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A survey on the availability, usage and perception of neuromuscular monitors in Europe

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Abstract

Purpose: Neuromuscular blocking agents (NMBAs) are routinely administered to patients in a multiplicity of anesthetic settings. Absence of postoperative residual neuromuscular block is widely considered an anesthetic patient safety mandate. Despite the increasing availability of a wider range of commercial quantitative neuromuscular monitors, the availability and use of neuromuscular monitoring devices is deemed to be suboptimal even in countries with above-average health system ratings. The present study aims to more precisely characterize the perceived availability, cost sensitivity and usability of neuromuscular monitoring devices within European anesthesia departments. Methods: A pre-registered internet-based survey assessing the availability, cost sensitivity and usability of neuromuscular monitoring devices was distributed as e-mail newsletter by the European Society of Anaesthesiology and Intensive Care (ESAIC) to all of its active full members. The survey was available online for a total of 120 days. Results: Having targeted a total of 7472 ESAIC members, the survey was completed by a total of 692 anesthesiologists (9.3%) distributed across 37 different European countries. Quantitative monitors were reported to be proportionally more available than qualitative ones (87.6% vs. 62.6%, respectively), as well as in greater monitor-per-operating room ratios. Most anesthesiologists (60.5%) expressed moderate confidence in quantitative monitors, with artifactual recordings and inaccurate measurements being the most frequently encountered issues (25.9%). The commercial pricing of quantitative devices was considered more representative of a device’s true value, when compared to qualitative instruments (average cost of €4.500 and €1.000 per device, respectively). Conclusion: The availability of quantitative NMM in European operating theaters has increased in comparison with that reported in previous decades, potentially indicating increasing monitoring rates. European anesthesiologists express moderate confidence in quantitative neuromuscular monitors, along with a sentiment of adequate pricing when compared to their qualitative counterparts. Trust in quantitative monitors is marked by caution and awareness for artifactual recordings, with a consequent expectation that developments focusing on accuracy, reliability and ergonomics of neuromuscular monitors be prioritized.

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This research was funded by the Flanders Innovation and Entrepreneurship Fund (VLAIO), the Willy Gepts Fund for Scientific Research, the Society for Anesthesia and Resuscitation of Belgium (BeSARPP), and the Vrije Universiteit Brussel (VUB).

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Authors and Affiliations

  1. Department of Anesthesia and Perioperative Medicine, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium

    Hugo Carvalho, Michaël Verdonck, Panagiotis Flamée & Jan Poelaert

  2. Department of Anaesthesia, St George’s University Hospitals, NHS Foundation Trust, London, UK

    Hugo Carvalho

  3. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA

    Sorin J. Brull

  4. University of Lorraine, Centre Hospitalier Universitaire de Nancy/Hôpitaux de Brabois, Lorraine, France

    Thomas Fuchs-Buder

  5. Institute of Applied Health Sciences, Epidemiology Group, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, AB25 2ZD, Foresterhill, Aberdeen, UK

    Patrice Forget

  6. Department of Anaesthesia, NHS Grampian, AB25 2ZD, Aberdeen, UK

    Patrice Forget

  7. Department of Intensive Care Medicine, Vrije Universiteit Brussel (VUB), University Hospital Brussels (UZ Brussel), Jette, Belgium

    Jan Poelaert

Authors
  1. Hugo Carvalho
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  2. Michaël Verdonck
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  3. Sorin J. Brull
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  4. Thomas Fuchs-Buder
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  5. Patrice Forget
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  6. Panagiotis Flamée
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  7. Jan Poelaert
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Corresponding author

Correspondence to Hugo Carvalho.

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Disclosures

SJB: Conflicts of Interest: S. J. Brull has intellectual property assigned to Mayo Clinic (Rochester, MN); has received research support (funds to Mayo Clinic) from Merck & Co, Inc (Kenilworth, NJ) and is a consultant for Merck & Co, Inc; is a principal, shareholder, and chief medical officer in Senzime AB (publ) (Uppsala, Sweden); and is a member of the scientific/ clinical advisory boards for the Doctors Company (Napa, CA), Coala Life, Inc (Irvine, CA), NMD Pharma (Aarhus, Denmark), and Takeda Pharmaceuticals (Cambridge, MA). TFB received lecture fees from MSD, France.

Conflict of interest

The other authors did not have any conflict of interest.

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Hugo Carvalho and Michaël Verdonck equally contributed to the present work.

Appendices

Appendix A

Q1

How reliable do perceive existing quaNtitative (objective) neuromuscular monitoring devices?

Q2

Which of the following issues have you encountered when using quaNtitative (objective) neuromuscular monitoring devices? Select all that apply.

Q3

If quaNtitative TOF monitors could be improved, which characteristics would you prioritize? Select all that apply.

Q4

Considering that a quaNtitative neuromuscular monitor costs on average €4.500, do you find that this price meets the expectations of the device?

Q5

Considering that most EMG quaNtitative TOF monitors require specific EMG sensor electrodes (consumables) costing approximately €20 per piece (per patient), do you find that these company specific electrodes add specific value towards neuromuscular monitoring?

Q6

Considering that a conventional nerve stimulator (quaLitative monitor) costs approximately €1.000, do you find that this price meets the expectations of the stimulator?

Q7

If a portable sensor would exist that could upgrade a conventional nerve stimulator (quaLitative monitor) into a quaNtitative TOF monitor, would you consider applying this sensor when utilizing a conventional nerve stimulator?

Q8

If a quaNtitative neuromuscular monitoring device could be controlled in a wireless fashion, i.e. a separate wireless monitor that can both stimulate and measure muscular responses, you would find this feature – Selected Choice.

Q9

If the TOF ratio/Post-tetanic Count (PTC) could be predicted and their expected future anesthesia course displayed on an anesthesia monitor during surgery by automatically integrating patient’s parameters, without necessarily using of a monitoring device, you would find this approach of monitoring – Selected Choice.

Q10

Are conventional nerve stimulators (quaLitative monitors) available in your department?

Q11

If conventional nerve stimulators (quaLitative monitors) are available, how are they distributed? - Select all that apply.

Q12

Are quaNtitative TOF monitors available in your department?

Q13

If yes, which units are available? - Selected Choice

Q14

If quaNtitative TOF monitors are available, how are they distributed? - Selected Choice

Q15

If you have both a qualitative and quantitative monitors, what is the average ratio of monitors per operating room? - Selected Choice

Q16

What is your professional experience level?

Q17

Which hospital/clinic do you work in? (For geographical purposes. Data will be anonymized during processing) - Selected Choice

Appendix B

Open Answers Q2. Which of the following issues have you encountered when using quaNtitative (objective) Neuromuscular Monitoring devices ? Select all that apply. - Other [Text]

Sensitivity to hand positioning.

Unclear instructions and unintuitive design. Most nurses do not know how to setup NMT monitors correctly.

Missing automatic PTC measurements.

Neuromuscular monitors should not measure if there is no fading.

Monitors are highly dependent on positioning and preload.

Exceptionally high impedance of skin/tissue in obese patients.

Difficult to obtain a good set-up in the surgical position.

Exceptionally high impedance of skin/tissue in obese patients.

Problems with measuring if both arms are positioned along the body (laparoscopic procedures).

Q3. If quaNtitative TOF monitors could be improved, which characteristics would you prioritize? Select all that apply. - Other [Text]

Improving reliability when patient has arms stuck against his body.

Measurements independent of arm positioning.

Accessories for different measurement sites (hand, toe, face…).

Q11. If conventional nerve stimulators (quaLitative monitors) are available, how are they distributed? - Other [Text]

1 per 4 operating rooms (8 respondents)

1 per 5 operating rooms (13 respondents)

Less than 1 per 5 operating rooms (24 respondents)

Q14. If quaNtitative TOF monitors are available, how are they distributed? - Other [Text]

2 per 1 operating room (3 respondents)

1 per 4 operating rooms (6 respondents)

1 per 5 operating rooms (5 respondents)

Less than 1 per 5 operating rooms (17 respondents)

Q15. If you have both a qualitative and quantitative monitors, what is the average ratio of monitors per operating room? - Other [Text]

2 per 1 operating room (1 respondents)

1 per 4 operating rooms (1 respondents)

1 per 5 operating rooms (2 respondents)

Less than 1 per 5 operating rooms (2 respondents)

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Carvalho, H., Verdonck, M., Brull, S.J. et al. A survey on the availability, usage and perception of neuromuscular monitors in Europe. J Clin Monit Comput 37, 549–558 (2023). https://doi.org/10.1007/s10877-022-00922-1

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