Nursing Service Guidelines

General

Title: USE OF PERIPHERAL NERVE STIMULATOR TO MONITOR NEUROMUSCULAR

BLOCKADE (NMBA).
Responsibility: RN's caring for patients receiving neuromuscular blocking agents
Equipment: 1. Peripheral Nerve Stimulator
2. Two gelled electrode pads (such as those used for external cardiac monitoring)

Standard of Use of peripheral nerve stimulator (PNS) by train-of-four (TOF) method to determine depth
Care: of paralysis of patients receiving non-depolarizing neuromuscular blocking agents.

Procedure Point of Emphasis

1. Setting up the Peripheral Nerve Stimulator: The optimal placement of the electrodes is the ulnar
Apply the two electrodes either at the ulnar nerve nerve. However, the conduction of the impulses is
area, the facial nerve area or the posterior tibial affected by wounds, edema and invasive lines, and
nerve area. (Please see pictures below to verify hair, therefore, if any of these are present the facial
proper placement.) nerve or the posterior tibial nerve should be used
instead.
Ulnar nerve area placement of electrodes:
Place the distal electrode on the skin at the flexor
crease on the ulnar surface of the wrist. Place
the second electrode approximately 1-2 cm. proximal
to the first, parallel to the flexor carpi ulnaris tendon.

Facial nerve area placement of electrodes:

Place one electrode on the face at the outer canthus
of the eye and the second electrode approximately 2
cm below, parallel with the tragus of the ear.

Posterior tibial nerve placement of electrodes:

Place one electrode approximately 2 cm from the
posterior to the medial malleolus in the foot. Place
the second electrode approximately 2 cm above the
first electrode.

NOTE: It is important to carefully place the

electrodes, to avoid direct stimulation of the
muscle rather than the nerve. If the electrodes
are placed on the muscle, it is impossible to
accurately assess the effect of the NMBA.
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Practice Guidelines Points of Emphasis

Plug in the lead wires to the nerve stimulator, Ulnar Nerve Placement: Connect the negative
attaching the negative (black) and positive (red) (black) lead to the distal electrode over the crease of
leads to the black and red connection sites. the palmer aspect of the wrist and the positive (red)
lead to the proximal electrode.

Facial Nerve Placement: Connect the negative

(black) lead to the distal electrode at the tragus of the
ear and the positive (red) lead to the proximal
electrode at the outer canthus of the eye.

Posterior Tibial Nerve Placement: Connect the

negative (black) lead to the distal electrode 2 cm
posterior to the medial malleolus in the foot.
Connect the positive (red) lead to the proximal
electrode 2 cm above the medial malleolus.
Turn on the PNS and select a low mA (10 to 20 Excessive amount of mA can lead to over stimulation
mA is typical). and repetitive nerve firing.
b. Depress the TOF button and observe and count Finger movements are a result of muscle stimulation,
the number of twitches of the thumb (do not not nerve stimulation. In a person not receiving
count finger movements, only the thumb), the NMBA therapy, a TOF stimulus, produces four serial
number of twitches of the muscle above the thumb adductions. In a person receiving NMBA
eyebrow or the number of twitches of the great therapy, the twitches gradually fade. For example,
toe. may see only 2 twitches in a person receiving
NMBA therapy.

Four electrical stimuli are given at 0.5 second

intervals.

The set of four stimuli should not be repeated more

frequently than every 20 seconds, otherwise over
stimulation can occur.
2. Determining the Supramaximal Stimulation If there is no increase in intensity of the muscle
(SMS). twitch when the mA is increased, the SMS is the
a. Increase the mA in increments of 10, until level at which four vigorous twitches was observed.
four twitches are observed. For example, if a strong response was observed at
b. Note the mA that corresponds to four vigorous 20mA, raise the current to 30 mA. If there is no
twitches. Administer one to two more TOFs. increase in intensity of the twitch, the SMS is 20mA.
If there is an additional increase in twitch intensity,
raise it to 40. If the intensity shows no further
increase, the SMS is 30 mA.
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Practice Guidelines Points of Emphasis

3. Determining the TOF response during NMBA

infusion.
a. Assess electrode condition and placement for
quality.
b. Retest the TOF 10 to 15 minutes after a bolus Evaluates the level of blockade provided.
dose and/or continuous infusion of NMBA is
given/initiated/changed.
c. If more than one or two twitches occur and Signifies that less than 85% to 90% of receptors are
neuromuscular blockade is unsatisfactory for blocked.
clinical goals, increase the infusion rate as
prescribed or according to hospital protocol
and retest in 10 to 15 minutes.
d. Retest every 4 to 8 hours after clinically stable Evaluates the level of blockade and avoids under-
and a satisfactory level of blockade is and overestimation of blockade.
achieved.
4. Troubleshooting when there is zero twitches.
a. Change electrodes. Dry electrode gel or poor contact effects conduction
b. Check lead connections and PNS for
mechanical failure (i.e. change the battery)
c. Increase the stimulating current.
d. Retest another nerve (the other ulnar nerve or
facial or posterior tibial nerves).
e. If there are no other explanations for a zero Excessive neuromuscular blockade produces absence
response, check the NMBA rate infusion dose of twitch response. The desired goal is 1-2 brisk
and concentration. Reduce the infusion rate twitches, as this represents 85-90% receptor
as needed. blockade. Adjust infusion rate of NMBA based upon
clinical indicators and TOF testing in order to obtain
the 1-2 twitches. Maintaining a receptor block of
greater than 90% has been linked to long-term
complications such as muscle weakness, prolonged
paralysis and difficulty weaning from the ventilator.
In addition, longer hospital stays result.
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Practice Guidelines Points of Emphasis

5. Patient monitoring and care issues

a. Cleanse and dry the skin before applying the Improves contact and adhesion of electrode.
electrodes.
b. Change the electrodes whenever they are loose
or when gel becomes dry.
c. Select the most accessible site with the smallest
degree of edema, with no wounds, catheters, or
dressings that impede accurate electrode
placement over the selected nerve.
d. Never use the “Single Twitch”, “Tetany” or These are less accurate and can cause severe
“Double Burst” settings if available on the discomfort for the patient.
PNS.
e. The patient may demonstrate subtle movement Clinical decisions should never be made based upon
of the extremities with an acceptable TOF one parameter, such as the TOF testing. Assessment
response. of oxygenation and ventilation, neurological
function, tissue perfusion, etc. must be used to
f. Micro shock hazard may be a risk to patients
evaluate before deciding to increase the rate of
with external pacing catheters. Extreme
NMBA infusion.
caution must be used to prevent the PNS lead
wires from contacting the pacing catheter or
pacing lead wires.
g. Perform TOF testing every 4-8 hours during
NMBA therapy once stable. For bolus therapy,
perform TOF testing before every dose and
NMBA drugs do not provide any sedating or
every 15 minutes after every dose.
analgesic effects.
h. If using NMBA therapy, ALWAYS provide
the patient with adequate sedation and
analgesia.

Resource Person: Tricia Yates, MSN, RN, FNP-C, CCRN

Reviewed by: Nursing Policy & Procedure Committee 9/2019
Approved: April, 1993
Reviewed: 11/95, 8/99, 1/01, 4/05, 7/2016, 9/2019
Revised: 8/02, 7/2008, 3/2009
Reviewed by Policy & Standard Committee
References: Whetstone Foster, J. G. (2005). Peripheral Nerve Stimulators. In D. J. Lynn-McHale & K. K. Carlson (Eds.), AACN
Procedure Manual for Critical Care (pp.837-844). Philadelphia, PA: Elsevier Saunders
Ballard, N., Robley, L., Barrett, D., Fraser, D>, Mendoza, I. (2006). Patients’ recollections of therapeutic paralysis
in the Intensive Care Unit [electronic version] American Journal of Critical Care 15(1), 86-95.