© Copyright 2010 Xavant Technology

Neuro Physiology  Organization of the Nervous System Neuro Physiology  Organization of the Nervous System Central Nervous System Peripheral Nervous System Brains Spinal Cord Brains Spinal Cord Sensory Division Motor 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 2010 Xavant Technology (Human Anatomy and Physiology – Marieb Third Edition 1995)

Neuro Physiology  Membrane Potentials Neuro Physiology  Membrane Potentials Resting Potential = -70mV © Copyright 2010 Xavant Technology (Human Anatomy and Physiology – Marieb Third Edition 1995)

Neuro Physiology  Gated Channels Neuro Physiology  Gated Channels © Copyright 2010 Xavant 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 2010 Xavant Technology (Human Anatomy and Physiology – Marieb Third Edition 1995)

Now with NMBA Monitoring © Copyright 2010 Xavant Technology

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 2010 Xavant 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 2010 Xavant Technology

Pulse Width (ms) Total Charge (uC) Current Amplitude (mA) Nerve Stimulators  How? Nerve Stimulators  How? Coulomb’s Law Charge (C) = Current (A) x Time (s) © Copyright 2010 Xavant Technology

Normal Impedance Impedance too high Nerve Stimulators  How? Nerve Stimulators  How? Ohm’s Law Voltage (V) = Current (A) x Resistance (Ω) © Copyright 2010 Xavant 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 2010 Xavant 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 2010 Xavant 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 2010 Xavant 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 2010 Xavant Technology

STIMPOD NMS450  NMBA Monitoring Stimulation Mode STIMPOD NMS450  NMBA Monitoring Stimulation Mode Train-of-Four (TOF) © Copyright 2010 Xavant 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 4 th pulse compared to the reaction to the 1 st pulse i.e. 70% TOF count indicates the number of reactions if there is no 4 th 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 4 th pulse compared to the reaction to the 1 st pulse i.e. 70% TOF count indicates the number of reactions if there is no 4 th 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 2010 Xavant Technology

STIMPOD NMS450  NMBA Monitoring Stimulation Mode STIMPOD NMS450  NMBA Monitoring Stimulation Mode Double Burst (DB) © Copyright 2010 Xavant 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 2 nd burst compared to the reaction to the 1 st 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 2 nd burst compared to the reaction to the 1 st 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 2010 Xavant Technology

STIMPOD NMS450  NMBA Monitoring Stimulation Mode STIMPOD NMS450  NMBA Monitoring Stimulation Mode Post Tetanic Count (PTC) © Copyright 2010 Xavant 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 1 st 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 1 st response on the TOF should appear soon © Copyright 2010 Xavant Technology

STIMPOD NMS450  NMBA Monitoring Stimulation Mode STIMPOD NMS450  NMBA Monitoring Stimulation Mode Twitch (TWI) © Copyright 2010 Xavant 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 2010 Xavant Technology

STIMPOD NMS450  NMBA Monitoring Stimulation Mode STIMPOD NMS450  NMBA Monitoring Stimulation Mode Tetanus (TET) © Copyright 2010 Xavant 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 2010 Xavant Technology

STIMPOD NMS410/450  Components STIMPOD NMS410/450  Components © Copyright 2010 Xavant Technology

STIMPOD NMS410/450  Screen Diagnostics STIMPOD NMS410/450  Screen Diagnostics © Copyright 2010 Xavant 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 II 22.5% Market Share (2009 Dollars) $86,803 sold (2009) 30.7% Market Share (2009 Units) 157 units sold (2009) ASP: $553 (2009) Life-Tech Tracer III 2.5% Market Share (2009 Dollars) $9,757 sold (2009) 2.9% Market Share (2009 Units) 15 units sold (2009) ASP: $ Stimulator Market Summary © Copyright 2010 Xavant 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 2010 Xavant Technology

BBRaun HNS12 STIMPOD NMS410 STIMPOD NMS450 SterilityOffers a remote control covered for use under sterile gloves Unit can be covered by sterile sheet Device attachmentNo attachment mechanism Special clip allows for attachment to drapes Current RangeNerve Locating 0.0 – 5.0 mA Nerve Mapping 0.0 – 5.0 mA NMBA Monitoring None Nerve Locating 0.0 – 5.0 mA Nerve mapping 0 – 20 mA NMBA Monitoring None Nerve Locating 0.0 – 5.0 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mA Pulse Width0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms Nerve MappingYes - 5mA maximum current Yes - 20mA maximum current Auto Sensing Technology NoYes Combination Cable Auto Sensing Yes Combination cable Auto Sensing Show Current Delivered Yes Yes – Actual waveform delivered showing exact charge NMBA MonitoringNoNo Yes - 3 dimensional accelerometer STIMPOD NMS410/450  Comparison Study STIMPOD NMS410/450  Comparison Study © Copyright 2010 Xavant 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 2010 Xavant 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 2010 Xavant 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 2010 Xavant 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 2010 Xavant 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 2010 Xavant Technology

LifeTech EzStim II STIMPOD NMS410 STIMPOD NMS450 SterilityNone Unit can be covered by sterile sheet Device attachmentIV Pole Attachment Special clip allows for attachment to drapes Current RangeNerve Locating 0.05 – 5.00 mA No Nerve Mapping NMBA Monitor 0 – 80 mA Nerve Locating 0.0 – 5.0 mA Nerve mapping 0 – 20 mA NMBA Monitoring None Nerve Locating 0.0 – 5.0 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mA Pulse Width0.1ms, 0.2ms 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms Nerve MappingNo Yes 20mA maximum current Auto Sensing Technology NoYes Combination Cable Auto Sensing Yes Combination cable Auto Sensing Show Current Delivered No Yes – Actual waveform delivered showing exact charge NMBA MonitoringYes - No AccelerometerNo Yes - 3 dimensional accelerometer STIMPOD NMS410/450  Comparison Study STIMPOD NMS410/450  Comparison Study © Copyright 2010 Xavant Technology

Pajunk MultiStim SWITCH Source: 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:

Pajunk MultiStim SENSOR Source: 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: 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 Plex The 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 mA, adjustable in 0,01 mA steps.

Pajunk MultiStim Vario STIMPOD NMS410 STIMPOD NMS450 SterilityNone Unit can be covered by sterile sheet Device attachmentNo attachment mechanism Special clip allows for attachment to drapes Current RangeNerve Locating 0.0 – 5.0 mA Nerve Mapping 0 – 60 mA* NMBA Monitoring 0 – 60 mA * Need Switchbox Nerve Locating 0.0 – 5.0 mA Nerve mapping 0 – 20 mA NMBA Monitoring None Nerve Locating 0.0 – 5.0 mA Nerve Mapping 0 – 20 mA NMBA Monitoring 0 – 80 mA Pulse Width0.1ms, 0.3ms, 0.5ms, 1ms 0.05ms, 0.1ms, 0.3ms, 0.5ms, 1ms Nerve MappingYes – Need “Switchbox” 60mA maximum current Yes - 20mA maximum current Auto Sensing Technology NoYes Combination Cable Auto Sensing Yes Combination cable Auto Sensing Show Current Delivered Yes Yes – Actual waveform delivered showing exact charge NMBA MonitoringYes - No AccelerometerNo Yes - 3 dimensional accelerometer STIMPOD NMS410/450  Comparison Study STIMPOD NMS410/450  Comparison Study © Copyright 2010 Xavant Technology

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