Train of Four (TOF) Monitoring - Neuromuscular Blockade



Used to titrate NMB to the minimum effective dose.

 • Muscles are are electrically stimulated 4 times in rapid succession & the number of contractions are noted. 

 • After achieving adequate sedation, electrodes are applied and the nerve is stimulated using a low current (10-20 mA); the current is increased until 4 vigorous twitches are seen. Further increasing the current should not lead to more forceful contraction (supramaximal stimulation).

 • Once the supramaximal stimulation is documented, NMB is initiated

 • Titrate NMB according to the number of twitches seen at the prior current: decrease NMB infusion if fewer than goal twitches seen



Excerpted from original infographic by Nick Mark MD @nickmmark



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