Electrical and mechanical train-of-four responses during depolarizing and nondepolarizing neuromuscular blockade

Simultaneous measurements of train-of-four (TOF) responses by integrated electromyography (IEMG) and twitch force were compared for atracurium, vecuronium, and succinylcholine in 30 subjects during nitrous oxide-fentanyl anesthesia. Determinations of TOF were made during neuromuscular blockade (NMB) onset and recovery. Scattergrams and least squares regression lines were plotted, and z-tests for parallel slope and common intercept were used to compare lines. Data for atracurium and vecuronium were indistinguishable in all groups (z less than 0.05), and therefore pooled to represent nondepolarizing blockade. During onset of nondepolarizing NMB, TOF showed a linear relationship indistinguishable from the line of identity (slope 0.93, intercept -0.06, z less than 0.05). During recovery the intercept was unchanged (z greater than 0.05), but the slope was significantly changed, indicating mechanical TOF lags behind IEMG during recovery. This finding is important for interpretation of IEMG when used for clinical monitoring. Comparison of data for depolarizing NMB shows more complex relationships. Integrated electromyography is found to be convenient and reliable for monitoring nondepolarizing NMB.