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The purpose of this section of CEACCP is to provide a forum for debate and
clarification of any controversies arising from previous articles
Dr Christian Egeler of Morriston Hospital, Swansea, wrote in
connection with the article by Phil Dalrymple and Subbiah
Chelliah on electrical nerve locators (CEACCP 2006; 6,1: 32–6)
to suggest another mechanism to explain the disappearance of the
elicited muscular twitch when a small amount of local anaesthetic
is injected, rather than the nerve being physically displaced away
by the injectate. Dr Egeler writes ‘Injecting electrolyte containing
local anaesthetic solution leads to a dispersion of the current making
it insufficient to reach the threshold required to stimulate motor
fibres. Tsui and colleagues1 demonstrated that following injection of
1 ml local anaesthetic solution a further 1 ml of non-conductive 5 %
dextrose will lead to re-emergence of the twitch’. Drs Dalrymple
and Chelliah replied that ‘This study raises more questions than it
answers. While the increase in the resistance between the needle and
the electrode after the injection of a non-conducting solution is
understandable, the re-emergence of the twitches is not fully
explained. Firstly, why should the conducting solution disperse
the current ‘‘away’’ from the nerve? Do the twitches increase or
not change if the electrode is placed directly opposite the needle
(which would mean that the dispersed current has to travel through
the nerve to the electrode to complete the circuit)? Coated needles
disperse current just from their tip. We would expect twitches to
significantly decrease or disappear after injection of 1 ml of non-
conducting solution as this volume is more than sufficient to cover
the entire conducting tip. The study has shown the opposite. Finally,
why do the twitches reappear after the injection of the non-conduct-
ing solution while the conducting solution is still there to disperse the
current? It is entirely plausible that both the electrophysiological
properties of the injectate and altering the distance from needle tip
to nerve on injection (related to Coulomb’s Law) both contribute to
current dispersal and subsequent abolition of twitching. Further
research is needed in this area’.
Drs Gary Matthews and WJ Peat of Derriford Hospital,
Plymouth, wrote in relation to the article on monitoring of
doi:10.1093/bjaceaccp/mkl022
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006
ª The Board of Management and Trustees of the British Journal of Anaesthesia [2006].
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
neuromuscular blockade (CEACCP 2006; 6,1: 7–12). They
quoted several references showing that adequate neuromuscular
blockade ‘improves intubating conditions, and reduces laryngeal
injury at intubation’. They go on to emphasize that ‘The nerve
stimulator should be attached to the patient before the induction of
anaesthesia. After induction of anaesthesia, a single twitch at 1 Hz
may be used to seek supramaximal stimulation and before a neu-
romuscular blocker is injected, the mode should be changed to train
of four (TOF). Only after the response to this stimulation has been
observed (the control response) should the neuromuscular blocker
be injected. This correct procedure for monitoring neuromuscular
blockade is becoming lost knowledge. They continue ‘Too often at
the end of a case the electrodes are placed and we wonder when there
is no twitch; is it the contact, the machine, the batteries or is the
patient heavily blocked? This could be avoided if we assessed neu-
romuscular blockade correctly and in certain situations, e.g. during
neuroanaesthesia, inadequate neuromuscular blockade during intu-
bation may not just show a lack finesse, it may be extremely det-
rimental’. The authors of the article, Drs Conor McGrath
and Professor Jennifer Hunter, congratulated Drs Matthews
and Peat on practising such high standards and state that the
use of neuromuscular monitoring is ‘based on sound theoretical
knowledge and its application to clinical practice. With increasing
evidence of its benefit during all stages of general anaesthesia, it is
a field in which training cannot be neglected’. In addition they
continue, ‘Failure to monitor block correctly increases the risk
of residual postoperative paralysis, with all its concomitant sequelae
such as bronchopneumonia’.
Reference
1. Tsui BCH, Wagner A, Finucaine B. Electrophysiological effect of
injectates on peripheral nerve stimulation. Reg Anes Pain Med 2004; 29:
189–93
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