NMBA reversal

dhb said:

Do you guys systematically reverse patients who have received a non depolarizing agent? What do you use to measure blockade: TOF, DBS, tetanus?

I usually don't monitor or reverse patients to which i give a low dose roc: 0.3-0.5mg/kg if the procedure lasts more than an hour and if no additional dose is given. In this setting i'm happy with indirect signs of reversal.

Is this unsafe practice as some authors suggest?
Do you worry about residual curarization in PP?

dhb

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Some people reverse everyone, some people try not to reverse, some people "taylor" their reversal dose to "match" what they think is appropriate.

Despite the variation seen above in practice, people get extubated after surgery and maintain their airway without residual NMB effects the majority of the time.

Your practice is not unsafe. It is common. With the caveat that rocuronium can sometimes last longer than you expect.

I'll hit a TOF or a tetanus to see what it looks like if I'm wondering where the patient's blockade is at.

If its still flat, its interesting to see whether or not a post-tetanic facilitation is present.

If the patient is breathing well at the end of the surgery, good tidal volumes, etc, you can probably get by without reversal.

If they need reversal, I give a full dose.

As an academic type I am aware that TOF can not detect anything better than a TOF ratio of 40%. Currently, the evidence is strong that postoperative morbitites and mortalities increase when the TOF is less than 90%. Therefore unless you are quantitatively measuring TOF you have to reverse all your patients or be ready to justify how you knew the patient was appropriately reversed (TOF of 90%) if they develop a morbidity. DBS and Tetany are only accurate to 60% at best!!

how about this? yesterday i used a nmb with an lma for a 4.5 hour case and didn't reverse the patient at the end.



(true story... saw him before i went home and he was right as rain. moral of the story: taylor your anesthetic to the patient.)

atrxnasd said:

As an academic type I am aware that TOF can not detect anything better than a TOF ratio of 40%. Currently, the evidence is strong that postoperative morbitites and mortalities increase when the TOF is less than 90%. Therefore unless you are quantitatively measuring TOF you have to reverse all your patients or be ready to justify how you knew the patient was appropriately reversed (TOF of 90%) if they develop a morbidity. DBS and Tetany are only accurate to 60% at best!!

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I remember those studies somewhat but to the best of my recollection they were in longer cases that were not going home the day of surgery. What I am getting at is that ambulatory pts may be different. They have shorter cases which don't require repeat relaxation and are generally healthier. Therefore, they don't suffer from residual blockade like the sicker pts do and the longer cases do that may have been given repeated doses.

Please, correct me if I am wrong.

Noyac said:

I remember those studies somewhat but to the best of my recollection they were in longer cases that were not going home the day of surgery. What I am getting at is that ambulatory pts may be different. They have shorter cases which don't require repeat relaxation and are generally healthier. Therefore, they don't suffer from residual blockade like the sicker pts do and the longer cases do that may have been given repeated doses.

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The pharmacokinetics in a healthy pt are probably different than in a sick pt. But, that's not the point of the above mentioned studies. What they are saying is that our clinical monitors don't really work, and hence you are better off reversing everybody. And, doing it when they already have 3 twitches.

dhb said:

"TOF can not detect anything better than a TOF ratio of 40%" then "justify how you knew the patient was appropriately reversed (TOF of 90%)"

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TOF with the naked eye of most people only gives you info up to 70%TOF. You cannot tell the difference between 70% or 100% TOF. Yet, at 70%TOF an individual cannot protect his airway (i.e.,can choke on his own saliva) To protect your airway you need 90%TOF which the naked eye cannot do, you need an accelerometer for that.

Everyday pts are extubated without being able to protect their own airway, because we have no way of knowing about this. Most of them do well, but the ones that do not, have a dismal prognosis. The current recommendation in order to achieve 90%TOF at extubation is to reverse everyone and only when they have 3 or more twitches.


BTW, this will probably change in the next few years as suggamadex starts playing a role in NMB reversal.

There are advantages for not giving a cholinesterase inhibitor to patients, like having less PONV and less abdominal pain, especially after biliary and GI interventions.
So I think if you use NMBA's intelligently, and only when they are indicated, you still can do a good anesthetic without having to reverse the patient.
You have to remember also that most studies are usually done in teaching hospitals, where the anesthetic is administered by people under training.
On the other hand, once we have a reversal agent that is deprived of any side effects, like Sugamadex, then reversing every patient would be more attractive provided the drug is not too expensive.

dhb said:

... or Gantacurium : http://www.averapharm.com/Gantacurium.html

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ummm... can anyone say "rapacuronium"?

i wouldn't get my hopes up too much until this gets on the market... and even then. besides, they're only in phase 2, so it'll probably be at least another 3-4 years before you get to use it. and, the fact that GSK decided not to pursue development of this themselves, a potential blockbuster (at least as far as anesthesia drugs go), has my doubt-meter pinging... the company itself is currently looking to out-license the development... my guess is that this will stay on the shelf for the foreseeable future.

dr doze said:

15 years private practice. I reverse everyone. worked alone for years and supervised for years. used to individualize therapy. no mas. I have seen patients who had single 2 ED95 or less dose of NMB many hours later have residual NMB. I have seen extremely competent residents and CRNAs who swore patient met criteria for extubation without reversing who were trying to minimize N/V, turn to floppy **** in PACU. I have never seen anyone regret giving FULL DOSE of reversal agent. Maybe there will be a few more barfing patients, but 1,000 extra barfers aren't worth one weak patient who got recognized as being in trouble a minute late.

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I cant say that your stance is wrong because many other capable anesthesiologists feel the same way. I would think that there is a higher probability of reversing everyone if you are supervising and only in the room for a small percentage of the time. You must remember that PONV is not a benign problem especially if it leads to an unexpected admission for a routine outpatient case. This exerts a physical and monetary toll on the patient and society at large. In today's climate we all will be held more accountable for the results of our actions. I must say that there have been several times that I DID regret giving a reversal agent when the patient was admitted unexpectedly for PONV (I was forced to do this because of my attending against my better judgement). You will never convince me that a healthy ASA 1 or 2 patient who is in a 2-4hr case needs reversal agents as a knee jerk response. We need to use our clinical judgement. Otherwise we are just robots.

VolatileAgent said:

ummm... can anyone say "rapacuronium"?

i wouldn't get my hopes up too much until this gets on the market... and even then. besides, they're only in phase 2, so it'll probably be at least another 3-4 years before you get to use it. and, the fact that GSK decided not to pursue development of this themselves, a potential blockbuster (at least as far as anesthesia drugs go), has my doubt-meter pinging... the company itself is currently looking to out-license the development... my guess is that this will stay on the shelf for the foreseeable future.

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While it may be a "potential blockbuster" as far as anesthesia drugs go, big pharma lives on the megablockbusters, like Zocor (annual sales of as much as $5.2 BILLION). When it costs $300-500 million to bring a drug to market, you've got to make a huge return on your investment in order to fund the drugs that don't make it past phase I, II, or III trials. If I had been advising GSK on the drug, I'd have told them to pass. A big pharma company like Merck will spend 2-3 billion per year on R&D. You can't bankroll that with little drugs like a NMBA.

mille125 said:

I must say that there have been several times that I DID regret giving a reversal agent when the patient was admitted unexpectedly for PONV (I was forced to do this because of my attending against my better judgement).

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How many pt you have admitted because of PONV?


Zero here.

urgewrx said:

How many pt you have admitted because of PONV?


Zero here.

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two in residency....both unexpected....could have been avoided....but at the time my attending was calling the shots.....

dr doze said:

Much of our practice is "robotlike" "Knee Jerk" choices, from the way that we set up our individual rooms, personal preferences or dislikes of certain drugs or equipment or techniques that other capable individuals disagree with us on.
I used to agree with you on this issue, but patient to patient variability that I can't explain physiologically, the limitations of the twitch monitor, and a desire to put as much medicolegal cover as possible over every patient interaction have made this a personal "standard of care" While I do care about N/V post op and do the usual things, considering omitting NMBA is no longer one of them.

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i assume that you meant omitting reversal agents.......


fair enough....we can agree to disagree......i will say that setting up a room does not take a lot of clinical decision making.....although everyone has personal preferences for various drugs, patient's physiology does dictate change......you dont use SUX for everyone, propofol for everyone, isoflurane for everyone (and for me reversal for everyone)...as I said before many others do agree with you...we will simply agree to disagree...........

urgewrx said:

How many pt you have admitted because of PONV?


Zero here.

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one case I still remember to this day.......


30 yo ASA 1 patient having a breast procedure in an ASC. History of PONV after abd hys and ENT surgery. No other remarkable history. My plan, which attending number 1 agreed with, was to do paravertebral blocks +/- propofol infusion. Attending number 1 was sick and attending number 2 disagreed with plan. Preferred pent/roc/tube with ondansetron. Patient had absolutely horrible PONV and was admitted unexpectedly. I was very very upset and still think about it to this day.........

mille125 said:

one case I still remember to this day.......


30 yo ASA 1 patient having a breast procedure in an ASC. History of PONV after abd hys and ENT surgery. No other remarkable history. My plan, which attending number 1 agreed with, was to do paravertebral blocks +/- propofol infusion. Attending number 1 was sick and attending number 2 disagreed with plan. Preferred pent/roc/tube with ondansetron. Patient had absolutely horrible PONV and was admitted unexpectedly. I was very very upset and still think about it to this day.........

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Wow, sounds like an old guy, your attending. Why pent? Did you do anything else other than zofran before she was dropped off in the RR?

Breast procedures suck as far as PONV is concerned. I do everything I can up front... 8mg zofran, decadron, 100% O2 (short cases), and reglan...phenergan in recovery. Chances are, they will still puke...but never admitted...(knock on wood).

As far as reversing....I honesltly would probably avoid it if all was well. Why was this patient intubated anyway?

The pravertibral block with Propofol would have been great. But I have never done one...so off to sleep they go....with an LMA.

I have heard that Dr. Miller at UCSF has said that he would testify against you in court if you used a NMB and didn't reverse - regardless of the time of the last dose of NMB.

Just a thougt......

bubalus said:

While it may be a "potential blockbuster" as far as anesthesia drugs go, big pharma lives on the megablockbusters, like Zocor (annual sales of as much as $5.2 BILLION). When it costs $300-500 million to bring a drug to market, you've got to make a huge return on your investment in order to fund the drugs that don't make it past phase I, II, or III trials. If I had been advising GSK on the drug, I'd have told them to pass. A big pharma company like Merck will spend 2-3 billion per year on R&D. You can't bankroll that with little drugs like a NMBA.

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i can't disagree with what you're saying. and, it's somehwhat sad, isn't it? i'm sure a small company like avera would be quite happy with a $30-40 million a year profit on such a drug. but, you're right. the stakes of developing such a drug through phase III, especially when they'll likely have to pay back a hefty licensing fee to GSK, are what are likely going to keep this drug on the shelf.

VolatileAgent said:

i can't disagree with what you're saying. and, it's somehwhat sad, isn't it? i'm sure a small company like avera would be quite happy with a $30-40 million a year profit on such a drug. but, you're right. the stakes of developing such a drug through phase III, especially when they'll likely have to pay back a hefty licensing fee to GSK, are what are likely going to keep this drug on the shelf.

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If it is as good as Sux without the muscle pain or K increase, they'll make a lot of money.

Imagine all the stat intubations done with that thing instead of SUX.
Imagine starting a case with Gapacurion (or however it is. BTW I still use sux since I don't like to wait...) and instead of tossing the rest, starting an infusion. Turn it off when they start closing fascia and you are done.

dr doze said:

15 years private practice. I reverse everyone. worked alone for years and supervised for years. used to individualize therapy. no mas. I have seen patients who had single 2 ED95 or less dose of NMB many hours later have residual NMB. I have seen extremely competent residents and CRNAs who swore patient met criteria for extubation without reversing who were trying to minimize N/V, turn to floppy **** in PACU. I have never seen anyone regret giving FULL DOSE of reversal agent. Maybe there will be a few more barfing patients, but 1,000 extra barfers aren't worth one weak patient who got recognized as being in trouble a minute late.

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Dude's post holds merit.

I feel the same way...if youre gonna reverse, give the full dose. I dont think giving 2mg neostigmine is gonna lower the incidence of post op NV enough compared to 5mg neostigmine. So what I'm saying is if they need reversal, reverse with the full dose.

That being said, I don't think everyone needs reversal.

Additionally, studies on this subject crack me up.

Naked eye TOF observance, TOF ratios 40%, 90%, blah blah blah.

Lets say a patient has a 40% TOF, just for argument. How do you quantify a 40% TOF? If you had Miller, Barasch, and 100 other clinicians look at a TOF, how many are gonna say its a 40% TOF? Whats the variance in observation gonna be? I've yet to see a laptop hooked to a twitch monitor in the OR.

Assaying neuromuscular blockade in the clinical setting is not the same as measuring fuel flow in the space shuttle, even though those studies make it sound extraordinarily scientific.

Since everything now has a corporate sponsor (Fed Ex French Open, Maxi Pad Indy 500, etc), here's the

COPENHAGEN GUIDE TO NMB REVERSAL

1) Patient breathing well on own at end of case? Havent dosed NMB in quite a while? Belly's empty? And if it wasnt empty to begin with, didja put down an OGT and suck it out? You apply twitch monitor and the left side of their face cringes like A-Rod looking at his picture in the newspaper with the hot (non wife) blondie?

Extubate. 99.99% of the time theres no problem.

Will you see somebody weak on occasion? Yep. You'll see this even after reversal on some patients. But isnt that why we monitor patients?

You are The Wolf. You solve problems. Thats what youre there for. Thats why we monitor people in the PACU.

So they're a little weak, but holding their sat. 99% of these people you give versed 2mg to so they wont remember the next twenty minutes.

Reintubation of a weak patient is very rare. Yes, it happens....in both reversed patients and non-reversed patients.


2) TWITCH MONITOR INTERPRETATION:

Theres three choices.

Its either 1)REALLY STRONG.....2)TWITCHES ARE BACK BUT KINDA WEAK.......or.....3)I FEEL LIKE STEVIE WONDER LOOKING AT THESE TWITCHES.

Wanna reverse everyone with REALLY STRONG twitches who is breathing well? I wont argue with you. I don't.

TWITCHES ARE BACK BUT KINDA WEAK: Give full reversal. Don't taylor the reversal. Give it all.

STEVIE WONDER TWITCHES: You just bought yourself twenty minutes of wasted time. Once you see a good twitch, reverese with full reversal...butcha may need to T-piece-em to the PACU. If you do, give midazolam 2mg so they wont remember.

There ya have it.

Jet's VERY SCIENTIFIC GUIDE TO TWITCH MONITOR UTILIZATION.

Look for Kopman. He is the one who described the .7TOF, the head lift,and biting on the tongue depressor. Then he changed the value to .9tof and said that the head lft, biting, and twitch monitor are not good.

urgewrx said:

Jet,

Weren't you asking me a week ago for evidence based EKG protocols?



Today there is an orgy of evidence based NMB reversal protocol, yet you totally disregard them?



You are a walking contradiction. Make up you mind. It's obvious you are not going to change how you practice.(...you are too old...?) But if you are going to argue, have some consistency in your arguments.
​

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Yeah, you're right. I'm forty-two. Geez, I gotta start looking for a long-term-care-facility....gotta lead on one for me?

An "orgy of evidence based NMB reversal protocol"?

HAHAHAHAHAHAHAHAHAHAHAHHAHAA

.7........ No... .9 .. head lift..... no, stick a tongue depressor in their mouth... no, don't ......

Wheres the reports of residual curarization killing and maiming patients? Or an increasing trend of unexpected hospitalizations of day-surgery patients? Has it been proven that reversing everyone definitively reduces PACU time?

urgewrx said:

Jet,​

Weren't you asking me a week ago for evidence based EKG protocols?​

Today there is an orgy of evidence based NMB reversal protocol, yet you totally disregard them?​

You are a walking contradiction. Make up you mind. It's obvious you are not going to change how you practice.(...you are too old...?) But if you are going to argue, have some consistency in your arguments.​

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I don't think he's contradicting anything.

You are talking about 2 COMPLETELY DIFFERENTL aspects of what we do....

1) testing...to minimize risk
2) therapy...to minimize risk

There is NO...ZERO...nada evidence to support EKG testing (after clinical history) preoperatively...to minimize risk.

There is SOME data to support ALWAYS reversing NMB after surgery to DECREASE complications.....but I always thought that data was in PEDIATRIC patients????

I must admit, I'm not 100% up to date on the literature in regards to NMB, but that's because it is something that is of little interest to me, because the solution is SOOOOOOO simple......ie if in doubt ...give the reversal.

jetproppilot said:

Dude's post holds merit.

I feel the same way...if youre gonna reverse, give the full dose. I dont think giving 2mg neostigmine is gonna lower the incidence of post op NV enough compared to 5mg neostigmine. So what I'm saying is if they need reversal, reverse with the full dose.

That being said, I don't think everyone needs reversal.

Additionally, studies on this subject crack me up.

Naked eye TOF observance, TOF ratios 40%, 90%, blah blah blah.

Lets say a patient has a 40% TOF, just for argument. How do you quantify a 40% TOF? If you had Miller, Barasch, and 100 other clinicians look at a TOF, how many are gonna say its a 40% TOF? Whats the variance in observation gonna be? I've yet to see a laptop hooked to a twitch monitor in the OR.

Assaying neuromuscular blockade in the clinical setting is not the same as measuring fuel flow in the space shuttle, even though those studies make it sound extraordinarily scientific.

Since everything now has a corporate sponsor (Fed Ex French Open, Maxi Pad Indy 500, etc), here's the

COPENHAGEN GUIDE TO NMB REVERSAL

1) Patient breathing well on own at end of case? Havent dosed NMB in quite a while? Belly's empty? And if it wasnt empty to begin with, didja put down an OGT and suck it out? You apply twitch monitor and the left side of their face cringes like A-Rod looking at his picture in the newspaper with the hot (non wife) blondie?

Extubate. 99.99% of the time theres no problem.

Will you see somebody weak on occasion? Yep. You'll see this even after reversal on some patients. But isnt that why we monitor patients?

You are The Wolf. You solve problems. Thats what youre there for. Thats why we monitor people in the PACU.

So they're a little weak, but holding their sat. 99% of these people you give versed 2mg to so they wont remember the next twenty minutes.

Reintubation of a weak patient is very rare. Yes, it happens....in both reversed patients and non-reversed patients.


2) TWITCH MONITOR INTERPRETATION:

Theres three choices.

Its either 1)REALLY STRONG.....2)TWITCHES ARE BACK BUT KINDA WEAK.......or.....3)I FEEL LIKE STEVIE WONDER LOOKING AT THESE TWITCHES.

Wanna reverse everyone with REALLY STRONG twitches who is breathing well? I wont argue with you. I don't.

TWITCHES ARE BACK BUT KINDA WEAK: Give full reversal. Don't taylor the reversal. Give it all.

STEVIE WONDER TWITCHES: You just bought yourself twenty minutes of wasted time. Once you see a good twitch, reverese with full reversal...butcha may need to T-piece-em to the PACU. If you do, give midazolam 2mg so they wont remember.

There ya have it.

Jet's VERY SCIENTIFIC GUIDE TO TWITCH MONITOR UTILIZATION.

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Pretty funny.....kind of what I do...except not as COLORFUL when I describe it.

CremeSickle said:

I had a patient a week ago that I got burnt on.

Nothing real bad, I had 4 twitches back with almost no fade. Had not given vecc in near 1.2 hours and it wasent a full dose. Decided not to reverse (ala PONV etc). Brought patient to PACU where in about 10 minutes he decompensated and i had to dose him with reversal and assist ventilations for about 30 seconds.

End of the story, I "thought" he was fine. Well, lucky (for pt and me) he did ok. However, that taught me a valuable lesson i wont soon forget "always reversing wont ever get you into trouble". Attending reinforced it with a point and laugh move ;P

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interesting....i have never had this scenerio happen to me (or even anything close to this happening)....i also have never been in the situation where I was supervising a CRNA or resident...if in that situation I would probably be closer to 100% reversal as well.....it is interesting how clinical situations can shape your practice...i have seen the worse of PONV which is why I have my philosophy..it sounds like creme sickle and dr doze have seen a few "weak" patients which is why they do what they do....

dhb said:

Well based on some of the post i have received i reversed my patient although she had only received 40mg of roc for a 5h procedure (since she was ASA 4 i thought why not avoid any resudual block)... and what did i get? PONV in PACU which i hadn't had in a long time i don't want to base my decisions on N=1 so i'll try again but i wasn't to impresssed this time

urge: any specific article by Kopman? i looked him up found nothing relevant to the discussion...

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not surprising to me at all..........

"STEVIE WONDER TWITCHES: You just bought yourself twenty minutes of wasted time. Once you see a good twitch, reverese with full reversal...butcha may need to T-piece-em to the PACU. If you do, give midazolam 2mg so they wont remember." -- from Jet's earlier post

I don't understand your reasoning here... If they're reversed enough to support ventilation through a t-piece, you can take the tube out (if they're awake). If they can't fly without the tube, they can't fly on a t-piece, right? The t-piece is for an anesthetized patient (or patient otherwise unable to protect their airway) with good ventilatory effort. Maybe I'm misunderstanding you.

On another point (maybe its just me), I've found that reversing rocuronium with just the one "good" twitch leads to a poorly reversed patient. For some reason, one really crappy twitch with vecuronium is easily reversed. Again, maybe its just me.

Intubate said:

"STEVIE WONDER TWITCHES: You just bought yourself twenty minutes of wasted time. Once you see a good twitch, reverese with full reversal...butcha may need to T-piece-em to the PACU. If you do, give midazolam 2mg so they wont remember." -- from Jet's earlier post

I don't understand your reasoning here... If they're reversed enough to support ventilation through a t-piece, you can take the tube out (if they're awake). If they can't fly without the tube, they can't fly on a t-piece, right? The t-piece is for an anesthetized patient (or patient otherwise unable to protect their airway) with good ventilatory effort. Maybe I'm misunderstanding you.

On another point (maybe its just me), I've found that reversing rocuronium with just the one "good" twitch leads to a poorly reversed patient. For some reason, one really crappy twitch with vecuronium is easily reversed. Again, maybe its just me.

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nope

Intubate said:

"
If they can't fly without the tube, they can't fly on a t-piece, right?

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Untrue.

Think about the end of the case.

Patient is spontaneously breathing. Anesthesiologist stands there watching for clinical indications that the patient is ready for extubation.

Assuming patient is breathing adequately enough that you arent having to assist them, and SpO2 is holding, the T piece allows you to move this process to the PACU.

hi .its me i am doctoer and doing post graduate in anaesthesia . i

sorry couldn't resist.

I guess I misunderstood. I thought you meant you were taking a weak patient to PACU on a t-piece. Thats not good. I guess you mean you'll be waiting around in the OR with an anesthetized patient, so as soon as they're reversible, you reverse them, get em breathing, then go on a t-piece to let them breathe off the gas in the pacu. If that's what you meant, I agree-- but then you wouldn't need the midazolam. I hope you don't take weak patients out on a t-piece.

Intubate said:

I guess I misunderstood. I thought you meant you were taking a weak patient to PACU on a t-piece. Thats not good. I guess you mean you'll be waiting around in the OR with an anesthetized patient, so as soon as they're reversible, you reverse them, get em breathing, then go on a t-piece to let them breathe off the gas in the pacu. If that's what you meant, I agree-- but then you wouldn't need the midazolam. I hope you don't take weak patients out on a t-piece.

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You can take a patient to PACU on a T piece if they are not 100 % recovered from muscle relaxants, in fact you take this kind of patients to PACU extubated everyday, if you think about it.
Think about a patient that is breathing adequately and not requiring any mechanical support, this patient might still have some residual muscle relaxant even if you reversed him, so the T piece will allow you to protect the airway until you are comfortable to extubate him but you won't have to sit in the OR and waste time.

Planktonmd said:

You can take a patient to PACU on a T piece if they are not 100 % recovered from muscle relaxants, in fact you take this kind of patients to PACU extubated everyday, if you think about it.
Think about a patient that is breathing adequately and not requiring any mechanical support, this patient might still have some residual muscle relaxant even if you reversed him, so the T piece will allow you to protect the airway until you are comfortable to extubate him but you won't have to sit in the OR and waste time.

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I won't argue that all patients have normal neuromuscular function when they go to PACU. But if a patient is so weak that you need to give them versed so they don't remember struggling to breathe, they should not be on a t-piece. I use a t-piece for a patient that is fully reversed (or never paralyzed), who is breathing spontaneously, but unable to protect thier airway because they're anesthetized. Not a patient who is too weak to swallow or gag. That's all.

Intubate said:

I won't argue that all patients have normal neuromuscular function when they go to PACU. But if a patient is so weak that you need to give them versed so they don't remember struggling to breathe, they should not be on a t-piece. I use a t-piece for a patient that is fully reversed (or never paralyzed), who is breathing spontaneously, but unable to protect thier airway because they're anesthetized. Not a patient who is too weak to swallow or gag. That's all.

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You are giving Midazolam to help them tolerate the ETT not because they are struggling to breathe.
If they are "struggling to breath" they don't get a T piece.
Your ability to move good tidal volume ( mostly diaphragm) comes back well before your upper airway reflexes.

Planktonmd said:

You are giving Midazolam to help them tolerate the ETT not because they are struggling to breathe.
If they are "struggling to breath" they don't get a T piece.
Your ability to move good tidal volume ( mostly diaphragm) comes back well before your upper airway reflexes.

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OK, thanks-- I'm aware of this.
I don't think patients who do not have adequate reversal of NMB (ie lack of airway reflexes) should be placed on a t-piece because of their potential to hypoventilate (yeah yeah, diaphragm comes back first, I know) in a situation where they are inappropriately monitored (no capnography). You can probably get away with it, but I won't do it with my patients.