© Copyright 2010 Xavant Technology. Neuro Physiology Organization of the Nervous System Neuro Physiology Organization of the Nervous System Central

© Copyright 2010Xavant Technology

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)


(Human Anatomy and Physiology – Marieb Third Edition 1995)

Neuro Physiology Membrane Potentials

Neuro Physiology Membrane Potentials

Resting Potential = -70mVResting Potential = -70mV



Neuro Physiology Gated Channels

Neuro Physiology Gated Channels



Neuro Physiology Action Potential – A all-or-none phenomenon

Neuro Physiology Action Potential – A all-or-none phenomenon



Now with NMBA

Monitoring


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)


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?


Coulomb’s Law

Coulomb’s Law

Charge (C) = Current (A) x Time (s)Charge (C) = Current (A) x Time (s)


Normal ImpedanceNormal Impedance Impedance too highImpedance too high



Ohm’s LawOhm’s Law Voltage (V) = Current (A) x Resistance (Ω)Voltage (V) = Current (A) x Resistance (Ω)




Nerve Mapping

Nerve Locating

NMBA Monitoring (NeuroMuscular Blocking Agent)

Nerve Mapping

Nerve Locating

NMBA Monitoring (NeuroMuscular Blocking Agent)


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




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




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


Train-of-Four (TOF)Train-of-Four (TOF)




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




Double Burst (DB)Double Burst (DB)




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




Post Tetanic Count (PTC)Post Tetanic Count (PTC)




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




Twitch (TWI)Twitch (TWI)




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





Tetanus (TET)Tetanus (TET)




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


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



STIMPOD NMS410/450 Components

STIMPOD NMS410/450 Components


STIMPOD NMS410/450 Screen Diagnostics

STIMPOD NMS410/450 Screen Diagnostics


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


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


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



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.


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


Life-Tech EZstim II


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


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


Life-Tech Tracer III


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


LifeTech EzStim II STIMPOD NMS410STIMPOD NMS410 STIMPOD NMS450STIMPOD NMS450

Sterility None Unit can be covered by Unit can be covered by sterile sheetsterile sheet


Device attachment

IV Pole Attachment 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



Pulse Width 0.1ms, 0.2ms 0.05ms, 0.1ms, 0.3ms, 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms0.5ms, 1ms


Nerve Mapping No Yes 20mA maximum currentYes 20mA maximum current Yes 20mA maximum currentYes 20mA maximum current





No 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




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


Pajunk MultiStim SENSOR


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


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


Device attachment

No attachment mechanism 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



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


Nerve Mapping Yes – Need “Switchbox”60mA maximum current

Yes - 20mA maximum Yes - 20mA maximum currentcurrent

Yes - 20mA maximum currentYes - 20mA maximum current





Yes 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




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© Copyright 2010 Xavant Technology. Neuro Physiology Organization of the Nervous System Neuro Physiology Organization of the Nervous System Central