Neuromuscular Blockade Monitoring Flashcards
Reasons to Monitor:
1) Wide inter-patient variability in ?
2) Facilitates ?
3) Allows careful ?
4) Allows assessment of ?
1) dose requirements
2) timing of intubation
3) titration to effect
4) readiness for reversal
Reasons to Monitor:
1) Allows assessment of ?
2) Differentiates ?
3) Facilitates early recognition of ?
1) adequacy of reversal
2) type of block
3) pseudocholinesterase activity
When should we monitor?
1) When a ___ is used.
2) In neuromuscular disease?
3) When post-op ___ must be maximal.
4) When continuous infusion of ___ is used.
1) long acting muscle relaxant
2) Myasthenia gravis
3) muscle power
4) muscle relaxant
Post-op muscle strength maximal need patient fully awake, full TVs.
Ex: 2
Respiratory compromise elderly
young
The most commonly used nerve?
- may also use median, posterior tibial, common peroneal and facial nerves.
- We monitor peripherally because our primary concern for emergence is the ___, which recovers faster than the peripheral muscle groups.
- ____ is needed to guarantee diaphragm paralysis post induction (establishes ?)
Ulnar nerve
- diaphragm
- post tetanic count (PTC)
- intense blockade
___ how quickly the muscle recovers from paralysis. The ___ recovers very quickly from paralysis whereas the ___ recovers slower.
Don’t confuse this with ___ with the drug this is the time from injection until there is a measurable effect.
-The measured onset time of muscle groups to muscle relaxant varies. These 3 all have faster onset times than other muscles?
Sensitivity
- diaphragm
- adductor pollicis
- Onset time
- Diaphragm, vocal cords and larynx
TOF:
- ___ = the twitch height for all 4 twitches reduces at the same time. TOF ratio for these drugs is constant at ?
- ___ = these will have fade, goal for reversal is to have all 4 back to baseline.
-Depolarizing Block
one
-Non-depolarizing block
Most precise form of neuromuscular monitoring?
*Considers?
Peripheral Nerve Stimulator
*individual variation
If ___ is back you know the diaphragm has returned to functioning.
obicularis oculi
1) Battery operated - no twitches may indicate loss of ___.
2) More than ___ is uncomfortable in conscious patient.
3) ___ is negative and ___ is positive.
1) battery power
2) 80 mA
3) red/negative, black/positive
1) ___ = continuous/intermittent stimulation (__ or __ hz)
2) ___ = Four supramaximal stimuli over 2 seconds. Presence of ___ is the assessment. Best for ?
3) __ = ___ to ___ hz supramaximal stimulation. Presence of fade is noted. Otherwise without a baseline the test is hard to interpret. Is not valid when performed repeatedly on the same muscle group. Very difficult to rule out ___ with this monitor.
1) Single Twitch stimulation
0.1 or 1 hz (0.1 most common)
2) Train of Four stimulation
fade
non-depolarizing blockade
3) Tetanic stimulation
50 hz to 200 hz
residual blockade
- ___ = tetany for 5 seconds, ___ second delay and single twitch stimulation follows. Useful for determining time to response to ___. It is a very good monitor of ___. Should not be performed more than every ___.
- ___ = Two, three twitch salvos, 600 milliseconds apart. This method makes it easier to detect residual neuromuscular blockade by ___, more than the TOF method.
*Post Tetanic stimulation 3 second train of four intense block 6 minutes *Double Burst stimulation feel
Use as the mode to assess muscle response on induction?
- The ___ is set by the machine itself, not by you.
- Assess at the ___, by the time you have lost single twitch here you can be sure the vocal cords and diaphragm are paralyzed because onset for relaxation of vocal cords and diaphragm is faster than ___.
Single Twitch Stimulation
- frequency
- thumb
- adductor pollicis
Pattern of Electrical Stimulation ~
Depolarizing Block vs. Non-depolarizing Block:
Except for the time difference - __ occurs faster than ___. There is no difference in actual response or in the strength of the response.
Depolarizing Block
Non-depolarizing Block
Disadvantages of Single Twitch:
1) Need to have pre-relaxant ___.
2) Can’t distinguish ?
3) Presence of ___ does not guarantee that full recovery from NMB has occurred.
4) Not ___ enough so not used for ___. Have no other twitches to compare to for height differences.
1) “control twitch”
2) btw Non-depolarizing and Depolarizing neuromuscular blockade
3) full twitch height
4) specific
emergence
With this frequency the immediately available store of AcH is depleted and the amount released by the nerve decreases with each successive stimulus?
Train of Four
Can compare the first twitch to the last twitch, gives you an indicator of depth and degree of block?
___ on PNS looks just like a non-depolarizer. In this block, DOA of ___ prolonged. The bad news is cannot reverse it.
Train of Four
Phase II Block
succinylcholine
___ is a ratio comparing the value of the 4th to the 1st twitch?
-Peak level = ?
Train of Four
-zero twitches
Train of Four:
1) Get ___ after induction drug.
2) Need to wait ___ for ___ to reaccumulate to get an accurate first twitch.
1) Baseline
2) 12 seconds
AcH
___ = these will have fade. Goal for reversal is to have all 4 twitches back to baseline.
___ = The twitch height for all 4 twitches reduces at the same time.
TOF ratio for depolarizers is constant at ONE.
- Non-depolarizers
- Depolarizers
During ___ or ___ progressive depletion of Ach output is balanced by increased synthesis and transfer from its mobilization stores in normal, non-paralyzed patient.
This is known as ___.
Tetany or TOF
Fade
*Use when there is a deep block (have zero twitches, want to know where am I? When is that single twitch going to come back)?
- If you give a TOF after tetany (tetany will mobilize ___) ___, you will see more than what you have seen with just a TOF.
- Do not want to start redosing with maintenance dose until we have at least a ? also do not want to ___ until we have this as well.
*Tetanic Stimulation
-Ach
post-tetanic facilitation
-single twitch back
reverse
Want to administer a ___ to see if there is any response, if there is zero response then you have a ___.
Tetany
Profound block
*___ = we have FADE and we have POST TETANIC facilitation also called ___.
*___ = we do not have fade, we do not have post-tetanic facilitation. If using ___ and you do have post tetanic facilitation probably due to ___.
*Non-depolarizers potentiation *Depolarizers succinylcholine phase 2 block
