We thank Dr Wong et al. for their useful comments [1] regarding the recently published standards of monitoring [2] and welcome their summary of the nuances of acceleromyography monitoring. The target train-of-four (TOF) ratio of 0.9 for recovery from neuromuscular blockade (NMB) is established and widely recommended [3]. Wong et al. have pointed out revised data that demonstrate TOF ratios >0.95 are required to reduce postoperative pulmonary complications [4]. For this reason, we suggest a TOF ratio of 0.9 at recovery is a minimum, but ideally the ratio should be as high and as close to unity as possible (or indeed >1.0 due to the reverse fade phenomenon). In practice some acceleromyography devices cap ratios at 1.0, while others display the raw ratio data, and the manufacturers’ instructions should be followed.

Despite any caveats about the use of acceleromyography, there is substantial evidence for the benefits of quantitative (acceleromyography) monitoring targeting TOF ratios >0.9. A recent meta-analysis of 53 studies and 12,666 patients measuring the pooled incidence of residual paralysis (TOF ratio <0.9) showed conclusively the benefits of quantitative monitoring, with many studies including acceleromyography monitors. Rates were 33% with no monitoring, 31% with qualitative monitoring and 11% with quantitative monitoring [5]. Quantitative, monitoring including acceleromyography, provides certainty rather than a ‘best guess’ in measuring recovery.

The Association’s standards recommend application of NMB monitoring devices along with other ‘routine’ monitoring, and device activation with TOF delivery after induction of anaesthesia and before paralysis. Doing so provides assurance of correct electrode positioning to stimulate the ulnar nerve rather than muscles directly, evidence that the device is functioning appropriately, with a baseline reading, and calibration, should this be recommended by the manufacturer. It also provides an insight into the individual pharmacokinetic variability of patient response to NMB drugs and judgement about airway management and tracheal intubation timing by objective response, rather than by elapsed time.

The evidence is clear. The caveats are relevant. Education and training is key. Use of quantitative NMB monitoring allows anaesthetists to optimise tracheal intubation and surgical conditions and provides an opportunity to eliminate residual paralysis and harmful consequences for patients.

We also thank Dr Lucas et al. [6] for their interest in the guideline. We share their devotion to the safety of mothers and babies alike. The title of the guideline explains its scope: monitoring during anaesthesia. Its recommendations do not encompass labour analgesia and we did not seek to imply this. The Working Party considered this outside its remit, and so on the correspondents' first point, we agree.

However, the Working Party's recommendations do encompass regional anaesthesia, whether it be obstetric or any other form. Topping up of a labour epidural to provide anaesthesia for surgery implies use of a significant dose of local anaesthetic, which can approach maximum recommended doses and which can have significant physiological effects. It is an accepted tenet that standards of monitoring for anaesthesia in remote sites should be to the same high standard as in the operating theatre; in that sense, the delivery room is no different to any other remote site. Small, portable monitoring systems now exist (many of which are 'plug and play' compatible with operating theatre systems for seamless continuity of monitoring). These can easily be brought to the delivery room and can be applied while preparation is being made for the epidural top up. This system has been implemented in one of the authors’ (TM) units. We would argue that in obstetric cases that have sufficient time for an epidural top up, there is sufficient time to attach a non-invasive blood pressure cuff, oximetry probe and ECG electrodes. We cannot think of any other situation where surgical anaesthesia is started before monitoring is established and, because compact portable monitors are now readily available, it is right that this safety discrepancy is finally addressed. These monitoring standards, including the Clinical Director checklist, aim to support departments in securing the necessary equipment for patient monitoring.

Finally, we also thank Dr van Zundert et al. [7] for their comments. We agree that in some situations monitoring, additional to the minimum monitoring specified in the guideline, is desirable. We agree that the videolaryngoscope may be useful, not only for the initial insertion of a tracheal tube, but also for subsequent inspection of the airway and verification of the tube's position. While not usually used for continuous monitoring, we would consider the videolaryngoscope to be a piece of equipment that should be immediately available to the anaesthetist.

我们感谢黄博士等人。感谢他们对最近发布的监测标准 [ 2 ]的有益评论 [ 1 ]，并欢迎他们对加速度计监测细微差别的总结。已建立并广泛推荐用于从神经肌肉阻滞 (NMB) 中恢复的目标四列 (TOF) 比率为 0.9 [ 3 ]。王等人。已经指出需要修订数据证明 TOF 比值 >0.95 才能减少术后肺部并发症 [ 4]]。出于这个原因，我们建议恢复时 0.9 的 TOF 比值是最小值，但理想情况下，该比值应尽可能高并尽可能接近统一（或者实际上 >1.0，由于反向衰减现象）。在实践中，一些加速度计设备将比率上限设置为 1.0，而其他设备显示原始比率数据，应遵循制造商的说明。

尽管有关于使用加速度计的任何警告，但有大量证据表明定量（加速度计）监测目标 TOF 比率 >0.9 的好处。最近对 53 项研究和 12,666 名患者进行的荟萃分析测量了残余麻痹的汇总发生率（TOF 比 <0.9），最终表明定量监测的好处，许多研究包括加速度计监测器。无监测的比率为 33%，定性监测为 31%，定量监测为 11% [ 5 ]。包括加速度计在内的定量监测提供了确定性，而不是测量恢复的“最佳猜测”。

该协会的标准建议将 NMB 监测设备与其他“常规”监测一起应用，并在麻醉诱导后和瘫痪前通过 TOF 传输激活设备。这样做可以确保正确的电极定位以刺激尺神经而不是直接刺激肌肉，证明设备功能正常，具有基线读数和校准，如果制造商建议这样做。它还提供了对患者对 NMB 药物反应的个体药代动力学变异性的洞察，以及通过客观反应而不是经过时间对气道管理和气管插管时间的判断。

证据很清楚。警告是相关的。教育和培训是关键。使用定量 NMB 监测允许麻醉师优化气管插管和手术条件，并提供机会消除残余麻痹和对患者的有害后果。

我们也感谢卢卡斯博士等人。[ 6 ] 他们对指南的兴趣。我们分享他们对母亲和婴儿安全的奉献。该指南的标题解释了其范围：麻醉期间的监测。它的建议不包括分娩镇痛，我们也没有试图暗示这一点。工作组认为这超出了其职责范围，因此我们同意记者的第一点。

然而，工作组的建议确实包括区域麻醉，无论是产科麻醉还是任何其他形式的麻醉。添加硬膜外麻醉以提供手术麻醉意味着使用大剂量的局部麻醉剂，这可以接近最大推荐剂量并且可以产生显着的生理效应。一个公认的原则是，偏远地区的麻醉监测标准应与手术室中的标准一样高；从这个意义上说，产房与任何其他远程站点没有什么不同。现在存在小型便携式监控系统（其中许多与手术室系统“即插即用”兼容，以实现监控的无缝连续性）。这些可以很容易地带到产房，并且可以在准备硬膜外麻醉时使用。该系统已在作者的 (TM) 单位之一中实施。我们认为，在有足够时间进行硬膜外加注的产科病例中，有足够的时间连接无创血压袖带、血氧饱和度探头和 ECG 电极。我们想不出任何在建立监测之前就开始手术麻醉的情况，而且由于紧凑型便携式监测仪现在很容易获得，因此最终解决了这种安全差异是正确的。这些监测标准，包括临床主任检查表，旨在支持各部门获得必要的患者监测设备。该系统已在作者的 (TM) 单位之一中实施。我们认为，在有足够时间进行硬膜外加注的产科病例中，有足够的时间连接无创血压袖带、血氧饱和度探头和 ECG 电极。我们想不出任何在建立监测之前就开始手术麻醉的情况，而且由于紧凑型便携式监测仪现在很容易获得，因此最终解决了这种安全差异是正确的。这些监测标准，包括临床主任检查表，旨在支持各部门获得必要的患者监测设备。该系统已在作者的 (TM) 单位之一中实施。我们认为，在有足够时间进行硬膜外加注的产科病例中，有足够的时间连接无创血压袖带、血氧饱和度探头和 ECG 电极。我们想不出任何在建立监测之前就开始手术麻醉的情况，而且由于紧凑型便携式监测仪现在很容易获得，因此最终解决了这种安全差异是正确的。这些监测标准，包括临床主任检查表，旨在支持各部门获得必要的患者监测设备。我们想不出任何在建立监测之前就开始手术麻醉的情况，而且由于紧凑型便携式监测仪现在很容易获得，因此最终解决了这种安全差异是正确的。这些监测标准，包括临床主任检查表，旨在支持各部门获得必要的患者监测设备。我们想不出任何在建立监测之前就开始手术麻醉的情况，而且由于紧凑型便携式监测仪现在很容易获得，因此最终解决了这种安全差异是正确的。这些监测标准，包括临床主任检查表，旨在支持各部门获得必要的患者监测设备。

最后，我们还要感谢 van Zundert 博士等人。[ 7 ] 他们的意见。我们同意，在某些情况下，除了指南中规定的最低限度监测之外，还需要进行监测。我们同意视频喉镜可能有用，不仅可以用于气管导管的初始插入，还可以用于随后的气道检查和导管位置的验证。虽然通常不用于连续监测，但我们认为视频喉镜是一种麻醉师应立即可用的设备。