how to dose NMB when you cannot check twitches?

[heathermed]

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hello...

I was wondering how you guys dose your NMB when you are not able to check twitches.
I'm doing a robotic case where it is imperative that the pt doesnt move but have no access to the face or arms. Is there a certain regimen anyone uses?

Any help would be great
thanks!

 

[sevoflurane]

hello...

I was wondering how you guys dose your NMB when you are not able to check twitches.
I'm doing a robotic case where it is imperative that the pt doesnt move but have no access to the face or arms. Is there a certain regimen anyone uses?

Any help would be great
thanks!

Check twtiches in the leg/foot. Posterior tibial.

 

[Gern Blansten]

Why no access to face? For ours, it is tougher to reach, but we still have access.

 

[BobBarker]

You don't need to check twitches or use paralytic to ensure zero movement. If you are interested in minimizing diaphragm movement keep them a touch hypocarbic with some opiate on board. You can run them on simv with an adequate rate so even if they do start breathing it will be smoother. You can tell by the etco2 waveform if the pt is starting to try to breath through the vent. I can hear the vent "straining" before the waveform changes if a pt is trying to breath against the ventilator. Or you can just get a twitch'ometer that works automatically off of the anesthesia monitor.

 

[pgg]

In the absence of objective monitoring, you sort of have to wait for the patient move to be sure the NMBD has worn off. 🙂

It's pretty unusual to be in a case where you truly can't check twitches, and I think it's generally bad practice to not monitor NMBD effects in circumstances where it matters.

But ... you can watch the vent for signs of respiratory effort to return. The diaphragm will usually be the first muscle to recover. Obvious caveats here -
- "Respiratory effort" that registers on the vent doesn't correlate well to X twitches; drive varies during the case depending on surgical stimulation, anesthesia depth, opiates, etc.
- High risk of over-paralyzing a patient. If you're going tubed to the unit, maybe no harm no foul. If you plan on a wakeup, maybe grab a Snickers.
- High risk of under-paralyzing a patient. If relaxation isn't needed for the case maybe no big deal, but then why are you paralyzing the patient in the first place? If relaxation is needed, you risk embarrassment (or worse) if the patient moves.

 

[Gern Blansten]

If you plan on a wakeup, maybe grab a Snickers.

Good reference.🙂

 

[Idiopathic]

You don't need to check twitches or use paralytic to ensure zero movement. If you are interested in minimizing diaphragm movement keep them a touch hypocarbic with some opiate on board. You can run them on simv with an adequate rate so even if they do start breathing it will be smoother. You can tell by the etco2 waveform if the pt is starting to try to breath through the vent. I can hear the vent "straining" before the waveform changes if a pt is trying to breath against the ventilator. Or you can just get a twitch'ometer that works automatically off of the anesthesia monitor.

 

[Idiopathic]

obviously there are other things you can look at, and some may be more valuable than a twitch monitor. but in all honesty, every one of us has seen a patient move at "zero twitches", etc. so the best thing you could do is combine your techniques (opioid-induced hypoventilation, hypocarbia to minimize stimulation, volatile anesthetic at appropriate level, SOME way to measure twitches - feet are okay)

 

[Pooh & Annie]

Twitch monitor on the face, FOB in place under the drapes trained on the orbicularis.

I dare you.

 

[dhb]

just ask the surgeon if the patient is relaxed

 

[Ignatius J]

Narcotic infusion is your friend. If you don't feel like dealing with that stuff, just keep 'em deep. Dose NMBs sparingly.

 

[Mman]

hello...

I was wondering how you guys dose your NMB when you are not able to check twitches.
I'm doing a robotic case where it is imperative that the pt doesnt move but have no access to the face or arms. Is there a certain regimen anyone uses?

Any help would be great
thanks!

1) cautiously

or

2) use an objective monitor on the wrist that you hook up prior to case and can run remotely (we have some that hook up off the monitor on the anesthesia machine)

 

[Gern Blansten]

just ask the surgeon if the patient is relaxed

**Underrated post**

 

[Orin]

You can slap a BIS on them, doesn't it have an EMG monitor which can correlate to NMB/paralysis level?

 

[Direct Laryngoscopy]

just ask the surgeon if the patient is relaxed

I'm not a surgeon but I don't know if the 'feel' of the patient is the same doing robotic surgery as if she uses her gloved hand.

 

[Planktonmd]

Give a lot of muscle relaxant and don't worry about the twitches.
Not too complicated.

 

[jwk]

just ask the surgeon if the patient is relaxed

This

Give a lot of muscle relaxant and don't worry about the twitches.
Not too complicated.

And this - especially once sugammadex is released.

Otherwise, you just get a feel for it. Average 70kg patient - 50mg roc for intubation, if it's "imperative" that they don't move (really????) then maybe another 20 before incision, then 10mg q30 or so if I "really" don't want them to move.

Don't be scared of robotic procedures. The "absolutes" are way over-rated. Our first surgeons were so paranoid about moving the OR table they actually had us unplug it from the wall once they were docked (uh, gee doc, what about the battery )

Most surgeons truly couldn't tell you if the patient is relaxed or not. 5cc of NS is my favorite NMB - works GREAT!!!

 

[BobBarker]

Nimbex infusion as well

 

[excalibur]

Ensure the pt doesn't move?

-Nimbex drip

-Pancuronium

 

[jetproppilot]

You don't need to check twitches or use paralytic to ensure zero movement. If you are interested in minimizing diaphragm movement keep them a touch hypocarbic with some opiate on board. You can run them on simv with an adequate rate so even if they do start breathing it will be smoother. You can tell by the etco2 waveform if the pt is starting to try to breath through the vent.

I've read the responses so far and our

FRIENDLY GAMESHOW HOST (WHO I THINK SCHTOOPED ALL

THE PRICE IS RIGHT

CHICKS BACK IN THE DAY LOL)

wins!

DO NOT OVERDOSE WITH NEUROMUSCULAR BLOCKERS

My advice is to

"UNDERDOSE WITH NEUROMUSCULAR BLOCKERS."

Why?

Because your goal is to become a

ROKKSTARR

who can extubate your patient

WHEN THE LAST STITCH HAS BEEN THROWN and

BEFORE THE DRAPES COME OFF.

That should be your goal,

ANESTHESIA RESIDENTS.

EXTUBATE BEFORE THE DRAPES COME OFF.

We can initiate some threads with specifics of how you keep someone asleep/nonmoving without overdosing NMBs and still be able to promptly awaken the patient.

ARE YOU A ROKKSTARR?

great enough to time your anesthetic

SO PRECISELY

that you can

EXTUBATE

as the last stitch is thrown?

OR,

ARE YOU THE DUDE SITTING IN THE OR TWENTY MINUTES AFTER THE CASE IS DONE AND 25 MINUTES AFTER YOUR REVERSAL,

WITH A WEAK PATIENT

BECAUSE YOU

RELY WAYYY TOO MUCH ON NMBs?

If you're in the latter group,

YOU NEED TO UP YOUR GAME MAN.

PRIVATE PRACTICE IS AN EFFICIENT MACHINE.

WE ARE LOOKING FOR

ROKKSTARRS.

Up your game.

 

[Jay K]

You can run them on simv....

👍

If SIMV's unavailable, then use the Force like I do...