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614 General Principles Of Anesthesia > Week 4- Peripheral Nerve Stimulators > Flashcards

Week 4- Peripheral Nerve Stimulators Flashcards

1
Q

Things that can affect contact of peripheral nerve stimulators (name 5)

A
  • diaphoresis
  • hair
  • edema
  • wounds
  • anything interfering with conduction
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2
Q

what nerve innervates the adductor pollicis muscle

A

ulnar nerve

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3
Q

when stimulating the adductor pollicis muscle, where/what response are you looking for

A

thumb adduction/twitching

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4
Q

stimulation of which peripheral nerve is a good indicator of recovery of upper airway muscle function

A

adductor pollicis muscle

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5
Q

the adductor pollicis is sensitive to NMBs and recovers later that what 3 muscles

A
  • diaphragm
  • laryngeal adductors
  • abdominal muscles
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6
Q

The surgeon says to you “the patient is breathing, their diaphragm is moving.” but you have no twitches. Why would this be?

A

you may be measuring your TO4 on adductor pollicis which recovers later than the diaphragm

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7
Q

where do you place the black and red leads of nerve stimulator on adductor pollicis

A
  • Distal (black lead) is placed at the level of the wrist on the ulnar surface of the flexor crease, as close to the nerve as possible
  • The second or proximal lead (red) is placed 1-2 cm proximal to the first parallel to the flexor carpi ulnaris tendon
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8
Q

stimulation of the facial nerve that covers the eyelid and its response to NMB is similar to the adductor pollicis (eyelid squint)

A

Orbicularis oculi

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9
Q

stimulation of the facial nerve that covers the eyebrow is its response is similar to the laryngeal adductors with faster onset and more rapid recovery

A

Corrugator supercilii

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10
Q

stimulation of __________ is a good predictor of good intubating conditions and profound block

A

eyebrow

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11
Q

Orbicularis oculi is the________ branch of the facial nerve

A

zygomatic

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12
Q

Corrugtor supercilli is the_________ branch of the facial nerve

A

temporal

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13
Q

similar in depth, onset, and recovery as the larynx and the diagram… quicker than the upper airway

A

corrugator supercilli

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14
Q

which facial nerve stimulation is a good indicator that it is safe to intubate

A

corrugator supercilli

***** she said this in email

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15
Q

which facial muscle has similar recovery time to the adductor pollicis muscle

A

obicularis occuli

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16
Q

correct placement of electrodes to test corrugator supercilli

A
  • 1st electrode (red)= outer canthus of eye
  • 2nd electrode (black) = 2 cm below 1st & parallel with tragus of ear
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17
Q

2x dose to paralyze this than adductor pollicis

A

Diaphragm

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18
Q

which is more sensitive to a block:

laryngeal muscles/diaphragm vs. adductor pollicis

A

adductor pollicis

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19
Q

T or F: if the diaphragm is still moving, you won’t have twitches in adductor pollicis

A

F. not necessarily true, need 2x dose to paralyze the diaphragm

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20
Q

t or F: the face muscles are not a good indication of when to intubate but are a good indication of when to extubate

A

F- good indication for intubation, bad for extubation

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21
Q

medication that may “alter the rules” for the diaphragm vs adductor pollicis return of twitches

A

Succynylcholine (Anectine)

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22
Q

Neuromuscular blockade develops _______, lasts a ______ amount of time, and recovers _______ at the laryngeal and diaphragmatic muscles

A

Faster;

Shorter;

Faster.

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23
Q

The eyebrow muscle, corrugator supercilii, has a similar time course of recovery to the ___________

A

laryngeal adductors

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24
Q

where is the posterior tibial nerve

A

Located behind the medial malleolus

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25
Q

what does the posterior tibial nerve stimulate/ produce?

A

plantar flexion of big toe by contraction of flexor hallucis muscle

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26
Q

muscle twitch that is comparable to adductor pollicis

A

posterior tibial nerve

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27
Q

how to place the posterior tibial nerve leads

A

1st (black -) = 2 cm distal posterior to medial malleolus on foot

2nd (red+) = 2 cm above the malleolus - 1st

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28
Q

peripheral nerve stimulators deliver currents between

A

0 to 70 milliamperes (mA)

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29
Q

what do peripheral nerve stimulators have to decrease resistence

A

electrodes with silver-silver chloride

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30
Q

is a peripheral nerve stimulator a DC or AC

A

DC

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31
Q

is the Peripheral Nerve Stimulator a quantitative or qualitative monitoring tool

A

qualitative

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32
Q

in what two ways should you check peripheral nerve stimulator

A

visual & tactile

*** tactile encouraged

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33
Q

some issues you can run into with peripheral nerve stimulators

A
  • improper placement = no nerve stimulation
  • improper electrode placement
  • obese patients
  • skin resistance (hairy arm)
  • takes time for optimal effectiveness.

***Surface electrodes don’t always stimulate ALL nerve fibers (unlike needle electrodes).

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34
Q

Increase stimulation from a single stimuli at _____ Hz (one every 10 seconds) to brief tetanic stimulation at ____ Hz causes sustained muscle contraction (tetanus) without fade

A

0.1

50

35
Q

supramaximal muscles stimulation with peripheral nerve stimulator can cause what? and at what Hz is this

A

muscles fatigue

> 70-200 Hz

36
Q

what can happen with repeated stimulation of peripheral nerve stimulator

A

fatigue

increased blood flow= increased delivery to stimulated muscle ESPECIALLY if stimulated BEFORE relaxant is given ***** Important

37
Q

patterns of stimulation

A

Single Switch (ST)
Train-Of-Four (TOF)
Tetanus (TET)
Posttetanic Count (PTC)
Double Burst (DBS)

38
Q

pattern of stimulation generally used for suggamedex

A

Posttetanic Count (PTC)

39
Q

The two frequencies for the single twitch stimuli:

A

Frequencies between 0.1 Hz (1 stimulus every 10 seconds)

and 1.0 Hz (1 stimulus per second)

40
Q

the least precise measure of peripheral nerve stimulation

A

Single Switch (ST)

** is a response to an individual stimuli.

41
Q

T or F: single twitch stimulators are used to determine onset of block NOT recovery

A

True

42
Q

T or F: single twitch does not require a baseline comparison

A

F - it does require baseline

43
Q

name that nerve stimulator! – 4 Repetitive stimuli at 2 Hz (2/sec)

A

Train-Of-Four (TOF)

44
Q

name that nerve stimulator! – Associated with fade in NDMR

A

Train-Of-Four (TOF)

45
Q

minimum standard for determining extubation readiness on TOF

A

TOFr>/= 0.9

46
Q

how do you express the relationship between the fourth vs 1st twitch in TOF:

A

fade ratio – T4/T1

No muscle relaxant = 1.0
Full muscle relaxation = 0

47
Q

with 4 twitches on To4, you can still have _______% of receptors blocked by NMB

A

75

48
Q

T or F - To4 can detect a phase I block

A

F- phase II block :)

49
Q

30% To4 block, pt can

A

Head lift/hand grasp sustained

50
Q

70-75% To4 block, pt can have

A

4 twitches on TOF, VC and TV can be normal

51
Q

90% To4 block, pt can have

A

1 twitch on TOF, adequate relaxation of abdominal muscles

52
Q

95% To4 block, pt can have

A

No twitches but the diaphragm may move

53
Q

100% To4 block, pt can have

A

No response, flaccid, no TOF

54
Q

TOF _____ to ______ indicates adequate surgical relaxations

A

0.15-0.25

55
Q

fades or fatigues when partially blocked
Sensitive indicator of residual NMB.. repetitive >30Hz (usually 50Hz).

A

Tetanic Stimulation

*Use 5 second durations to evaluate neuromuscular function

56
Q

Used in profound block and no TOF

5 second, 50 Hz tetanic stimulus followed 3 seconds later by a single-twitch stimuli at 1 Hz

A

Posttetanic Count (PTC)

57
Q

Can help guide reversal especially with Sugammadex

A

Posttetanic Count (PTC)

58
Q

Posttetanic Count (PTC) – with tetanus, it mobilizes ACh where

A

at prejunctional membrane so more is available @ endplate to get PT twitches

59
Q

explain use of To4 in conjunction with PTC

A

to4 = 0, 50 Hz for 5 seconds –> depending on twitches after will tell you how soon you may get twitches back on to4.

2 twitches mean you got a while
8 twitches would mean you will get t04 response back soon

60
Q

Two short bursts of tetanus at 50 Hz (each burst will have three impulses lasting 0.2 ms)

The two bursts are separated by 750 ms

A

double burst stimulation (DBS)

61
Q

T or F: double burst stimulation (DBS) has better magnitude of muscle response than. to4

A

true

62
Q

DBS can detect fade at a TOF of about_______

A

0.60

63
Q

is depolarizing or nondepolarizing - “all or nothing” in reference to twitches/fade

A

depolarizing is all or nothing

64
Q

a phase 1 block is preceded by

A

muscle fasciculation

65
Q

Characterized by decrease in twitch tension, no fade during repeated stimulation (Tetanic or TOF) and no posttetanic potentiation

A

phase 1 block of depolarizing agent

66
Q

what yields a phase II block of DMB

A

Fade develops in response to TO4

  • Result of too much depolarizer or repeated use
67
Q

true or false: phase 1 block T4/T1 ratio is 0.5 until all twitches disappear together

A

F- 1.0 not 0.5 bc no fade!

68
Q

T or F: You should always check for twitches after using Succinylcholine before administering a nondepolarizing muscle relaxant

A

T

69
Q

Onset and offset of block is faster in central muscles with a good blood supply, for example (name 2)

A

diaphragm and larynx

70
Q

peripheral muscles, with a relatively poor blood supply, will have a slower onset of block and a longer recovery time – name an example

A

adductor pollicis

71
Q

the muscles of the upper airway and pharynx behave similar to ________ muscles on onset and mirror _________ muscles in recovery.

A

central

peripheral

72
Q

on induction and intubation, what is the ideal muscle to use and what is the most valuable stimulation pattern

A
  • Corrugator Supercilli (FACE) or

(She said facial nerve as well).

  • Single twitch or TOF stimulation
73
Q

for maintenance of Anesthesia, what muscle stimulation will best reflect diaphragm:

A

Corrugator Supercilli

74
Q

_______&______ monitoring are most useful during the profound neuromuscular block.

A

PTC and TOF

75
Q

Before administering a neuromuscular antagonist, the TOF count should be at least

A

1 or 2

76
Q

for Reversal and Recovery, monitoring what nerve stimulation is best option

A

adductor pollicis

77
Q

true or false: peripheral nerve stimulators are a very precise way to measure return of muscle strength

A

F- suuuupppperrrrr unreliable bc its subjective

78
Q

what it the best way to monitor the return of muscle twitch

A

Acceleromyography (AMG)

79
Q

Acceleromyography (AMG):
- where
- what does it measure
- ______ based
- reading may be altered by ______

A
  • ulnar nerve
  • Measures acceleration of muscle response and converts it to a ratio
  • TOFR based
  • patient movement
80
Q

Meds that can potentiate the actions of NMBDs and increase the difficulty of reversal (7):

A
  • antibiotics (esp. aminoglycosides)
  • loop diuretics
  • mag sulfate
  • lithium salts
  • CCBs
  • quinidine
  • procainamide
81
Q

Neuromuscular blockade develops _______, lasts a ______ amount of time, and recovers _______ at the laryngeal and diaphragmatic muscles

A

Faster;

Shorter;

Faster.

82
Q

Central nerves (facial) are paralyzed faster and recover quicker than peripheral nerves (ulnar) (T/F)

A

True

83
Q

Corrugator supercilii may show _______recovery but the adductor pollicis may show ________ recovery

A

complete; incomplete

84
Q

the theory behind acceleromyography is based on:

A

Newtons second law of motion: force = mass x acceleration

614 General Principles Of Anesthesia (14 decks)

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