© copyright 2010 xavant technology. neuro physiology organization of the nervous system neuro...
TRANSCRIPT
Neuro Physiology Organization of the Nervous System
Neuro Physiology Organization of the Nervous System
Central Nervous SystemCentral Nervous System
Peripheral Nervous SystemPeripheral Nervous System
Brains
Spinal Cord
Brains
Spinal Cord
Sensory DivisionSensory Division
Motor DivisionMotor Division
Somatic Sensory
Visceral Sensory
Somatic Sensory
Visceral Sensory
Voluntary (Somatic)
Involuntary (Autonomic)
Voluntary (Somatic)
Involuntary (Autonomic)
Sympathetic
Parasympathetic
Sympathetic
Parasympathetic© Copyright 2010
Xavant Technology
Neuro Physiology Structure of a motor neuron
Neuro Physiology Structure of a motor neuron
Receptive (Input)
Conducting
Secretory (Output)
Receptive (Input)
Conducting
Secretory (Output)
© Copyright 2010Xavant Technology
(Human Anatomy and Physiology – Marieb Third Edition 1995)
Neuro Physiology Membrane Potentials
Neuro Physiology Membrane Potentials
Resting Potential = -70mVResting Potential = -70mV
© Copyright 2010Xavant Technology
(Human Anatomy and Physiology – Marieb Third Edition 1995)
Neuro Physiology Gated Channels
Neuro Physiology Gated Channels
© Copyright 2010Xavant Technology
(Human Anatomy and Physiology – Marieb Third Edition 1995)
Neuro Physiology Action Potential – A all-or-none phenomenon
Neuro Physiology Action Potential – A all-or-none phenomenon
© Copyright 2010Xavant Technology
(Human Anatomy and Physiology – Marieb Third Edition 1995)
Nerve Stimulators Where?
Nerve Stimulators Where?
Nerve Stimulators can be used for
Regional Anesthesia for various procedures using single
shot needles or stimulating catheters for post operative
pain management etc.
Peripheral nerve blocks in trauma patients (Ambulances,
Emergency Room etc)
Nerve Location in pain clinics
Monitor the onset and reversal of muscle relaxants
(NMBA Monitoring)
Nerve Stimulators can be used for
Regional Anesthesia for various procedures using single
shot needles or stimulating catheters for post operative
pain management etc.
Peripheral nerve blocks in trauma patients (Ambulances,
Emergency Room etc)
Nerve Location in pain clinics
Monitor the onset and reversal of muscle relaxants
(NMBA Monitoring)
© Copyright 2010Xavant Technology
Nerve Stimulators Why?
Nerve Stimulators Why?
60-80% increase in the success rate of peripheral nerve
blocks
Reduce time for performing nerve blocks (New Generation)
Significantly reduce occurrence of nerve damage (New
Generation)
Avoid hematomas caused by multiple needle injections
(Nerve mapping)
Less experience is needed for successful regional blocks
Nerve mapping is a great educational tool for teaching
purposes
60-80% increase in the success rate of peripheral nerve
blocks
Reduce time for performing nerve blocks (New Generation)
Significantly reduce occurrence of nerve damage (New
Generation)
Avoid hematomas caused by multiple needle injections
(Nerve mapping)
Less experience is needed for successful regional blocks
Nerve mapping is a great educational tool for teaching
purposes© Copyright 2010Xavant Technology
Pulse Width (ms)Pulse Width (ms)
Total Charge (uC)Total Charge (uC)
Current Amplitude (mA)Current Amplitude (mA)
Nerve Stimulators How?
Nerve Stimulators How?
Coulomb’s Law
Coulomb’s Law
Charge (C) = Current (A) x Time (s)Charge (C) = Current (A) x Time (s)
© Copyright 2010Xavant Technology
Normal ImpedanceNormal Impedance Impedance too highImpedance too high
Nerve Stimulators How?
Nerve Stimulators How?
Ohm’s LawOhm’s Law Voltage (V) = Current (A) x Resistance (Ω)Voltage (V) = Current (A) x Resistance (Ω)
© Copyright 2010Xavant Technology
Nerve Stimulators How?
Nerve Stimulators How?
Nerve Mapping
Nerve Locating
NMBA Monitoring (NeuroMuscular Blocking Agent)
Nerve Mapping
Nerve Locating
NMBA Monitoring (NeuroMuscular Blocking Agent)
© Copyright 2010Xavant Technology
STIMPOD NMS410 Features
STIMPOD NMS410 Features
Display real-time feedback of the actual
delivered stimulus
Proximity Indicator™ for near nerve functionality
Single cable with auto-switching for nerve
mapping and nerve locating
Display real-time feedback of the actual
delivered stimulus
Proximity Indicator™ for near nerve functionality
Single cable with auto-switching for nerve
mapping and nerve locating
© Copyright 2010Xavant Technology
STIMPOD NMS410 Features
STIMPOD NMS410 Features
Open circuit detection
Non-linear mode allowing the user to customize
current and pulse width setting positions
Set current adjustment intervals in 3 different
current ranges
0.0 – 0.6 mA
0.6 – 2.0 mA
2.0 – 5.0 mA
Open circuit detection
Non-linear mode allowing the user to customize
current and pulse width setting positions
Set current adjustment intervals in 3 different
current ranges
0.0 – 0.6 mA
0.6 – 2.0 mA
2.0 – 5.0 mA
© Copyright 2010Xavant Technology
STIMPOD NMS450 Features
STIMPOD NMS450 Features
NMBA Monitoring using 3 dimensional Accelerometer
80mA current range
Repeat timer for continuous monitoring
Separate driving circuits for Locating and Mapping/NMBA
Only 100V is generated for Locating mode
400V is only generated for Mapping/NMBA mode
+ all the NMS410 features
NMBA Monitoring using 3 dimensional Accelerometer
80mA current range
Repeat timer for continuous monitoring
Separate driving circuits for Locating and Mapping/NMBA
Only 100V is generated for Locating mode
400V is only generated for Mapping/NMBA mode
+ all the NMS410 features© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Train-of-Four (TOF)Train-of-Four (TOF)
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Train-of-Four (TOF)
• TOF ratio is the relation between the reaction to the 4th pulse
compared to the reaction to the 1st pulse i.e. 70%
• TOF count indicates the number of reactions if there is no 4th
reaction i.e. 2/4
• A typical TOF ratio > 0.7 is required to indicate reversal
• Used during onset, maintenance and recovery until no fade is
detected
Train-of-Four (TOF)
• TOF ratio is the relation between the reaction to the 4th pulse
compared to the reaction to the 1st pulse i.e. 70%
• TOF count indicates the number of reactions if there is no 4th
reaction i.e. 2/4
• A typical TOF ratio > 0.7 is required to indicate reversal
• Used during onset, maintenance and recovery until no fade is
detected
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Double Burst (DB)Double Burst (DB)
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Double Burst (DB)
• DB ratio is the relation between the reaction to the 2nd burst
compared to the reaction to the 1st burst i.e. 70%
• Used to detect residual paralysis
• Presence of fade indicates a residual neuromuscular blockade
• Could be followed by a clinical evaluation i.e. head lift for 5
seconds
Double Burst (DB)
• DB ratio is the relation between the reaction to the 2nd burst
compared to the reaction to the 1st burst i.e. 70%
• Used to detect residual paralysis
• Presence of fade indicates a residual neuromuscular blockade
• Could be followed by a clinical evaluation i.e. head lift for 5
seconds
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Post Tetanic Count (PTC)Post Tetanic Count (PTC)
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Post Tetanic Count (PTC)
• Use to assess intense block when there is no TOF count
• A response to PTC will be seen before any response to TOF
• The level of block is indicated by the number of counts
compared to the previous measurement i.e. 18 compared to 15
indicates a reversal
• If a count of 10 or higher is achieved it is indicative that the 1st
response on the TOF should appear soon
Post Tetanic Count (PTC)
• Use to assess intense block when there is no TOF count
• A response to PTC will be seen before any response to TOF
• The level of block is indicated by the number of counts
compared to the previous measurement i.e. 18 compared to 15
indicates a reversal
• If a count of 10 or higher is achieved it is indicative that the 1st
response on the TOF should appear soon
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Twitch (TWI)Twitch (TWI)
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Twitch (TWI)
• Not a very sensitive measure for onset and reversal
• Usually used to test the placement of the electrodes
• No accelerometer feedback
Twitch (TWI)
• Not a very sensitive measure for onset and reversal
• Usually used to test the placement of the electrodes
• No accelerometer feedback
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Tetanus (TET)Tetanus (TET)
© Copyright 2010Xavant Technology
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
STIMPOD NMS450 NMBA Monitoring Stimulation Mode
Tetanus (TET)
• Sustained response to this pattern corresponds with adequate
reversal
• Is not very reliable
• Is very painful
• Should not be performed on the awake patient
• No accelerometer feedback
Tetanus (TET)
• Sustained response to this pattern corresponds with adequate
reversal
• Is not very reliable
• Is very painful
• Should not be performed on the awake patient
• No accelerometer feedback
© Copyright 2010Xavant Technology
STIMPOD NMS410/450 Screen Diagnostics
STIMPOD NMS410/450 Screen Diagnostics
© Copyright 2010Xavant Technology
B. Braun HNS-12 – MARKET LEADER (for now)75% Market Share (2009 Dollars)
$288,840 sold (2009)66% Market Share (2009 Units)
339 units sold (2009)ASP: $852 (2009)
Life-Tech EZStim II22.5% Market Share (2009 Dollars)
$86,803 sold (2009)30.7% Market Share (2009 Units)
157 units sold (2009)ASP: $553 (2009)
Life-Tech Tracer III2.5% Market Share (2009 Dollars)
$9,757 sold (2009)2.9% Market Share (2009 Units)
15 units sold (2009)
ASP: $650
2009 Stimulator Market Summary
© Copyright 2010Xavant Technology
B. Braun HNS-12 with SENSe
User Benefits:
• Now with SENSe technology for safer, easier, and more efficient nerve stimulation
• Advanced ergonomic shape and large display
• Digital ratchet dial for precise tactile current adjustment
• Quick access buttons allow direct switching of key parameter values during procedure
• Alarm screens and acoustic signals inform the user of any relevant deviations
• StimuPlex Remote Control allows sterile one-handed operation
• StimuPlex Pen helps pre-assess the puncture site
• Study: “An objective assessment of nerve stimulators for peripheral nerve blockade” – HNS-12 #1, but StimPod not included
© Copyright 2010Xavant Technology
BBRaun HNS12 STIMPOD NMS410STIMPOD NMS410 STIMPOD NMS450STIMPOD NMS450
Sterility Offers a remote control covered for use under sterile gloves
Unit can be covered by Unit can be covered by sterile sheetsterile sheet
Unit can be covered by sterile Unit can be covered by sterile sheetsheet
Device attachment
No attachment mechanism Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Current Range Nerve Locating 0.0 – 5.0 mANerve Mapping 0.0 – 5.0 mANMBA Monitoring None
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve mapping 0 – 20 mANerve mapping 0 – 20 mANMBA Monitoring NoneNMBA Monitoring None
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve Mapping 0 – 20 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mANMBA Monitoring 0 – 80 mA
Pulse Width 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms
0.05ms, 0.1ms, 0.3ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms0.5ms, 1ms
0.05ms, 0.1ms, 0.3ms, 0.5ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms1ms
Nerve Mapping Yes - 5mA maximum current
Yes - 20mA maximum Yes - 20mA maximum currentcurrent
Yes - 20mA maximum currentYes - 20mA maximum current
Auto Sensing Technology
No YesYesCombination Cable Auto Combination Cable Auto SensingSensing
YesYesCombination cable Auto Combination cable Auto SensingSensing
Show Current Delivered
Yes Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
NMBA Monitoring
No NoNo Yes - 3 dimensional Yes - 3 dimensional accelerometeraccelerometer
STIMPOD NMS410/450 Comparison Study
STIMPOD NMS410/450 Comparison Study
© Copyright 2010Xavant Technology
B. Braun HNS-12 with SENSe
What is SENSe?
The SENSe technology (Sequential Electrical Nerve Stimulation) is a sequence of two fixed impulse durations of 0.1 ms along with a third longer impulse duration. This results in getting the first muscle twitch already at a distance from the nerve and requires less adjustments to the amperage control, while maintaining the visual feedback.
© Copyright 2010Xavant Technology
Life-Tech EZstim II
Source: Life-Tech EZstim II Brochure
User Benefits:
• Large, bright, easily read LCD continuously displays all instrument settings and battery status.
• eShield protects agains electromagnetic interference. Unique interference protection capability eliminates need to disconnect the stimulator from the patient during electro-surgery procedures
• Audible and visual warning of any open circuit or high resistance condition
• Detachable lead sets allow quick and easy replacement of patient leads
•Function-specific electrode connectors guard against inappropriate use of stimulator
• Large, high-sensitivity control knob facilitates precise current adjustment
• Pause mode allows changing stimulus parameters without stimulating
• Optional protective boot and IV pole mount
© Copyright 2010Xavant Technology
Life-Tech EZstim II
Source: Life-Tech EZstim II Brochure
User Benefits:
• Neuromuscular Block Monitor Function: Complete selection of stimulus patterns – twitch, train of four, double burst, or tetanus
• Nerve Block Function: Audible “chirp” pulse amplitude indicator frees operator from having to watch the display
• Optional SoloStim foot control allows hands-free operation in nerve locator mode
• Dual current range (1.5 or 5 mA) with SoloStim provides a wide range when distant from nerve, and fine control when close to nerve
© Copyright 2010Xavant Technology
Life-Tech Tracer III
Source: Life-Tech Tracer III Brochure
User Benefits:
• Large, bright, easily read LCD continuously displays all instrument settings and battery status.
• Pause mode allows changing stimulus parameters without stimulating
• Audible “chirp” indicator of pulse delivery and amplitude frees the operator from having to watch the display
• Chirp volume is adjustable to be optimal for any environment
• Adjustable pulse width allows selective stimulation of motor or sensory fibers
• Both audible and visual warnings indicate any discrepancy between actual current and selected current
• Large, high sensitivity current control knob
• Detachable lead set allows quick and easy replacement of patient leads
© Copyright 2010Xavant Technology
Life-Tech Tracer III
Source: Life-Tech EZstim II Brochure
User Benefits:
• SoloStim Foot Control
• Dual current range (1.5/5.0 mA) provides wide range when distant from nerve and narrow range with finer control when close to nerve
• Hands-free operation increases the ease, rapidity and accuracy of current adjustment and in many facilities eliminates the need for an assistant
© Copyright 2010Xavant Technology
LifeTech EzStim II STIMPOD NMS410STIMPOD NMS410 STIMPOD NMS450STIMPOD NMS450
Sterility None Unit can be covered by Unit can be covered by sterile sheetsterile sheet
Unit can be covered by sterile Unit can be covered by sterile sheetsheet
Device attachment
IV Pole Attachment Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Current Range Nerve Locating 0.05 – 5.00 mA No Nerve MappingNMBA Monitor 0 – 80 mA
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve mapping 0 – 20 mANerve mapping 0 – 20 mANMBA Monitoring NoneNMBA Monitoring None
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve Mapping 0 – 20 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mANMBA Monitoring 0 – 80 mA
Pulse Width 0.1ms, 0.2ms 0.05ms, 0.1ms, 0.3ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms0.5ms, 1ms
0.05ms, 0.1ms, 0.3ms, 0.5ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms1ms
Nerve Mapping No Yes 20mA maximum currentYes 20mA maximum current Yes 20mA maximum currentYes 20mA maximum current
Auto Sensing Technology
No YesYesCombination Cable Auto Combination Cable Auto SensingSensing
YesYesCombination cable Auto Combination cable Auto SensingSensing
Show Current Delivered
No Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
NMBA Monitoring
Yes - No Accelerometer NoNo Yes - 3 dimensional Yes - 3 dimensional accelerometeraccelerometer
STIMPOD NMS410/450 Comparison Study
STIMPOD NMS410/450 Comparison Study
© Copyright 2010Xavant Technology
Pajunk MultiStim SWITCH
Source: www.PAJUNK.com
User Benefits:
• Large, clearly arranged display
• Analogous setting of the intensity of the stimulation current by means of a notched turning-knob
• Integrated safety features
• High-precision, microprocessor-controlled adjustment of constant current
• Added continuous indication of the patient resistance by means of two analogous bar graphs
• Switch over key switches stimulation from needle to catheter
User Benefits:
• Switch over key switches stimulation from needle to catheter
• Stimulation by cannula
• cannula symbol appears on the display
• maximum stimulation current intensity will be 6 mA
• Stimulation by catheter
• the word “CATH” will appear on the display
• range of stimulation current intensity will be increased to 20 mA
• correspond with the specific requirements of epidural stimulation
Pajunk MultiStim SWITCH
Source: www.PAJUNK.com
Pajunk MultiStim SENSOR
Source: www.PAJUNK.com
User Benefits:
• When using the PEG-electrode, the nerve is stimulated through the skin
• Will evoke a reflexive response when the nerve is encountered
• The cannula is introduced at the insertion point identified by means of this method
• The stimulation current is switched over to the cannula by keystroke
• Pressing the PEG- or Cannula button will cause the stimulation to be switched to the handle or the cannula, as may be required
• The intensity and the frequency of the stimulation current, as well as the pulse width can be adjusted separately for both outputs
• The stimulation pulse width can be adjusted fast and simple with a button of its own in a number of steps
Pajunk MultiStim VARIO/ MultiStim PLEX
Source: www.PAJUNK.com
User Benefits:
• Used for nerve stimulation for the identification of peripheral nerves, as well as the percutaneous stimulation of neuromuscular monitoring in general anesthesia
• Operation with one hand and audio visual signals with adjustable volume allow a full concentration on the patient
• All required stimulation impulse patterns and frequencies are recallable
• The bandwidth of the stimulation impulse is adjustable step by step, from 0.1 to 1.0 ms.
• Available constant current region 0-60 mA, adjustable in 0.1 mA steps
•The Pause function facilitates the change of the stimulation parameters without impulse output
MultiStim PlexThe MultiStim PLEX is very easy to handle. The nerve stimulator is used in the plexus anaesthesia particularly for training purposes. In comparison with the MultiStim VARIO, MultiStim PLEX has no function for the percutaneous relaxation monitoring and no PAUSE-function. The bandwidth of the stimulation impulse are defined with 0,1ms. The constant current field is between 0 - 6 mA, adjustable in 0,01 mA steps.
Pajunk MultiStim Vario STIMPOD NMS410STIMPOD NMS410 STIMPOD NMS450STIMPOD NMS450
Sterility None Unit can be covered by Unit can be covered by sterile sheetsterile sheet
Unit can be covered by sterile Unit can be covered by sterile sheetsheet
Device attachment
No attachment mechanism Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Special clip allows for Special clip allows for attachment to drapesattachment to drapes
Current Range Nerve Locating 0.0 – 5.0 mANerve Mapping 0 – 60 mA*NMBA Monitoring 0 – 60 mA* Need Switchbox
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve mapping 0 – 20 mANerve mapping 0 – 20 mANMBA Monitoring NoneNMBA Monitoring None
Nerve Locating 0.0 – 5.0 Nerve Locating 0.0 – 5.0 mAmANerve Mapping 0 – 20 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mANMBA Monitoring 0 – 80 mA
Pulse Width 0.1ms, 0.3ms, 0.5ms, 1ms 0.05ms, 0.1ms, 0.3ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms0.5ms, 1ms
0.05ms, 0.1ms, 0.3ms, 0.5ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms1ms
Nerve Mapping Yes – Need “Switchbox”60mA maximum current
Yes - 20mA maximum Yes - 20mA maximum currentcurrent
Yes - 20mA maximum currentYes - 20mA maximum current
Auto Sensing Technology
No YesYesCombination Cable Auto Combination Cable Auto SensingSensing
YesYesCombination cable Auto Combination cable Auto SensingSensing
Show Current Delivered
Yes Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
Yes – Actual waveform Yes – Actual waveform delivered showing exact delivered showing exact chargecharge
NMBA Monitoring
Yes - No Accelerometer NoNo Yes - 3 dimensional Yes - 3 dimensional accelerometeraccelerometer
STIMPOD NMS410/450 Comparison Study
STIMPOD NMS410/450 Comparison Study
© Copyright 2010Xavant Technology