Technical and Interpretive Problems of Peripheral Nerve Stimulation in Monitoring Neuromuscular Blockade in the Intensive Care Unit

1996 ◽  
Vol 30 (2) ◽  
pp. 165-172 ◽  
Author(s):  
Maria I Rudis ◽  
Benjamin G Guslits ◽  
Barbara J Zarowitz
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
Critically Ill ◽  
Nerve Stimulation ◽  
Peripheral Nerve Stimulation ◽  
Motor Neuropathy ◽  
Operator Technique ◽  
Peripheral Nerve Stimulator

OBJECTIVE: To review the literature and provide an overview of the technical and interpretive problems associated with peripheral nerve stimulation in monitoring neuromuscular blockade in the intensive care unit. DATA SOURCES: A computerized search on MEDLINE from 1985 through 1994 was performed to identify English-language comparative studies, abstracts, and review articles pertaining to peripheral nerve stimulation, train-of-four monitoring, and neuromuscular blockade in the critical care setting. STUDY SELECTION AND DATA EXTRACTION: Relevant studies in humans were selected and information was extracted on the use of peripheral nerve monitoring in the critically ill. DATA SYNTHESIS: Use of peripheral nerve stimulation is complicated in the intensive care unit. Problems may occur with the patient, the device, as well as operator technique, all of which may lead to errors in interpretation of the depth of paralysis. The critically ill patient has changing comorbid disease states and total body water composition, which may impair the accuracy or reproducibility of measurements. Technical problems relate to the operation of the device, electrode placement, and suboptimal delivery of the desired current. Difficulties in performing peripheral nerve stimulation and interassessor variability contribute to errors of interpretation. CONCLUSIONS: These difficulties compromise the precision, accuracy, and reliability of the peripheral nerve stimulator as a tool for monitoring neuromuscular blockade in the critically ill. Peripheral nerve stimulation should be used in conjunction with clinical parameters to make decisions regarding dose adjustments. Doses should be reduced as much as possible to provide the minimum depth of paralysis that is clinically appropriate. Technical directions and training programs for peripheral nerve stimulation should be developed, and designated individuals should be trained in its application. Large, prospective, controlled studies are necessary to evaluate the incidence of prolonged paralysis or motor neuropathy with administration of neuromuscular blocking agents in patients whose dose is adjusted on the basis of peripheral nerve stimulation.

Neuromuscular Blockade in the Pediatric Intensive Care Unit: Pancuronium, Vecuronium, Rocuronium, or Atracurium

1997 ◽  
Vol 12 (4) ◽  
pp. 213-217 ◽  
Author(s):  
Joseph D. Tobias
Keyword(s):  
Intensive Care Unit ◽  
Renal Function ◽  
Intensive Care ◽  
Peripheral Nerve ◽  
Continuous Infusion ◽  
Neuromuscular Blockade ◽  
Pediatric Intensive Care Unit ◽  
Pediatric Intensive Care ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator

Certain conditions may necessitate use of neuromuscular blocking agents (NMBAs) in children in the pediatric intensive care unit (PICU). Despite information concerning individual agents, there are limited studies comparing agents. I compare 4 of the more commonly used NMBAs: pancuronium, vecuronium, rocuronium, and atracurium. All agents were administered by bolus followed by a continuous infusion with the rate adjusted by use of a peripheral nerve stimulator to maintain one twitch of the train-of-four. Ten patients with normal hepatic and renal function were included in each group. The study period included the first 72 hours of neuromuscular blockade. All 4 agents were easily titrated by continuous infusion to maintain the desired level of blockade. Pancuronium infusion requirements varied from 0.03 to 0.12 mg/kg/hr, vecuronium requirements from 0.05 to 0.2 mg/kg/hr, rocuronium requirements from 0.5 to 1.9 mg/kg/hr, and atracurium requirements from 0.8 to 2.2 mg/kg/hr. No significant advantage of one agent over another was noted. The wide range of infusion requirements further stresses the need for close monitoring of the degree of neuromuscular blockade with a peripheral nerve stimulator. An additional 10 patients with abnormal hepatic/renal function received atracurium. The dose requirements were the same as in patients with normal end-organ function, ranging from 0.6 to 2.0 mg/kg/hr. In patients with abnormal hepatic or renal function, atracurium may be used without the need to alter the dose.

scholarly journals Novel technique for trialing peripheral nerve stimulation: ultrasonography-guided StimuCath trial

2017 ◽  
Vol 42 (3) ◽  
pp. E5 ◽  
Author(s):  
Chandan G. Reddy ◽  
Oliver E. Flouty ◽  
Marshall T. Holland ◽  
Leigh A. Rettenmaier ◽  
Mario Zanaty ◽  
...  
Keyword(s):  
Neuropathic Pain ◽  
Pain Relief ◽  
Peripheral Nerve ◽  
Nerve Stimulation ◽  
Relative Effectiveness ◽  
Peripheral Nerve Stimulation ◽  
Insurance Companies ◽  
Peripheral Nerve Stimulator ◽  
Vas Score

OBJECTIVE Peripheral nerve stimulation (PNS) has been used for the treatment of neuropathic pain for many decades. Despite the specific indications for PNS, clinicians often have difficulty screening for candidates likely to have a good or fair outcome. Given the expense of a permanent implant, most insurance companies will not pay for the implant without a successful PNS trial. And since PNS has only recently been approved by the US Food and Drug Administration, many insurance companies will not pay for a conventional trial of PNS. The objective of this study is to describe a short low-cost method for trialing and screening patients for peripheral nerve stimulator implantation. Additionally, this study demonstrates the long-term efficacy of PNS in the treatment of chronic neuropathic pain and the relative effectiveness of this novel screening method. METHODS The records of all patients who had undergone trialing and implantation of a PNS system for chronic refractory pain at the authors' institution over a 1-year period (August 1, 2012–July 31, 2013) were examined in this retrospective case series. The search revealed 17 patients, 13 who had undergone a novel in-office ultrasonography-guided StimuCath screening technique and 4 who had undergone a traditional week-long screening procedure. All 17 patients experienced a successful PNS trial and proceeded to permanent PNS system implantation. Patients were followed up for a mean duration of 3.0 years. Visual analog scale (VAS) pain scores were used to assess pain relief in the short-term (< 6 weeks), at 1 year, and at the last follow-up. Final outcome was also characterized as good, fair, poor, or bad. RESULTS Of these 17 patients, 10 were still using their stimulator at the last follow-up, with 8 of them obtaining good relief (classified as ≥ 50% pain relief, with an average 81% reduction in the VAS score) and 2 patients attaining fair relief (< 50% relief but still using stimulation therapy). Among the remaining 7 patients, the stimulator had been explanted in 4 and there had been no relief in 3. Excluding explanted cases, follow-up ranged from 14 to 46 months, with an average of 36 months. Patients with good or fair relief had experienced pain prior to implantation for an average of 5.1 years (range 1.8–15.2 years). A longer duration of pain trended toward a poorer outcome (bad outcome 7.6 years vs good outcome 4.1 years, p = 0.03). Seven (54%) of the 13 patients with the shorter trial experienced a good or fair outcome with an average 79% reduction in the VAS score; however, all 4 of the bad outcome cases came from this group. Three (75%) of the 4 patients with the longer trial experienced a good or fair outcome at the last follow-up, with an average 54% reduction in the VAS score. There was no difference between the trialing methods and the proportion of favorable (good or fair) outcomes (p = 0.71). CONCLUSIONS Short, ultrasonography-guided StimuCath trials were feasible in screening patients for permanent implantation of PNS, with efficacy similar to the traditional week-long screening noted at the 3-year follow-up.

scholarly journals Sacral Neuromodulation as a Treatment for Pudendal Neuralgia

2014 ◽  
Vol 5;17 (5;9) ◽  
pp. E645-E650 ◽  
Author(s):  
Assia Valovska
Keyword(s):  
Peripheral Nerve ◽  
Pelvic Pain ◽  
Nerve Stimulation ◽  
Pudendal Nerve ◽  
Peripheral Nerve Stimulation ◽  
Treatment Modalities ◽  
Pudendal Neuralgia ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Sacral Neurostimulation

Pudendal neuralgia is a debilitating pain syndrome, and finding long-lasting treatment modalities has been challenging in pain management. The pudendal nerve has sensory and motor functions, and influences autonomic functions. Thus, entrapment or damage of this nerve can have multiple serious implications. The constellation of symptoms which result from injury to this nerve is commonly referred to as pudendal neuralgia. When conservative therapy does not provide adequate pain relief and surgical procedures fail or are not viable options, central and peripheral nerve stimulation can be effective treatment modalities. More recent approaches to treatment include the use of peripheral nerve stimulation through the use of an electrical lead placed next to the pudendal nerve in the ischioanal fossa. Also, epidural stimulation of the conus medullaris and pulsed radiofrequency ablation of the pudendal nerve have been shown to be effective in small patient populations. We present the case of a 36-year-old woman who sustained pudendal nerve injury during a hysterectomy and subsequently developed intractable pelvic pain and pudendal neuralgia. Conservative treatment measures failed, but she obtained excellent results from peripheral nerve stimulator therapy. Permanent implantation consisted of 4 tined Interstim leads, individually placed into the bilateral S3 and S4 foramina. The patient has been followed for approximately 4 years since her procedure, demonstrating increased function as she is able to stand and sit for prolonged periods of time. She has returned to her usual daily activities, including horseback riding. This is the first reported case of transforminal sacral neurostimulation providing excellent relief of pudendal neuralgia related symptoms. Key words: Pudendal neuralgia, sacral neurostimulation, peripheral nerve stimulator, pelvic pain, nerve stimulation, interventional pain procedures, surgical management of pain

Peripheral Nerve Stimulation: A New Treatment for Meralgia Paresthetica

Pain Medicine ◽  
2020 ◽  
Author(s):  
Brendan Langford ◽  
William D Mauck
Keyword(s):  
Minimally Invasive ◽  
Peripheral Nerve ◽  
Nerve Stimulation ◽  
Peripheral Nerve Stimulation ◽  
Peripheral Nerve Stimulator ◽  
Meralgia Paresthetica ◽  
Device Implantation ◽  
Imaging Results ◽  
New Treatment ◽  
The Right

Abstract Background Meralgia paresthetica is a condition caused by entrapment of the lateral femoral cutaneous nerve that leads to paresthesia along the anterolateral portion of the thigh. Because of advancements in neuromodulation, peripheral nerve stimulation (PNS) has been considered a new treatment option for meralgia paresthetica. Newer PNS technology targets peripheral nerves directly yet in a minimally invasive manner. We report a case in which a PNS device provided more than 12 months of complete pain relief in a patient with meralgia paresthetica and helped the patient avoid a neurolysis procedure. Case Presentation A 57-year-old male presented to clinic with a 6-year history of “painful numbness [and] burning” along the right lateral thigh. He rated his pain as 8 out of 10, which decreased to a rating of 2 out of 10 with the use of gabapentin, but unwanted side effects motivated him to seek alternative treatment. On the basis of his history, physical exam, and imaging results, he was diagnosed with meralgia paresthetica. He was offered neurolysis; however, after seeing a pain specialist, he agreed to the implantation of a SPRINT peripheral nerve stimulator. After the implantation procedure, his pain reduced to 0 out of 10, and his quality of life improved, with better sleep and less somnolence. The device was removed after 60 days, as planned. He continued to have complete resolution of pain at 12 months after the date of device implantation. Conclusion With recent advancements, PNS can be used to treat meralgia paresthetica in an effective yet minimally invasive manner. As newer PNS technology becomes more familiar to physicians and pain specialists, it is likely to be used as a mainstay treatment for meralgia paresthetica.

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