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The Eyes are the Window to Your Soul

We all know this quote, but its origin is a little unclear. It has been attributed to William Shakespeare, Leonardo Da Vinci, the philosopher Cicero and even the bible.

Whatever the origins of this well-known quote, throughout history we have been aware that our eyes are incredibly precious organs. Not only do they allow us to see the world around us but through them we can tell what a person feels and thinks.

However, despite being aware that somehow our eyes are special, we have been a bit blasé about protecting them. Eye protection has evolved over time(1) via several different routes including:

  1. Combat – To lose an eye in battle and wear an eye patch was once considered an honour. The use of helmets did offer some protection. The use of gas during World War 1 resulted in gas masks with glass windows to protect the eyes from the deadly gas. More recently the rise of IEDs resulted in the percentage of combat causalities hospitalised due to ocular trauma increasing from 2% in 1914 to 13% in the 1990s Desert Storm conflict. In modern armies today eye protection is mandatory.
  2. Sports and Recreation – Jousting required the riders to wear helmets with visors, but eye injuries were common. King Henry II, the French-born King of England, suffered an eye injury during a jousting tournament in 1559.  The king had not fastened his visor upon returning to the arena and a splinter from his opponent’s lance entered his right orbit. Complications resulted in the death of ‘the young lion’ from his eye injury. His death significantly changed the respective roles of France and England and the course of Western civilisation and history. Recently, ice hockey, Baseball and Basketball were the first sports to embrace eye protection followed by Squash, Cricket Hockey and Lacrosse.
  3. Occupational Eye Injuries – The rise of industry in the late 19th century resulted in a huge increase in mining and metalwork. This led to a surge in corneal abrasions in miners, heat cataracts in foundry workers and arc eye in welders. Gradually, visors and goggles. . Gradually, improved understanding of the impact resistance of materials and the nature of hazards brought about improvements in visors and goggles in the workplace

Thankfully, mainly due to the rise of Health and Safety, eye protection is now mandatory in many workplaces. There is good reason why this is necessary. Thousands of workers suffer painful eye injuries each year around the world. Many are minor but around 10-20% result in partial or full blindness. Equally, we only have two eyes and whilst some parts of the eye can be transplanted, a complete eyeball transplant is not yet possible. So, we need to do everything we can to protect our eyes as much as we can.

The most common types of injuries are:

  • Invasion of foreign bodies – The eye/s may sometimes be invaded by small foreign particles (e.g. dust from manufacturing activities) which can cause irritation and inflammation. Chemical Eye Burns – Both highly acidic (pH <4) and highly alkaline (pH >10) substances are toxic to the eye and cause chemical eye burns if they come into contact with the surface of the eye. Such substances are commonly found in the workplace, for example in laboratory chemicals or industrial cleaning products.Penetrating Injuries – When an object pierces the eye, penetration occurs, and this can lead to loss of vision or blindness. Staples, nails and flying debris commonly cause this type of injury.Blunt trauma injuries – These are injuries which do not penetrate the skin and do not result in external bleeding.  The eye is struck by a heavy object and this can cause the eye to bleed internally.Allergic conjunctivitis – Is common amongst workers in the food handling and agricultural sectors who are regularly exposed to spices, fruits, and vegetables. Eye diseases associated with ultraviolet radiation exposure – Outdoor workers are often exposed to ultraviolet radiation (in the form of sunlight) in excessive quantities. Artificial sources of ultraviolet radiation are also found in a range of workplaces and can damage the eyes. These include welding arcs, germicidal lamps, and lasers. Computer use disorders – Using a computer for extended periods of time is associated with a range of temporary eye disorders including pain and altered vision.

Of course, when we go about our daily lives, we meet all sorts of people wearing eye protection. These can be construction site workers, the mechanic fixing your car, the gardener mowing your lawn, the person mending your shoes. Many jobs now take eye protection seriously.

Eye protection is also taken seriously even if you are unfortunate to be here –

However, can you guess by looking at these photographs what the problem is?

Where is the eye protection for the patient? Everyone else in theatre has eye protection so why not the patient? A nurse will take a roll of non-sterile tape that has been lying in theatre and tape your eyes. A piece of equipment could hit you in the eye or even someone’s elbow. You are the most vulnerable person in the room and yet nothing is done to protect your eyes from an infection, a corneal abrasion or even a trauma blow. Surely, if a gardener or a cobbler has eye protection then patients undergoing surgery should equally have their eyes protected.


  1. Hoskin A.K, Mackey D.A, Agrawal R, Watson S. (2019). Eye Injuries across history and the evolution of eye protection. Acta Ophthalmologica, 97: 637–643.

Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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Measures to Control the Transmission of Covid-19

Ever since the first reports of Covid-19 in China (1) there has been a great deal of focus on how the virus spreads.

 It is now clear that, the virus causing COVID-19, is primarily transmitted between people through respiratory droplets and contact routes.

Droplet transmission occurs when a person is in close contact (within 1 m) of someone with respiratory symptoms (e.g. coughing or sneezing) and is therefore at risk of having their mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. Transmission may also occur through fomites in the immediate environment around the infected person. Therefore, transmission of the COVID-19 virus may occur by direct contact with infected people and indirect contact with surfaces in the immediate environment or with objects used on the infected person. (2) Studies from a variety of disciplines investigating viruses clearly support the following:

  • most respiratory and enteric viruses can survive on fomites and hands for varying lengths of time.
  •  fomites and hands can become contaminated with viruses from both natural and laboratory sources.
  •   viral transfer from fomites to hands is possible.
  •   hands come in contact with portals of entry for viral infection.

 If viruses remain viable on surfaces long enough to come into contact with a host, the virus may only need to be present in small numbers to infect the host. (3)

The virus can also be spread via airborne transmission which is different to droplet transmission. This refers to the presence of microbes within droplet nuclei. Droplet nuclei are generally considered to be particles ≤ 5μm in diameter that can remain in the air for longer periods of time and can be transmitted to others over distances greater than 1 metre. Airborne transmission of the COVID-19 virus is possible under circumstances and settings where aerosol generating procedures (AGPs) are performed. (2)

We are all aware of the measures that are being taken in the community to prevent the transmission of the virus via the droplet and contact routes. (4) But what is happening in hospitals; particularly when a patient needs emergency surgery or, as is now happening an elective or planned procedure?

In planned procedures the patient should isolate for several days and test negative for Covid-19 before entering theatre. Emergency patients are identified as symptomatic or asymptomatic and appropriate Infection Prevention and Control procedures are put in place. (5)

Much is being done in hospitals generally and more specifically in operating theatres to reduce transmission rates. While the rates of overall infection in a country may be below 1%, (6) in hospitals the rates could be anywhere between 5% and 15%. (7)

So, what more could be done in hospitals to bring the rates of infection down? In my opinion, whilst some effort is being made to reduce fomite spread of covid-19 in the operating theatre with regular disinfection and greater use of single use items, much more could be done. (8,9)

Rolls of medical tape are often to be found in the operating theatre. Studies have shown that 51 % of rolls of tape found lying around in theatre may have VRE or MRSA, so multiple resistant bacterial organisms on them, which we then apply to patients. (10) These rolls of tape may well have Covid-19 on them and if applied to the patient’s eyes may well infect them.

It would be far safer, and better practice to use our sterile, single use EyePro™ to cover the patient’s eyes (11) thereby removing a potential Covid-19 transmission route.

Many theatres make up their own bite blocks using gauze and rolls of tape on the anaesthetic trolley. All this activity carries a high risk of fomite transmission. If you use a single wrapped clean BiteMe™ with clean gloves, BiteMe™ should pose less risk compared to rolled up gauze with respect to viral transmission. (12)

Thus, by making two small changes to operating theatre procedures you could be doing so much more to reduce the potential transmission of Covid-19.

  • Use sterile single use EyePro™, the only sterile eyelid occlusion dressing available and stop using medical tape on your patient’s eyes.
  • Use single use, clean BiteMe™ as your bite block of choice and stop making your own bite blocks.

Dr Andrew Wallis

BSc., BMedSci., MBBS (hons), FANZCA

Private Anaesthetist

Member of Medical Advisory Committee, Calvary Hospital, Launceston, Tasmania.

Medical Director Innovgas Pty Ltd


  1.  Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 16-24 February 2020. World Health Organisation.
  2.  Infection prevention and control during health care when coronavirus disease (COVID-19) is suspected or confirmed. Interim guidance 29 June 2020. World Health Organisation
  3. S. A. Boone* and C. P. Gerba. Significance of Fomites in the Spread of Respiratory and Enteric Viral Disease. Applied and Environmental Microbiology, Mar. 2007, p. 1687–1696.
  4. Transmission of SARS-CoV-2: implications for infection prevention precautions. Scientific brief 09 July 2020. World Health Organisation.
  5. Operating framework for urgent and planned services in hospital settings during COVID-19. 14 May 2020. NHS England.
  6. COVID-19 situation update for the EU/EEA and the UK, as of 14 July 2020. European Centre for Disease Prevention and Control.
  7. G. Iacobucci. Covid-19: Doctors sound alarm over hospital transmissions. BMJ 2020;369. 19 May 2020.
  8. Infection prevention and control and preparedness for COVID-19 in healthcare settings. Third update – 13 May 2020. European Centre for Disease Prevention and Control.
  9. COVID-19: infection prevention and control guidance. 21st May 2020. NHS England.
  10.  Harris PN et al. Adhesive tape in the health care setting: another high-risk fomite? Med J Aust. z2012;196(1):34.
  11.  EyePro™ Brochure.
  12.  BiteMe™ Brochure.
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Why Quantitative NMT Monitoring is Critical in Surgical Patients and How Best to Do It

Some sort of assessment of neuromuscular transmission (NMT) is necessary in surgical patients by clinicians and anesthetists to get a feel for the depth of anesthesia. This assessment can be done using simple yet subjective clinical parameters or through more advanced and objective monitoring devices. NMT monitoring is required to

  • ascertain that anesthesia is appropriate for tracheal intubation
  • check the adequacy of neuromuscular blockade during a procedure
  • determine the need for adjusting the dose of neuromuscular blocking agents (NMBAs)
  • decide the timing and dose of reversal agents
  • ensure full patient recovery before extubation

When NMT monitoring is absent, inadequate, or inaccurate, it is associated with an increased risk of

  • aspiration
  • airway obstruction
  • adverse respiratory events
  • pharyngeal dysfunction
  • prolonged post-anesthesia stays
  • unpleasant postoperative symptoms including muscle weakness

Almost 40% of patients have incomplete neuromuscular recovery in the early recovery period from anesthesia

Having said that, it may come as a surprise that anesthesiologists often overlook the importance of effective monitoring. Research reveals that less than 40% of patients receive subjective assessment using nerve stimulators, while objective monitoring is performed in only 17% of patients. Furthermore, almost 40% of patients have incomplete neuromuscular recovery in the early recovery period from anesthesia. Against this backdrop, it is easy to understand why proper NMT monitoring is the need of the hour in surgical patients. We will now discuss how such monitoring can be achieved.

Current Approaches to NMT Monitoring

There are three ways to monitor the neuromuscular status:

  1. Clinical assessment—most commonly employed by clinicians, it is a subjective evaluation of clinical parameters such as respiratory measures and muscle function. However, none of the tests has a sensitivity greater than 0.35 or positive predictive value more than 0.52. Clearly, it’s not the most reliable approach.
  2. Qualitative monitoring/peripheral nerve stimulation—Qualitative monitoring uses peripheral nerve stimulators (PNSs). The evoked response of the stimulated muscle is then assessed visually or tactilely. It’s more reliable than a simple clinical assessment but less so than quantitative monitoring.
  3. Quantitative monitoring—this involves the use of devices that quantify the NMT blockade and display the measurements numerically. Quantitative monitoring offers the virtues of reliability, accuracy, and objectivity. We describe quantitative monitoring in more detail below.

Why Quantitative Monitoring is the Way to Go

Following are just some of the benefits of quantitative neuromuscular monitoring:

  • Objective measurements—stimulation is provided to a suitable muscle and the evoked response is quantified objectively. It can be through measuring the action potentials generated within the muscle, the strength of its contraction, or even the crackling sounds associated with muscle movement. Whichever the underlying mechanism for the monitoring device, nothing is left to the subjective opinion of the clinician. Hence, the results are consistent and reproducible.
  • Display of results—quantitative monitoring devices are smart and internally compute any raw data to display final results in numerical form that can then be used to guide clinical decision-making.
  • Automatic processes—most devices just need their leads to be attached at the appropriate locations and then they do the rest themselves, including providing stimuli, recording responses, computing results, and displaying the same. Modern devices also require no calibration.
  • Risk of PRNB nearly eliminated—the risk of postoperative residual neuromuscular blockade (PRNB) is almost completely eliminated with the use of quantitative monitors for tracheal extubation.

Quantitative NMT Monitoring Devices

There are several methods to perform quantitative NMT monitoring:

Modern quantitative NMT monitoring devices are capable of automatically providing stimulation to the muscle and recording and interpreting the response. The impulses can be given in various patterns such as train of four (TOF), double-burst (DBS), tetanic and post-tetanic count (PTC), which can be used to determine the train-of-four count (TOFC) or the degree of fade. The evoked muscle response can then be measured by using different scientific techniques giving rise to several types of devices:

  1. Mechanomyography (MMG)—the device detects muscle isometric force of contraction and converts it into an electrical signal. The amplitude of the signal reflects contraction strength.
  2. Electromyography (EMG)—it records compound muscle action potentials generated in the muscle and this electrical activity is proportional to the contraction force.
  3. Acceleromyography (AMG)—the monitor measures muscle acceleration via a piezoelectric sensor. The piezoelectric crystal generates voltage when it is put into motion due to muscle contraction.
  4. Kinemyography (KMG)—such devices quantify muscle movement via a motion sensor strip. The strip once again contains piezoelectric sensors.
  5. Phonomyography (PMG)—it calculates muscle response based on sounds picked up a by microphone. This is possible because muscle contraction produces low-frequency sounds.

Decades of research demonstrate that AMG technology can detect residual paralysis in 97% of patients.

While the above seem some fantastic methods to quantitatively monitor NMT blockade in clinical settings, MMG and PMG monitors are not commercially available and only used for research purposes, there is only one EMG monitor available for commercial use but it’s not standalone, and studies comparing KMG to MMG (the “gold standard”) have found its data to have a large bias and it cannot be used interchangeably. In the end, the AMG technology has been the most successful for commercial and clinical deployment. The Stimpod NMS 450X is a classic example of a cutting-edge AMG monitor.

Why the Stimpod NMS 450X is the Monitor of Choice for Quantitative NMT Monitoring

There are many features that make the Stimpod NMS 450X the monitor of choice for quantitative neuromuscular transmission monitoring. You can review these features in detail here. We will go over some of the more pertinent features of this device in light of what we have discussed so far about neuromuscular monitoring:

Stimpod NMS450X Neuromuscular Patient Monitor

The Stimpod NMS450X reduces the incidence of residual paralysis in 97% of patients

  • Global coverage—There is no point in reading up about the importance of NMT monitoring and researching a monitor only to find that either it’s not commercially manufactured or it’s not available in your area. Xavant’s worldwide coverage ensures Stimpod’s availability across the globe. In his comprehensive review article covering NMT monitoring in the perioperative period, Dr. Glenn Murphy, a senior anesthesiologist affiliated with the NorthShore University HealthSystem, points out, “At the present time, only one stand-alone portable device is available in the United States, the STIMPOD (Xavant Technologies, Pretoria, South Africa).”
  • Fully automated—The Stimpod NMS 450X’s OneTouch NMT™ technology allows users to monitor an entire case from electrode placement to extubation by pressing a single button. The device automatically verifies optimal electrode placement, provides the appropriate supramaximal current, begins TOF monitoring and moves to PTC when a deep block is reached. Upon reversal, it automatically reinitiates monitoring until the patient is 90%+ recovered.
  • 3D AMG transducer—The Stimpod NMS 450X uses a 3D AMG transducer which is most effective in capturing the full force of muscle contraction. In his seminal article, Dr. Murphy observes, “An important disadvantage of first-generation AMG monitors … is that acceleration of a muscle following nerve stimulation is only measured in a single direction (perpendicular to the face of the transducer). However, stimulation of the ulnar nerve results in isotonic contractions of the adductor pollicis that are often in three dimensions, involving three joints, frictional forces, and deformation of tissues.”

Decades of research demonstrate that AMG technology can detect residual paralysis in 97% of patients. The Stimpod NMS450X is an embodiment of that technology and an all-in-one solution for neuromuscular monitoring. Please contact us to know more about NMT monitoring, train of four monitoring and our solutions.


Murphy GS. Neuromuscular monitoring in the perioperative period. Anesth Analg. 2018;126:464–468.
Duţu M, Ivaşcu R, Tudorache O, et al. Neuromuscular monitoring: an update. Rom J Anaesth Intensive Care. 2018;25(1):55–60. doi:10.21454/rjaic.7518.251.nrm

Thilen SR, Bhananker SM. Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade. Curr Anesthesiol Rep. 2016;6:164–169. doi:10.1007/s40140-016-0155-8

Hemmerling TM, Le N. Brief review: Neuromuscular monitoring: an update for the clinician. Canadian Journal of Anesthesia. 2007;54(1):58-72.

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The Cost of Postoperative Respiratory Adverse Events

Respiratory impairment following general anaesthesia can pose a significant problem. Adverse and critical respiratory events (AREs and CREs) have been responsible for increased morbidity and mortality. The main cause of AREs after surgery is related to the use of neuromuscular blockers (NMBAs) during general anaesthesia. The action of NMBAs might not cease completely at the end of the procedure, leading to residual muscle paralysis. Postoperative residual neuromuscular blockade, aka postoperative residual curarization (PORC), ranks among the top three critical events in the post-anesthesia care unit (PACU) that require emergency intervention.1 It has been estimated that approximately 40% of the patients brought to the PACU have residual blockages.2 Apart from the obvious effects on patients’ life and health, AREs can have other consequences. Caregivers have to undergo increased physical and emotional stress, which can affect delivery of care to other patients in the PACU. Financial costs can increase for both patients and hospitals as substantial critical care resources are devoted to solving such problems.

How big is the problem of residual neuromuscular blockade?

Muscle paralysis is estimated using a clinical tool called train-of-four ratio (TOFR). Residual neuromuscular blockade is believed to have significant clinical effects if the TOFR goes below 0.9.3 With just a single dose of intermediate acting NMBAs, it has been shown that up to 45% of patients can have residual blockade (TOFR < 0.9).4 Lower TOFRs have been associated with increased risk of CREs. This was demonstrated by Murphy et al, who collected data of over 7400 patients who had received general anaesthesia.5 They found that the incidence of critical respiratory events in this group of patients due to residual blockade was 0.8%. Based on these statistics, Brull et al estimated that each year about 81,000 people in the United States and almost 0.5 million people worldwide experience CREs after general anaesthesia.2

What is the main cause of CRE after surgery?

It was shown that the incidence of CREs was higher by 50% in patients who had TOFR less than 0.76

While there can be several causes of CRE, a large proportion of cases have been associated with residual neuromuscular blockade. In one study by Bissenger et al, it was shown that the incidence of CREs was higher by 50% in patients who had TOFR less than 0.7.6 In a separate case-control study, Murphy et al compared TOFRs in patients who had developed CREs and controls who did not have CREs. They showed that while patients in the control group had TOFRs above 0.7, 78.3% of patients who had CREs had TOFRs that were below 0.7.3 Xara et al also investigated the determinants of AREs in 340 patients who underwent surgery. They found that patients who were administered NMBAs during the surgical procedure had increased incidence of AREs (79%) as compared to those who did not receive them (55%).7 They also noted that the incidence of ARE was increased in patients who had received neostigmine. Grosse-Sundrup et al showed that the use of intermediate NMBAs increased the risk of postoperative desaturation and re-intubation.8

What are the costs involved?

Residual neuromuscular blockade can cause upper airway obstruction, aspiration and pharyngeal dysfunction. These situations may require emergency intervention in the form of re-intubation and positive pressure ventilation. The costs associated with these interventions can be considerable. Patients who develop respiratory complications after surgery generally often have to be hospitalised for longer, which increases costs.

The cost of treatment for patients with respiratory complications was $62,000, compared to $5000 without complications, with an additional 92,000 more ICU admissions per year10

Zhan et al found that postoperative respiratory failure (that did not include pulmonary embolism) increased hospital stay by nine additional days, and translated to an additional $53,000 in healthcare costs.9

A report developed by the National Surgical Quality improvement program showed that patients with respiratory complications stayed at the hospital for at least 14 days longer vs. those who did not have these complications.10 The same report estimated the cost of treatment for patients with respiratory complications was around $62,000, while those without such complications were set back by a mere $5,000 in comparison. On a national level, pulmonary complications after surgery lead to 92,000 more ICU admissions per year, which alone imposes a burden of $3.42 billion annually.

What is the best way to deal with the situation?

Residual neuromuscular blockade can be avoided by monitoring neuromuscular status during the surgical procedure. If neuromuscular function is allowed to return to optimal levels prior to extubating the patient, chances of residual blockade in the PACU decrease. Ideally, the anaesthetist should be able to monitor the TOFR, so that it may be allowed to reach the critical threshold of 0.9 prior to extubation.

What kind of monitoring works best?

Severe hypoxaemia occurred in 21.1% of patients in the conventional group but in none of the patients in the acceleromyography group11

There are three methods to monitor neuromuscular function—clinical, qualitative monitoring and quantitative monitoring. Clinical methods (such as head-lift and grip-strength tests) have low sensitivity and specificity, and are not really suited for patients prior to extubation. Qualitative evaluation using peripheral nerve stimulators is a common practice. However, it involves subjective assessment of TOFR and studies have shown that TOFRs above 0.4 may not be effectively detected by this method. Quantitative (or objective) methods of calculating TOFR, using techniques such as mechanomyography, electromyography and acceleromyography, have proven more effective. Murphy et al assessed the risk of residual neuromuscular blockade and AREs in patients who were monitored by both qualitative and quantitative means.11 Patients were randomised for NMB monitoring using either conventional peripheral nerve stimulators or acceleromyography. Residual NMBs in the PACU were documented in 30% of patients in the conventional group and only 4.5% of patients in the acceleromyography group. More significantly, severe hypoxaemia occurred in 21.1% of patients in the conventional group but in none of the patients in the acceleromyography group.

The bottom line is this: quantitative neuromuscular transmission monitoring has the potential to reduce residual blockades, decrease CRE risk, and reduce costs.

Stimpod NMS450X Neuromuscular Transmission Monitor

The Stimpod NMS450X Neuromuscular Transmission Monitor

The Stimpod NMS450X is a standalone neuromuscular transmission monitor that can easily be integrated into the anaesthetic setup. During reversal of neuromuscular blockade, the monitor automatically initiates TOFR monitoring, which continues until recovery is complete. Its portable design makes it easy to shift between the OR and PACU, and it can easily be attached to the IV pole. Its economical pricing and proven efficacy make it a sensible investment for hospitals who wish to make optimum use of resources and cut costs in the long term. For more details, visit or request a quotation.


  1. Strauss P, Lewis M. Identifying and Treating Postanesthesia Emergencies. Or Nurse. 2015 Nov 1;9(6):24-30.
  2. Brull, S. J., & Kopman, A. F. Current Status of Neuromuscular Reversal and Monitoring: Challenges and Opportunities. Anesthesiology 2017; 126(1): 173-90.
  3. Murphy GS, Szokol JW, Avram MJ, et al. Postoperative Residual Neuromuscular Blockade is Associated with Impaired Clinical Recovery. Anesth Analg. 2013;117(1):133–141
  4. Debaene B, Plaud B, Dilly MP, Donati F. Residual Paralysis in the PACU After a Single Intubating Dose of Nondepolarizing Muscle Relaxant with an Intermediate Duration of Action. Anesthesiology 2003;98: 1042–8
  5. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS: Residual Neuromuscular Blockade and Critical Respiratory Events in the Postanesthesia Care Unit. Anesth Analg 2008; 107:130–7
  6. Bissinger U, Schimek F, Lenz G. Postoperative Residual Paralysis and Respiratory Status: A Comparative Study of Pancuronium and Vecuronium. Physiol Res/Acad Sci Bohemoslovaca. 2000; 49(4):455–462
  7. Xará D, Santos A, Abelha F. Adverse Respiratory Events in a Post-anesthesia Care Unit. Archivos de Bronconeumología (English Edition). 2015 Feb 1;51(2):69-75.
  8. Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate Acting Non-depolarizing Neuromuscular Blocking Agents and Risk of Postoperative Respiratory Complications: Prospective Propensity Score Matched Cohort Study. BMJ. 2012;345:6329.
  9. Zhan C, Miller MR: Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries During Hospitalization. JAMA 2003; 290: 1868–1874
  10. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA. Hospital Costs Associated with Surgical Complications: A Report from the Private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199(4):531–537
  11. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Nisman M. Intraoperative Acceleromyographic Monitoring Reduces the Risk of Residual Meeting Abstracts and Adverse Respiratory Events in the Postanesthesia Care Unit. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2008 Sep 1;109(3):389-98.
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Increased PACU Length of Stay – A Costly Matter

Postoperative residual curarization (PORC), also known as residual neuromuscular blockade, refers to the residual muscle paralysis that occurs after emergence from general anesthesia. PORC stems from the use of neuromuscular blocking agents (NMBAs). It is defined as a Train-of-Four (TOF) ratio of <0.9 and may occur in around 41% of patients who receive intermediate-acting neuromuscular blockers.1 PORC has been associated with critical respiratory events and impaired postoperative respiratory functions.2 It is also independently associated with an increased length of stay (LOS) in the post-anesthesia care unit (PACU). The increased PACU length of stay in turn impacts operating room throughput and results in prolonged waiting time for new PACU admissions.3

The Use of Quantitative NMT Monitoring to Avoid PORC

Subjective tests of NMT monitoring are not sensitive enough to detect residual weakness

Quantitative neuromuscular transmission (NMT) monitoring can help reduce the incidence of PORC. Neuromuscular monitoring is recommended when neuromuscular blockers have been administered as a part of general anesthesia. It can be carried out through subjective techniques, such as clinical assessment or peripheral nerve stimulation (qualitative monitoring), or with the help of objective or quantitative NMT monitors that provide a numeric value representing the depth of neuromuscular blockade. There is mounting evidence that clinical or subjective tests of NMT monitoring are not sensitive enough to detect residual weakness and do not predict adequate neuromuscular recovery. Quantitative or objective neuromuscular monitors should therefore be used whenever non-depolarizing NMBAs are administered.4,5,6

The Stimpod NMS 450X is a quantitative neuromuscular monitor that uses a 3D acceleromyography (AMG) transducer which is effective in detecting the full force of muscle contraction. It minimizes the risk of residual neuromuscular blockade and associated adverse respiratory events.7 As discussed below, this leads to a decrease in the average length of stay in the PACU and substantial cost savings for the hospital.

Reduction in the PACU Length of Stay as a Cost-reducing Measure

The economic structure of the PACU determines whether a cost-saving measure such as reducing the PACU length of stay is likely to reduce hospital costs. Hospital costs can be divided into fixed and variable components. Fixed costs are one-time costs that do not change in relation to the number of surgical cases. These include capital expenditures, such as gurneys, monitors, and the physical plant of the PACU. On the other hand, variable costs are directly related to the number of surgical cases, and include X-ray films, pharmaceuticals, dressings, and laundry.

The only real way of reducing PACU costs is to increase the productivity of the PACU and the staff

It is important to bear in mind that reducing the PACU length of stay will only affect variable costs. Small reductions in the length of time that patients stay in a PACU are unlikely to impact fixed costs at ambulatory surgery centers, which include the labor costs of staffing the PACU with full-time nurses.8 This means that reducing the length of stay of a patient in the PACU by one minute is not equivalent to saving one minute of PACU costs. Therefore, the only real way of reducing PACU costs is increasing the productivity of the PACU and the staff working in it.

Reduction in the Peak Number of Patients Improves Productivity and Reduces Costs

A reduction in the peak number of patients in the PACU is the most effective way to increase the productivity of the PACU and its staff. One way of doing this is to use anesthetic agents that permit a quicker discharge of patients from the PACU. However, if for example the average total time a patient stays in the PACU is 120 minutes, then for a modern anesthetic drug to reduce the peak number of PACU patients by 25%, the drug would have to reduce the mean time to discharge from a total of 120 minutes to just 34 minutes. Such a drastic change is unrealistic and therefore this method is limited in its effectiveness to achieve a substantial increase in PACU productivity.8

Optimization of the time of arrival of patients into the PACU is the single most important measure

For a PACU with salaried or full-time hourly employees, optimization of the time of arrival of patients into the PACU is the single most important measure that can reduce the peak number of patients in the PACU and decrease the peak requirements of nursing staff. This increases PACU productivity and results in PACU cost savings.8 According to a study conducted by Butterly et al., the mean length of stay in the PACU for patients with PORC was found to be 323 minutes whereas the length of stay for patients without PORC was 243 minutes.3 This shows that using the Stimpod NMT monitor for performing objective monitoring and avoiding residual neuromuscular blockade can save up to 80 minutes of the PACU time per patient. The Stimpod thus makes possible the “unrealistic” change that results in a significant reduction in peak patient numbers in the PACU.

Decrease in Operating Room Holding Time Results in Cost Reduction

Postoperative residual curarization results in delayed discharge of the patient from the PACU. If the PACU gets filled up with patients, the next patient has to wait before leaving the operating room resulting in operating room holds. The operating room/PACU system becomes congested. This has debilitating financial fallout as it increases the operating room costs. For instance, if all the operating rooms are filled up with patients waiting for PACU beds, some surgical cases may be delayed or cancelled. Also, in some situations, incentive salaries may have to be paid to the nurses and anesthetists for the extra time that they monitor patients in the operating rooms.3,9,10

The Stimpod quantitative NMT monitor provides an excellent solution to this problem—it minimizes the incidence of PORC and with it PORC-induced delay in PACU discharge. The increased availability of beds in the PACU allows for a quicker release of patients from the operating room. This cuts down operating room costs.

Stimpod NMS 450X—The Ultimate Cost-Saving Option

Stimpod NMS450X Neuromuscular Monitor

The Stimpod NMS450X Neuromuscular Monitor reduces the incidence of residual paralysis in 97% of patients

The Stimpod NMS 450X is a fully-automated neuromuscular monitor that supports Train-of-Four (TOF), Double Burst (DB), Post-Tetanic Count (PTC), Tetanus and Twitch Stimulation modes to perform accurate, real-time neuromuscular monitoring. It uses OneTouchTM technology that allows an entire case to be monitored—starting from automatic electrode placement to extubation—with the press of a single button. The Stimpod begins TOF monitoring and moves to PTC when a deep block is achieved. It detects the depth of neuromuscular blockade throughout the procedure and automatically reinitiates TOF monitoring when the patient begins the reversal process. The monitoring continues until the patient is more than 90% recovered.

The Stimpod NMS 450X is an all-in-one solution for quantitative NMT monitoring that can

  • minimize the incidence of PORC
  • reduce the length of stay in the PACU
  • increase the PACU productivity by decreasing the peak number of patients
  • decrease the operating room hold time

In short, it’s the perfect cost-saving measure for any PACU.


  1. Naguib M, Brull SJ, Johnson KB. Conceptual and technical insights into the basis of neuromuscular monitoring. Anaesthesia 2017; 72: 16–37.
  2. Boon M, Martini C, Dahan A. Recent advances in neuromuscular block during anesthesia. F1000Res. 2018;7:167. Published 2018 Feb 9. doi:10.12688/f1000research.13169.1
  3. Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth 2010; 105: 304–9.
  4. Duţu M, Ivaşcu R, Tudorache O, et al. Neuromuscular monitoring: an update. Rom J Anaesth Intensive Care. 2018;25(1):55–60. doi:10.21454/rjaic.7518.251.nrm
  5. Abdulatif M. Neuromuscular transmission monitoring: Beyond the electric shocks and the shaking hands. Saudi J Anaesth. 2013;7(2):115–117. doi:10.4103/1658-354X.114045
  6. Naguib M, Brull SJ, Kopman AF, et al. Consensus statement on perioperative use of neuromuscular monitoring. Anesth Analg 2018; 127: 71–80.
  7. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS, Nisman M. Intraoperative acceleromyographic monitoring reduces the risk of residual neuromuscular blockade and adverse respiratory events in the postanesthesia care unit. Anesthesiology 2008;109:389–98.
  8. Macario A., D. Glenn and F. Dexter, 1999, What can the postanesthesia care unit manager do to decrease costs in the postanesthesia care unit?, J Perianesth, vol 14, pp. 248-93.
  9. McLaren JM, Reynolds JA, Cox MM, et al. Decreasing the length of stay in phase I postanesthesia care unit: an evidence-based approach. J Perianesth Nurs. 2015;30:116-123.
  10. Cammu G. Sugammadex: Appropriate Use in the Context of Budgetary Constraints. Curr Anesthesiol Rep. 2018;8(2):178–185. doi:10.1007/s40140-018-0265-6
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Anesthesia Hygiene – Infectious Control

Anesthesia Machine Covers Prevent Infections!

Guidance issued by Society for Healthcare Epidemiology of America (SHEA): “…explore the use of disposable covers”

Anesthesia Hygiene machine covers have tear away pouches that hold and contain contaminated supplies such as laryngoscopes and yankauer suction! The use of disposable covers is endorsed by SHEA and ASPF.

Anesthesia Hygiene Covers protect your patient and your anesthesia machine from pathogens and infectious diseases. To view videos and more information on our webpage Anesthesia Hygiene Covers and .

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POM Mask – Don’t just detect Hypoxia, Prevent it.

“The Procedural Oxygen Mask achieves the triple goal of the following: 1) providing reliable FiO2 delivery of 0.90 to 0.95 at O2 flow rates of 10 to 15 L/min, 2) allowing easy access to the nose and mouth via the self-sealing endoscopy ports, and 3) providing a continuous capnography sampling port.”

René Miguel Gonzalez, MD, Department of Anesthesiology, Hackensack Meridian Health Southern Ocean Medical Center, Stafford Township, N.J.

 Benefits of The POM Procedural Sedation Mask:
 • Dual oral and nasal entry ports for endoscopes
 • Improves O2 concentration during conscious sedation up to 92%FiO2
 • Measures capnography reliably even at high oxygen flows
 • Allows easy unobstructed access to the patient
 • Ideal for Oral or Nasal fiber optic intubations

Enhanced Patient Safety: The POM provides accurate capnography readings allowing clinicians to intervene proactively, while providing over twice the FiO2 of standard O2/CO2 nasal cannulas.  POM reduces the risk of hypoxia during gastrointestinal endoscopy procedures.  Now available with Oridion MicroStream capnography sample lines. 

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AANA 2019 Annual Congress

Nasoral - Murphy - Cuffed

Bell Medical will feature six new and innovative products at the AANA 2019 Annual Congress in Chicago. Come see us at Booth 710 for FREE label samples, a demonstration, or a trial.


The EyePro is a sterile dressing that keeps the eyelid closed during procedures.


The NoPress is a mask shield that protects the eyes.


BiteMe tooth protectors.

Total Control Introducer

Total Control Introducer takes the “difficult” out of “difficult airways”.

Stimpod 450X Quantitative TOF Monitor

The Stimpod 450X is a quantitive Train-of-Four monitor that requires no calibration.

Click-To-Comply Syringe Labeling System

Two-Clicks, Two Seconds. The Vigilant Labeling System is USP 797 compliant.

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Stimpod NMS460 by Xavant Receives FDA Approval

PRETORIA, South Africa, Aug. 1, 2017 /PRNewswire/ — Xavant Technology (Pty) Ltd today announced that the U.S. Food and Drug Administration (FDA) cleared their Stimpod NMS460. With the U.S. patent awarded on proprietary hybrid pulsed radio frequency (PRF) waveform, this non-invasive neuromodulation device is focused on the symptomatic relief and management of chronic intractable pain, as well as an adjunctive treatment in the management of post-surgical pain, post-traumatic acute pain problems, and an adjunct for pain control due to rehabilitation.

The need for this device is profound. More than 100 million Americans report that they have a problem with pain.[1] Chronic pain is characterized by neuroplastic changes that cause sensitization of the nervous system. These changes result in anatomical and physiological changes that affect neurological function, which causes long-term potentiation and gene expression changes that then allow the pain to continue with or without further peripheral input, and a lower pain threshold; this dysfunction then also accounts for the epiphenomena associated with the disease, including emotional, memory, and motor changes, which then becomes the illness of chronic pain.[2]

Treatment of chronic pain in the United States is estimated to cost $600 billion annually.[3] The current standard of care for chronic pain includes drug cocktails such as Corticosteroids, Opiate pain relievers, injections, and beyond combined with treatments like physical therapy and counseling. Treatments can come with various short-term and long-term side effects.

The Stimpod NMS460, however, will greatly impact the industry as a non-invasive, non-drug solution with zero side effects and a fast onset of effect at a fraction of the cost of comparable treatments. The device applies its patented PRF waveform to the affected area transcutaneously. This waveform creates electromagnetic effects similar to invasive pulsed radio frequency treatments, and several case studies have shown instant and dramatic relief of chronic intractable pain. The Stimpod NMS460 also incorporates the nerve-locating technology which features a nerve mapping probe that enables practitioners to locate nerves and evaluate the treatment progress of damaged nerves. Bell Medical has been selected as the master distributor for both the U.S. and Canada.

“We are thrilled at the news that our revolutionary device can now be used in the U.S.,” said Corlius Birkill, CEO of Xavant Technology (Pty) Ltd. “This groundbreaking technology has the ability to help tens if not hundreds of millions of people just in the U.S. as a valuable treatment asset for neurologists, chiropractors, acupuncturists, physical therapists, physiatrists, and medical pain practitioners.”

About Xavant Technology (Pty) Ltd
Xavant Technology (Pty) Ltd is a leading supplier of nerve stimulators for regional and general anesthesia applications. The current Stimpod range has three models – the NMS410, NMS450 and NMS460. The Stimpod NMS460 is a neuromodulation device used for symptomatic relief of chronic intractable pain, implementing a unique patented Pulsed Radio Frequency waveform for the treatment of neuropathies. The Stimpod NMS410 model is a specialized nerve locating device, with its unique nerve mapping and locating cable, used primarily during Regional Anesthesia procedures. The Stimpod NMS450 adds the option to monitor neuromuscular blocking agents with its advanced three-dimensional accelerometer. Learn More About STIMPODNMS460 at

Media Contact:
Lourie Höll
Phone: +27 12 743 5959
Email: [email protected]

[1] Gaskin, Darrell J., and Patrick Richard. “The Economic Costs of Pain in the United States.” The Journal of Pain: Official Journal of the American Pain Society (2012): 715-24. Web. 21 June 2017.

[2] American Academy Of Pain Medicine. Neuropathic Pain Recognized as a Disease. N.p.: American Medical Association, 27 Sept. 2016. PDF.

[3] Gaskin, Darrell J., and Patrick Richard. “The Economic Costs of Pain in the United States.” The Journal of Pain: Official Journal of the American Pain Society (2012): 715-24. Web. 21 June 2017.

Source: PR Newswire

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Amsorb Plus Review

When choosing a type of CO2 absorbent, it is important to understand the absorbents environmental impact, effect on patient safety, ease of use and the effect on the consumption of volatile anesthetics. Today we are going to review Amsorb vs. soda limes that contain traces of Sodium Hydroxide, NaOH, such as Medisorb, Sodasorb, Dragersorb and others.

Environmental Impact

Soda limes can have a pH of up to 14 and may require disposal as a hazardous waste according to U.S. Federal Code of Regulations. Soda limes contain sodium hydroxide and are considered corrosive.

Amsorb Plus has a pH of less than 12.5 and is safe for our water table and landfills where it will break down into harmless organic compounds. Amsorb Plus comes with certification of such (see Amsorb Plus disposal document). Kaiser Permanente independently tested all the types of CO2 absorbents readily available on the market and determined Amsorb Plus to be the only one that was safe for disposal in regular landfills. Other types of CO2 absorbents had higher pH and needed to be red bagged and incinerated at greater expense. Amsorb Plus is not harmful in disposal to the environment which translates into a cost savings for hospitals and surgery centers since red bagging is expensive and time consuming.

Patient Safety

Soda limes are known to degrade volatile anesthetics to Carbon Monoxide, Compounds A – F, and Formaldehyde.

Amsorb Plus has no strong alkali and is incapable of producing any of these toxins. Clinical Anesthesia by Barash, 2012, recommends using Amsorb Plus by name and states doing so: (Amsorb Plus)

eliminates all of the potential complications related to anesthetic breakdown and therefore minimizes the possibility of additional costs from those complications, including additional laboratory tests, hospital days, and medical/legal expenses. Adoption of [Amsorb Plus] into routine clinical practice is consistent with the patient safety goals of our anesthesia society.

Ease of Use & Consumption of Volatile Anesthetic

Soda Lime users generally change absorbent based on color change and never know for sure when to change product. Users usually error on the side of caution and change soda lime more often (a wasteful and confusing practice) because if they don’t change soda lime it is possible to endanger the patient by producing toxins such as Compound A, Formaldehyde and Carbon Monoxide. Soda Lime includes a dye that changes color to indicate exhaustion. However, it does not retain color change for long before reverting back to looking fresh. The user can never be sure when product should be changed. Ask any clinician that has used a soda lime and they will verify it is not uncommon to begin a case with what they think is fresh absorbent only to immediately find out they have high levels of FiCO2 and rapid color change of their absorbent.

Soda Limes “adsorbs” (significant amounts of volatile anesthetic which means clinicians wait longer periods of time for their machines and vaporizers to equilibriate. They are less able to reach desired drug percentages without increasing vaporizer settings.

Amsorb Plus has permanent, consistent, and reliable color change. Thus allowing the user to easily tell the state of the absorbent at a glance. Amsorb Plus also adsorbs far less anesthetic vapor than soda limes so machines and vaporizers reach equilibriation faster and accurately reach desired drug percentages without needing to increase vaporizer settings above what is desired for patient inspiration. This saves time and money (utilizing less anesthetic vapor).

Amsorb vs. Soda Lime Review Summary

Soda Lime Amsorb Plus
Environmental Impact
Patient Safety
Ease of Use & Consumption of Volatile Anesthetic