Intensive Care Medicine

, Volume 44, Issue 12, pp 2305–2306 | Cite as

Monitoring of neuromuscular blockade: a comparison of train-of-four and the Campbell diagram

  • Elias Baedorf KassisEmail author
  • Sarah Train
  • Bruce MacNeil
  • Stephen H. Loring
  • Daniel Talmor

Dear Editor,

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 [1]. The benefit may be secondary to removal of spontaneous breathing, dyssynchrony and expiratory efforts [2] thereby decreasing inflammation [3]. NMB dosing protocols, however, do not utilize monitoring of spontaneous breathing activity when determining efficacy [4]. Prior studies used standardized dosing [1] 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 [4], 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 [5]. Furthermore, TOF response and interpretation vary as a result of patient factors (edema, temperature,...



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Conflicts of interest

The authors declare no conflicts of interest.

Ethical standards

All ethical standards were met in writing and submitting this correspondence.

Supplementary material

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical CareBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Department of MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  3. 3.Department of Respiratory CareBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  4. 4.Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA

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