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From the Department of Anesthesiology, Hôtel-Dieu, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montréal, Québec, Canada.
Address correspondence to: Dr. Thomas M. Hemmerling, Centre Hospitalier de l’Université de Montréal (CHUM), Hôtel-Dieu, Département d’anesthésie, 3840, rue Saint-Urbain, Montréal, Québec H2W 1T8, Canada. Phone: 514-890-8000, ext. 14570; Fax: 514-412-7222; E-mail: thomashemmerling{at}hotmail.com
Purpose: To review recent findings concerning neuromuscular blockade and monitoring at the larynx, the diaphragm, and the corrugator supercilii muscle.
Source: This narrative review is based on recent publications.
Principal findings: Neuromuscular blockade at the larynx and the diaphragm is less intense than at the adductor pollicis muscle; the onset and offset of neuromuscular blockade is more rapid. The corrugator supercilii muscle reflects better the time course of neuromuscular blockade of the larynx than the adductor pollicis muscle, is better suited to monitor the onset of neuromuscular blockade for intubation, and should give a better reflection of the time course and degree of neuromuscular blockade of the larynx or the diaphragm. Recovery of neuromuscular function at the end of any procedure is best reflected at the adductor pollicis muscle where neuromuscular transmission is last restored. Clinical monitoring of the larynx or the diaphragm is still limited by the absence of a simple method. Acceleromyography of the corrugator supercilii muscle is prone to artifacts that do not occur during monitoring of the adductor pollicis muscle. Phonomyography, a new method of monitoring that is currently being tested, is based on the phenomenon that muscle contraction creates low-frequency sound waves, which can be detected using special microphones to quantify neuromuscular blockade. This method seems promising because it can be easily used on all muscles of interest.
Conclusion: Research during the last 15 years has greatly enhanced our knowledge about how muscles react differently to muscle relaxants and has enabled us to achieve better surgical conditions with safer use of muscle relaxants. Interesting technologies have been developed to reliably monitor neuromuscular blockade at the larynx and the diaphragm, but are currently restricted to research settings. Our increased understanding should help us in ongoing efforts to develop the "ideal" muscle relaxant and the "ideal" method of neuromuscular monitoring.
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  T. M. Hemmerling and N. Le Brief review: Neuromuscular monitoring: an update for the clinician: [Article de synthese court : Monitorage neuromusculaire : une mise a jour pour le clinicien] Can J Anesth, January 1, 2007; 54(1): 58 - 72. [Abstract] [Full Text] [PDF]
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J. Schmidt, A. Irouschek, T. Muenster, T. M. Hemmerling, and S. Albrecht A priming technique accelerates onset of neuromuscular blockade at the laryngeal adductor muscles: [Une technique d'amorcage accelere le blocage neuromusculaire au niveau des muscles adducteurs du larynx] Can J Anesth, January 1, 2005; 52(1): 50 - 54. [Abstract] [Full Text] [PDF]
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A. Michalek-Sauberer, H. Gilly, T. M. Hemmerling, G. Michaud, S. Deschamps, and G. Trager Neuromuscular Blockade at Laryngeal Muscles * Response Anesth. Analg., January 1, 2005; 100(1): 297 - 298. [Full Text] [PDF]
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