J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 17, Number 4, April 2026, pages 163-169

Intraoperative Neuromuscular Monitoring: Electromyography Monitor Versus Peripheral Nerve Stimulator. Does the Face Lie?

Figures

Figure 1. TetraGraph™ electromyography based quantitative TOF monitor (Senzime BV, Uppsala, Sweden). The displayed TOFC is 0/4. TOFC: train-of-four count.

Figure 2. TetraSens™ (Senzime AB) pediatric size strip with recording electrodes on the palmar surface (adductor pollicis muscle) and stimulating electrodes over the ulnar nerve. This is an illustrative image of placement and is not from the reported case.

Figure 3. Left: end-tidal carbon dioxide (ETCO₂) waveform showing a classical curare cleft. Right: ventilator screen displaying spontaneous respiratory efforts and ventilator settings.

Table

**Table 1.** Timeline of Rocuronium Administration and Neuromuscular Monitoring Using EMG and PNS
Absolute time	Rocuronium bolus (mg/kg)	Rocuronium infusion rate (mg/kg/h)	EMG TOFC (twitches)	PNS assessment	Event
EMG: electromyography; PNS: peripheral nerve stimulator; TOFC: train-of-four count; TOFR: train-of-four ratio.
8:05	—	—	—	—	Induction
8:17	1.2	—	Not assessed	Not assessed
8:19	—	—	0/4	Not assessed	Endotracheal intubation
8:52	—	Start (0.6)	1/4	1/4
9:04	0.4	0.72	2/4	2/4
9:55	—	0.6	0/4	0/4
10:47	—	0.48	0/4	1/4
11:07	—	0.48	0/4	1/4
11:40	—	0.36	0/4	2/4
12:08	—	0.36	1/4	4/4
12:15	—	0.36	1/4	4/4	Onset of spontaneous breathing
12:29	0.6	0.48	1/4	4/4
12:31	—	0.48	0/4	0/4
12:52	—	0.48	0/4	1/4
13:52	—	0.48	0/4	2/4
14:01	—	Stop	0/4	2/4
14:07	—	—	0/4	2/4	Onset of spontaneous breathing
14:08	0.2	—	0/4	2/4
14:51	—	—	1/4	4/4	Sugammadex administration
15:08	—	—	4/4 (TOFR was ≥ 0.9)	Not assessed	Tracheal extubation