How would you have handled this case? (GYN and muscle relaxation)

[ABCfib]

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Hey guys – I have a little case presentation for you and would like to hear your experienced views on it. On a side note, I am a resident in anesthesia currently working in my second month at a smaller hospital (NOT in the US). My problem might seem a bit boring to some of you but I hope to profit from your opinions.

The question essentially revolves around muscle relaxation issues. The case: woman, mid 50s, 70kg, ASA 2, scheduled for a lap-assisted vaginal hysterectomy. Induction with 10ug sufentanil, 180mg propofol and 7mg cis-atracurium. Easy intubation. In terms of timeline: total case length 130min, intubation at t=0, cut at t+15mins (10ug sufentanil, 2mg cis-atracurium, maintenance with sevo at 1.0 exspiratory). TOF monitoring with initial TOF 0, later at t+80mins TOF 2, gave 2mg of cis-atracurium bringing TOF to 0. Sufentanil bolus of 10ug titrated for effect (approx. every 20-30mins, earlier if HR or BP up).

Here it comes now: later, about 20mins before end of case, (laparoscopic part finished with trocars in place for last look, surgeons about to extract uterus), surgeons start complaining about level of relaxation, stating that patient is pressing and small bowel is prolapsing. At that point I did not notice any diaphragmatic movement, TOF at 1, sevo 1,0, no patient stress. Unsure what to do (I did not want to give more cis-atracurium so close to the end) I decided to deepen the anesthesia and gave 50mg propofol, 5ug sufentanil and increased sevo to 1.3. Nothing helped, the surgeons proceeded and finally finished but with constant complaints, always stating that relaxation was horrible. In addition, when I noticed that I wondered why the relaxation was insufficient with a TOF of 1, the surgeon noted that TOF monitoring is completely unreliable and that she “had seen people stand up from the operating table with a TOF of 1”.

At the end of the case I tried to get some rapport from a couple of my colleagues and received pretty much multiple approaches:
1) one colleague stated that surgeons have the best view of patient relaxation and that I should think about supplementing relaxation despite TOF monitoring (even if it means giving an antagonist or waiting some time after finishing the case).
2) Another colleague said that he would have done the same (propofol, sevo, sufenta)
3) The last colleague stated that he would have given mivacurium

Especially the third solution seems dangerous since, in my understanding, multiple studies have shown that miva given after a different muscle relaxant a) has additive or synergistic effects and b) assumes the characteristics of the former relaxant. Looking at literature like Larsen, authors state that muscle relaxation deeper than TOF of 1 or 2 is rarely necessary for most procedures.

I am pretty confused what to believe now - I recognize that different views and approaches exist and would appreciate your feedback. Thanks!

 

[coprolalia]

Hey guys – I have a little case presentation for you and would like to hear your experienced views on it. On a side note, I am a resident in anesthesia currently working in my second month at a smaller hospital (NOT in the US). My problem might seem a bit boring to some of you but I hope to profit from your opinions.

The question essentially revolves around muscle relaxation issues. The case: woman, mid 50s, 70kg, ASA 2, scheduled for a lap-assisted vaginal hysterectomy. Induction with 10ug sufentanil, 180mg propofol and 7mg cis-atracurium. Easy intubation. In terms of timeline: total case length 130min, intubation at t=0, cut at t+15mins (10ug sufentanil, 2mg cis-atracurium, maintenance with sevo at 1.0 exspiratory). TOF monitoring with initial TOF 0, later at t+80mins TOF 2, gave 2mg of cis-atracurium bringing TOF to 0. Sufentanil bolus of 10ug titrated for effect (approx. every 20-30mins, earlier if HR or BP up).

Here it comes now: later, about 20mins before end of case, (laparoscopic part finished with trocars in place for last look, surgeons about to extract uterus), surgeons start complaining about level of relaxation, stating that patient is pressing and small bowel is prolapsing. At that point I did not notice any diaphragmatic movement, TOF at 1, sevo 1,0, no patient stress. Unsure what to do (I did not want to give more cis-atracurium so close to the end) I decided to deepen the anesthesia and gave 50mg propofol, 5ug sufentanil and increased sevo to 1.3. Nothing helped, the surgeons proceeded and finally finished but with constant complaints, always stating that relaxation was horrible. In addition, when I noticed that I wondered why the relaxation was insufficient with a TOF of 1, the surgeon noted that TOF monitoring is completely unreliable and that she "had seen people stand up from the operating table with a TOF of 1".

At the end of the case I tried to get some rapport from a couple of my colleagues and received pretty much multiple approaches:
1) one colleague stated that surgeons have the best view of patient relaxation and that I should think about supplementing relaxation despite TOF monitoring (even if it means giving an antagonist or waiting some time after finishing the case).
2) Another colleague said that he would have done the same (propofol, sevo, sufenta)
3) The last colleague stated that he would have given mivacurium

Especially the third solution seems dangerous since, in my understanding, multiple studies have shown that miva given after a different muscle relaxant a) has additive or synergistic effects and b) assumes the characteristics of the former relaxant. Looking at literature like Larsen, authors state that muscle relaxation deeper than TOF of 1 or 2 is rarely necessary for most procedures.

I am pretty confused what to believe now - I recognize that different views and approaches exist and would appreciate your feedback. Thanks!

First, get used to such comments. Not every case is going to go perfectly. They got through it, safely, and the patient did fine, right? This is okay provided that the bulk of your anesthetics don't go like this.

Secondly, I find it interesting that you used cis-atricurium (was there a kidney issue?) rather than vecuronium or rocuronium. Otherwise, I would've done essentially the same thing, except we don't routinely use sufentanil in my training and practice. With sufentanil, you have to walk a fine line of giving just enough or too much, where you end-up with the patient apneic or with hypopnea for prolonged periods.

We can't get mivacurium in the U.S. anymore secondary to manufacturer shortage (i.e., no $$$).

Lastly, the best thing I can say is try to work on your timing with your relaxants. This just comes with practice. If they're still trying to get the uterus out, then you're not really near the end of the case (the still have to pull the trocars out and close skin, etc... at least another 15-20 minutes until you wake). The best thing to have done would've been to figure out when the uterus was coming out, and give a little more Nimbex roughly 15-20 minutes beforehand. Personally, I don't like Nimbex and only use it in cases where the patient has kidney problems because I find it is very unpredictable in its duration of action. That's why, unless it's contraindicated or you can't get it, I feel like vecuronium is the relaxant of choice in most procedures that take more than an hour. Although, now that rocuronium is off-patent, this is a good choice as well.

Just my $0.02.

-copro

 

[Noyac]

I would have given more cisatracurium. It is easy to reverse. I think your ET sevo was low as well.

As far as your surgeon, she is wrong. The pt can't get up off the table with a TOF=1 unless the twitch monitor is weak which means the TOF was not 1.

Finally, don't worry about what the surgeon says here. THere will be more times when the surgeon is not happy as a clam but if you are good at your job they will give you the benefit of the doubt and trust your assessment. That takes some time. Until then always act like you are fixing the situation whether there is anything to do or not. I have pushed zofran (b/c its the end of the case and time to give it) or saline b/4 and said "there, how's that?" To which they have replied, "better."

 

[powermd]

Hey guys – I have a little case presentation for you and would like to hear your experienced views on it. On a side note, I am a resident in anesthesia currently working in my second month at a smaller hospital (NOT in the US). My problem might seem a bit boring to some of you but I hope to profit from your opinions.

The question essentially revolves around muscle relaxation issues. The case: woman, mid 50s, 70kg, ASA 2, scheduled for a lap-assisted vaginal hysterectomy. Induction with 10ug sufentanil, 180mg propofol and 7mg cis-atracurium. Easy intubation. In terms of timeline: total case length 130min, intubation at t=0, cut at t+15mins (10ug sufentanil, 2mg cis-atracurium, maintenance with sevo at 1.0 exspiratory). TOF monitoring with initial TOF 0, later at t+80mins TOF 2, gave 2mg of cis-atracurium bringing TOF to 0. Sufentanil bolus of 10ug titrated for effect (approx. every 20-30mins, earlier if HR or BP up).

Here it comes now: later, about 20mins before end of case, (laparoscopic part finished with trocars in place for last look, surgeons about to extract uterus), surgeons start complaining about level of relaxation, stating that patient is pressing and small bowel is prolapsing. At that point I did not notice any diaphragmatic movement, TOF at 1, sevo 1,0, no patient stress. Unsure what to do (I did not want to give more cis-atracurium so close to the end) I decided to deepen the anesthesia and gave 50mg propofol, 5ug sufentanil and increased sevo to 1.3. Nothing helped, the surgeons proceeded and finally finished but with constant complaints, always stating that relaxation was horrible. In addition, when I noticed that I wondered why the relaxation was insufficient with a TOF of 1, the surgeon noted that TOF monitoring is completely unreliable and that she "had seen people stand up from the operating table with a TOF of 1".

At the end of the case I tried to get some rapport from a couple of my colleagues and received pretty much multiple approaches:
1) one colleague stated that surgeons have the best view of patient relaxation and that I should think about supplementing relaxation despite TOF monitoring (even if it means giving an antagonist or waiting some time after finishing the case).
2) Another colleague said that he would have done the same (propofol, sevo, sufenta)
3) The last colleague stated that he would have given mivacurium

Especially the third solution seems dangerous since, in my understanding, multiple studies have shown that miva given after a different muscle relaxant a) has additive or synergistic effects and b) assumes the characteristics of the former relaxant. Looking at literature like Larsen, authors state that muscle relaxation deeper than TOF of 1 or 2 is rarely necessary for most procedures.

I am pretty confused what to believe now - I recognize that different views and approaches exist and would appreciate your feedback. Thanks!

I would have assured the very imaginative surgeons that the patient is fully relaxed, and has NO TWITCHES. I think they understand that phrase. At that point I might supplement with a little propofol, and if some opioid was due, I'd give it. With a 1/4 TOF the patient is pretty well relaxed and the problem is most likely supratentorial on the part of the surgeons. If they were adamant that more relaxant be given, just explain that this may result in delayed room turnover, but you'd be happy to do it. Noyac has a point. It's amazing the placebo response you get just by pretending to push something.

Incidentally, can you think of any reason not to give a quick bolus of sux?

 

[aphistis]

I would have assured the very imaginative surgeons that the patient is fully relaxed, and has NO TWITCHES. I think they understand that phrase. At that point I might supplement with a little propofol, and if some opioid was due, I'd give it. With a 1/4 TOF the patient is pretty well relaxed and the problem is most likely supratentorial on the part of the surgeons. If they were adamant that more relaxant be given, just explain that this may result in delayed room turnover, but you'd be happy to do it. Noyac has a point. It's amazing the placebo response you get just by pretending to push something.

Incidentally, can you think of any reason not to give a quick bolus of sux?

1.0 sevo seems low to me too. Were you running it with nitrous?

I've heard from more than one upper-level resident that you can still reverse cis from 0 twitches, so you can be more aggressive with it. I haven't had to try it yet, fortunately.

Like Noyac said, it's also remarkable how often a stick of therapeutic IV fluid will fix the surgeon's problem.

 

[Jeff05]

turn sevo up and give some prop. if that doesn't work give some sux. just be careful not too reverse too soon after sux.

there will always be surgeons that complain about relaxation.

 

[Jeff05]

turn sevo up and give some prop. if that doesn't work give some sux. just be careful not too reverse too soon after sux.

there will always be surgeons that complain about relaxation.

 

[Jeff05]

turn sevo up and give some prop. if that doesn't work give some sux. just be careful not too reverse too soon after sux.

there will always be surgeons that complain about relaxation.

 

[Planktonmd]

I think you had 2 problems:
1- Light anesthetic: Remember what you do is called "Anesthesia" and that means your first priority is to anesthetize the patient not to just provide muscle relaxation, and from what you mentioned it seems that you are not even providing 1 MAC of anesthesia to this patient, so I would have dialed in more Sevo.
2- Incompetent surgeon: There is nothing you can do about that.

 

[Bertelman]

turn sevo up and give some prop. If that doesn't work give some sux. Just be careful not too reverse too soon after sux.

There will always be surgeons that complain about relaxation.

o.k.

turn sevo up and give some prop. If that doesn't work give some sux. Just be careful not too reverse too soon after sux.

There will always be surgeons that complain about relaxation.

o.k.

turn sevo up and give some prop. If that doesn't work give some sux. Just be careful not too reverse too soon after sux.

There will always be surgeons that complain about relaxation.

o.k.

 

[bigeyedfish]

I think you had 2 problems:
1- Light anesthetic: Remember what you do is called "Anesthesia" and that means your first priority is to anesthetize the patient not to just provide muscle relaxation, and from what you mentioned it seems that you are not even providing 1 MAC of anesthesia to this patient, so I would have dialed in more Sevo.
2- Incompetent surgeon: There is nothing you can do about that.

Are you suggesting that anything less than 1 mac equals an unanesthetized patient?

 

[aphistis]

Are you suggesting that anything less than 1 mac equals an unanesthetized patient?

 

[huktonfonix]

Are you suggesting that anything less than 1 mac equals an unanesthetized patient?


Cmon, what he's saying is that for a 50s ish patient even with a 6% decrease in MAC requirement per dacade >40, that a sevoflurane dial of 1 or even 1.3 is likely gonna be inadequate to provide certain neccesary components of anesthesia given the concentration. We are looking at a MAC of 0.5 or at best maybe up to 0.7 with a sevo dial of 1.0 to 1.3. This can't even claim to reliably prevent amnesia.

 

[Bertelman]

Are you suggesting that anything less than 1 mac equals an unanesthetized patient?

Poor surgical conditions with 0.5 MAC inhaled agent might be best corrected with a full MAC. I don't think that's revolutionary.

Do you routinely run your agents at 0.5 MAC?

 

[ABCfib]

First, I’d like to thank all of you for your replies. I think I learned a lot just from reading the posts.

@copro: luckily, a lot of my other cases definitely run smoother. In fact, I am having this relaxation issue always with a particular GYN team. The patient did fine. In my hospital, we are fortunate to have panc, roc, vec, atracurium, cis-atracurium and miva at our disposal. Most colleagues routinely use atracurium. Due to my huge experience with panc, roc and vec (zero cases ;-), and the patient having a (questionable) history of asthma with inhaler use until recently, I went with cis-atracurium (histamine-release). Her kidneys were fine. It was interesting to read your view about sufenta. Again, almost everybody at our place uses it routinely and I just started to add alfentanil to my repertoire for shorter cases. I kind of shy away from fentanyl at this point but probably should start to use it more often…. Lastly, I guess your point about my timing with relaxation is spot on.

@noyac, aphistis, planktonmd, bigeyedfish, bertelman: I was thinking that I use too low sevo concentrations too (when I started, I always ran 1.5-2.5% exspiratory), until people constantly pointed out that I do not have to run it that high when I was combining it with regular boluses of sufenta (every 15-25mins). One textbook points out that in combination with opiates you should aim at 0.5-0.6MAC. Looking at the iso-MAC values from Nickalls et al (Br J Anaesth, 2003, 91:170-174) the 0.6MAC value for a 50yr-old is about 1.0%. That was my rationale behind using this value. Again, at our place people rarely use nitrous (also a drug that I was thinking about adding to my repertoire). What sevo settings are you routinely aiming for? The antagonization point with cis-atracurium is interesting (possibility of reversing TOF 0), I will definitely look into it!

@powermd, jeff05: great point with the sux. So far I stayed away from it except occasional situations like RSI because I thought that the side effect profile put it in the box of drugs being used less and less often. But the duration and onset would make it the ideal drug for my particular situation.

I was wondering why people did not talk too much about TOF monitoring. I am not sure how much I should rely on it and sometimes I think despite TOF monitoring being a good adjunct, it may give you a false sense of security. Are you guys using it routinely? And how much do you trust it?

So I guess it boils down to a) bad relaxation timing and b) not enough sevo.

 

[ozzie20]

I don't understand how you can press just enough to cause small bowel prolapse but not enough to affect your vent settings at all.

 

[Planktonmd]

From a practical point of view you always want to give an anesthetic that is a little bit deeper than what the surgical stimulation requires at any given moment because the surgical stimulus is a dynamic process and can suddenly increase without warning.
So if you titrate your anesthetic to a light level that is barely keeping the patient from moving you will have frequent occasions where the surgeon suddenly does something unexpected and the patient starts moving.
10-15 mcg of sufenta with 1/2 mac of Sevo is light anesthesia for a hysterectomy on a 50 Y/O (IMHO).
Muscle relaxants are a good tool but they should not be used to replace adequate anesthesia.
Your choice of Cisatracurium is a good choice and even here in the US there are places where it is used routinely the only prohibitive factor is cost because here Cisatracurium is $20 while Atracurium is $2 and Rocuronium is probably $6.
Sufenta is a great Narcotic but again here in the U.S. it is more expensive than Fentanyl, and Sufenta tends to have more steep onset and elimination curves which could mean more rapid progress from good analgesia to no analgesia.

First, I'd like to thank all of you for your replies. I think I learned a lot just from reading the posts.

@copro: luckily, a lot of my other cases definitely run smoother. In fact, I am having this relaxation issue always with a particular GYN team. The patient did fine. In my hospital, we are fortunate to have panc, roc, vec, atracurium, cis-atracurium and miva at our disposal. Most colleagues routinely use atracurium. Due to my huge experience with panc, roc and vec (zero cases ;-), and the patient having a (questionable) history of asthma with inhaler use until recently, I went with cis-atracurium (histamine-release). Her kidneys were fine. It was interesting to read your view about sufenta. Again, almost everybody at our place uses it routinely and I just started to add alfentanil to my repertoire for shorter cases. I kind of shy away from fentanyl at this point but probably should start to use it more often…. Lastly, I guess your point about my timing with relaxation is spot on.

@noyac, aphistis, planktonmd, bigeyedfish, bertelman: I was thinking that I use too low sevo concentrations too (when I started, I always ran 1.5-2.5% exspiratory), until people constantly pointed out that I do not have to run it that high when I was combining it with regular boluses of sufenta (every 15-25mins). One textbook points out that in combination with opiates you should aim at 0.5-0.6MAC. Looking at the iso-MAC values from Nickalls et al (Br J Anaesth, 2003, 91:170-174) the 0.6MAC value for a 50yr-old is about 1.0%. That was my rationale behind using this value. Again, at our place people rarely use nitrous (also a drug that I was thinking about adding to my repertoire). What sevo settings are you routinely aiming for? The antagonization point with cis-atracurium is interesting (possibility of reversing TOF 0), I will definitely look into it!

@powermd, jeff05: great point with the sux. So far I stayed away from it except occasional situations like RSI because I thought that the side effect profile put it in the box of drugs being used less and less often. But the duration and onset would make it the ideal drug for my particular situation.

I was wondering why people did not talk too much about TOF monitoring. I am not sure how much I should rely on it and sometimes I think despite TOF monitoring being a good adjunct, it may give you a false sense of security. Are you guys using it routinely? And how much do you trust it?

So I guess it boils down to a) bad relaxation timing and b) not enough sevo.

 

[Planktonmd]

Are you suggesting that anything less than 1 mac equals an unanesthetized patient?

No, I am suggesting that anything less than 1 mac (adding all the anesthetics you are using) equals a crappy anesthetic where more than 50 % of your patients are going to move as a response to surgical stimulus by definition.

 

[Bertelman]

@noyac, aphistis, planktonmd, bigeyedfish, bertelman: I was thinking that I use too low sevo concentrations too (when I started, I always ran 1.5-2.5% exspiratory), until people constantly pointed out that I do not have to run it that high when I was combining it with regular boluses of sufenta (every 15-25mins). One textbook points out that in combination with opiates you should aim at 0.5-0.6MAC. Looking at the iso-MAC values from Nickalls et al (Br J Anaesth, 2003, 91:170-174) the 0.6MAC value for a 50yr-old is about 1.0%. That was my rationale behind using this value. Again, at our place people rarely use nitrous (also a drug that I was thinking about adding to my repertoire). What sevo settings are you routinely aiming for? The antagonization point with cis-atracurium is interesting (possibility of reversing TOF 0), I will definitely look into it!

I can't comment much on the use of sufenta, because I have about as much experience with that drug as you do with fent, which is nil. I will say that if you plan on starting a case that you know will last 2-3 hrs., I'm not sure there is much benefit of choosing a drug you have to augment every 15 min. If you have good experience with sufenta and 0.6 MAC sevo on your other cases, though, stick with it.

It does seem as though you have identified this surgical team as an outlier. That's either because they just want to have more "relaxation" than can be expected, or maybe their technique is causing more painful stimulus, requiring more drug. Try running higher sevo for their cases only.

 

[aphistis]

@noyac, aphistis, planktonmd, bigeyedfish, bertelman: I was thinking that I use too low sevo concentrations too (when I started, I always ran 1.5-2.5% exspiratory), until people constantly pointed out that I do not have to run it that high when I was combining it with regular boluses of sufenta (every 15-25mins). One textbook points out that in combination with opiates you should aim at 0.5-0.6MAC. Looking at the iso-MAC values from Nickalls et al (Br J Anaesth, 2003, 91:170-174) the 0.6MAC value for a 50yr-old is about 1.0%. That was my rationale behind using this value. Again, at our place people rarely use nitrous (also a drug that I was thinking about adding to my repertoire). What sevo settings are you routinely aiming for? The antagonization point with cis-atracurium is interesting (possibility of reversing TOF 0), I will definitely look into it!

1) 1.5-2.5% is a big range for sevo. I agree that there's usually no need to run a paralyzed patient at 2.5%et sevo, especially not if you're supplementing with narcotics.

At that point in the case, with all the cutting behind you, I'd probably be at about 1.5-1.6% end tidal with maybe 75mcg/kg of morphine on board for post-op pain. I'm sure other people's mileage will vary, but with my limited experience I'd still prefer to keep things a little deeper than I think is exactly necessary at that moment. Like Plank said, it gives you some wiggle room since surgical stimulation is variable from moment to moment.

2) Like I said, I've heard about the cis reversal from other residents, but I wouldn't want to bet the house on it.

 

[bigeyedfish]

Poor surgical conditions with 0.5 MAC inhaled agent might be best corrected with a full MAC. I don't think that's revolutionary.

Do you routinely run your agents at 0.5 MAC?

I don't use the gas to keep patients from moving, that's what NMB is for. I use the gas to keep the patient asleep and prevent recall, and that occurs before 1 mac. Maybe I'm biased because where I train all we mostly use is iso, so if I run the 1.2 mac needed to keep 95% of people from moving they're going to be blowing it off all day.

 

[bigeyedfish]

@noyac, aphistis, planktonmd, bigeyedfish, bertelman: I was thinking that I use too low sevo concentrations too (when I started, I always ran 1.5-2.5% exspiratory), until people constantly pointed out that I do not have to run it that high when I was combining it with regular boluses of sufenta (every 15-25mins). One textbook points out that in combination with opiates you should aim at 0.5-0.6MAC. Looking at the iso-MAC values from Nickalls et al (Br J Anaesth, 2003, 91:170-174) the 0.6MAC value for a 50yr-old is about 1.0%. That was my rationale behind using this value. Again, at our place people rarely use nitrous (also a drug that I was thinking about adding to my repertoire). What sevo settings are you routinely aiming for? The antagonization point with cis-atracurium is interesting (possibility of reversing TOF 0), I will definitely look into it!

There's a graph in Barasch that shows sufenta infusion rate vs mac requirements. 0.3 mc/kg/hr will lower your mac requirement by 50%. The curve asymptotes at about 60% at 0.5 mc/kg/hr. I like sufenta for some cases but I think its better used as an infusion than boluses. You just have to be sure to turn it off 45 minutes before the end of the case.

 

[Planktonmd]

I don't use the gas to keep patients from moving, that's what NMB is for. I use the gas to keep the patient asleep and prevent recall, and that occurs before 1 mac. Maybe I'm biased because where I train all we mostly use is iso, so if I run the 1.2 mac needed to keep 95% of people from moving they're going to be blowing it off all day.

😕
So, you basically can't give a general anesthetic without muscle relaxants?
Do you ever do cases where the patient is breathing spontaneously?
Are you really being taught that the only way to prevent patients from moving in response to surgical stimulus is by keeping them paralyzed?
Even if you have to use Iso all the time (I am not sure why), you certainly don't need to paralyze every patient to achieve good surgical conditions, you just need to learn how use other drugs to deepen your anesthetic: Narcotics, IV hypnotics, regional anesthetics..... and to better time your vapor administration.
The purpose of your anesthetic is not to only achieve amnesia, you are also supposed to attenuate the physiological responses to pain and these responses include voluntary and involuntary movements, autonomic changes, hormonal changes, and inflammatory changes.
It's not only about amnesia.

 

[Bertelman]

I don't use the gas to keep patients from moving, that's what NMB is for. I use the gas to keep the patient asleep and prevent recall, and that occurs before 1 mac. Maybe I'm biased because where I train all we mostly use is iso, so if I run the 1.2 mac needed to keep 95% of people from moving they're going to be blowing it off all day.

I invite you to visit my program and work with the attending that willed me to do a subtotal colectomy with sux only.

 

[Noyac]

😕
So, you basically can't give a general anesthetic without muscle relaxants?
Do you ever do cases where the patient is breathing spontaneously?
Are you really being taught that the only way to prevent patients from moving in response to surgical stimulus is by keeping them paralyzed?
Even if you have to use Iso all the time (I am not sure why), you certainly don't need to paralyze every patient to achieve good surgical conditions, you just need to learn how use other drugs to deepen your anesthetic: Narcotics, IV hypnotics, regional anesthetics..... and to better time your vapor administration.
The purpose of your anesthetic is not to only achieve amnesia, you are also supposed to attenuate the physiological responses to pain and these responses include voluntary and involuntary movements, autonomic changes, hormonal changes, and inflammatory changes.
It's not only about amnesia.

Might I add another purpose. To maximize surgical conditions.

 

[bigeyedfish]

😕
So, you basically can't give a general anesthetic without muscle relaxants?
Do you ever do cases where the patient is breathing spontaneously?
Are you really being taught that the only way to prevent patients from moving in response to surgical stimulus is by keeping them paralyzed?
Even if you have to use Iso all the time (I am not sure why), you certainly don't need to paralyze every patient to achieve good surgical conditions, you just need to learn how use other drugs to deepen your anesthetic: Narcotics, IV hypnotics, regional anesthetics..... and to better time your vapor administration.
The purpose of your anesthetic is not to only achieve amnesia, you are also supposed to attenuate the physiological responses to pain and these responses include voluntary and involuntary movements, autonomic changes, hormonal changes, and inflammatory changes.
It's not only about amnesia.

No professor. My point was that you can give an adequate anesthetic with less than one mac of agent.

 

[bigeyedfish]

I invite you to visit my program and work with the attending that willed me to do a subtotal colectomy with sux only.

I have some staff that are similar. There is certainly more than one way to skin a cat.

 

[Planktonmd]

][/COLOR]No professor. My point was that you can give an adequate anesthetic with less than one mac of agent.

Do i detect some sarcasm here?
You said that you don't use vapors to prevent movement because "that's what muscle relaxants are for".
This seems to indicate that you use muscle relaxants to make an inadequate anesthetic look good which is not how I define a good anesthetic, but that's my opinion and you are welcome to ignore it if it doesn't appeal to you "professor".

 

[Gern Blansten]

This is supposed to be an anonymous forum, but plankton's cover is blown.

 

[Planktonmd]

How did you know??

This is supposed to be an anonymous forum, but plankton's cover is blown.

 

[jennyboo]

1) one colleague stated that surgeons have the best view of patient relaxation and that I should think about supplementing relaxation despite TOF monitoring (even if it means giving an antagonist or waiting some time after finishing the case).

If they are looking through an open thorax or abdomen directly at the diaphragm and they see it twitching with their own eyes, then they get a point: patient is not 100% relaxed. Sometimes there is nothing you can do about it anyway (the diaphragm twitches before your twitch monitor does) unless you have time to give deep paralysis, lose all twitches, and lose all ability to reverse neuromuscular blockade.

Otherwise, I disagree with your colleague. Oftentimes it's the surgeon's imagination. Gynecologists in particular are extremely... imaginative.

2) Another colleague said that he would have done the same (propofol, sevo, sufenta)

Yes, I agree this was a perfectly appropriate thing to do.

3) The last colleague stated that he would have given mivacurium

Had you known that there would be 20 minutes for certain, you could have easily given cisatracurium 2mg and still had at least a twitch by the time the surgeons were done.

If it's a reasonable surgeon (some gynecologists often aren't, sorry to say) you could also ask, "How many minutes do you need more paralysis for? 5 minutes? Or 20 minutes?" If they tell you 20 minutes and you paralyze and they finish early, it's their fault. Succinylcholine (suxamethonium) bolus for 5 minutes or infusion for 20 minutes are also options (not sure many people ever do sux infusion but it's doable).

We don't have mivacurium in the US so don't know how to use it.

 

[jennyboo]

2- Incompetent surgeon: There is nothing you can do about that.

So true.

 

[Bertelman]

... If they tell you 20 minutes and you paralyze and they finish early, it's their fault.

I don't care who's at fault. The surgeon is off eating a muffin while I/you/we are waiting for twitches in the OR.

 

[bigeyedfish]

Do i detect some sarcasm here?
You said that you don't use vapors to prevent movement because "that's what muscle relaxants are for".
This seems to indicate that you use muscle relaxants to make an inadequate anesthetic look good which is not how I define a good anesthetic, but that's my opinion and you are welcome to ignore it if it doesn't appeal to you "professor".

Fair enough, professor.