Ease of Application of Various Neuromuscular Devices for Routine Monitoring.

BACKGROUND: Subjective evaluations to confirm recovery from neuromuscular blockade with a peripheral nerve stimulator (PNS) is inadequate. Quantitative monitors are the only reliable method to confirm adequate recovery of neuromuscular function. Unfortunately, many clinicians are unfamiliar with such devices and there is concern that the introduction of objective monitoring would be exceedingly laborious and could cause workflow delays. This study investigates how long it takes experienced nurse anesthetists to apply various neuromuscular devices as well as their perception regarding the ease of application. METHODS: Twenty nurse anesthetists were consented and participated in an educational session that familiarized them with 3 devices: SunStim Plus PNS (SunMed, Grand Rapids, MI), the acceleromyography-based IntelliVue NMT device (Philips, Amsterdam, the Netherlands), and electromyography-based TetraGraph device (Senzime B.V., Uppsala, Sweden). Participants were timed while placing each monitor on patients in a real-world setting. For the quantitative devices (IntelliVue NMT and TetraGraph), participants were also timed when obtaining calibrated baseline train-of-four (TOF) ratios. Friedman test and pairwise Wilcoxon signed-rank tests were used to evaluate the difference in time to connect different devices. Participants were surveyed about how easy they found it to utilize these devices. RESULTS: After adjusting for multiple comparison, time to connect was significantly less for PNS (median, 29; range, 16-58 seconds) compared to either the TetraGraph device (median, 62.8; range, 32-101 seconds; P < .001) or the IntelliVue NMT device (median, 46; range: 28-90 seconds; P < .001). The difference in time to connect between the TetraGraph device and the IntelliVue NMT device was not statistically significant (P = .053), but it took significantly less time to calibrate the TetraGraph device than the IntelliVue NMT device (median difference, -16; range, -88 to 49 seconds; P = .002). The participants found applying either the IntelliVue NMT device (P = .042) or the TetraGraph device (P = .048) more difficult than applying a PNS while finding it easier to calibrate the TetraGraph device versus the IntelliVue NMT device (P < .001). CONCLUSIONS: It takes 19 seconds longer to apply a quantitative neuromuscular monitor (the IntelliVue NMT device) than a PNS. While this difference reached significance, this relatively minimal additional time represents an inappropriate barrier to the application of quantitative monitors. Regardless of which quantitative monitor was utilized, these nurse anesthetists found the application and utilization of such devices relatively straightforward.

Assessment of spontaneous neuromuscular recovery: A comparison of the TOF-Cuff® with the TOF Watch SX®.

BACKGROUND: TOF-Cuff® is a modified blood pressure cuff used to monitor neuromuscular block. We compared the assessment of spontaneous neuromuscular recovery between TOF-Cuff® (test device) and TOF Watch SX® (reference device). METHODS: Forty patients aged 18-65 years undergoing elective surgery were enrolled. TOF-Cuff® was installed on an upper arm and the TOF Watch SX® on the thumb of the opposite side. Anaesthesia was induced and maintained with intravenous propofol and sufentanil. After induction, the devices were calibrated and continuous train-of-four (TOF) stimulation was started. A single intravenous dose of rocuronium (0.6 mg kg-1 ) was administered for intubation. The primary outcome was total recovery time (time in minutes from the injection of rocuronium to a normalized TOF ratio of 90%). Agreement between the two devices was calculated using mean difference and limits of agreement. RESULTS: The primary outcome could be analysed in 27 patients because of 13 exclusions due to neuromuscular block reversal for shorter procedure surgical time, necessity of reinjection of rocuronium or technical failures of one of the two devices. Median total recovery time with the test device was 45 minutes (interquartile range [IQR] 38.5-61.5) and 63 minutes (IQR 51.1-74.5) with the reference device. Total recovery time with the test device was on average 16.4 minutes shorter (limits of agreement, -6.1 to 39); increasing total recovery time was associated with increasing difference. The TOF ratio of the reference device was on average 0.59 (SD 0.23) when the test device indicated complete recovery. The TOF ratio of the test device was on average 0.98 (SD 0.03) when the reference device indicated complete recovery. CONCLUSION: When compared with the TOF Watch SX® , TOF-Cuff® overestimates spontaneous recovery of a rocuronium-induced neuromuscular block.

Comparative Study of TOF-Cuff, a New Neuromuscular Blockade Monitor, and TOF-Watch, an Acceleromyography.

Train-of-four ratios were recorded to assess the agreement between the TOF-Cuff and TOF-Watch, and residual paresis was assessed to evaluate the clinical utility of TOF-Cuff. Train-of-four ratios were evaluated using Lin concordance correlation coefficient and Bland-Altman analyses. Measured train-of-four ratios demonstrated high accuracy and precision over the entire range of train-of-four ratios. Although precision and Lin concordance correlation coefficients decreased with train-of-four ratios >0.7, none of the patients showed signs of residual paresis. Because TOF-Cuff underestimated train-of-four ratios in the recovery period, the clinical safety of train-of-four ratios >0.9 indicated by TOF-Cuff is unclear; the issue of residual paresis requires future research that rigorously evaluates outcomes.

Comparison of the TOFscan and the TOF-Watch SX during Recovery of Neuromuscular Function.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Quantitative neuromuscular monitoring is required to ensure neuromuscular function has recovered completely at the time of tracheal extubation. The TOFscan (Drager Technologies, Canada) is a new three-dimensional acceleromyography device that measures movement of the thumb in multiple planes. The aim of this observational investigation was to assess the agreement between nonnormalized and normalized train-of-four values obtained with the TOF-Watch SX (Organon, Ireland) and those obtained with the TOFscan during recovery from neuromuscular blockade. METHODS: Twenty-five patients were administered rocuronium, and spontaneous recovery of neuromuscular blockade was allowed to occur. The TOFscan and TOF-Watch SX devices were applied to opposite arms. A preload was applied to the TOF-Watch SX, and calibration was performed before rocuronium administration. Both devices were activated, and train-of-four values were obtained every 15 s. Modified Bland-Altman analyses were conducted to compare train-of-four ratios measured with the TOFscan to those measured with the TOF-Watch SX (when train-of-four thresholds of 0.2 to 1.0 were achieved). RESULTS: Bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at nonnormalized train-of-four ratios between 0.2 and 1.0 were 0.021 and -0.100 to 0.141, respectively. When train-of-four measures with the TOF-Watch SX were normalized, bias and 95% limits of agreement between the TOF-Watch SX and the TOFscan at ratios between 0.2 and 1.0 were 0.015 and -0.097 to 0.126, respectively. CONCLUSIONS: Good agreement between the TOF-Watch SX with calibration and preload application and the uncalibrated TOFscan was observed throughout all stages of neuromuscular recovery.

Residual neuromuscular blockade: management and impact on postoperative pulmonary outcome.

PURPOSE OF REVIEW: To revise the current literature on concepts for neuromuscular block management. Moreover, consequences of incomplete neuromuscular recovery on patients' postoperative pulmonary outcome are evaluated as well. RECENT FINDINGS: The incidence of residual paralysis may be as high as 70% and even small degrees of residual paralysis may have clinical consequences. Neostigmine should not be given before return of the fourth response of the train-of-four-stimulation and no more than 40-50 µg/kg should be given. Sugammadex acts more rapidly and more predictably than neostigmine. Finally, there is convincing evidence in the literature that incomplete neuromuscular recovery may lead to a poor postoperative pulmonary outcome. SUMMARY: New evidence has emerged about the pathophysiological implications of incomplete neuromuscular recovery. Not only are the pulmonary muscles functionally impaired, but respiratory control is also affected. Residual paralysis endangers the coordination of the pharyngeal muscles and the integrity of the upper airway. However, neuromuscular monitoring and whenever needed pharmacological reversal prevent residual paralysis.

A Technique for Preoperative Identification of the Facial Nerve Mandibular Branch Using a Nerve Stimulator.

We established the method of preoperative identification to facial nerve marginal mandibular branch (FNMB) identification using a nerve stimulator with bipolar probe for upper-neck surgery. The bipolar electrode is placed on the region while patients were awake; the patient should be in the same position and posture as during the surgery, with the neck skin stretched. A nerve course is confirmed by observing the movement of the lower lip. In this study, 5 upper-neck surgeries were conducted. Preoperative analysis revealed that 4 of the 5 cases had 2 branches of FNMB, and 1 with 3 branches. All FNMB immediately confirmed preoperatively were identified during surgery. We performed this method in much surgery including the surgery of the upper neck. It was easy to identify the facial nerve by this method and came to be able to do it precisely, and an operative time was shortened. We concluded that the preoperative FNMB identification using a nerve stimulator is most useful and benefit for upper-neck surgery patients and lead to avoid lower lip paralysis.

An ipsilateral comparison of acceleromyography and electromyography during recovery from nondepolarizing neuromuscular block under general anesthesia in humans.

BACKGROUND: Residual neuromuscular block is defined as a mechanomyography (MMG) or electromyography (EMG) train-of-four (TOF) ratio <0.90, and is common in patients receiving neuromuscular blocking drugs. Objective neuromuscular monitoring is the only reliable way to detect and exclude residual neuromuscular block. Acceleromyography (AMG) is commercially available and easy to use in the clinical setting. However, AMG is not interchangeable with MMG or EMG. Currently, it is unclear what value must be reached by AMG TOF ratio to reliably exclude residual neuromuscular block. METHODS: During spontaneous recovery from neuromuscular block, we monitored TOF ratio on the same arm using AMG at the adductor pollicis and EMG at the first dorsal interosseus. AMG and EMG TOF ratios were compared by the Bland-Altman analysis for repeated measurements. The precision of each device was assessed by the repeatability coefficient. A small repeatability coefficient indicates high precision of the device. The agreement between the devices was assessed by the bias and the 95% limits of agreement. Small bias and narrow limits of agreement indicate strong agreement. We defined clinically acceptable agreement between AMG and EMG as a bias <0.025 and limits of agreement within -0.050 to 0.050, provided that the control comparison between EMG and itself can fulfill these criteria. RESULTS: In 26 patients, 261 comparisons between AMG and EMG were made. The repeatability coefficient of AMG and EMG were 0.094 (95% confidence interval [CI], 0.088-0.100) and 0.051 (95% CI, 0.048-0.055), respectively. The bias between AMG and EMG TOF ratio was 0.176 (95% CI, 0.162-0.190), with limits of agreement -0.045 to 0.396 (95% CI, -0.067 to 0.419). CONCLUSIONS: AMG is less precise than EMG and overestimates EMG TOF ratio by at least 0.15. The lack of agreement cannot be attributed to instrumental imprecision or the baseline difference between successive measurements during spontaneous recovery of neuromuscular function. Residual neuromuscular block cannot be excluded on reaching an AMG TOF ratio of 1.00.

Survey of muscle relaxant effects management with a kinemyographic-based data archiving system: a retrospective quantitative and contextual quality control approach.

In a retrospective quality control study of muscle relaxant management, we assessed unbiased files provided by an automatic archiving system using quantitative monitoring generated by a kinemyographic transducer and suggest improvements for a possible future design. 200 randomly selected files were double checked to collect the values of twitch height ratio (THr), train of four ratio (TOFr) and TOF count in four periods: references values acquisition (REF), maximal level of paralysis, paralysis maintenance, pre-tracheal extubation residual paralysis assessment (RPA). The parameter values were selected according to period-specific predefined rules. A quantitative quality control was based upon standardized cut-offs values. A contextual quality control was based upon the detection of "difficult-to-interpret" episodes. Results were expressed on a descriptive basis only. For the REF period, THrs and TOFrs were lacking in, respectively, 47 and 18 of the 200 recordings analysed. A starting TOFr above 0.90 existed in 119 files. Concomitant THrs and TOFrs >0.90 were evidenced 93 times. During RPA period, TOFr >0.90 was recorded on 82 occasions. The optimal combination of THr >0.80 and TOFr >0.90 was detected in 30 files only. Presence of "difficult to interpret" episodes started with 18 files for the REF period and increased to 42, 86 and 52 in the subsequent ones most of them probably related to the absence of initial calibration procedure. In the real life conditions, a near to optimal quality control is not always observable with the quantitative neuromuscular monitoring studied. To improve the NMT monitoring, the calibration of the sensor should be performed vigorously by the anaesthesia provider and the quality of this calibration must be displayed on the screen of the monitor.

[Evaluation of neuromuscular blockade using TOF-Watch SX in type 2 diabetes patients].

BACKGROUND: Differences in the supramaximal current (STIM) and sensitivity of the transducer (SENS) after calibration using mode "CAL2" of the neuromuscular accelermyography (TOF-Watch SX, MSD, Japan) between type 2 diabetic and non-diabetic patients were evaluated undergoing general anesthesia. METHODS: Thirty four elective surgical patients (20-69 years) were enrolled in this study. We evaluated STIM, SENS, onset time of rocuronium (onset time), time from onset to first T1 appearance (T1 appearance) and time from T1 appearance to T2 appearance (T1-T2 time) by using TOF stimulation between type 2 diabetic patients and non-diabetic patients, retrospectively. RESULTS: Thirteen diabetic patients (DM group) and twenty one non-diabetic patients (non-DM group) were included in this analysis. The values of SENS in DM group were significantly higher compared to non-DM patients (207 +/- 59 vs 113 +/- 44). However, STIM did not differ significantly between the two groups. Anesthesia in the 6 patients in DM group (SEV-DM group) and 14 patients in the non-DM group (SEV-non DM group) were maintained with sevoflurane. The other 14 patients were maintained with desflurane (DES-DM: n = 7 and DES-non DM: n = 7). A significant difference in the SENS values only was observed between the two SEV groups. On the other hand, the onset time, T1 appearance and T1-T2 time were significantly longer in DES-DM patients than those in the DES-non DM group. CONCLUSIONS: It is demonstrated that the values in the SENS and the recovery speed (T1-T2 time) under measuring the degree of neuromuscular blockade by TOF stimulation were significantly higher in diabetic patients compared to non-diabetic patients. The present study provides additional confirmation of low neuromuscular response under peripheral electrical stimulation using TOF-Watch SX in type 2 diabetes patients, and attention should be paid to the evaluation of neuromuscular block using TOF-Watch SX in diabetic patients.

An Implantable System For Chronic In Vivo Electromyography.

Electromyography (EMG) measures the muscle response to electrical stimulation or spontaneous activity of motor units and plays an important role in assessing neuromuscular function. Chronic recording of EMG activity reflecting a muscle's reinnervation status after nerve injury has been limited, due to the invasive nature of traditional EMG recording techniques. In this regard, an implantable system is designed for long-term, in vivo EMG recording and nerve stimulation. It has been applied and tested in a study on reinnervation of laryngeal muscles. This system consists of 1) two bipolar electrode nerve cuffs and leads for stimulating each of two nerves: the recurrent laryngeal nerve (RLN) and internal branch of the superior laryngeal nerve (SLN); 2) two EMG recording electrodes and leads for each of the two laryngeal muscles: posterior cricoarytenoid (PCA) muscle and thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex; and 3) a skin receptacle interfacing all implanted lead terminals to an external recording preamplifier and stimulator using a connection cable. The wire leads are Teflon-coated, multi-filament, type 316 stainless steel. They are coiled and can stretch during body movement of the awake animal to prevent lead breakage and electrode migration. This system is implanted during an aseptic surgery. Afterwards, baseline EMG recordings are performed before the RLN is transected in the second surgery to study muscle reinnervation. Throughout the study, multiple physiological sessions are conducted in the anesthetized animal to obtain evoked and spontaneous EMG activity that reflects the reinnervation status of laryngeal muscles. The system is compact, free of infection over the course of the study, and highly durable. This implantable system can provide a reliable platform for research in which long-term recording or nerve stimulation is required in an anesthetized or freely moving animal.

Rapid prototyping of soft bioelectronic implants for use as neuromuscular interfaces.

Neuromuscular interfaces are required to translate bioelectronic technologies for application in clinical medicine. Here, by leveraging the robotically controlled ink-jet deposition of low-viscosity conductive inks, extrusion of insulating silicone pastes and in situ activation of electrode surfaces via cold-air plasma, we show that soft biocompatible materials can be rapidly printed for the on-demand prototyping of customized electrode arrays well adjusted to specific anatomical environments, functions and experimental models. We also show, with the monitoring and activation of neuronal pathways in the brain, spinal cord and neuromuscular system of cats, rats and zebrafish, that the printed bioelectronic interfaces allow for long-term integration and functional stability. This technology might enable personalized bioelectronics for neuroprosthetic applications.

Neuromuscular monitoring during modified rapid sequence induction: A comparison of TOF-Cuff® and TOF-Scan®.

BACKGROUND: Acceleromyometry is the clinical standard for quantitative neuromuscular monitoring, mostly using the stimulation pattern train-of-four (TOF). TOF-Cuff®, a recently introduced neuromuscular monitor with stimulating electrodes integrated within a blood pressure cuff, assesses the muscular response in the upper arm. METHODS: The time from administration of a neuromuscular blocking agent to TOF-ratio 0% during modified rapid sequence induction was compared between TOF-Cuff® and acceleromyometry (TOF-Scan®). Included were 26 adults with body mass index <35 kg/m2. TOF-Scan® and TOF-Cuff® were simultaneously fitted on patients' opposite arms. The mean difference to TOF-ratio 0% was compared using the one sample t-test (p < 0.05) and Bland-Altman plots. RESULTS: After anesthesia induction, atracurium 0.9 mg/kg (±0.08) i.v. was administered. The mean time to TOF ratio 0% for TOF-Scan® was 140.4 s (±34.3), and 132.7 s (±32.5) for TOF-Cuff®, with a mean difference of 5.4 (95% CI: -9.9 to 20.7, p = 0.472). The maximum difference between the two modalities was 135 s when the TOF-Cuff® was faster and 60 s when the TOF-Scan® was faster. CONCLUSIONS: No statistically significant systematic difference was found between TOF-Scan® and TOF-Cuff®. However, there was high variability and wide limits of agreement. The two devices cannot be used interchangeably.

SPiQE: An automated analytical tool for detecting and characterising fasciculations in amyotrophic lateral sclerosis.

OBJECTIVES: Fasciculations are a clinical hallmark of amyotrophic lateral sclerosis (ALS). Compared to concentric needle EMG, high-density surface EMG (HDSEMG) is non-invasive and records fasciculation potentials (FPs) from greater muscle volumes over longer durations. To detect and characterise FPs from vast data sets generated by serial HDSEMG, we developed an automated analytical tool. METHODS: Six ALS patients and two control patients (one with benign fasciculation syndrome and one with multifocal motor neuropathy) underwent 30-minute HDSEMG from biceps and gastrocnemius monthly. In MATLAB we developed a novel, innovative method to identify FPs amidst fluctuating noise levels. One hundred repeats of 5-fold cross validation estimated the model's predictive ability. RESULTS: By applying this method, we identified 5,318 FPs from 80 minutes of recordings with a sensitivity of 83.6% (+/- 0.2 SEM), specificity of 91.6% (+/- 0.1 SEM) and classification accuracy of 87.9% (+/- 0.1 SEM). An amplitude exclusion threshold (100 µV) removed excessively noisy data without compromising sensitivity. The resulting automated FP counts were not significantly different to the manual counts (p = 0.394). CONCLUSION: We have devised and internally validated an automated method to accurately identify FPs from HDSEMG, a technique we have named Surface Potential Quantification Engine (SPiQE). SIGNIFICANCE: Longitudinal quantification of fasciculations in ALS could provide unique insight into motor neuron health.

Neuromuscular Performance and Hormonal Profile During Military Training and Subsequent Recovery Period.

INTRODUCTION: Military training loads may induce different physiological responses in garrison and field training and only a little is known about how short-time recovery, lasting a few days, affects neuromuscular fitness and hormonal profile. This study aimed to investigate the effects of garrison and field military service on neuromuscular performance and hormonal profile and to evaluate the effects of a 3-day recovery on those factors. METHODS: Twenty healthy male soldiers (20 ± 1 years) participated in the study, which consisted of 4 days of garrison training [days (D) 1-4] and 7 days of military field training (Days 5-12) followed by a 3-day recovery period (Day 15). Serum hormone concentrations [testosterone (TES), cortisol (COR), sex-hormone binding globulin (SHBG), free thyroxine (T4)] were assessed at D1, D5, D8-12, and D15. Handgrip strength was measured in 10 participants at D1, D5, D8, D12, and D15. Maximal isometric force, electromyography, and rate of force development (RFD) of the knee extensors and arm flexors were also measured at D5, D12, and D15. RESULTS: The maximal force of both the arm flexors and knee extensors was not affected by the garrison or field training, whereas the RFD of the knee extensors was decreased during the field training (D5: 383 ± 130 vs. D12: 321 ± 120 N/s, p < 0.05). In addition, handgrip strength was mostly no affected, although a significant difference was observed between D8 and D12 (531 ± 53 vs. 507 ± 43 N, p < 0.05) during the field training. TES decreased already during the garrison training (D1: 18.2 ± 3.9 vs. D5: 16.2 ± 4.0 nmol/L, p < 0.05) and decreased further during the field training compared to baseline (D8: 10.2 ± 3.6 - D11: 11.4 ± 5.4 nmol/L, p < 0.05) exceeding the lowest concentration in the end of the field training (D12: 7.1 ± 4.1 nmol/L, p < 0.05). Similar changes were observed in free TES (D1: 72.2 ± 31.4 vs. D12: 35.1 ± 21.5 nmol/L, p < 0.001). The TES concentration recovered back to the baseline level and free TES increased after the recovery period compared with the baseline values (D15: 19.9 ± 5.3 nmol/L, D15: 99.7 ± 41.1 nmol/L, respectively). No changes were observed in the COR or SHBG concentrations during the garrison period. COR was decreased in the end of the field training (D12: 388 ± 109 nmol/L) compared with baseline (D1: 536 ± 113 nmol/L) (p < 0.05-0.001) but recovered back to the baseline levels after the recovery period (D15: 495 ± 58 nmol/L), whereas SHBG linearly increased towards the end of the field training (p < 0.05-0.001). CONCLUSIONS: The present findings demonstrate that neuromuscular performance can be relatively well maintained during short-term garrison and field training even when a clear decrease in hormonal profile is evident. In addition, hormonal responses during field training seem to be greater compared to garrison training, however, the recovery of 3-day in free-living conditions seems to be sufficient for hormonal recovery. Therefore, a short-term recovery period lasting few days after the military field training may be required to maintain operational readiness after the field training.

Stretchable organic optoelectronic sensorimotor synapse.

Emulation of human sensory and motor functions becomes a core technology in bioinspired electronics for next-generation electronic prosthetics and neurologically inspired robotics. An electronic synapse functionalized with an artificial sensory receptor and an artificial motor unit can be a fundamental element of bioinspired soft electronics. Here, we report an organic optoelectronic sensorimotor synapse that uses an organic optoelectronic synapse and a neuromuscular system based on a stretchable organic nanowire synaptic transistor (s-ONWST). The voltage pulses of a self-powered photodetector triggered by optical signals drive the s-ONWST, and resultant informative synaptic outputs are used not only for optical wireless communication of human-machine interfaces but also for light-interactive actuation of an artificial muscle actuator in the same way that a biological muscle fiber contracts. Our organic optoelectronic sensorimotor synapse suggests a promising strategy toward developing bioinspired soft electronics, neurologically inspired robotics, and electronic prostheses.

Comparison of general anaesthesia versus regional anaesthesia with sedation in selected maxillofacial surgery: a randomized controlled trial.

BACKGROUND: The airway is the foremost challenge in maxillofacial surgery. The major concerns are difficulty in managing the patient's airway and sharing it between the anaesthetist and surgeons. General anaesthesia, with endotracheal intubation, is the commonly used technique for maxillofacial procedures. We assessed the efficacy and safety of a regional block with sedation technique in certain maxillofacial operations, specifically temporomandibular joint (TMJ) ankylosis and mandibular fracture cases, and compared it with conventional general anaesthesia. We compared the time to discharge from the post anaesthesia care unit (PACU) and the occurrence of side effects, as well as surgeon and patient satisfaction with the anaesthetic technique, between the two groups. MATERIALS & METHODS: We enrolled 50 patients of ASA grade 1 or 2, aged 15-50 years, scheduled for maxillofacial surgery (mandibular fracture or TMJ ankylosis). The patients were divided into two groups of 25 each, to receive sedation with a regional block with the use of a peripheral nerve stimulator in group I and general anaesthesia in group II. We observed haemodynamic parameters, intraoperative and postoperative complications and the amount of surgical bleeding in the two groups. Total anaesthesia time, patient and surgeon satisfaction, time to rescue analgesia, the number of rescue doses required, and the time to discharge from the PACU were compared. RESULTS: The groups were comparable with respect to demographic profile, intraoperative haemodynamic parameters, surgical time, and amount of blood loss. Postoperative pain was assessed using the visual analogue score (VAS). Patients in group I had lower VAS scores after surgery and remained pain-free for longer than those in group II. The mean pain-free interval in group I was 159.12 ± 43.95 min and in group II was 60.36 ± 19.77 min (p < 0.005). Patients in group I required lower doses of rescue analgesia than those undergoing the surgery under general anaesthesia (p < 0.005). Patients receiving regional blocks also had fewer episodes of postoperative nausea and vomiting (p = 0.005). These results led to earlier discharge of patients in group I from the PACU. CONCLUSIONS: Regional block with sedation is a safe alternative technique for patients undergoing surgery for mandible fracture or TMJ ankylosis, with clear advantages over general anaesthesia.