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Summer Pharmacology > NMB Monitor > Flashcards

NMB Monitor Flashcards

1
Q

If you have zero twitches, you have a ?

If you want to deepen your block, what do you do?

A

profound block

Turn up the IA (gas)

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2
Q

What are reasons to monitor your patient after giving them a NMB?

A
    1. Wide inter-patient variability in dose requirements •2.Facilitates timing of intubation
    1. Allows careful titration to effect
    1. Allows assessment of readiness for reversal
    1. Allows assessment of adequacy of reversal
    1. Differentiates type of block
    1. Facilitates early recognition of pseudocholinesterase deficiency
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3
Q

When should we monitor with a nerve stimulator?

A

ALWAYS when a long acting muscle relaxant is used

When pharmacokinetics of relaxant are abnormal (hypothermia)

Disease states: Extreme age, liver disease, kidney disease

In neuromuscular disease

Myasthenia gravis

When post-op muscle power must be maximal

When continuous Infusion of muscle relaxant used

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4
Q

The nerve stimulator is

_ operated,

provide constant _

able to generate up to __

_ of electrodes

capable of delivering many modes

A

The nerve stimulator is

battery operated

provides constant currents

able to generate up to 100mA

polarity of electrodes (negative is normally distal)

capable of delivering many modes

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5
Q

you are recording your results from the nerve stimulator every _ minutes.

A

15

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6
Q

Explain Subjective and Objective

A

Subjective:

Visual and tactile. How strong was the response. This is the method most commonly used by practitioners

Objective:

PERI Nerve stimulator -Measurement of evoked responses

Mechanomyography cumbesome (requires resting tension measures) Gold standard

Electromyography many easily monitored muscles, Compounded measurement difficult to perform reliably.

Accelerometry

Phonomyography (research)

kinemyography ??(Piezoelectric motion sensor)

M-NMT (Datex-Ohmeda)

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7
Q

Electrical impluses are trasnmitted from _ to _ by electrodes.

Evoked muscle response relfects _ of muscle fibers _

Frrequency of stimuli expressed in hERTZ =

10 Hz =

0.1 Hz =

Common range =

A

Stimulator to nerve

, blocked

1 cycle/sec

10 stimuli/sec

1 stimulus/10 seconds

0.1-100 Hz

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8
Q

What are the sites of nerve stimulation?

A
  • Any superficially located peripheral motor nerve may be stimulated
  • Ulnar nerve -elicits adduction of adductor pollicis •Facial nerve -elicit obicularis oculi –

ALSO, Median, posterior tibia, common peroneal

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9
Q

In neuro cases, if arms are tucked monitor on the ?

In abd/throat cases, monitor on the ?

A

feet

head if arms are tucked.

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10
Q

What is the most popular site for monitoring?

A

ulnar nerve

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11
Q

–_ electrode should be placed 1 cm proximal to the crease of wrist

–proximal electrode should be placed _ cm proximal to the distal electrode

–Placement of negative electrode more distal will elicit most ______

A

distal - negative - red

2.5 cm

pronounced muscular response

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12
Q

Electrode placement for stimulation of what nerve?

A

ulnar

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13
Q

What is the clinical significance of a nerve stimulator?

  • Different muscle groups have different responses to neuromuscular blockers
  • Results obtained from one muscle cannot be ?

• It is appropriate to choose ___ to muscle of interest

A
  • Different muscle groups have different responses to neuromuscular blockers
  • Results obtained from one muscle cannot be extrapolated to other muscles
  • It is appropriate to choose a site for monitoring that has similar response to muscle of interest
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14
Q

When talking about sensitivity we are referring to?

A

When talking about sensitivity we are referring to how quickly the muscle recovers from paralysis.

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15
Q

List the muscle groups from most resistant to most sensitive.

A

Vocal cord

Diaphragm

Ocibularis oculi

Abdominal rectus

Adductor pollicis

Masseter

Pharyngeal

Extraocular

•The obicularis oculi response reflects the extent of neuromuscular blockade of the diaphragm better than the response of the adductor pollicis • •Median, posterior tibia, common peroneal stimulation will have similar response to ulnar nerve stimulation •

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16
Q

Disadvantage of adductor pollicis monitoring.

Advantage of adductor pollicis monitoring

A

Disadvantage: possibility of mvmt of the diaphragm even with total elimination of response to TOF or single twitch

Advantage: No residual blockade exists in disphragm if adductor pollicis recovered from relaxation

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17
Q

•Current (milliamps)- stimulates muscle fibers to __

__ is what we set.

The range is from ?

–Frequency (hertz)= ?

•0.1Hz=1 stimulus every 10 seconds, 10Hz=10 stimuli every second

Frequent stimulation promotes?

A

•Current (milliamps)- stimulates muscle fibers to contract

–Milliamps is what we set.

The range is from 0-100mA

Frequency (hertz)=1 cycle/second

•0.1Hz=1 stimulus every 10 seconds, 10Hz=10 stimuli every second

Frequent stimulation promotes muscle fatigue

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18
Q

Evaluation of neuromuscular function uses what 5 patterns?

A

Evaluation of neuromuscular function uses 5 patterns

  1. Single twitch
  2. Train-of-four (TOF)
  3. Tetanic
  4. Post-tetanic count (PTC)
  5. Double burst stimulation
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19
Q

Battery operated: no twitches may indicate ?

More than __ is uncomfortable in conscious pt

Red is __ and black is __

Single twitch stimulation:

Continuous intermitent stimulation __ hz.

Train of Four stimulation:

Four supramaximal stimuli over __. Presence of __ is the assessment. Best for ___.

Tetanic stimulation:

___ hz supramaximal stimulation. Presence __ is noted. Otherwise without a baseline the test is hard to interpret. Is not valid when performed repeatedly on __. Very difficult to rule out __ __with this monitor.

Post tetanic stimulation:

Tetany for __ seconds, __ second delay, and single twitch stimulation follows. Usefull for determining time to response to __ . It is a very good monitor of __ __. Should not be performed more than __ minutes.

Double Burst Stimulation:

Two 3 twitch salvos ___. This method makes it easier to detect residual neuromuscular blockade by ___, than the TOF method.

A

Battery operated: no twitches may indicate loss of battery power

More than 80mA is uncomfortable in conscious pt

Red is negative and black is positive

Single twitch stimulation:

Continuous intermitent stimulation 1 to .1 hz.

Train of Four stimulation:

Four supramaximal stimuli over 2 seconds. Presence of fade is the assessment. Best for nondepolarizing blockade.

Tetanic stimulation:

50 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 residual blockade with this monitor.

Post tetanic stimulation:

Tetany for 5 seconds, 3 second delay, and single twitch stimulation follows. Usefull for determining time to response to TOF. It is a very good monitor of intense block. Should not be performed more than Q6 minutes.

Double Burst Stimulation:

Two 3 twitch salvos 600 milliseconds apart. This method makes it easier to detect residual neuromuscular blockade by feel, than the TOF method.

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20
Q

What does baseline mean?

When can you do a baseline?

A

height of the contraction

After you give an induction dose and test a last test reflex

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21
Q

Single Twitch Stimulation

__ electrical stimuli

0.1 z (one stimulus/10 seconds) or 1 Hz (1 stimulus/second)

Frequency of ___ most common

Pattern is not different when comparing __ to __

Used to determine baseline stregnth prior to __

A
  • Single electrical stimuli
  • 0.1 Hz (one stimulus /10 seconds) or 1 Hz (1 stimulus/ second)
  • Frequency of 0.1 most common
  • Pattern is not different comparing nondepolarizers and depolarizers
  • Used to determine baseline strength prior to administration of any blocker
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22
Q

This describes….

The frequency is set by the machine itself not by you.

Used as the mode to assess muscle response on induction.

Assess at thumb

  • by the time you’ve lost single twitch in thumb you can be sure vocal cords and diaphragm are paralized because onset for relaxation of vocal cords and diaphragm is faster than adductor pollicis. .
A

single twitch stimulation

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23
Q

Pattern of electrical stimulation and evoked response to single twitch stimulation

Arrow = injection of drug

// = 0/4 twitches

A
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24
Q

Disadvantages of single twitch stimulation

  • Need to have “___” twitch –response before patient receives relaxant
  • Can’t distinguish between __ and __
  • Presence of full twitch height does not guarantee ?

Not specific enough so not used for __. Have no other twitches to compare to for height differences.

A
  • Need to have “control” twitch –response before patient receives relaxant
  • Can’t distinguish between depolarizers and nondepolarizers
  • Presence of full twitch height does not guarantee that full recovery from NMB has occurred •

Not specific enough so not used for emergence. Have no other twitches to compare to for height differences.

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25
Q

Train of four stimulation

  • __ single pulses of equal intensity delivered at intervals of __ (one every 0.5 sec) =to a frequency of __ HZ
  • Continuous mode- each set or train is repeated every ____
  • Each stimulus causes muscle to ?
  • Dividing amplitude of __ twitch by the amplitude of __ twitch = the train of four ratio
  • Useful for determining ?
  • Detects ___ block
A
  • 4 single pulses of equal intensity delivered at intervals of 2/sec (one every 0.5 sec) =to a frequency of 2 HZ •Continuous mode- each set or train is repeated every 10-12th second
  • Each stimulus causes muscle to contract and “fade” •Dividing amplitude of 4th twitch by the amplitude of 1st twitch = the train of four ratio
  • Useful for determining degree NDMR block
  • Detects Phase II block
26
Q

Train of Four

  • In control response the TOF ratio is __ (no MR on board)
  • During __ block the TOF will __ and the ratio will decrease
  • During a depolarizing block the TOF will not produce __

A 1.0 TOF ratio remains, the amplitude however will __

A
  • In control response the TOF ratio is 1.0 (no MR on board)
  • During nondepolarizing block the TOF will decrease (fade) and the ratio will decrease
  • During a depolarizing block the TOF will not produce fade.

A 1.0 TOF ratio remains, the amplitude however will decrease

27
Q

TOF

  • Advantage of TOF is degree of block can be obtained without having ?
  • TOF is less __
  • Should not repeat TOF stimulus more frequently than every __ seconds. why?
A
  • Advantage of TOF is degree of block can be obtained without having control value
  • TOF is less painful
  • Should not repeat TOF stimulus more frequently than every 12 seconds bc need to wait 12 seconds for Ach to reaccumulate to get an accurate first twitch.
28
Q

Pattern of electrical stimulation and evoked response to TOF before adn after nondepol and depolarizer

TOF 2Hz= 4 stimulus/ 2 seconds (1 every 0.5 seconds)

What is fade?

A

During tetany or TOF progressive depletion of Ach output is balanced by increased synthesis and transfer from it’s mobilization stores in normal nonparalyzed pt.

NDMR reduces the number of free cholinergic receptors and impaires the mobilization of Ach with in the nerve terminal thereby producing fade in the response to tetany and TOF.

29
Q

Tetanic Stimulation

  • Rapid __ Hz delivery of stimulus given for __ seconds •During normal neuromuscular transmission and depolarizing block the muscle response to tetanic stimulation is __
  • During __ depolarizing block response is not sustained
    50Hz is equal to \_\_ stimuli in one second

Tetanic stimulation leads to _______ and mobilization and synthesis of new Ach is equal.

A

•Rapid 50-200 Hz delivery of stimulus given for 5 seconds •During normal neuromuscular transmission and depolarizing block the muscle response to tetanic stimulation is sustained •During non-depolarizing and phase II depolarizing block response is not sustained

50Hz is equal to 50 stimuli in one second

Tetanic stimulation leads to large amounts of Ach release leads to stores becoming depleted and mobilization and synthesis of new Ach is equal.

30
Q
  • Tetanic stimulation is very _ and not generally used in _ patients
  • Antagonize neuromuscular blockade in stimulated muscle so response to tested site no longer represents accurate assessment of paralysis
A
  • Tetanic stimulation is very painful and not generally used in non anesthetized patients
  • Antagonize neuromuscular blockade in stimulated muscle so response to tested site no longer represents accurate assessment of paralysis
31
Q

Response to 50 Hz tetany and 1 Hz post tetanic twitches before injection of muscle block and during moderate blockage.

50Hz = 50 stimuli every 1 second

Same as 1 stimuli every 20 ms

NDNMB: Note fade present with tetany and post tetanic stimulation

DNMB:No fade tetany is sustained but at a lower amplitude. Note no post tetanic potentiation

What creates a post tetanic potentiation?

A

After tetany Ach continues to be released for some. Synthesis of Ach is actually enhanced and mobilization continues, immediately after tetany there is an increase in the available stores of Ach.

32
Q

Tetanic stimulation

  • Generally used to evaluate ?
  • Except in connection with ___ has little place in clinical practice
  • Useful in determining __
A

•Generally used to evaluate residual neuromuscular blockade (adequacy of reversal) •Except in connection with post-tetanic count has little place in clinical practice •Useful in determining Phase 2 Block

33
Q

Post Tetanic potentiation

  • Ability of tetanic stimulation during partial nondepolarizing block to ?
  • Related to compensatory increase in __ following tetanic stimulation

Never reverse unless you have 1 twitch out of 4

A

•Ability of tetanic stimulation during partial nondepolarizing block to increase the evoked response to a subsequent twitch •Related to compensatory increase in Ach mobilization following tetanic stimulation

34
Q

Post tetanic count stimulation

After injection of non-depolarizer for intubation there will be ?

___ done by tetanic stimulation (50Hz, 5 seconds) and observing response to single twitch given at 1Hz 3 seconds after end of tetanic stimulation

A

After injection of non-depolarizer for intubation there will be no response to TOF or single twitch

Quantifying intensity of blockade done by tetanic stimulation (50Hz, 5 seconds) and observing response to single twitch given at 1Hz 3 seconds after end of tetanic stimulation

35
Q

Post tetanic count

  • # of ___is counted
  • # of twitches __ as NMB depth ___
  • During ___ no response to either tetanic or post tetanic stimulation
  • When blockade dissipates and before first TOF response returns, response to ?
A
  • # of post tetanic twitches is counted
  • # of twitches increases as NMB depth decreases •During intense blockade no response to either tetanic or post tetanic stimulation
  • When blockade dissipates and before first TOF response returns, response to post-tetanic twitch occurs
36
Q

Post tetanic count

  • As intensity of block dissipates more and more responses to post-tetanic twitch appear and can be counted
  • Post-tetanic count is 1 during __, 3 during __ and __ during surgical block
A
  • As intensity of block dissipates more and more responses to post-tetanic twitch appear and can be counted
  • Post-tetanic count is 1 during intense block, 3 during less intense block and increases during surgical block
37
Q

Response to TOF, 50Hz tetany and 1.0 Hz post tetanic twtich druring different levels of muscle blockade

A= very intense block

B= no TOF, PTS begins to occur, if I gave vec then I would have about 10 minutes before I would see the first twitch of my train of four.

C= no TOF3 PTC

D= first TOF occurs and 8 PTC present

A
38
Q

Post tetanic count (example)

  • Pancuronium given for intubation –Response to post-tetanic stimuli appears 35 minutes before first TOF response
  • Vecuronium, rocuronium and atracurium –Response to post tetanic stimuli appears about 10 minutes before first TOF response
A
39
Q

Relationship b/w time to first TOF response and number of post tetanic twitches during intense block

One post tetanic count:

10 minutes to first TOF

35 minutes to first train of four

A
40
Q

Post Tetanic count clinical apps

  • Main application of PTC is in evaluating __?
  • Used to ensure bucking and coughing from intubation eliminated must have ?
  • Used during __infusions

Infusions ie atracurium infusion. All responses to TOF are obliterated at a PTC of less than 10 The PTC will help you predict time to reappearance of first response to TOF thus useful in predicting an appropriate time to turn off drip.

A
  • Main application of PTC is in evaluating degree of blockade when there is no reaction to single twitch or TOF
  • Used to ensure bucking and coughing from intubation eliminated must have intense block and zero PTC
  • Used during NDMR infusions
41
Q

Double Burst Stimulation

  • Two train of three impulses at _Hz separated by _ms •Evaluate the ratio of ?
  • In non-paralyzed muscle response to double burst stimuli is two short contractions of _ strength
  • In paralyzed muscle the second response ? which indicates _ •
A
  • Two train of three impulses at 50Hz separated by 750ms
  • Evaluate the ratio of second to first response
  • In non-paralyzed muscle response to double burst stimuli is two short contractions of equal strength
  • In paralyzed muscle the second response is weaker than the first (fade) •
42
Q

Response to TOF and double burst stimulation before and after muscle relaxant

Two train of three impulses at 50Hz separated by 750ms stimuli occur so rapidly they feel like two tetanic impulses.

human senses detect DBS fade better than TOF when the ratio becomes so low in the TOF

A
43
Q

Double burst stimulation clinical application

•TOF less than_ is difficult to detect •

Evaluation of DBS 3,3 response is superior to ?

•Easier to feel _ in DBS 3,3 response when compared to fade from TOF

A
  • TOF less than 0.3 is difficult to detect
  • Evaluation of DBS 3,3 response is superior to tactile evaluation of TOF response
  • Easier to feel fade in DBS 3,3 response when compared to fade from TOF
44
Q

Phases of blockade

What are they?

A
  • Pre Blockade (baseline)
  • Intense blockade (no response)
  • Moderate blockade (surgical)
  • Recovery
45
Q

NDMB

•After injection of non-depolarizer TOF will demonstrate __ phases of blockade

What are the phases?

A

•After injection of non-depolarizer TOF will demonstrate 3 phases of blockade

1) Intense block phase
2) Moderate or surgical block phase
3) Recovery phase

46
Q
  1. INTENSE neuromuscular block phase
  • Occurs within __ of injection
  • Called “__”
  • Length will vary depending on ?
A
  • Occurs within 3-6 minutes of injection
  • Called “period of no response”
  • Length will vary depending on agent given, dose and sensitivity of patient
47
Q
  1. Moderate or surgical block phase
  • Begins when ?
  • Characterized by ?

TOF % of receptors blocked clinical relevance

No response 100% sufficient for ETT

One response 90% sufficient for surgery

Two responses 80-90% “

Three responses 75-80% needs reversal

Four responses 0-75% recovery phase

A

•Begins when first response to TOF appears •Characterized by gradual return of TOF response

TOF % of receptors blocked clinical relevance

No response 100% sufficient for ETT

One response 90% sufficient for surgery

Two responses 80-90% “

Three responses 75-80% needs reversal

Four responses 0-75% recovery phase

48
Q
  1. Moderate or surgical block phase

•Antagonism of block should not be attempted when ?

  • Results in __ reversal

•In general antagonism of block should not be initiated before at least_____responses to TOF present

A
  • Results in partial reversal
  • Antagonism of block should not be attempted when intense block present
  • In general antagonism of block should not be initiated before at least two, preferably three, responses to TOF present
49
Q

Monitoring during reversal

  • The minimum number of responses required for reversal is __ twitches to TOF stimulation
  • ___ is when DBS is most useful.

If Four twitches are present, full reversal is almost assured within ten minutes of reversal agent administration.

A

•The minimum number of responses required for reversal is •2 and preferably 3 twitches to TOF stimulation •Post reversal is when DBS is most useful.

50
Q

Recovery phase

•Return of __ twitches on TOF begins recovery phase •TOF and residual observations correlates fairly well •TOF ratio of ___ patient not able to lift head or arm •Ratio __ most patients able to lift head for __ seconds, open eyes and stick out tongue •Ratio __ patient able to cough lift head for __ seconds but grip strength weak

0.8 vital capacity and inspiratory force norm

A
  • Return of 4 twitches on TOF begins recovery phase •TOF and residual observations correlates fairly well •TOF ratio of 0.4 or less patient able to lift head or arm •Ratio 0.6 most patients able to lift head for 3 seconds, open eyes and stick out tongue
  • Ratio 0.75 patient able to cough lift head for 5 seconds but grip strength weak

0.8 vital capacity and inspiratory force norm

51
Q

Recovery phase

  • TOF ratio ___ believed to reflect adequate recovery of neuromuscular function
  • Recent studies show however residual paralysis with TOF ratio ____
  • Predisposed patient to ?
A
  • TOF ratio >0.75 believed to reflect adequate recovery of neuromuscular function
  • Recent studies show however residual paralysis with TOF ratio 0.8 or even 0.9
  • Predisposed patient to regurgitation, aspiration, postop pulmonary complications
52
Q

Response to TOF during non depolarizing muscle blockade

A
53
Q

Phase 2 blockade

•An abnormal response to a __ agent in a genetically abnormal individual

Manifests as ?

Can also occur after prolonged infusion of Succinylcholine.

Note in a genetically normal patient anticholinesterase drugs will reverse the blockade. In genetically abnormal patients it will not. With unpredictable results. Reversal of Phase two blockade should only be done in known cases of drug induced phase two blockade. Can potentiate or only partially reverse the block in mutants. :-)

A

•An abnormal response to a depolarizing agent in a genetically abnormal individual Manifests as Post tetanic fade and very prolonged blockade

54
Q

Depolarizing neuromuscular blockade

•Phase I block –Response to depolarizer is typical –

No ___ and No ____

•Phase II block –Seen in patient with ?

–Seen in normal patients after ?

–Characterized by ?

–Also presence of ?

A

•Phase I block –Response to depolarizer is typical –No fade to TOF or tetanic stimulation –No post-tetanic potentiation

•Phase II block –Seen in patient with plasma cholinesterase deficiency –Seen in normal patients after infusion of sux –Characterized by fade in TOF and tetanic stimulation –Also presence of post-tetanic potentiation

55
Q

phase 2 block

  • Altered plasma cholinesterses produce greatly __ of depolarizer (phase II block)
  • Reversal of phase II block occurs spontaneously in ? •Advised that patient allowed to recover from block up to __ minutes
  • Reversal with anticholinesterase can then be ensued
A
  • Altered plasma cholinesterses produce greatly prolonged duration of action of depolarizer (phase II block)
  • Reversal of phase II block occurs spontaneously in 10-15 minutes with 50% of population
  • Advised that patient allowed to recover from block up to 20-25 minutes
  • Reversal with anticholinesterase can then be ensued
56
Q

Comparison of Tests of neuromuscular function

Test # receptors Occupied/blocked

Tidal Volume

Twitch Height

Tetanic Stim (30 Hz)

Vital Capacity

Train of Four

Tetanic Stim(100 Hz)

Inspiratory Force

Head Lift (5 sec)

A

Comparison of Tests of neuromuscular function

Test # receptors Occupied/blocked

Tidal Volume 80

Twitch Height 75-80

Tetanic Stim (30 Hz) 75-80

Vital Capacity 75-80

Train of Four 75-80

Tetanic Stim(100 Hz) 50

Inspiratory Force 50

Head Lift (5 sec) 33

57
Q

Comparison of Tests of neuromuscular function

Test # receptors Occupied/blocked

        80

    75-80

     75-80

       75-80

      75-80

 50

       50

         33
A
58
Q

Use of nerve stimulator on induction

  • Attach nerve stimulator to patient ___ but turned off •TOF or 0.1 Hz twitch stimulation used once patient rendered __
  • Observation of control response
  • __ is then injected
  • Observation of TOF (or twitch) until twitch disappears
  • Intubate
A

•Attach nerve stimulator to patient prior to induction but turned off •TOF or 0.1 Hz twitch stimulation used once patient rendered unconscious but not relaxed •Observation of control response •Neuromuscular agent is then injected •Observation of TOF (or twitch) until twitch disappears •Intubate

59
Q

Use of nerve stimulator during surgery

  • If sux used for intubation must wait for ?
  • If ____, normal twitch returns in 4-8 minutes
  • Patient usually maintained at ___during case facilitating ability to reverse
  • May need to keep patient with __ to minimize cough buck need to monitor PTC as TOF will have no twitches
A
  • If sux used for intubation must wait for response to return
  • If plasma cholinesterase normal twitch returns in 4-8 minutes
  • Patient usually maintained at 1 or 2 twitches during case facilitating ability to reverse
  • May need to keep patient with intense block to minimize cough buck need to monitor PTC as TOF will have no twitches
60
Q

Use of nerve stimulator in reversing muscle block

  • Antagonism of blockade should not be initiated until ? •If all __ present on TOF still can’t assume full recovery of muscle block
  • More accurate assessment seen in ___(look for no fade) than in TOF
  • Must use clinical signs to gage residual muscle block ie. ?
A
  • Antagonism of blockade should not be initiated until return of at least 1 twitch on TOF
  • If all 4 twitches present on TOF still can’t assume full recovery of muscle block
  • More accurate assessment seen in double burst (look for no fade) than in TOF
  • Must use clinical signs to gage residual muscle block ie. ability to lift head 5 seconds, open eyes, stick out tongue •
61
Q
A

Summer Pharmacology (4 decks)

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