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LANCE > Peripheral Nerve Stimulator > Flashcards

Peripheral Nerve Stimulator Flashcards

1
Q

nerve stimulator outline (6)

A

1-nerve electrically stimulated
2-ach released
3-ach binds nicotinic ach R
4- ach eventually degraded
5-prejunctional ach R allow choline and acetic acid to enter nerve again
6- choline and acetic acid form ach again

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2
Q

how long does each stimulus last?

A

0.2msec (200 microseconds)

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3
Q

Why wouldn’t you use stimulation durations of >500microseconds?

A

it would have the ability to cause direct muscle stimulation

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4
Q

when Ach binds to nicotinic R and the R arnt blocked what happens?

A

twitch occurs

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5
Q

when Ach binds to nicotinic R and the R are blocked what happens?

A

weaker twitch or no twitch occurs

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6
Q

what is Ach degraded into?

A

acetic acid and choline

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7
Q

what plays an important role in preventing the stockpiles of Ach inside the nerve from being depleted?

A

prejunctional Ach R

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8
Q

weak muscle contraction

A

some of the R are blocked by muscle relaxant

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9
Q

zero muscle contraction

A

100% of R are blocked

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10
Q

reversing muscle paralysis with neostigmine

A

muscle relaxants and Ach competitively bind

junction being flooded with Ach then Ach overcomes muscle relaxant

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11
Q

reveral with neostigmine and there is too much muscle relaxant on board

A

wont be able to overcome the muscle relaxant

need some muscle function before neostigmine

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12
Q

reversal with sugammadex

A

binding and encapsulates muscle relaxant and removes it from junction
can reverse deeper levels of relaxation

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13
Q

what are the 5 types of nerve stimulation patterns?

A 
single twitch
train of four
tetanus
post tetanic count
double burst stimulation
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14
Q

pulse duration

A

0.2msec

200microseconds

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15
Q

what are the two types of single twitch nerve stimulation

A 
1 Hz (1 stimuation per second)
0.1 Hz (1 stimulation per 10 seconds)
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16
Q

describe train of four nerve stimulation

A

delivers 4 stimuli (0.2msec each) over 2 second period (2Hz)

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17
Q

what is the amount of time between stimuli for train of four

A

500msec

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18
Q

if the person is unparalyzed what will TOF show?

A

four twitches

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19
Q

tetanus

A

continuous nerve stimulation at 50-100Hz
floods junction with max Ach
sustained muscle contraction

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20
Q

what is the time limit for tetanus?

A

5 seconds

very painful

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21
Q

post tetanic count (PTC)

A

50Hz tetanus for 5seconds
3 second pause
single twitch stimulation at 1Hz

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22
Q

Double burst stimulation (DBS)

A

two short tetanic stimulations separated by 750msec pause

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23
Q

first stimulation DBS

A

3 impulses at 50Hz

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24
Q

second stimulation DBS

A

2 options:
two impulses at 50Hz (DBS 3,2)
three impulses at 50Hz (DBS 3,3)

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25
Q

fade

A

ocurrs when nerve is stimulated multiple times in a row and partial blockade
1st twitch stronger than 2nd
2nd stronger than 3rd
etc

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26
Q

what does fade mean for the ach stockpiles?

A

less ach is released with subsequent twitch
stockpiles are more and more depleted
muscle contraction smaller

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27
Q

absence of fade

A

equal amounts of ach released from nerve on all twitches

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28
Q

fade and depolarizers vs nondepolarizers

A

fade will occur with nondepolarizing block

fade will NOT occur with depolarizing (phase I) block

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29
Q

where do nondepolarizing muscle relaxants block?

A

presynaptic and postsynaptic Ach R

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30
Q

partial nondepolarizing block with fade explained

A

presyn Ach R blocked
choline and acetic acid cannot get back in
stockpiles diminish
less ach available for repeated stimuli

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31
Q

how do the stockpiles of Ach get back to normal in partial nondepolarizing block?

A

nerve rest for short period of time

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32
Q

the greater the degree of muscle paralysis (from partial nondep block) means (4)

A

1-higher number of presyn R blocked
2- lower amount of ach released on back to back stimuli
3- higher degree of fade
4- longer the nerve will have to rest before stockpiles refill

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33
Q

where do depolarizing muscle relaxants block?

A

postsynaptic ach R

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34
Q

partial depolarizing (phase I) block

A

choline and acetic acid can rapidly reenter
stockpiles will NOT diminish
equal amounts of Ach available for repeated stimuli
no fade observed

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35
Q

Will the twitches in a partial depolarizing (phase I) block be even in back to back stimulation? what about will they be the same height (strength) as before the block?

A

even twitches for partial

the height will be diminished when comparing before block and during block

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36
Q

what are the two things needed in order for fade to occur?

A

partial nondepolarizing block

nerve stimulated at relatively high frequency

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37
Q

what is the gold standard of assessment of recovery of neuromuscular blockade?

A

fade

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38
Q

If the patients fourth twitch is as strong as the first twitch what does that mean?

A

the patient has for sure adequately recovered from neuromuscular blockade

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39
Q

during the onset of a partial nondepolarizing block what will you see?

A

twitch height gradually decrease or fade away (TOF and single twitch)

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40
Q

during onset of a partial depolarizing block what will you see?

A

twitch height gradually decrease or fade away (TOF and single twitch)
no fade with each individual train of four pattern

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41
Q

during recovery of partial nondepolarizing block what will you see?

A

fade with TOF but not single twitch stimulation (bc single isnt fast enough frequencies to deplete stockpiles)

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42
Q

during recovery of partial depolarizing block what will you see?

A

fade patterns are not observed even with TOF

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43
Q

Can single twitch stimulation differentiate between depolarizing and non depolarizing blocks?

A

no, because the twitches gradually fade away during onset and gradually return during recovery with both depolarizing and nondepolarizing

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44
Q

Can TOF differentiate between depolarizing and nondepolarizing block?

A

yes, because it is faster you will see fade with the nondepolarizers and NO fade with depolarizers.

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45
Q

Can tetanus differentiate between depolarizing and nondepolarizing block?

A

yes, tetanus is faster stimulation so fade will be observed in nondepolarizers

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46
Q

Can post tetanic count differentiate between depolarizing and nondepolarizing blocks?

A

yes, tetanus is faster stimulation so fade will be observed in nondepolarizers

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47
Q

Can double burst stimulation differentiate between depolarizing and nondepolarizing blocks?

A

yes, double burst happens quickly enough that fade will be observed with the nondepolarizers

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48
Q

textbook definition of fade

A

nerve stimulation patterns utilized during recovery of block

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49
Q

When do the textbooks say that fade happens? Why?

A

recovery

b/c we only use nerve stimulators to assess recovery of block

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50
Q

what is the only nerve stimulation pattern that doesn’t detect fade or distinguish different blocks?

A

single twitch

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51
Q

What are the patterns that can detect fade and distinguish the different blocks?

A

TOF, tetanus, PTC, DBS

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52
Q

quantitative data

A

information about quantities (measured in numbers)

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53
Q

qualitative data

A

information about qualities (cannot be measured)

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54
Q

are traditional nerve stimulators qualitative or quantitative?

A

qualitative

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55
Q

are newer nerve stimulators qualitative or quantitative?

A

quantitative

monitor to measure how strong 4th twitch is to 1st twitch

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56
Q

peripheral nerve stimulator (sunmed brand) max output

A

70mA
1= 7mA
10= 70mA

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57
Q

peripheral nerve stimulator (sunmed brand) tetanus Hz max

A

100Hz

or 50Hz; if you open battery theres a switch

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58
Q

standby button

A

no pulse generated

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59
Q

How does the StimPod Quantitative stimulator work?

A

measures the strength of each contraction and displays it on the monitor
more accurate than qualitative

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60
Q

What are the two types of electrodes?

A

surface electrodes

needle electrodes

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61
Q

surface electrodes

A

EKG gel electrodes (may need to remove excess hair and alcojhol swab)
initial threshold is <15mA

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62
Q

needle electrodes

A

useful for conditions when unable to deliver supramaximal stimulus (obese pts)

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63
Q

which electrode is negatively charged?

A

black
depolarizing membrane
should be placed in closest proximity to the nerve

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64
Q

When is the charge required to deliver a supramaximal stimulus less?

A

when the negative electrode is placed distally

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65
Q

which lead should be closest to the heart (proximal)?

A

red

hyperpolarizing lead

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66
Q

how far apart should the leads be placed?

A

3-6cm

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67
Q

subthreshold stimulus

A

no motor units respond

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68
Q

threshold stimulus

A

one motor unit respondes

initial threshold stimulation (ITS)

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69
Q

submaximal stimuli

A

increasing number of motor units respond

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70
Q

maximal stimulus

A

all motor units respond

“pre-relaxant control response”

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71
Q

supramaximal stimuli

A

all motor units respond

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72
Q

Why should an anesthetist use supramaximal stimulus current?

A

if submaximal is applied we cant diagnose if a weak twitch is due to partial block or submax current

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73
Q

How to determine supramaximal stimulus?

A

use single twitch stimulation every 1-10 sec and increase current until max twitch observed

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74
Q

current required to stimulate fibers maximally

A

at least 40mA

could be 80mA for obese pt

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75
Q

What should the anesthetist do in order to ensure supramaximal current is delivered?

A

10-20% higher than the maximal stimulus

76
Q

direct muscle stimulation

A

twitches would be seen but the pt could still be paralyzed

77
Q

two problems with direct muscle stimulation

A

giving more paralytic when the pt is already paralyzed

reversing when the pt isnt ready

78
Q

Why is direct muscle stimulation unlikely with our stimulators?

A

pulse duration is 200microseconds

max current output is 60-80mA

79
Q

what are the three things that single twitch stimulation is used for?

A

muscle relaxant onset
supramaximal stimulus
PTC

80
Q

single twitch stimulation with muscle relaxant onset order:

A

stimulate once every 1-10 secs before relaxant
relaxant given
twitch strength begins to fade

81
Q

3 disadvantages to single twitch stimulation

A

no fade during recovery
cant distinguish between depol and nondepol
limited use in assessing recovery of block

82
Q

assessing recovery from neuromuscular blockade with single twitch what do you do

A

compare max twitch height prior to muscle relaxant to max twitch height at the end of the case

83
Q

2 problems with single twitch for assessing recovery

A

max twitch height prior to dosing MR must be obtained by eyeball
max twitch height at the end of the case could be the same and 75% of receptors could still be blocked

84
Q

TOF definition

A

4 stimulations over 2 second period

85
Q

When are patients considered “reversible” with neostigmine?

A

display at least 1 out of four possible muscle twitches

86
Q

how many twitches are RECOMMENDED prior to neostigmine reversal?

A

2-3 twitches

87
Q

0/4 twitches how many receptors are blocked?

A

> 90%

88
Q

1/4 twitches how many receptors are blocked?

A

90%

89
Q

2/4 twitches how many receptors are blocked?

A

80%

90
Q

3/4 twitches how many receptors are blocked?

A

75%

91
Q

4/4 twitches how many receptors are blocked?

A

<75%

92
Q

train of four ratio definition

A

the strength of the first twitch compared to the strength of the first twitch
expressed as %

93
Q

if the T4:T1 ratio is higher what does that mean?

A

the pt has stronger muscle function

94
Q

What TOF ratio should be achieved before extubation

A

0.9

some say 0.7

95
Q

at what TOF ratio does the pt have a residual neuromuscular blockade?

A

<0.9

96
Q

What has to be used in order to obtain a TOF ratio?

A

quantitive nerve stimulator

97
Q

3 TOF disadvantages

A

less useful in assessing partial depolarizing block (no fade)
not good at measuring deep levels of blockade
not as useful in onset of blockade

98
Q

how long do you have to wait between TOF stimulations?

A

10-30 seconds

99
Q

Which stimulation is good at testing deeper levels of blockade? Why?

A

tetanus

stimulates nerve at higher frequency and releases more Ach

100
Q

2 values of tetanus

A

assess deeper levels of blockade

sustained tetanus >5sec withour fade for adequate reversal

101
Q

a pt is profoundly paralyzed because no response to TOF or tetanus, how long until TOF twitch

A

will be awhile before generate TOF twitch

102
Q

a pt is not profoundly paralyzed bc no response to TOF but has a response to tetanus, how long until TOF twitch

A

might only be a few minutes until generate twitch TOF

103
Q

can tetanus differentiate between depolarizers and non depolarizers?

A

yes, fade is present in nondep

104
Q

what is special about fade with 100Hz tetanus

A

fade may occur in absence of muscle relaxant from muscular fatigue

105
Q

what is special about 50Hz tetanus

A

fade only occurs if partial neuromuscular block

degree of fade similar to TOF

106
Q

PTC

A

may be able to be elicited even when there is no response to TOF or tetanus

107
Q

mechanism of PTC

A

after tetanus NMJ flooded with Ach for several mins
muscle may contract even if no response to tetanus
potential to be larger than it would have been prior to tetanus

108
Q

PTC: twitch before tetanus vs twitch after tetanus explain difference

A

twitch before: smaller contraction, less Ach

twitch after: larger contraction, more Ach

109
Q

what can assess deeper levels of blockade than tetanus?

A

PTC

110
Q

With PTC what predicts the time of recovery?

A

the number of visible twitches
lower #: longer time to wait
higher #: less time to wait

111
Q

for intermediate duration drugs what is the time from a PTC of 1 to reappearance of twitch?

A

15-20 min

112
Q

A what PTC twitch count should reversal with neostigmine be possible?

A

10 or greater

113
Q

what is the purpose of a DBS?

A

in TOF it can be difficult for an anesthetist to detect fade with naked eye, with DBS fade is more detectable

114
Q

What are the two advantages of DBS?

A

better indicator of fade than tetanus or TOF

less painful than tetanus

115
Q

effect of the nerve stimulation on the NMJ

A

if nerve is stimulated faster than 1Hz the NMJ becomes temporarily flooded with Ach

116
Q

what is the one stimulation that can’t flood the NMJ with Ach?

A

single twitch the freqency is 0.1-1Hz (too low)

117
Q

the degree to which the NMJ is flooded with Ach by patterns is proportional to: (2)

A 
stimulation frequency (higher= more Ach)
stimulation duration (longer= more Ach)
118
Q

Why does it matter that the NMJ can become flooded with Ach?

A

if the NMJ is flooded then the stimulation would produce a stronger muscle contraction
we could UNDERESTIMATE THE BLOCK

119
Q

how often can DBS be repeated w/o flood of NMJ?

A

must wait 12-15 seconds

120
Q

how often can TOF be repeated w/o flood of NMJ?

A 
sources disagree:
at least 10 seconds
12-15 seconds
15-30 seconds
SO USE 10-30 seconds
121
Q

how often can tetanus be repeated w/o flood of NMJ?

A

at least 2 minutes

122
Q

how often can PTC be repeated w/o flood of NMJ?

A

at least 6 minutes

123
Q

list recovery of muscles soonest to latest

HIGHLY TESTABLE

A 
SOON
diaphragm
rectus abdominus
laryngeal adductors
orbicularis oculi (facial stimulation)
adductor pollicis (ulnar stimulation)
LATEST
124
Q

what is the most useful site for determining the onset time for intubation

A

orbicularis oculi

because approximates the laryngeal adductors

125
Q

what is the most useful site for confidence that breathing muscles have recovered?

A

adductor pollicis, ulnar nerve stimulus

126
Q

what site is more likely to have direct muscle stimulation?

A

facial nerve stimulation

127
Q

what is special about the median nerve?

A

P6 acupuncture point

reduces PONV

128
Q

median nerve and PONV prophylaxis?

A

deliver 50mA current over median nerve single twitch stimulation 1Hz throughout

129
Q

what is an alternative site to facial and ulnar stimulation?

A

posterior tibial nerve

130
Q

When can reversal with neostigmine be given?

A

display at least 1/4 twitches

2-3 twitches recommended

131
Q

neostigmine dose 4 twitches without fade

A

0-1mg

132
Q

neostigmine dose 4 twitches with fade

A

1-2mg

133
Q

neostigmine dose 2-3 twitches

A

2-3 mg

134
Q

neostigmine dose 1-2 twitches

A

4-5mg

135
Q

sugammadex reversal dose 4/4 with or without fade and NDMR within prev 3 hr

A

1mg/kg

136
Q

sugammadex reversal dose 2/4 or 3/4 twitches

A

2mg/kg

137
Q

sugammadex reversal dose 1/4 twitches

A

3mg/kg

138
Q

sugammadex reversal dose 0/4 twitches and 1 PTC

A

4mg/kg

139
Q

sugammadex reversal dose 0/4 twitches and no PTC

A

wait unless emergency

140
Q

sugammadex immediate reversal dose of RSI roc dose (1-1.2 mg/kg) 3 mins after administration

A

16mg/kg

141
Q

If neuromuscular blockade is required before the recommended wait time has elapsed (from using sugammadex) what should be used?

A

nonsteriodal (cisatracurium)

142
Q

if 16mg/kg of bridion was used what is the minimum wait time before giving dose of roc?

A

24 hours for both 0.6mg/kg and 1.2mg/kg of roc

143
Q

if 4mg/kg of bridion was used what is the minimum wait time before giving another dose of 0.6 roc?

A

4 hours

should wait >24 hr if mild renal impairment

144
Q

if 4mg/kg of bridion was used what is the minimum wait time before giving another dose of 1.2 roc?

A

5 minutes
block may be delayed up to 4 min
duration may be shortened by 15 min

145
Q

6 indicators of adequate reversal

A 
sustained head lift 5 sec
sustained tetanus 5 sec
tidal volume 5-10mL/kg
strong hand grip
Negative inspiratory force (NIF)
TOF ratio
146
Q

Negative inspiratory force (NIF) definition and normal value

A

greatest negative pressure a pt can generate during inspiration
-50–100 cm/H2O

147
Q

what is NIF measured with?

A

manometer

connected to ETT

148
Q

what NIF is adequate for reversal of NM blockade?

A

-30cmH2O or more

149
Q

what is the most reliable indictor of adequate reversal?

A

TOF ratio

150
Q

TOF ratio >0.75 indicates what type of reversal?

A

sustained tetanus 5 sec
head lift 5 sec
NIF -25cmH2O

151
Q

TOF ratio >0.9 indicates what type of reversal?

A

sit up unassisted and normal pharyngeal function

152
Q

TOF ratio <0.9 indicates what type of reversal?

A

phayngeal disfunction with risk of aspiration should receive neostigmine

153
Q

physiological factors that prolong duration of MR (6)

A 
hepatic and renal disease
hypothermia
increased age
premature neonates
acidosis
Myasthenia gravis
154
Q

electrolyte abnormalities that prolong duration of MR (4)

A

hypocalcemia and hypercalcemia
hypomag and hypermag
hypokalemia
hypernatremia

155
Q

medications that prolong the duration of MR (4)

A

antibiotics
antiarrhythmics
inhalation agents
prior administration of sux prolongs nondep

156
Q

when is it possible to get fade with a depolarizing MR?

A

if a large enough dose of Sux is used and phase II block occurs

157
Q

can you distinguish with TOF between a nondep and dep phase II?

A

no

158
Q

when is it possible to get a phase II block?

A

larger than normal sux dose

infusion of sux or dosed repeatedly

159
Q

mechanism of phase II dep block

A

unknown, possible that postjunctional membrane repolarize and there desensitized to Ach

160
Q

when is tachyphylaxis seen with neuromuscular blocks?

A

phase II depolarizing blockade

161
Q

can a phase II block be reversed?

A

yes with neostigmine but unpredictable response so suggested to wait until block resolves
unknown whether sugammadex would reverse (probably not)

162
Q

advantages awake extubation (2)

A

less likely for airway obstruction or laryngospasm

airway protected

163
Q

disadvantages of awake extubation (2)

A

coughing and bronchospasm more likely

turn over time prolonged if wake up slow

164
Q

awake extubation criteria (3)

A

breathing spontaneously
strong enough to breathe adequately (adequate reversal)
awake enough to protect airway and avoid laryngospasm

165
Q

deep extubation definition

A

extubates when the patient is breathing spontaneously but ~1MAC

166
Q

advantages of deep extubation

A

less likely to cough or bronchospasm

dont have to wait for pt to wake up turnover is faster

167
Q

when is deep extubation preferred?

A

hernia surgery
nasal septoplasty
tonsillectomy

168
Q

disadvantage to deep extubation (3)

A

airway not protected
airway will obstruct (always need nasal or oral airway)
laryngospasm still possible

169
Q

deep extubation criteria (3)

A

breathing spontaneously with adequate tidal volumes
must be truly deep
thoroughly suctioned (prevent laryngospasm)

170
Q

how can you test if a patient is truly deep?

A

no cough with ETT cuff deflation

absence of reaction with forceful jaw thrust

171
Q

deep extubation absolute contraindication (4)

A

full stomach
GERD/hiatal hernia
difficult airway/intubation
airway edema

172
Q

deep extubation relative contraindications

A

obesity

patients with OSA

173
Q

post extubation hypoxia possibilities (6)

A 
apnea
bronchospasm
atelectasis
pulmonary edema
inadequate reversal
hypoventilation/oversedation
174
Q

if you followed extubation criteria what is the most likely cause of post extubation apnea? effective initial treatment?

A

obstruction or laryngospasm

jaw thrust/oral/nasal airway

175
Q

treatment of airway obstruction/laryngospasm (4)

A

1-jaw thrust with mask
2- jaw lift with mask and oral airway
3-gentle positive pressure and oral airway
4- LMAvs propofol and sux

(you go up the steps if the first one doesn’t work)

176
Q

diagnosis of bronchosparm

A

auscultation (wheezing)

177
Q

treatment of post extubation bronchospasm

A

breathing treatment

epi if severe and nonresponsive to breathing treatment

178
Q

diagnosis of atelectasis

A

auscultation (diminished breath sounds)

chest xray

179
Q

treatment for atelectasis post extubation

A

Bi-level positive airway pressure (BiPAP) mask

180
Q

BiPAP definition

A

continous positive pressure but higher during inspiration to open alveloi

181
Q

when is BiPAP indicated?

A

OSA and atelectasis

182
Q

What makes BiPAP better than CPAP

A

reduced air trapping and easier exhalation compared to CPAP

183
Q

What can BiPAP be performed with?

A

ETT or facemask

184
Q

diagnosis of pulmonary edema

A

auscultation (crackles)

chest x ray

185
Q

treatment of pulmonary edema post extubation

A

diuretics (if cause is fluid overload)

possible intubation vs pressure support ventilation

LANCE (17 decks)

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