(508) Endotracheal Tube Electrode Wrap Failure Limits Neuromonitoring Adoption in Resource-Constrained Thyroid Surgery Settings

Introduction: Intraoperative nerve monitoring may improve recurrent laryngeal nerve (RLN) safety during thyroidectomy, but implementation barriers in low-resource settings are not well defined. We report initial intraoperative nerve monitoring implementation at a resource-constrained hospital in Rwanda (the first time at this institution) and prospectively characterized technical barriers to acquiring baseline EMG signals during routine video intubation.

Methods: We conducted a prospective, consecutive case series of 18 thyroidectomies performed in October 2025 at Kibagabaga Hospital (Kigali, Rwanda) using a standardized RLN-preservation protocol incorporating intermittent checkpoint stimulation and perioperative point-of-care vocal fold ultrasound (POCUS-VF). Full intraoperative nerve monitoring capability was introduced through training for surgeons, anesthesia providers, and OR staff. Two commercially available EMG endotracheal tube electrode wrap designs were assessed during routine video laryngoscopic intubation. Primary outcomes were post-intubation wrap integrity (visual inspection) and acquisition of reliable EMG signals while the independent variable was electrode wrap design.

Results: No RLN injuries occurred in 18 thyroidectomies. Postoperative POCUS-VF showed normal vocal fold motion in all patients, avoiding laryngoscopy. Reliable EMG baseline signals were obtained in 2/18 cases (11%). Electrode wrap disruption after intubation occurred in 16/18 cases (89%) and was associated with failure to obtain baseline signals. Checkpoint stimulation enabled RLN identification in all cases (18/18).

Conclusions: Intraoperative nerve monitoring implementation was feasible with structured training, but EMG electrode wrap durability during video laryngoscopic intubation was the dominant barrier, limiting baseline signal acquisition to 11%. Scale-up will likely require more durable electrode designs, standardized intubations, and tube-positioning workflows. POCUS-VF continues to provide an equipment-sparing and low cost option for peri-operative RLN assessment.