Language：English   Publishing type：Research paper (scientific journal)  

In August 2025, the Japanese Society of Anesthesiologists revised the section on neuromuscular block monitoring in its guidelines "Monitoring for Safe Anesthesia". The revised section states: "When using neuromuscular blocking agents and antagonists, it is recommended to quantitatively evaluate the depth of neuromuscular block and confirm a TOF ratio of ≥ 0.9 at the hand before tracheal extubation," replacing the previously revised 2019 statement, which simply recommended "Monitor the depth of neuromuscular block when using neuromuscular blocking agents and antagonists." The latest revision explicitly states the use of quantitative neuromuscular monitoring and recommends objectively determining a TOF ratio of ≥ 0.9 for adequate recovery. Currently, rocuronium is the primary neuromuscular blocking agent used in Japan. However, its duration of action is influenced by factors such as age, sex, patient condition, and type of anesthetic agent and, therefore, shows significant individual variation. Therefore, neuromuscular monitoring is essential for maintaining an appropriate depth of neuromuscular block and avoiding rocuronium overdose. Quantitative monitoring of the TOF ratio is particularly essential during emergence from anesthesia, as it also serves as an indicator for calculating the optimal dose of the rocuronium antagonist sugammadex. Failure to administer the optimal dose of sugammadex carries risks of residual neuromuscular blockade and recurarization, potentially leading to critical respiratory complications postoperatively, such as hypoxia, atelectasis, or pneumonia. Evaluation of the TOF ratio in hand muscles indicates recovery of the upper airway muscles, which are highly sensitive to rocuronium. This would facilitate safe tracheal extubation and ensure adequate ventilatory recovery.

DOI： 10.1007/s00540-026-03698-9

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INTRODUCTION: To date, no study has evaluated the appropriate sugammadex dose in underweight patients. Therefore, we aimed to compare time to recovery from deep neuromuscular block after administration of sugammadex based on either actual or ideal body weight in patients with a body mass index (BMI) of less than 18.5 kg/m2. METHODS: Patients with a BMI < 18.5 kg/m2 who underwent elective surgery under general anesthesia were enrolled. Anesthesia was induced and maintained with total intravenous anesthesia. Train-of-four (TOF) responses were monitored at the abductor digiti minimi muscle using electromyography following administration of rocuronium 0.6-0.9 mg/kg. An additional dose of rocuronium 0.2 mg/kg was administered to maintain deep neuromuscular block. When the post-tetanic count reached 1 or 2, sugammadex 4 mg/kg was administered, calculated based on either actual or ideal body weight. The primary outcome was the time from sugammadex administration to a TOF ratio ≥ 90%. Data were analyzed using the unpaired t-test, with statistical significance defined as p < 0.05. RESULTS: A total of 32 patients were included in the analysis. The difference between the actual and ideal body weight groups was not statistically significant (185.6 ± 89.5 s vs 147.3 ± 71.0 s; p = 0.19). CONCLUSION: There was no significant difference in sugammadex recovery time from deep neuromuscular block between dosing based on actual body weight and dosing based on ideal body weight in underweight patients.

DOI： 10.7759/cureus.102536

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DOI： 10.1016/j.accpm.2025.101686

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Neuromuscular monitoring in patients with cerebral palsy (CP) is technically challenging due to limb contractures and muscle atrophy. We report a case of a 28-year-old male with CP who underwent surgery under general anesthesia. Intraoperative recovery from neuromuscular block was successfully monitored using an electromyography-based neuromuscular monitor. Due to finger deformities, the abductor digiti minimi muscle was selected for monitoring. The onset of rocuronium 0.65 mg/kg was delayed and its duration markedly prolonged. Adequate recovery of neuromuscular function was confirmed with a train-of-four ratio ≥ 0.9, demonstrating the feasibility and clinical utility of TetraGraph in CP patients.

DOI： 10.1213/XAA.0000000000002074

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The aim of this study was to compare the supramaximal currents obtained simultaneously by acceleromyography (AMG) TOF-Watch® SX and electromyography (EMG) AF-201P in pediatric patients. Patients aged 2-11 years who underwent elective surgery under general anesthesia were enrolled. AMG and EMG monitors were placed on opposite arms of the patient to stimulate the ulnar nerve and monitor the adductor pollicis muscles following the induction of general anesthesia. After the monitors were calibrated, rocuronium 0.6 mg/kg was administered. Endotracheal intubation was performed when the EMG showed a train-of-four (TOF) count of 0. The primary outcome was the supramaximal current set by each device's calibration. The secondary outcomes were the time from the administration of rocuronium to a TOF count of 0, the baseline and final TOF ratios, and the conditions surrounding intubation. The paired t test and the Wilcoxon signed-rank test were used to analyze parametric and nonparametric data. A P value < 0.05 indicated statistical significance. Clinical data from 25 pediatric patients were analyzed. The supramaximal current was significantly lower with EMG than with AMG (27.4 ± 6.1 vs. 54.2 ± 8.4 mA, p <.001). The time to a TOF count of 0 was significantly shorter with EMG than with AMG (58 [24-170] vs. 75 [26-236] seconds, p <.001). Both the baseline and final TOF ratios were significantly lower with EMG than with AMG. The ease of laryngoscopy was rated as excellent for all patients. The vocal cords were abducted in 76% of patients, and no movement to insertion of the endotracheal tube was confirmed in 96% of patients. We found that the supramaximal current was significantly lower with EMG than with AMG.

DOI： 10.1007/s10877-025-01286-y

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The present study aimed to evaluate the effect of electrosurgical devices on neuromuscular monitoring using an electromyography (EMG)-based neuromuscular monitor during abdominal laparotomy. Seventeen women (aged 32-64 years) undergoing gynecological laparotomy under total intravenous general anesthesia were enrolled in the study. A TetraGraph™ was placed to stimulate the ulnar nerve and to monitor the abductor digiti minimi muscle. After device calibration, train-of-four (TOF) measurements were repeated at intervals of 20 s. Rocuronium 0.6 to 0.9 mg/kg was administered for induction, and additional doses of 0.1 to 0.2 mg/kg were administered to maintain TOF counts ≤ 2 during the surgery. The primary outcome of the study was the ratio of measurement failure. The secondary outcomes of the study were the total number of measurements, the number of measurement failures, and the most extended consecutive number of measurement failures. The data are expressed as median (range). Of the 3091 (1480-8134) measurements, the number of measurement failures was 94 (60-200), resulting in a failure ratio of 3.5% (1.4-6.5%). The most extended consecutive number of measurement failures was 8 (4-13). All attending anesthesiologists were able to maintain and reverse neuromuscular blocks under EMG guidance. This prospective observational study demonstrated that the use of EMG-based neuromuscular monitoring does not seem to be heavily affected by electrical interference during lower abdominal laparotomic surgery. Trial registration This trial was registered in the University Hospital Medical Information Network under registration number UMIN000048138 (registration date; June 23, 2022).

DOI： 10.1007/s10877-023-01039-9

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Robotic-assisted laparoscopic prostatectomy (RALP) requires intraoperative fluid restriction to maintain the optimal view of the operative field during vesicourethral anastomosis and to prevent upper airway edema that may occur due to the steep Trendelenburg position. The aim of this study was to demonstrate that our fluid restriction regimen would not increase postoperative serum creatinine (sCr) levels in patients undergoing RALP. The fluid regimen involved maintaining a crystalloid infusion at 1 ml/kg/h until completion of vesicourethral anastomosis, then rapid infusion of 15 ml/kg within 30 min, followed by maintenance at 1.5 ml/kg/h until post-operative day (POD) 1. The primary outcome of this study was the change in the sCr level from baseline to POD7. Secondary outcomes were the sCr levels on PODs 1 and 2, the surgical view during vesicourethral anastomosis, and the incidences of re-intubation and acute kidney injury (AKI). Sixty-six patients were eligible for the analysis. The paired t test for non-inferiority showed no significant difference in sCr levels between baseline and POD7 (mean ± standard deviation, 0.79 ± 0.14 vs. 0.80 ± 0.18 mg/dl, p < 0.001). Seven patients developed AKI on POD1, but all but one recovered on POD2. Ninety-seven percent of operations were rated as having a good view of the operative field. There were no cases of re-intubation. This study demonstrated that the fluid restriction regimen of 1 ml/kg/h until completion of vesicourethral anastomosis created a good view of the operative field during vesicourethral anastomosis without increasing postoperative sCr levels in patients undergoing RALP. Trial registration: This trial was registered in the University Hospital Medical Information Network under registration number UMIN000018088 (registration date; July 1, 2015).

DOI： 10.1007/s11701-023-01610-1

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Authorship：Lead author,　Corresponding author   Language：English   Publishing type：Research paper (scientific journal)  

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BACKGROUND: The commonly used acceleromyography (AMG)-based neuromuscular monitor TOF-Watch SX is no longer manufactured. Recently, a new portable electromyography (EMG)-based neuromuscular monitor TetraGraph was introduced in clinical anesthesia. The aim of the study was to compare the responses obtained simultaneously from the abductor digiti minimi (ADM) muscle with TetraGraph and the adductor pollicis (AP) muscle with TOF-Watch SX during rocuronium-induced neuromuscular block. METHODS: Patients undergoing orthopedic surgery with general anesthesia were enrolled in this prospective, observational study. During total intravenous general anesthesia, train-of-four (TOF) responses following 0.9-mg·kg -1 rocuronium administration were monitored at the AP muscle with TOF-Watch SX and the ADM muscle with TetraGraph on the opposite arms. Sugammadex 2 mg·kg -1 was administered when both devices showed TOF counts (TOFCs) = 2. The primary outcome was time from rocuronium administration to first appearance of posttetanic count (PTC) response (first PTC). The secondary outcomes were baseline TOF ratios (TOFRs), onset time, time to first reappearance of TOFC = 1 (time to TOFC1), time to first reappearance of TOFC = 2 (time to TOFC2), and time from sugammadex administration to TOFR ≥0.9 with TetraGraph or to normalized TOFR ≥0.9 with TOF-Watch SX (recovery time). We used paired t test and Wilcoxon signed-rank test to analyze parametric and nonparametric data, respectively. P <.05 defined statistical significance. RESULTS: A total of 20 patients were analyzed. The baseline TOFRs were significantly higher with TOF-Watch SX than with TetraGraph (105 [96-110] vs 100 [98-101]; P = .0002). The time to first PTC (minutes) (31.7 ± 9.6 vs 41.1 ± 12.3; P < .001), time to TOFC1 (minutes) (48.0 ± 12.7 vs 58.8 ± 19.2; P < .001), time to TOFC2 (minutes) (56.2 ± 15.7 vs 74.2 ± 23.7; P < .001), and recovery time (seconds) (61.5 [32-148] vs 75.5 [94-102]); P = .043) were significantly faster with TOF-Watch SX than with TetraGraph. There were no significant differences in onset time. CONCLUSIONS: TOF-Watch SX overestimated recovery from rocuronium-induced neuromuscular block compared with TetraGraph.

DOI： 10.1213/ANE.0000000000005897

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Background Rocuronium consumption with or without intraoperative objective neuromuscular monitoring in clinical settings of unrestricted use of sugammadex and neuromuscular monitoring has not been reported earlier. The study aimed to investigate the association between the use of intraoperative objective neuromuscular monitoring and rocuronium consumption in patients undergoing laparoscopic abdominal surgery. Methods Data were collected by reviewing electronic medical records of patients who received laparoscopic abdominal surgery under general anesthesia with rocuronium and reversal with sugammadex at a university teaching hospital between May 2017 and April 2018. A multivariate linear regression model was developed to compare the amount of rocuronium consumption (mg) per weight (kg) per hour (mg/kg/h) between the group in which intraoperative objective neuromuscular monitoring was used (NMM+ group) and the group in which intraoperative neuromuscular monitoring was not used (NMM- group). Additionally, we performed an interaction test. Results A total of 429 patients were evaluated, with 371 patients (86%) included in the NMM+ group and 58 patients (14%) in the NMM- group. Log-transformed rocuronium consumption between the NMM+ group and NMM- group was not significantly different (back-transformed β coefficients [95% CI]: 1.080 [0.951-1.226]; P = 0.23). Male sex and body mass index (BMI) were independent factors associated with 15% (0.853 [0.788-0.924]; P < 0.001) and 3% (for every 1 kg/m2 increase in BMI) (0.971 [0.963-0.979]; P < 0.001) decrease in intraoperative rocuronium consumption, respectively. A significant interaction was detected only between the use of neuromuscular monitoring and age ≥65 years (β: 0.803 [0.662-0.974]; P = 0.026). Conclusions Although the use of intraoperative objective neuromuscular monitoring was not an individual factor influencing intraoperative rocuronium consumption, this retrospective study demonstrated that the use of intraoperative neuromuscular monitoring reduced rocuronium consumption for approximately 20% of elderly patients (age ≥65 years) undergoing laparoscopic abdominal surgery.

DOI： 10.7759/cureus.19245

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Language：English   Publishing type：Research paper (scientific journal)   Publisher：Springer Science and Business Media LLC  

DOI： 10.1007/s10877-021-00692-2

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Other Link： https://link.springer.com/article/10.1007/s10877-021-00692-2/fulltext.html

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DOI： 10.1007/s10877-021-00768-2

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DOI： 10.1186/s12871-017-0429-9

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Authorship：Lead author,　Corresponding author   Language：English   Publishing type：Research paper (scientific journal)   Publisher：[Springer Japan]  

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DOI： 10.1155/2014/848051

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DOI： 10.1007/s12630-013-0042-4

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Authorship：Lead author   Language：Japanese   Publishing type：Research paper (scientific journal)  

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Language：Japanese   Book type：Scholarly book

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Responsible for pages：293-295, 333-334   Language：Japanese   Book type：Scholarly book

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Responsible for pages：100-101   Language：Japanese   Book type：Scholarly book

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Responsible for pages：345, 654   Language：Japanese   Book type：Scholarly book

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Responsible for pages：73, 184-193   Language：Japanese   Book type：Scholarly book

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Event date： 2022.11

Language：Japanese   Presentation type：Symposium, workshop panel (nominated)  

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Event date： 2022.11

Language：English   Presentation type：Oral presentation (general)  

Venue：京都  

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Event date： 2021.11

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Event date： 2021.6

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Event date： 2019.11

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