2. MONITORIA DE LA
RELAJACION
NEUROMUSCULAR
NANCY TATIANA RODRIGUEZ BETANCOURT
ESTUDIANTE NIVEL I
ANESTESIOLOGIA Y REANIMACION
U DE C

4. Diagnostic Attributes of the Clinical Tests: Sensitivity, Specificity, Positive and Negative
Predictive Values of an Individual Clinical Test for a Train-of-Four <90%
Positive Negative
Sensitivity Specificity predictive predictive
value value
Inability to smile 0.29 0.80 0.47 0.64
Inability to swallow 0.21 0.85 0.47 0.63
Inability to speak 0.29 0.80 0.47 0.64
General weakness 0.35 0.78 0.51 0.66
Inability to lift head for
0.19 0.88 0.51 0.64
5s
Inability to lift leg for 5
0.25 0.84 0.50 0.64
s
Inability to sustained
0.18 0.89 0.51 0.63
hand grip for 5 s
Inability to perform
sustained tongue 0.22 0.88 0.52 0.64
depressor test
Sorin J. Brull, MD, Glenn S. Murphy. Residual Neuromuscular Block: Lessons Unlearned. Part II:
Methods to Reduce the Risk of Residual Weakness. A & A July 2010 vol. 111 no. 1 129-140

7. ESTIMULACIÓN ÚNICA
Fcia >0,15 hz disminuye el
nivel de la rta evocada para
ser supramaximo. No
comparables.
DESPOLARIZANTES: fcia +
alta, no desvanecimiento

8. TRAIN OF FOUR
ALI 70 S
Estímulos
supramaximos cada
0,5 seg (2.0hz)
Repetir: 12-15 seg
• control
• Bloqueo parcial
• radio TOF
• fase II
•Tof 0,7  rta a
estímulo único

9. ESTIMULACIÓN TETÁNICA
>30hz  50HZ 5 SEG >1-2
50-100-200 HZ 1 SEG
NORMAL Y BNMD  SOSTENIDO
BNMND Y FASE II  NO
SOSTENIDO
Liberación de acetilcolina
(presináptico) equilibrio
liberación/producción
“márgen de seguridad”
Receptores bloqueados =
desvanecimiento
“facilitación”: 60 seg PTC

10. CONTEO POSTETANICO
3 SEG

12. Figure 39-5 Relationship between the post-tetanic count
(PTC) and time when onset of train-of-four (T1 )

13. Eliminar
movimientos
indeseados
(oftalmo)
Fcia> 6min
Carina
Severa: <2-3rtas
Total: leves +
severas

14. DOBLE RÁFAGA
• 50Hz
• 750msec
• 2 ráfagas de
3 impulsos
• + sensible
visual/tactil
DBS3,3 ratio: 2da/1ra

15. EVALUACIÓN SUBJETIVA: DBS > TOF
NINGUNO 100%

16. ESTIMULADOR:
longitud pulso: 0,2-
0,3msec (>0,5=mm)
corriente constante 60-
70mA (25-50 
resistencia <2,5kΩ; frío
5kΩ

17. Área conducción 7-11
mm
Limpiar abrasivo

19. • Hipotenar: ulnar  flexor y aductor
del 5to. Discrepancia tof 15-20%
• Corrugado superciliar: >20-30 mA
• Tibial posterior  flexor hallux
• Peroneo dorsiflexión

20. 1 cm
3-6 cm

22. Dosis – rta:
Bajas: 1ro laringeos
Bloqueo 100%
aductor: 1ro aductor
Bloqueo 100%
laringeos: 1 ro
laríngeos

24. • Tof > 0,3 : falla evaluación visual
• DBS: hasta tof 0,6-0,7
• Tetánico 100hz: desvanecimiento tof
0,8-0,9

25. VALORACIÓN OBJETIVA

26. MECANOMIOGRAFIA
• Tension 200-300 gr de precarga 
fuerza de contracción.
• Control: 8-12 min, 2-5seg 50Hz

27. ELECTROMIOGRAFIA
• Potenciales de acción: placa (1/3
medio mm), inserción y uno neutro
• Osciloscopio
• % control o radio tof
• Mediano y ulnar
• Interoseo, hipotenar (< artefactos,
sobreestimar)

28. Cuerdas vocales
Diafragma: paravertebral t2l1
derecho. Estímulo frénico en
cuello.
Confiabilidad: posición de
electrodos, precarga, posición
sobre el músculo, interferencia.
No retorna a basal.

29. Figure 39-13 Evoked electromyographic printout from a Relaxograph. Initially, single-twitch stimulation
was given at
0.1 Hz, and vecuronium (70 μg/kg) was given intravenously for tracheal intubation. After approximately 5
minutes, the
mode of stimulation was changed to TOF stimulation every 60 seconds. At a twitch height (first twitch in TOF
response)
of approximately 30% of control (marker 1), 1 mg of vecuronium was given intravenously. At marker 2, 1 mg of
neostigmine was given intravenously, preceded by 2 mg of glycopyrrolate. The printout also illustrates the
common
problem of failure of the electromyographic response to return to control level. (Courtesy of Datex-Ohmeda,
Helsinki,
Finland.)

30. ACELEROMIOGRAFIA

31. Comparable mmg y emg. Radio
>1.0

33. MONITOR PIEZOELECTRICO
• Movimiento de
banda = voltaje
• No validado

34. FONOMIOGRAFIA

35. EVALUACION DE LAS
RESPUESTAS EVOCADAS
TOF:
1: 90-95%
3-6
4: 60-85%
QX: 1-2

36. BLOQUEO RESIDUAL
• <0,9 Train-of-Four Ratio
0.70-0.75
Signs and Symptoms
Diplopia and visual
disturbances
• Alt esfinter Decreased handgrip
strength
esofágico y mm Inability to maintain
apposition of the incisor
faríngeos: teeth
“Tongue depressor test”
aspiración negative
Inability to sit up without
• Rta hipoxia assistance
Severe facial weakness
Speaking a major effort
• Uso bnm Overall weakness and
tiredness
intermedios: 0.85-0.90
Diplopia and visual
disturbances
3010% Generalized fatigue

37. Clinical Tests of Postoperative Neuromuscular Recovery
Unreliable
Sustained eye opening
Protrusion of the tongue
Arm lift to the opposite shoulder
Normal tidal volume
Normal or nearly normal vital capacity
Maximum inspiratory pressure less than 40 to 50 cm H2O
Most Reliable
Sustained head lift for 5 seconds
Sustained leg lift for 5 seconds
Sustained handgrip for 5 seconds
Sustained “tongue depressor test”
Maximum inspiratory pressure 40 to 50 cm H2O or greater

39. Anestesia: > sensibilidad a
bnm con disminución del
VC y >CO2 esp

40. Complicaciones POP
Cx < 200 min
Negra: TOF < 0.70 pancuronio
Roja, atracurio y vecuronio: TOF ≥ 0.70
pancuronio

41. Figure 39-19 Typical recording of the
mechanical response (Myograph 2000) to
TOF nerve stimulation of the ulnar
nerve after injection of 1 mg/kg of
succinylcholine (arrow) in a patient with
genetically determined abnormal plasma
cholinesterase activity. The prolonged duration
of action and the pronounced fade in the
response indicate a phase II
block.

42. UTILIDAD CLINICA

43. ALTERAN LA MONITORIA
• Hipotermia central
• Hipotermia de la extremidad
• Lesión nervio, ME, SNC
• Edad
• Tipo de cx