HOW TO MONITOR WITH TRAIN-OF-FOUR

How It Works:

  • A battery-powered stimulator delivers a small electric current to a superficial nerve, usually the ulnar nerve
  • Activity stimulated by the four consecutive impulses is assessed by watching or feeling for associated muscle movement
  • The muscle movement (“twitch”) observed is used to estimate the level of blockade (see the chart below)

Things to Keep in Mind:

  • Adequate muscle relaxation exists when 2 of 4 twitches are present
  • Good intubating conditions exist when 1 of 4 twitches remains
  • It is important to take the patient off the NMB periodically to determine if it is still needed
train-of-four
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