we use a peripheral nerve stimulator on all of our patients who are in chemically induced paralysis.
we have neuromuscular blockade protocol that encompasses the pns protocol.
we use the ulnar nerve...we place 2 electrodes ~2 inches apart on the inside of the forearm just above the wrist vertically on the little finger side (ensuring the area is clean, free of hair etc)
we use the train-of-four (usually with ~40-50Mas) to determine level of paralysis, with 1-2 twitches (adductions) of the THUMB (twitching of the fingers doesn't count) being the goal.
if more than 2 twitches are elicited, the medication is tritrated up and reassessment occurs q15min until the desired level is reached. if no twitches are elicited, the medication is titrated down, again with reassessment occurring q15min until the desired level is reached.
once the desired # of thumb adductions is reached, reassessment occurs q4hrs, unless of course there is a need for titration again.
ideally, a baseline assessment would be documented, but usually the patients we receive from the ED or post-op have already been medicated with the blockade when we get them.
when the blockade is discontinued, q15min assessments are done until 4 of 4 adductions of the thumb are seen, especially, if extubation is in the near future.
hope this helps,