NMB Monitoring

Question 1

Reasons to monitor

Answer 1

Inter pt variability in dosing, intub timing, titration to effect, readiness of reversal, adequacy of reversal, differentiates type of block, early recog of pseudocholinesterase def

Question 2

When to monitor

Answer 2

Muscle relaxant used, hypothermia, neuro/renal/hepatic disease, post op power, gtt

Question 3

1 hertz =

Answer 3

1 cycle/sec

Question 4

10 hz=
0.1 hz=
Range

Answer 4

10 stim per sec
1 stim per 10 sec
0.1-100 hz

Question 5

Stim which muscles: ulnar nerve, facial nerve

Answer 5

Adductor pollicis, orbicularis oculi

Question 6

3 non main nerves that can be used

Answer 6

Median, post tibia, common peroneal

Question 7

Placing of electrodes on ulnar nerve

Answer 7

• electrode 1 cm proximal to wrist crease. + electrode 2-5 cm of distal one.

Question 8

Most sensitive to most resistant muscles

Answer 8

Extraocular, pharyngeal, masseter, adductor pollicis, abd rectus, orbicularis, diaphragm, VC

Question 9

__ __ response reflect NMB extent of diaphragm better than response of __ __

Answer 9

Orbicularis > adductor pollicis

Question 10

Pro and con to adductor pollicis monitoring

Answer 10

Diaphragm can still move even if no twitch on TOF. But no block left in diaphragm if adductor pollicis is recovered.

Question 11

Single twitch stim

Common settings, use

Answer 11

0.1-1 hz. 0.1 frequency most common. Not diff between depol/nondepol. Assess baseline strength before NMB given

Question 12

Does presence of full twitch height guarantee recovery from NMB

Answer 12

No

Question 13

TOF

What it delivers

Answer 13

4 pulses of equal intensity of 2/sec (0.5 sec) to 2 hz freq

Question 14

TOF

Detects which phase of block

Answer 14

Phase 2

Question 15

TOF
Ratio when no NMB given
What happens w NDMR
What happens w depolarizing

Answer 15

1. Fade and ratio decreases. 1 ratio remains, amplitude decreases

Question 16

TOF pros

Shouldn’t be repeated more frequently than what

Answer 16

Less painful and dont need control value. 12 sec

Question 17

Tectanic stim

Settings

Answer 17

50-200 hz for 5 sec

Question 18

Tetanic stim

When sustained, not sustained

Answer 18

Sustained- normal nm transmission and depolarizing block.

Not- non depolarizing, phase 2

Question 19

Post tetanic potentiation
What it is
Related to what

Answer 19

Ability during nondep block to inc evoked response to a seubsequent twitch. Rel to inc in ach mobilization after stim

Question 20

How to post tetanic count

Answer 20

50 hz 5 sec. then 1 hz 3 seconds after tetanic stim

Question 21

Post tetanic count values

Answer 21

1- intense block
3- less intense
Inc during surgical block

Question 22

Post tetanic stim when it appears:
Panc for intubation before TOF?
Vec/roc/atra before TOF

Answer 22

35 min

10 min

Question 23

PTC uses

Answer 23

Ensure coughing from intub elim (zero PTC), NDMR gtt, when no single twitch or TOF

Question 24

Double burst stim

What it delivers

Answer 24

2 train of 3 impulses at 50 hz separated by 750 ms

Question 25

Double burst stim Evaluate what Non paralyzed vs paralyzed

Answer 25

Ratio of 2nd to 1st response. Non par: equal strength. Par: 2nd response weaker

Question 26

Double burst stim TOF less than what hard to detect Superior to what Easier to feel what

Answer 26

0.3. Sup to TOF tactile eval, easier to feel fade in dbs than TOF

Question 27

Phases of block

Answer 27

Pre block. Intense block (can intubate, no response). Moderate block (surgical). Recovery

Question 28

Intense nm block phase | Occurs when, what its called, varies based on

Answer 28

3-6 min after med. no response period. Length varies based on agent, dose, and pt sensitivity

Question 29

Moderate/surgical block | Begins when

Answer 29

1st response to TOF

Question 30

``` TOF- % block- clinical None- 1 2 3 4 ```

Answer 30

``` 100, ett 90, surgery 80-90 75-80, needs reversal 0-75, recovery ```

Question 31

When antagonism of block shouldn't occur

Answer 31

Before at least 2, preferably 3 responses to TOF

Question 32

When dbs most useful

Answer 32

After reversal

Question 33

How many TOF twitches to begin recovery phase, ratio, or what

Answer 33

4 twitches, 0.4 or lift head/arm

Question 34

TOF ratio 0.6 pt can do what | 0.75

Answer 34

Lift head 3 sec, open eyes protrude tongue | Cough, lift head 5 sec, grip weak

Question 35

Recovery phase | TOF ratio of what= return of nm function adequate

Answer 35

> 0.75

Question 36

Phase 2 block | An abn response to what in who. Manifests as what two things

Answer 36

Depolarizing agent, genetically abn individual. | Post tetanic fade and prolonged block

Question 37

Depol nm block | Phase 1: 3

Answer 37

Response typical, no fade to TOF or tetanic, no post tetanic potentiation

Question 38

Phase 2 block with depolarizer: seen in who. Charac by what

Answer 38

Plasma cholinesterase def or normal pts w sux. Fade in TOF/tetanic stim, post tetanic potentiation

Question 39

Phase 2 | Reversal occurs in __ min 50% ppl. Advised recovery time. When can happen after this

Answer 39

10-15 min | 20-25 min. Anticholinesterase reversal

Question 40

receptors occupied with: TV, twitch height, tetanic stim 30 hz

Answer 40

80. | 80-75 for last two

Question 41

receptors occupied in VC, TOF, Tetanic stim 100hz, ins force, head lift 5 sec

Answer 41

75-80, 75-80, 50, 50, 33

Question 42

TOF or __ hz when pt unconscious but not relaxed

Answer 42

0.1

Question 43

After sux for intub when twitch returns.

Answer 43

4-8 min