When do you need paralysis?

[FiO2@21]

Had a femoral nailing on an 11 year old the other week. Dropped an LMA in. I usually ask the surgeon if that's fine, but got used to that being fine for most of the orthopedic surgeons I worked with in the past.

Halfway through the case, he asks me if the patient is "relaxed". He obviously wasn't, so I had to choose between paralyzing with an LMA or intubating mid case. Wasn't fun.

Are there factors such as anatomic, patient-related, time-since-fracture, etc that require paralysis from a surgical standpoint for these cases? I've had this come up with knee manipulations, closed reductions across different age and size patients.

I always ask to avoid awkward moments intraop, but it would be helpful for me to know when/why. Not trying to sandbag the surgeon, that ultimately keeps me in the room longer than I want to be.

Are you just looking for guaranteed immobility?

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[DrMcLovin]

Most commonly it will be for fractures and dislocations. The surrounding muscles are pulling on the fracture fragments acting as a deforming force.

With paralysis it makes it easier to line them back up for fixation.

 

[DarkHorizon]

Long bone fractures, dislocations, big patients with hip and shoulder replacement.