Monitoring of neuromuscular blockade: a comparison of train-of-four and the Campbell diagram
Neuromuscular blockers (NMB) are frequently used in acute respiratory distress syndrome (ARDS) for severe hypoxemia and ventilator dyssynchrony and have been shown to improve mortality . The benefit may be secondary to removal of spontaneous breathing, dyssynchrony and expiratory efforts  thereby decreasing inflammation . NMB dosing protocols, however, do not utilize monitoring of spontaneous breathing activity when determining efficacy . Prior studies used standardized dosing  regardless of weight which may under- or overdose patients. Additionally current guidelines recommend using train-of-four (TOF) monitoring, a type of peripheral nerve stimulation as a surrogate marker , despite the fact that NMB has variable effects on different muscles and the degree of peripheral paralysis may not reflect diaphragmatic and respiratory muscle paralysis . Furthermore, TOF response and interpretation vary as a result of patient factors (edema, temperature,...
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