U.S. patent number 3,565,080 [Application Number 04/662,249] was granted by the patent office on 1971-02-23 for neuromuscular block monitoring apparatus.
This patent grant is currently assigned to Burroughs Wellcome & Co. (U.S.A.) Inc., Tuckahoe, NY. Invention is credited to Walter S. Ide, William H. Nickerson.
United States Patent |
3,565,080 |
|
February 23, 1971 |
**Please see images for:
( Certificate of Correction ) ** |
NEUROMUSCULAR BLOCK MONITORING APPARATUS
Abstract
A neuromuscular block monitoring device, comprising a battery,
an oscillator circuit to translate the power supplied by said
battery into electrical impulses and having a variable impedance
and switch arranged to set the frequency at either a twitching or a
tetanus frequency, a potentiometer coupled to said oscillator
circuit to control the amplitude of said impulses to form an
electrical signal having the effect of stimulating the ulnar nerve
and/or the nerve motor point muscle junction of a limb of the body,
and a pair of spaced electrodes to apply the output of the
potentiometer to the ulnar nerve and/or the nerve motor point
muscle junction of a limb of the body. There is also provided a
splint having a strain gage mounted thereon and a display device
for displaying the electrical output from said strain gage, the
splint being adapted to fit on the thumb of a patient, and said
strain gage responsive to the movement of the splint resulting from
the application of electrical impulses to the patient.
Inventors: |
Walter S. Ide (Eastchester,
NY), William H. Nickerson (Tuckahoe, NY) |
Assignee: |
Burroughs Wellcome & Co.
(U.S.A.) Inc., Tuckahoe, NY (N/A)
|
Family
ID: |
27024682 |
Appl.
No.: |
04/662,249 |
Filed: |
July 19, 1967 |
Current U.S.
Class: |
607/48; 600/595;
331/111; 331/179; 607/74 |
Current CPC
Class: |
A61B
5/1106 (20130101); A61N 1/36017 (20130101); A61B
5/05 (20130101); A61N 1/36003 (20130101); A61B
5/6826 (20130101); A61B 2505/05 (20130101); A61N
1/36021 (20130101) |
Current International
Class: |
A61B
5/05 (20060101); A61B 5/11 (20060101); A61N
1/32 (20060101); A61N 1/34 (20060101); A61N
1/36 (20060101); H05g 0/00 () |
Field of
Search: |
;128/2.1,422 |
References Cited
[Referenced By]
U.S. Patent Documents
Primary Examiner: Delbert B. Lowe
Attorney, Agent or Firm: Dike, Thompson & Bronstein
Claims
1. A neuromuscular block monitoring device comprising a battery, an
oscillator circuit to translate the power supplied by said battery
into electrical impulses, said oscillator circuit including first
circuit elements to produce said electrical impulses at a twitching
frequency and second circiut elements to produce said electrical
impulses at a tetanus frequency, a switch arranged to select either
of said first and second circuit elements to provide either one or
the other of said frequencies, means coupled to said oscillator
circuit to control the amplitude of said impulses to form an
electrical signal having the effect of stimulating the ulnar nerve
and/or the nerve motor point muscle junction of a limb of the body,
and a pair of spaced electrodes to apply the output of the control
means to the ulnar nerve and/or the nerve motor point muscle
junction of a limb of the body.
2. A device in accordance with claim 1, wherein said control means
includes a transformer for stepping up the voltage of the
electrical impulses to a voltage level required for
stimulation.
3. A neuromuscular block monitoring device, comprising a battery, a
transistorized relaxation oscillator circuit to translate the power
supplied by said battery into electrical impulses, said oscillator
including a first amplifying means, a second amplifying means, a
capacitor coupled between said first and second means, and first
and second circuit means coupled at one end intermediate said first
amplifying means and said capacitor and at the other end to said
battery to set the frequency of said impulses at either a twitching
or a tetanus frequency, said circuit means including a switch for
selecting one or the other of said circuit means coupled to said
oscillator circuit to control the voltage, current and wave shape
of said impulses to form an electrical signal having the effect of
stimulating the ulnar nerve and/or the nerve motor point muscle
junction of a limb of the body, and a pair of spaced electrodes to
apply the output of the control means to the ulnar nerve and/or the
nerve motor point muscle junction of a limb of the body.
4. A neuromuscular block monitoring device, comprising a battery, a
transistorized relaxation oscillator circuit to translate the power
supplied by said battery into electrical impulses, said oscillator
including a first transistor amplifying means of a first
conductivity type, a second transistor amplifying means of an
opposite conductivity type, a capacitor coupled between said first
and second amplifying means, and a variable resistance means to
provide only two different values of resistance, said variable
resistance means coupled between said capacitor and said first
means to establish the frequency of said impulses at a twitching
frequency or at a tetanus frequency, and a switch arranged to
select either one or the other of said values of resistance to
select one or the other of said frequencies, a transformer coupled
to said first and second means to step up the voltage of said
impulses from said oscillator to a level such as to have an effect
of stimulating the ulnar nerve and/or the nerve motor point muscle
junction of a limb of the body, and a pair of spaced electrodes for
applying the electrical impulses to the body of a patient.
5. An ulnar nerve and/or nerve motor point muscle junction of a
limb of a body stimulating device, comprising in combination a
source of direct current energy, a first transistor of a first
conductivity type having emitter, base and collector electrodes,
said emitter of said first transistor coupled to the source of
energy, a second transistor of an opposite conductivity type having
emitter, base and collector electrodes, said collector of said
first transistor coupled to the base of the second transistor, a
capacitor coupled to the base of said first transistor and to the
collector of said second transistor, and the emitter of said second
transistor coupled to said source of energy, a voltage step-up
transformer coupled to the emitter of said first transistor and to
the collector of said second transistor, means coupled to said
transformer for applying the output of said transformer to the
ulnar nerve and/or the nerve motor point muscle junction of a limb,
and a variable resistance means coupled at one end intermediate the
capacitor and the base of the first transistor and at the other end
to the source of energy to set the frequency of the device to
either a twitching frequency or a tetanus frequency, and a switch
arranged to vary said resistance means to select either one or the
other of said frequencies.
6. A device according to claim 5, wherein said variable resistance
means comprises a first resistor and a second resistor and wherein
the switch is connected to select either one or the other of said
resistors.
7. A device according to claim 6, wherein said means coupled to
said transformer includes a pair of electrodes and a gas tube
indicating means coupled across said electrodes.
8. A neuromuscular block monitoring device for providing two
different frequency signals to the ulnar nerve and/or the nerve
motor point muscle junction of a limb of the body and for
monitoring the effect of said signals, said device comprising in
combination, a source of direct current energy, an oscillator
circuit to translate the power supplied from said energy source
into electrical impulses and having means to set the frequency of
said impulses only at a twitching frequency rate and or at a
tetanus frequency rate, means coupled to said oscillator circuit to
control the amplitude of said impulses to form an electrical signal
having the effect of stimulating the ulnar nerve and/or the nerve
motor point muscle junction of a limb of the body, a pair of spaced
electrodes suitable for applying said electrical impulses to the
ulnar nerve and/or the nerve motor point muscle junction of a limb
of the body, a switch arranged to adjust said frequency setting
means to select one or the other of said a detection device adapted
to be positioned upon a limb of the body for detecting the degree
of flexing of the limb in response to said electrical impulses.
9. A device according to claim 8, wherein said detection device
comprises a splint adapted to be mounted on a body limb and a
strain gauge supported by said splint to detect bending of said
splint.
10. A device according to claim 9, including a display device
coupled to said strain gauge for detecting the change in current
passing through the gauge.
Description
This invention relates to a monitoring device for applying
electrical stimuli to a patient to determine the type of
neuromuscular block that exists within the patient.
Anesthesiologists and others have determined that the
administration of muscle relaxant drugs, such as succinylcholine,
dimethyl tubocurare and hexacarbacholine, produce depolarizing and
nondepolarizing neuromuscular blocks in patients. During the course
of surgery and after the completion of surgery, it is sometimes
required that the patient who has been administered a muscle
relaxant drug be stimulated by the administration of an antagonist
drug to counteract the effects of the muscle relaxant drug.
Commonly used antagonist drugs are physostigmine, eserine and
edrophonium. In some instances instead of the antagonist
stimulating the patient a continuation of the relaxation of the
patient for prolonged periods has occurred. The prolonged period of
relaxation has tended to be greater than that which would
ordinarily occur without the administration of the antagonist. It
is believed that this continuation of relaxation is related to the
type of neuromuscular block existing in the patient.
In view of the foregoing, a new and improved apparatus for
determining the correct time to administer muscle antagonist drugs
was required.
Accordingly, it is an object of this invention to provide a new and
improved apparatus for providing electrical stimuli to
differentiate between depolarizing and nondepolarizing
neuromuscular blocks due to the action of certain muscle relaxant
drugs.
It is an additional object of this invention to provide a new and
improved and simplified monitoring apparatus for stimulating the
patient and to determine the type of neuromuscular block exhibited
by the patient.
Other objects of the invention will in part be obvious and will in
part appear hereinafter.
For a fuller understanding of the nature and objects of the
invention, reference should be had to the following detailed
description taken in conjunction with the accompanying drawings, in
which:
FIG. 1 illustrates schematically a transistorized, neuromuscular
block monitoring device;
FIG. 2 is an isometric representation of a splint for mounting on a
patient to detect response of a patient to electrical stimuli;
FIG. 3a is a graph illustrating the sequential electrical stimuli
applied to the patient in accordance with this invention;
FIG. 3b is a graph showing the resultant response of a patient to
the electrical stimuli as a result of a nondepolarizing block
affecting the nerves of the patient;
FIG. 3c is a graph illustrating a depolarizing block of a patient
in response to electrical stimuli; and
FIG. 4 shows one of the electrodes.
Referring now to FIGS. 1 and 2, a monitor oscillator or pulse
generator is shown at 20 for generating an electrical stimulus in
accordance with this invention. The pulse generator 20 includes a
relaxation oscillator circuit having an NPN transistor 21 with an
emitter electrode 22, a base electrode 23 and a collector electrode
24, and a PNP transistor 25 with an emitter electrode 26, a base
electrode 27 and a collector electrode 28. The collector 24 of
transistor 21 is coupled to the base 27 of transistor 25. Connected
between the base electrode 23 of transistor 21 and collector
electrode 28 of transistor 25 is a capacitor 30. Coupled
intermediate the base 23 of transistor 21 and capacitor 30 is a
variable resistance network for varying the frequency of the
oscillator. The resistance network includes a switch 31 and two
resistors 33 and 34. Switch 31 can be connected to either of
resistors 33 and 34 to control the frequency of the oscillator. A
source of direct current energy 35, such as a battery, is coupled
at its positive terminal to emitter 26 of transistor 25 and to the
other end of resistors 33 and 34. A switch 36 is provided in the
line to place the DC energy source 35 in the circuit. One end of
the switch is coupled to the emitter 22 and the other end of the
switch is coupled to the battery 35. A voltage step-up transformer
is generally shown at 37. Transformer 37 has its primary winding 38
between the collector 28 of transistor 25 and emitter 22 of
transistor 21.
A resistor 40 coupled in series with capacitor 30 and a capacitor
41 connected across winding 38 are preferably included to decrease
extraneous voltages in the circuit. The secondary winding 39 of
transformer 37 is coupled across a resistor 45 and a gas tube 46.
The resistor 45 and gas tube 46 are in parallel with a variable
resistor 47. The gas tube 46 indicates when the device 20 is
providing a signal of a predetermined voltage level. Coupled in
parallel with the top portion of the variable resistor 47 is a
first electrode 50 and a second electrode 51 connected to resistor
47 through a resistor 49. The electrodes may be surface-type
electrodes which are suitable for applying electrical stimuli to
the arm 52 of a patient, but, preferably, needle-type electrodes
are utilized which may be of the standard 25 gauge metal needle
type.
The electrodes are placed on the arm or the legs of a patient in a
well-known manner such that the ulnar nerve and/or the nerve motor
point muscle function is stimulated by the signal provided from the
oscillator 20. The oscillator 20 operates as follows: upon closure
of switch 36 and the connection of switch 31 to one of resistors 33
and 34, the circuit 20 will begin to oscillate. Assume, for
example, that switch 31 is coupled to resistor 34. The value of
resistor 34 is selected such that the relaxation oscillator 20 will
oscillate at a frequency somewhat above zero impulses per second
but below 30 impulses per second. This is commonly termed as the
frequency which will produce twitching of a digital member of a
limb of a patient, as for example, a finger or a toe. This will
henceforth be defined as the twitching frequency. The exact impulse
frequency range to produce twitching will vary with the patient,
and therefore a frequency of 20 impulses per second is preferred.
With switch 31 coupled to the resistor 34, a voltage will be
applied to transistor base 23 in such a direction as to cause
transistor 21 to turn on. The turning on of transistor 21 causes
transistor 25 to turn on. This causes a current to flow within the
primary 38 of the transformer 37. Transistors 21 and 25 will
continue to conduct as long as the transformer 37 is unsaturated.
After a period of time, transformer 37 becomes saturated and a
voltage across secondary 39 rapidly reverses according to Lenze's
law. This causes a potential to be applied to base 23 of transistor
21 of such a polarity as to turn off transistor 21. This, in turn,
turns off transistor 25. Capacitor 30 which charged in the reverse
direction to cut off transistor 21 due to the saturation of
transformer 37 then gradually discharges until the potential at the
base electrode 23 of transistor 21 once again becomes of the proper
polarity to turn on transistor 21 to restart the cycle.
The resultant output waveform of the oscillator is shown across
electrodes 50 and 51. It is to be noted that the topmost portion of
the turn-on cycle is slightly clipped due to the presence of gas
tube 46. This gas tube flickering indicates to the observer that
the impulse generating device 20 is operating. Assume now that the
switch 31 is coupled to resistor 33. Resistor 33 is selected such
that the impulse frequency rate will be on the order of between
35-- 120 impulses per second. In the preferred embodiment, 50
impulses per second was chosen. This range of frequencies is
generally referred to as the tetanus frequency rate. The tetanus
frequency reaction is observed by noticing the involuntary closing
of a finger or a toe of a patient. The exact values for the
frequency rate for both tetanus and twitching are generally a
function of the patient and it is, therefore, to be understood that
the ranges described are only illustrative and are not
limiting.
Although it is to be understood that many modifications may be made
to the above circuit, the following circuit values may be utilized
to provide an impulse generating device suitable for generating
both tetanus and twitching frequency impulses. Transistor 21 -2 N
335 Transistor 25 -2 N 116 Capacitor 30 -20 microfarads Resistor 33
-5.1 K. ohms Resistor 34 -330 K ohms Battery 35 -3 volts
Transformer 37 -voltage step-up of approximately 30 Resistor 46
-100 ohms Capacitor 41 -15 microfarads Gas tube 46 -NE 51 H
The device 20 is capable of providing approximately a 90 volts rms
output signal across electrodes 50 and 51 when used with a 3 volt
battery as the energy source for the circuit. This circuit is
particularly usable during the administration of an anesthesia and
during operations because it is explosion-proof due to the low
value of currents and voltages utilized. To detect the response to
the electrical stimuli provided across the electrodes 50 and 51, a
digital member such as a thumb 53 of arm 52 may be observed. This
may be accomplished without the use of any of the auxiliary
detecting and monitoring devices shown in FIG. 1. On applying a
twitching frequency signal to the electrodes 50 and 51, the
twitching signal will produce a periodic contraction of the thumb
53. The application of a tetanus signal will draw the thumb closed.
Thus, the twitching and tetanus signals may be observed by watching
the motion of a finger or the toes of a patient.
The use of this information will be described at a later time in
this specification.
Although the reaction of the patient to the application of tetanus
and twitching muscle electrical stimuli may be observed without the
use of electrical equipment, it is preferred that some type of
electrical monitoring device be utilized to better assist in the
recognition of the patient's response.
By the use of a splint, generally shown at 55, which is suitable
for mounting on thumb 53, a device for indicating and displaying
the response of the patient may be provided. The splint 55
comprises resilient flat portions 56 and 57 having a bend 58
therebetween. Positioned at one end of resilient member 57 is ring
61 suitable for surrounding the tip portion of the patient's thumb
53. Attached to the other member 56 of splint 55 are clamps 62 and
63. These clamps are shaped like rings, but have cutout portions
for permitting the clamps to extend over the upper portion of the
patient's thumb 53 above the joint. To record the bending of the
splint 55, a suitable strain gauge 70 is mounted thereon in a
position to record the pressure produced by the thumb against the
splint. A strain gauge, such as the type SR-4 available from
Baldwin-Lima Hamilton Corp. Waltham, Mass., may be used. Other
types of strain or stress transducers such as strain sensitive
diodes and transistors may also be utilized as well as
piezo-electric devices. Strain gauge 70 is connected to a suitable
circuit comprising resistor 72 and battery 73 for providing a
current through the strain gauge. The variations of the current
flow through the strain gauge, due to a change in resistance of the
strain gauge because of flexing of thumb 53, can then be monitored
on a meter such as a voltage meter or an oscilloscope 75. Further,
other display devices may be utilized, for example, electrical-type
brush recorders.
Referring now to FIGS. 3a, 3b and 3c for a description of the
method, assume that the patient has been injected with a syringe 80
carrying muscle relaxant drugs such as succinylcholine, or dimethyl
tubocurare. Further assume that an anesthesiologist deems it
necessary to introduce a muscle antagonistic drug to counteract the
effects of the muscle relaxant drug. To determine the proper time
to inject the muscle relaxant antagonist, for example, by the use
of a syringe 80 as shown in FIG. 1, the neuromuscular block
monitoring device 20 is turned on and set to provide electrical
stimuli at a twitching frequency. The electrical stimuli are
applied at the ulnar nerve at the wrist or elbow or at a motor
junction point. It is preferable to use needle electrodes, which
may be inserted into the arm of the patient, rather than surface
electrodes which tend to cause slight damage to the skin due to
irritation by the electrodes after long periods of time as, for
example, four hours. FIG. 3a shows the application of the
electrical stimuli at a twitching frequency of about 20 impulses
per second, although variations may exist due to the particular
patient. The response of the patient is shown in FIGS. 3b and 3c
and may be observed on the oscilloscope 75. The spikes in FIGS. 3b
and 3c indicate that the patient has reacted to the stimuli such as
to produce a twitching of the digital member. This can also be
observed by watching the digital member itself. After a period of
time as, for example, 20 seconds, monitor oscillating device 20 is
then set to provide electrical stimuli at a tetanus frequency. In
the preferred embodiment, the monitor is set to provide 50 impulses
per second, which is shown in FIG, 3a. The application of
electrical impulses at tetanus frequency produces a clamping
response of the patient's hand or toes such that the hand or toes
tend to close during the application of the tetanus stimuli. This
may be observed by noticing the square wave representation in FIGS.
3b and 3c or, again, by watching the digital member.
In the preferred method, the tetanus frequency is held for
approximately 2 or to 3 seconds although many variations may be
possible depending on the response of the patient. To determine the
nature of the neuromuscular block, the monitor 20 is switched to
provide electrical stimuli at the twitching frequency once again.
FIG. 3b shows the response of the patient's digital members to the
reapplication of the twitch frequency when there exists a
nondepolarizing neuromuscular block within the patient. This figure
further shows what is generally termed post-tetanic facilitation
and which is represented by a sudden increase in the amplitude of
the twitch response. This has been determined to be the response by
the patient to a twitch frequency after the application of tetanus
frequency electrical stimuli when there exists a nondepolarizing
block within the patient. In FIG. 3c there is shown the response of
the patient to the twitch electrical frequency stimuli when there
exists a depolarizing neuromuscular block within the patient. In
this figure it may be seen that there is no post-tetanic
facilitation which is indicative of a depolarizing neuromuscular
block.
It has been determined that a muscle antagonist drug should be
introduced into the patient only when there exists a
nondepolarizing block such as shown by the post-tetanic
facilitation of FIG. 3b. The introduction of an antagonist drug
when there is a depolarizing block such as shown in FIG. 3c
potentiates the depolarizing block rather than counteracting the
muscle relaxant drug. If the drug is administered when there is a
depolarizing block, the patient generally requires a longer period
of time to overcome the relaxant drug than would normally be
required if the neuromuscular block were permitted to switch from a
depolarizing to a nondepolarizing neuromuscular block by itself.
This will generally occur after a predetermined time interval has
elapsed to permit the muscle relaxant drug to lose at least some of
its potency. It should be understood that a sensor strapped to an
arm or leg of the patient could also be utilized, although a sensor
strapped to a digital member is preferred.
It will thus be seen that the objects set forth above, a,pmg those
made apparent from the preceding description, are efficiently
attained and, since certain changes may be made in the above
devices without departing from the scope of the invention, it is
intended that all matter contained in the above description or
shown in the accompanying drawings shall be interpreted as
illustrative and not in a limiting sense.
It is also to be understood that the following claims are intended
to cover all of the generic and specific features of the invention
herein described, and all statements of the scope of the invention
which, as a matter of language, might be said to fall
therebetween.
* * * * *