Peripheral nerve

stimulator

Dr. Rochana Perera

NMJ monitoring
Usually assessed clinically.
Quantitative assessment is needed in
Intubation ( open eye injury, neurosurgery)
Maintenance ( intraocular, myasthenia)
Extubation (pancuronium)

Also needed to diagnose / differentiate

Suxamethonium apnoea
Dual block

Could also be used to locate nerves for

regional blocks

Peripheral nerve stimulator

( PNS)

Adductor pollicis

Produces a constant, monophasic

square wave impulse (0.1 0.5
msec.)
Multiple pattern generation possible

Single twitch
Train of four (TOF)
Tetanus & PTC
Double burst

Battery operated; must have a

battery check.
Inbuilt warning system for low
current.
Polarity indicators for electrode
leads.

Electrodes

Gel covered skin electrodes to reduce the

transcutaeneous impedance.
Subcutaneous (needle) electrodes are also used.
Very effective as impedance is less.
Local irritation, infection, nerve damage, diathermy burns

Normal ECG electrodes are commonly used, but

not suitable due to high impedance.

Electrode leads

+ve
Normal leads

Crocodile clips

-ve

Monopolar leads

Crocodile clips are used with needle electrodes.

Negative electrode must lie directly over the
nerve.
Negative electrode is always distal and positive
one is proximally placed to avoid the direct
stimulation of the muscle.

Electrical stimulation
Strength
Is the depolarizing intensity
depends on
duration of the current (pulse width))
cu rre nt inte nsity r eaching the nerve fibe r.

Must be strong enough to stimulate all the

fibers of the nerve.
Should not be excessive to directly
stimulate muscle fibers ( not more than 80
mA).

Pulse width
Is the duration of an impulse.
Usually 0.2 msec.
Should not exceed 0.5 sec as it leads
to repeated firing (exceeds the
refractory period).

Current intensity
Is the current (mA) generated by the
PNS.
Usually about 50-60 mA
(supramaximal). Can vary from 0 80
mA.
Same current reaches the nerve
regardless of the resistance by altering
the voltage.
Intensity could be threshold, sub
maximal, maximal or supramaximal.

 Threshold current
Is the minimal intensity
required to produce a
detectable response

Sub maximal current

Current that stimulates only a
fraction of fibers

Maximal current
Stimulates all the fibers

Supramaximal current
Is used for stimulation.
2 3 times the threshold
current.
10 -20% more than the
maximal current.
Is about 50 60 mA.

Individual fibers show

ALL OR NONE
phenomenon.

Evoked response
supramaximal
maximal

Threshold current (15 mA)

10 20 30 40 50 60 70
Current (mA)

Patterns of stimulations

Single twitch
Train of four
Tetanus
Post-tetanic count
Double burst
stimulation

Single twitch
2 ms
2

Single, supramaximal current of 0.2 msec

duration.
Is the only method to assess depolarizing
blocks.
Is used to define the ED95 of muscle relaxants
Degree of twitch depression (compared to
preblock) is observed (T1 T0 ratio).
Is used at a frequency of 1 Hz until the effect
is detected.

Response
Depolarizing block (sux)
Reduced twitch height
No fade

Nondepolarizing block
Characteristic fade (decremental
response)

stimulus

response

 Incremental response
Is seen in pre-junctional blocks.
Mg therapy
Eaten Lambert syndrome
bungarotoxin

Train of four (TOF)

0.2 ms

Most commonly used mode for NDMR

drugs..
Four successive stimuli at 2 Hz.
Shows a fade in non-depolarizing blocks.
T4 / T1 is called TOF ratio.
With a depolarizing block
Reduced twitch height
Fade occurs only if theres a dual block.

Responses
Depolarising

Nondepolarizing block
T1

Recordings

TOF count
Is the number of responses seen or felt.
Is useful to assess deep blocks.
To intubate when the count is 2.

Not useful to assess the recovery when the

count is 4.
At 80% receptor block, T4 disappears.
At 85%, T3 disappears.
At 90% block, T2 disappears.
At 95% block, T1 also disappears.

TOF ratio
Is the ratio of T4 to T1 .
Is used when the count is 4.
Visual or tactile assessment is
difficult when the ratio is more than
0.2 -0.3.
Extubation when the ratio is 0.9 -1.

TOF - advantages
Can quantify the block without a
control.
2 Hz frequency is less painful and
allows visual or manual evaluation.
Same fade could be elicited with a
sub maximal current (less painful,
but not recommended).
Could be repeated after 12 seconds.

Double burst stimulation

(DBS)
2 ms

Used when the TOF count is 4 (during recovery).

Detection of fade is better than with TOF.
3 impulses at 50 Hz (tetanic stimulation)
followed by 750 msec interval. A second burst of
either 2 ( DBS3,2 ) or 3 ( DBS3,3 ) impulses at the
same frequency.
There must be at least 12 15 seconds gap
between 2 DBSs.

Response
DBS3,2
NDMR

DMR

Tetanic stimulation
2 ms

Most painful stimulation.

Usually 50 Hz stimulation for 5 sec.
Shows fade with nondepolarizing blocks, but
cant assess with naked eye..
Sensitivity almost same as TOF at 50 Hz.
Causes post-tatanic facilitation showing an
artificial normalcy for 1-2 min.
As it cant be repeated for 6 min & is painful, it is
less useful than TOF.

Post-tetanic count ( PTC )

Is used when the TOF count is 0.

Detects the post-tetanic facilitation
Tetanic stimulation for 5 sec is followed 3 sec later by
single twitches at 1 Hz for 20 sec.
The count is inversely correlates with the time to
recovery.
A PTC of 10 indicates the imminent return of TOF
Is useful in neuro & eye surgery.

Response
Tetanus & PTC
X 20

Responses
Method of stimulation
TOF

Tetanic

DBS

PTC

DPB

Phase 2

NDPB

Receptor occupancy & clinical

response

No detectable response up to about 75%

occupancy.
High frequency tetanus is the most sensitive.

Monitoring sites
ulnar

facial

median
peroneal

Monitoring sites
Ulnar nerve
the commonest site.
Electrodes are placed over the medial
border of the forearm at the proximal wrist
crease and 2 cm above that.
The stimulation of the adductor pollicis
(opponence ) is monitored as it is not
directly stimulated.
However, it shows a different sensitivity
than the diaphragm and laryngeal muscles.

Facial nerve stimulation

In front of the tragus, 2-3 cm posterior to the

lateral border of the orbit.
Contraction of the eye brow (orbicularis oculi)
or the lip (orbicularis oris) is monitored.
Well correlated with diaphragmatic paralysis.
Risk of direct stimulation of the muscles.

Assessment of the response

Visual
Tactile
Recording devices ( quantitative
assessment )

Electromyography (EMG)
Mechanomyography
Acceleromyography
phonomyography

Visual & tactile assessment

Visual
TOF count or ratio

Tactile
Feel the contraction in stead of
visual assessment
More sensitive than visual

Both techniques are subjective

and less sensitive.
Cant be used for suxamethonium
(single twitch) as preblock
comparison is difficult.

Tactile assessment

Electromyography (EMG)
neutral
sensing electrodes
Stimulating
electrodes

Uses 2 active electrodes (on the body & the

tendon respectively) and a neutral electrode
out side the muscle.
Calculates the amplitude of the signal
( cumulative action potential)
Less bulky & easy to set up

EMG - disadvantages
Expensive device
Results affected by

Electrical interference
Improper electrode placement
Direct stimulation of the muscle
Hypothermia

Used only for research purposes.

Mechanomyography
( MMG)
pre load & sensor

arm board

Measures the isometric

contraction using a force
transducer.
Hand must be
immobilized.
A preload of 200 300 g
must be attached to the
muscle.
Transducer aligned with
the direction of the
thumb movement.
Usually for research only.

Acceleromyography (AMG)
Measures isotonic contraction.
Uses a piezo electric transducer to
assess the rate of angular
acceleration during isotonic phase.
Distortion of the PE crystal
produces a current proportional to
the force.
As force = mass x acceleration,
acceleration is recorded.
The muscle must be able to move
freely.

 No preload needed.
Immobilization of the arm / fingers not
important.
Simple method used in clinical practice.
Can be used for orbicularis oculi (MMG
cant)
Disadvantages
Tetanus cant be recorded as no
movements.

Phonomyography
microphone

Measures the
sound produced by
the muscle
contraction using a
microphone over
the muscle.

Clinical use
Check the equipment & batteries.
Clean & shave the skin.
Apply positive electrode proximally to
prevent direct stimulation of the muscle
(for ulnar nerve)
First recording must be taken
immediately after induction, but before
administering relaxants.
Always use a supramaximal current.

Clinical applications
Use TOF as the base line for NDMR.
PTC if the TOF count is 0
DBS if the count is 4.

Intubation ( open eye surgery )

TOF count 0

Maintenance
Laparatomy
TOF count 1-2

Diaphragmatic paralysis
TOF count 0

Eye / neuro (no movements acceptable)

TOF 0, PTC below 10

 Reversal
TOF count is 4.

Extubation
TOF ratio 0.9 -1
Better seen with DBS