Date 07/07/2015 E.

By – ASTEWALE TESFIE ( ACCPM R1 )

Uses of Nerve Stimulators & Its Clinical Implication in reversal of the effects of
Neuromuscular Blockage ( Assigment to be summated on 08/07/15 E.C)

Introduction - Neuromuscular monitoring is usually required for patients suffering from

neuromuscular diseases and muscular dystrophies or in patients who had received long-acting
muscle relaxants. The clinical basis of nerve stimulation involves applying an electrical stimulus
directly over a motor nerve and monitoring the associated response. This motor response can
be used to determine the degree of neuromuscular blockade and is important to ensure ideal
intubating conditions, maintain adequate paralysis during critical operative periods, and
monitor return of function so that extubation criteria can be met. With the administration of
neuromuscular blocking agents, paralysis is evident in the following sequence: diaphragm,
adductor muscles of the vocal cords, orbicularis oculi, and the masseter muscle. However, the
diaphragm and laryngeal muscles are relatively resistant to most neuromuscular blocking
agents meaning that, although the diaphragm is the first muscle to be affected, the time to
reach maximum effect is prolonged when compared to the adductor pollicus muscle. This is
also true on return of function. The first evidence of return to function is in proximal muscle
groups, but return of full strength is seen first in the diaphragm.

Indications
Because of the variation in patient sensitivity to neuromuscular blocking agents, the
neuromuscular function of all patients receiving intermediate- or long-acting neuromuscular
blocking agents must be monitored. In addition, peripheral nerve stimulation is helpful in
detecting the onset of paralysis during anesthesia inductions or the adequacy of the block
during continuous infusions with short-acting agents.

Contraindications
There are no contraindications to neuromuscular monitoring, though certain sites may be
precluded by the surgical procedure. Additionally, atrophied muscles in areas of hemiplegia or
nerve damage may appear refractory to neuromuscular blockade secondary to the proliferation
of receptors. Determining the degree of neuromuscular blockade using such an extremity could
lead to the potential overdosing of competitive neuromuscular blocking agents.

Techniques
Two electrodes are placed on the skin over a desired nerve, typically <6 cm apart . Then A nerve
is stimulated over its course and the response ( visual and tactile or electromyographic) is
observed in the muscle supplied by it. As the effect in Corrugator Supercilii and Orbicularis oculi
(supplied by facial nerve) parallels with the laryngeal muscles they are the ideal muscles for
monitoring (Corrugator Supercilii considered more ideal than Orbicularis oculi). However, due
to technical infeasibility of applying electrodes over face, they are not used routinely; most
commonly used muscle for neuromuscular monitoring is adductor pollicis supplied by ulnar
nerve. Other nerves which can be used are median, posterior tibial with the flexor hallucis
brevis contracting upon stimulation .
Clinically, the facial nerve response is a better predictor of intubating conditions, whereas the
ulnar nerve response is a better predictor of pharyngeal muscle recovery. The latter may prove
useful in determining whether extubation criteria are met.

Stimuli Used for Neuromuscular Monitoring

A. Train of four: Train of four is the most commonly used modality for neuromuscular
monitoring in clinical practice to titrate the administration of neuro-muscular blocking drugs
and reversal agent . The monitor delivers 4 stimuli, each of 2 Hz for 2 seconds and recordings
are taken. Four responses recorded are labeled as T1, T2, T3 and T4 . The ratio of T4 to Tl (called
as TO4 ratio) is automatically calculated by monitors. In normal condition, the amplitude height
of fourth and first response will be same, i.e. T4/T1 ratio will be 1.
It is observed that with depolarizing muscle relaxants all four responses decrease
simultaneously in amplitude, i.e. T4 /T1 remains 1 to finally become O when all four responses
becomes absent (required for intubation). With nondepolarizing muscle relaxants, first there
will be decrease in T4/T1 ratio followed by FADING which means T4 response will disappear
first, then T3 and so on. This is called as TO4 score. If only one response is seen means TO4
score is 1 and if 2 responses are seen means TO4 score is 2 . The reason for fading seen with
non-depolarizers is not only slow and progressive blockage of acetylcholine receptors at
neuromuscular junction but also slow and progressive blockage of acetylcholine mobilization at
prejunctional level. Absence of T4 response means 75% - 80% blockade of receptors which is
sufficient for most of surgeries. Absence of T3 means 80%- 85% blockade and absence of T2
means 90% block (Diaphragm is completely blocked at this level) & Absence of T1 means 98 -
100% blokage. Intubation requires complete absence of all 4 responses (100% block).
Train of four ratio is best utilized to assess reversal. The ratio of 0.7 (i.e. fourth response has a
70% height of first response) indicates adequate recovery but recovery is guaranteed only at a
ratio of >0.9. Train of four is also very useful in diagnosing phase II block (which is seen in over
dosage of succinylcholine or abnormal plasma cholinesterase activity). If the patient on
succinylcholine shows Jading, it is pathognomonic of phase JI block.
B. Tetanic stimulation: A sustained stimulus of 50- 100 I lz is given for 5 seconds. Depolarizers
will exhibit diminution of all responses while non-depolarizers will show fading followed by
post-tetanic facilitation. This facilitation occurs as a result of response generated by increased
acetylcholine released from prejunctional area by tetanic stimulus. If there is a full response
and lack of fade, this can be indicative of recovery from neuromuscular blockade.

C. Post-tetanic count (PTC) : A stimulus is given just after the tetanic stimulation. As you know,
tetanic stimulation will increase acetylcholine levels at neuromuscular junction . This increased
acetylcholine will replace some molecules of non-depolarizers from its binding site on receptors
producing a response while on the other hand the depolarizers produces relaxation by making
the membrane refractory due to continuous stimulation, therefore will not respond to
increased acetylcholine. Absence of PTC with non-depolarizers indicates a very intense block.
This method can be used when there is partial or no response to a TOF

D. Double burst stimulation (DBS 3, 3): As the name suggests, two sets, each consisting of 3
stimuli of high frequency {50 Hz), are given at a gap of 750 milliseconds. The results are similar
to other responses with non-depolarizers exhibiting fading. Tetanic, post-tetanic count and
double burst stimulus are very high intensity stimuli, therefore are used to assess deep blocks
or where neuromuscular monitoring is done by visual observation 'of movement (like adduction
of thumb after stimulating ulnar nerve).

E. Single twitch: A single stimulus is given for 0.2 milliseconds. Both depolarizing and non-
depolarizing muscle relaxants will cause depression of single twitch in dose-dependent manner.
It can be used to monitor neuromuscular blockade provided by succinylcholine during
endotracheal intubation or when it is administered as an infusion. It is also used in research
when evaluating the onset of action of new neuromuscular blocking agents .
Possible Complications

Complications of nerve stimulation are limited to skin irritation and abrasion at the site of
electrode attachment.

Summary: Because Patients & muscle groups of each patient differ in their sensitivity to
neuromuscular blocking agents, use of the peripheral nerve stimulator cannot replace direct
observation of the muscles (eg, the diaphragm) that need to be relaxed for a specific surgical
procedure. Furthermore, recovery of adductor pollicis function does not exactly parallel
recovery of muscles required to maintain an airway. The diaphragm, rectus abdominis,
laryngeal adductors, and orbicularis oculi muscles recover from neuromuscular blockade sooner
than the adductor pollicis. Other indicators of adequate recovery include sustained (≥5 s) head
lift, the ability to generate an inspiratory pressure of at least –25 cm H2O, and a forceful hand
grip. Twitch tension is reduced by hypothermia of the monitored muscle group (6%/°C).
Decisions regarding the adequacy of reversal of neuromuscular blockade, as well as the timig of
extubation, should be made only by considering the patient’s clinical presentation and
assessments determined by peripheral nerve stimulation. Postoperative residual paralysis
remains a problem in postanesthesia care, producing potentially injurious airway and
respiratory function compromise and increasing length of stay and cost in the postanesthesia
care unit (PACU). Reversal of neuromuscular blocking agents is warranted, as is the use of
intermediate-acting neuromuscular blocking agents instead of longer-acting drugs. Quantitative
monitors of neuromuscular blockade are recommended to reduce the incidence of patients
admitted to the PACU with residual paralysis.

Adductor pollicis (supplied by ulnar nerve) is the most commonly chosen muscle and Train of
four is the most commonly used stimulus for neuromuscular monitoring. Fading, post-tetanic
facilitation and post-tetanic count are only exhibited by non-depolarizing muscle relaxants.

References

I. Basic Clinical Anesthesia 2015

II. Morgan & Mikhails 7th Edition
III. Text Book of Anesthesia