measurements were collected. Since no neuromuscular blocking drugs were used, the expected train-of-four ratio was 1.0. All of the acceleromyograph monitors produced overshoot in the train-of-four ratio (estimated means, 1.10 to 1.13) and substantial variability (gauge SDs, 0.07 to 0.18). Normalization of the train-of-four ratio measured by acceleromyography improved the estimated mean for each device (0.97 to 1.0), but the variability was not improved (gauge SDs, 0.06 to 0.17). The electromyograph and the mechanomyograph monitors produced minimal overshoot (estimated means, 0.99 to 1.01) and substantially less variation (gauge SDs, 0.01 to 0.02). For electromyography and mechanomyography, 0.3% of all train-of-four ratios were outside of the range 0.9 to 1.1. For acceleromyography, 27 to 51% of normalized train-of-four ratios were outside the range of 0.9 to 1.1.
Conclusions: Three currently available acceleromyograph monitors produced overshoot and substantial variability that could be clinically significant. Normalization corrected the overshoot in the average results but did not reduce the wide variability. Three electromyograph monitors measured the train-of-four ratio with minimal overshoot and variability, similar to a mechanomyograph.
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