Just to clarify- Train of Four's should be done on completely paralyzed patients only. If your patient is moving, breathing or coughing AT ALL, there is no need to deliver a painful shock to them. The purpose of the train of four is to determine whether or not the paralytic dose is appropriate, it has nothing to do with sedation. On the other hand, if the patient's TOF is 0/4 at 40 (max) try repositioning the electrodes to be sure they are placed correctly over the ulnar artery- the distal lead should be placed at the wrist crease in a straight line from the base of the pinky, and the proximal lead should be placed 1 to 2 cm along the same plane. If the TOF remains 0/4 at 40, the MD should be notified. In many cases, the paralytic dose needs to be decreased to a therapeutic level, or a paralytic holiday should be given. Please let me know if you have any questions.
Thanks,
Erin
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