Neostigmine Paradoxical Muscle Relaxation

[JWebar]

Hey guys... Im in need of some help here.
I've read that you should watch the dose of Neostigmine in patients with partial reversal of muscle blockade (TOF > 0.4 and specially > 0.7) cause there is risk of paradoxical muscle relaxation. The same occurs if you give it to a patient without muscle relaxation.

Whats the mechanism behind these paradoxical reaction?

PD: I have the same question about Benzodiazepines paradoxical agitation, just in case you can algo help me with that one

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[BLADEMDA]

Anesthesiology. 2010 Dec;113(6):1280-8. doi: 10.1097/ALN.0b013e3181f70f3d.
Neostigmine/glycopyrrolate administered after recovery from neuromuscular block increases upper airway collapsibility by decreasing genioglossus muscle activity in response to negative pharyngeal pressure.
Herbstreit F1, Zigrahn D, Ochterbeck C, Peters J, Eikermann M.
Author information

Abstract
BACKGROUND:
Reversal of residual neuromuscular blockade by acetylcholinesterase inhibitors (e.g., neostigmine) improves respiratory function. However, neostigmine may also impair muscle strength. We hypothesized that neostigmine administered after recovery of the train-of-four (TOF) ratio impairs upper airway integrity and genioglossus muscle function.

METHODS:
We measured, in 10 healthy male volunteers, epiglottic and nasal mask pressures, genioglossus electromyogram, air flow, respiratory timing, and changes in lung volume before, during (TOF ratio: 0.5), and after recovery of the TOF ratio to unity, and after administration of neostigmine 0.03 mg/kg IV (with glycopyrrolate 0.0075 mg/kg). Upper airway critical closing pressure (Pcrit) was calculated from flow-limited breaths during random pharyngeal negative pressure challenges.

RESULTS:
Pcrit increased significantly after administration of neostigmine/glycopyrrolate compared with both TOF recovery (mean ± SD, by 27 ± 21%; P = 0.02) and baseline (by 38 ± 17%; P = 0.002). In parallel, phasic genioglossus activity evoked by negative pharyngeal pressure decreased (by 37 ± 29%, P = 0.005) compared with recovery, almost to a level observed at a TOF ratio of 0.5. Lung volume, respiratory timing, tidal volume, and minute ventilation remained unchanged after neostigmine/glycopyrrolate injection.

CONCLUSION:
Neostigmine/glycopyrrolate, when administered after recovery from neuromuscular block, increases upper airway collapsibility and impairs genioglossus muscle activation in response to negative pharyngeal pressure. Reversal with acetylcholinesterase inhibitors may be undesirable in the absence of neuromuscular blockade.

 

[BLADEMDA]

https://books.google.com/books?id=L...enioglossus weakness with neostigmine&f=false

Most Anesthesiologists use Qualitative Monitoring in the USA if they use anything at all.

 

[BLADEMDA]

Paradoxical reactions to benzodiazepines are relatively uncommon and occur in less than 1% of patients. The exact mechanism of paradoxical reactions remains unclear. Most cases are idiosyncratic; however, there is some evidence that these reactions may occur secondary to young or advanced age, a genetic link, history of alcohol abuse, or psychological disturbances, particularly those associated with a history of anger and aggressive behavior. The excitatory reactions that may occur, including excessive talkativeness, movement, and emotional release, can prevent the performance of such procedures as gastrointestinal endoscopy. Reactions have occurred in both adults and children; however, clinical data have not identified differences in the presentation or treatment of these reactions between the two populations. Flumazenil, a benzodiazepine antagonist, has been shown to manage these reactions successfully with minimal adverse effects. As more information is learned regarding the mechanism of paradoxical reactions to benzodiazepines, better treatment options may become available.


Paradoxical Reactions to Benzodiazepines: Literature Review and Treatment Options
Carissa E. Mancuso, PharmD, Maria G. Tanzi, PharmD, Michael Gabay, PharmD

Disclosures
Pharmacotherapy. 2004;24(9)

 

[BLADEMDA]

Benzodiazepines stimulate the effect of gamma-aminobutyric acid (GABA) in the ascending reticular activating system. Paradoxical reactions have been described for many drugs that interact with the GABA receptor,[3] including barbiturates, volatile anesthetics, and etomidate. There are different theories concerning the mechanism of paradoxical reactions, involving a central cholinergic effect or the serotonin imbalance, although the exact mechanism of paradoxical reactions remains unclear. Most cases are idiosyncratic; however, some evidence suggests that these reactions may occur secondary to a genetic link, history of alcohol abuse, or psychological disturbances.[4,5]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938526/

 

[RK.md]

Whats the mechanism behind these paradoxical reaction?

The way I like to think about the paradoxical block with excess neostigmine is akin to a phase II block achieved by high doses of sux. You end up having significantly high levels of agonist (in the case of neostigmine, you end up with excess acetylcholine) which bind more nicotinic endplate receptors for relatively longer periods of time effectively extending the refractory period (hyperpolarized) state. More hyperpolarization = less excitation = more neuromuscular relaxation.

 

[pgg]

Neostigmine is a nerve agent / pesticide. A judiciously small dose in the context of a partial acetylcholine blockade (ie when we reverse NMBDs) improves transmission at the NMJ and restores strength.

The glyco/atropine we give with it just counters the undesired muscarinic effects.

In the absence of that blockade you're just getting the nicotinic effects of a whiff of sarin. Easy to see how that would cause weakness ...

 

[GassmanMD]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to hear some opinions.

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. Case lasted about an hour to an hour and a half. CRNA said the patient had 4 twitches before receiving 3mg of neostigmine. The CRNA then extubated the patient, but the patient was not pulling in adequate tidal volumes and was somnolent. She gave flumazenil and then another 3mg of neostigmine (6mg total). 1mg of versed had been administered preop. By the time she called for help and I arrived she was bagging the patient and asking for suggamedex. I could elicit 4 strong twitches and no real discernible fade on tetany, although maybe a little, was hard to tell. The patient was breathing spontaneously but very low tidal volumes and was tachypnic, somnolent and slow to follow commands. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

 

[drmwvr]

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

What does "relatively healthy" mean? Was she cold? OSA? Residual capnoperitoneum? Sub cut. CO2?

 

[GassmanMD]

What does "relatively healthy" mean? Was she cold? OSA? Residual capnoperitoneum? Sub cut. CO2?

I said relatively healthy because she didn't have any major medical problems or at least nothing I discerned from the brief history I received from the CRNA. No OSA though. Did not check her temperature. How do you check for capnoperitoneum?

 

[fakin' the funk]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to here some opinions.

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. Case lasted about an hour to an hour and a half. CRNA said the patient had 4 twitches before receiving 3mg of neostigmine. The CRNA then extubated the patient, but the patient was not pulling in adequate tidal volumes and was somnolent. She gave flumazenil and then another 3mg of neostigmine (6mg total). 1mg of versed had been administered preop. By the time she called for help and I arrived she was bagging the patient and asking for suggamedex. I could elicit 4 strong twitches and no real discernible fade on tetany, although maybe a little, was hard to tell. The patient was breathing spontaneously but very low tidal volumes and was tachypnic, somnolent and slow to follow commands. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

Average size lady = 60kg. 3mg neostigmine = 50 mcg/kg; too much for 4 twitches (fade? tetany? not perfect but helpful). 6mg neostigmine = 100 mcg/kg; ridiculous. CRNA extubated pt with inadequate tidal volumes. Inappropriate neostigmine dosing and poor decision making are more common than pseudocholinesterase deficiency. Of course, we'll never know, because the CRNA didn't observe the spontaneous TV's.

 

[GassmanMD]

Average size lady = 60kg. 3mg neostigmine = 50 mcg/kg; too much for 4 twitches (fade? tetany? not perfect but helpful). 6mg neostigmine = 100 mcg/kg; ridiculous. CRNA extubated pt with inadequate tidal volumes. Inappropriate neostigmine dosing and poor decision making are more common than pseudocholinesterase deficiency. Of course, we'll never know, because the CRNA didn't observe the spontaneous TV's.

Good points. It is so strange seeing how some practice and being exposed to scenarios you would never put yourself in. I wasn't sure what to do, give atropine? The heart rate was in the 120s, which further confused the situation. Guess I'll never know if it was neostigmine overdose, but I am curious if anyone thinks this could have been a result of residual neuromuscular blockade?

 

[Iso4ane]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to hear some opinions.
Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

I swear, I had a bad batch of neostigmine once, patient went from 3 twitches to 4 with fade, but back on point, if it was residual roc, Sugammadex kicks in way faster that that.

 

[Planktonmd]

Neostigmine is a nerve agent / pesticide. A judiciously small dose in the context of a partial acetylcholine blockade (ie when we reverse NMBDs) improves transmission at the NMJ and restores strength.

The glyco/atropine we give with it just counters the undesired muscarinic effects.

In the absence of that blockade you're just getting the nicotinic effects of a whiff of sarin. Easy to see how that would cause weakness ...

Nice explanation.

 

[Planktonmd]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to hear some opinions.

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. Case lasted about an hour to an hour and a half. CRNA said the patient had 4 twitches before receiving 3mg of neostigmine. The CRNA then extubated the patient, but the patient was not pulling in adequate tidal volumes and was somnolent. She gave flumazenil and then another 3mg of neostigmine (6mg total). 1mg of versed had been administered preop. By the time she called for help and I arrived she was bagging the patient and asking for suggamedex. I could elicit 4 strong twitches and no real discernible fade on tetany, although maybe a little, was hard to tell. The patient was breathing spontaneously but very low tidal volumes and was tachypnic, somnolent and slow to follow commands. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

Most likely the CRNA did not tell you what else was given to the patient before you walked in the OR.

 

[pgg]

Most likely the CRNA did not tell you what else was given to the patient before you walked in the OR.

Yeah, from a distance this sounds like garden-variety "too much anesthesia", probably opiates. Occam's Razor and all. A little naloxone might've had better results.

 

[Noyac]

It is my opinion that people routinely give to large of a dose of reversal.
I seriously doubt that this pt even needed any reversal.
But I think something else was going on at first. Then after the mega dose of reversal the picture became even more blurred.

 

[Urzuz]

Couldn't have been pseudocholinesterase deficiency if you actually believe that the patient had four strong twitches prior to administering neostigmine...especially if it had only been an hour after succinylcholine administration.

Too much opioids/other anesthetics is my bet. Additionally, as someone else alluded to, why don't we know what her TVs were PRIOR to extubation...?! And asking for suggamadex after giving a humongous dose of neostigmine AFTER the patient supposedly had four twitches...and not knowing if the patient had twitches prior to administering rocuronium...I'm speechless.

I really feel bad for everyone that has to manage CRNAs...what a @$&!ing chore.

 

[propadope]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to hear some opinions.

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. Case lasted about an hour to an hour and a half. CRNA said the patient had 4 twitches before receiving 3mg of neostigmine. The CRNA then extubated the patient, but the patient was not pulling in adequate tidal volumes and was somnolent. She gave flumazenil and then another 3mg of neostigmine (6mg total). 1mg of versed had been administered preop. By the time she called for help and I arrived she was bagging the patient and asking for suggamedex. I could elicit 4 strong twitches and no real discernible fade on tetany, although maybe a little, was hard to tell. The patient was breathing spontaneously but very low tidal volumes and was tachypnic, somnolent and slow to follow commands. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

Flumazenil after 1mg of versed in the preop? WTF?

 

[GassmanMD]

I actually did try naloxone but it didn't change anything, especially given the tachypnea and the pupil size, doubt that is was the narc.

She is one of our best CRNAs, works really hard and knows when to call for help, so working with her is a dream. I think moments like this are unfortunate but they happen.

 

[DrZzZz]

I actually did try naloxone but it didn't change anything, especially given the tachypnea and the pupil size, doubt that is was the narc.

She is one of our best CRNAs, works really hard and knows when to call for help, so working with her is a dream. I think moments like this are unfortunate but they happen.

Is she the only CRNA at your place? Between the insane dose of neo and the flumazenil after what little benzo the patient got....your group needs to clean house if she's one your BEST CRNAs

 

[deleted171991]

I think a CRNA might have experienced this phenomenon today. Never seen it before, not sure if it was the neostigmine, but I would like to hear some opinions.

It was a 59 yr old, relatively healthy, average size lady having a lap chole. Got suxx for intubation then 20mg of rocuronium after intubation. Case lasted about an hour to an hour and a half. CRNA said the patient had 4 twitches before receiving 3mg of neostigmine. The CRNA then extubated the patient, but the patient was not pulling in adequate tidal volumes and was somnolent. She gave flumazenil and then another 3mg of neostigmine (6mg total). 1mg of versed had been administered preop. By the time she called for help and I arrived she was bagging the patient and asking for suggamedex. I could elicit 4 strong twitches and no real discernible fade on tetany, although maybe a little, was hard to tell. The patient was breathing spontaneously but very low tidal volumes and was tachypnic, somnolent and slow to follow commands. I didn't feel comfortable giving the suggamedex in the situation because I was pretty convinced this was neostigmine overdose, so I called the supervising MD. This wasn't my case, I was just passing by when help was called. When my partner arrived, he thought maybe pseudocholinesterase deficiency, which was a good thought. The patient has had surgery in the past but there were no records to review to see if she had received suxx. Well anyways, they ended up administering the suggamedex, and nothing really changed at first, the twitches looked pretty much exactly the same to my eye. Maybe 5 minutes later the tidal volumes improved and the patient began following commands better, but still seemed a little slow. Who knows what it was, but what are your thoughts?

Residual muscle relaxation does not cause "somnolence". If you have TOF 4/4 and sustained tetany, it's not a muscle strength issue, as proven by the lack of change with suggamadex. It was probably a residual anesthetic/CO2 narcosis issue. Also, do NOT give flumazenil unless you have ruled out everything else. It can cause seizures. Definitely not after just 1 mg of Versed.

I haven't read the rest of the answers yet, but this just jumps out to me. Oh, and the fact that the CRNA should be gone at the first opportunity. She's nice because she knows she's not too bright.

 

[IlDestriero]

Pseudocholinesterase deficiency leaves you with profound paralysis. 4/4 strong twitches w/o discernible fade means you're not going to have clinically significant weakness to the point the patient can't pull adequate tidal volumes. Double dose neo was clearly wrong here and may have worsened the problem.
This is CO2 narcosis, almost certainly, on top of residual anesthetics, and ****ty management.
Reversing 1mg of midaz? Really? Double dose of neo when the patient showed no evidence of paralysis? Suggamedex? WTF are they treating?
Stupid. What we call stupid the attorneys call malpractice BTW.
Her differential diagnosis list is missing a lot of actual possible causes of this lady's problems and potential treatments.
She probably pulled the tube deep, didn't pay attention to the already elevated CO2, and then ignored the shallow breathing for a while. Then it's narcosis time. Add some atelectasis, residual pneumoperitoneum, wasted time not calling someone who might know an actual DDX for the problem, ineffective treatment, more wasted time, and there you are.
That's why she miraculously got better after a few minutes of BMV.
That's dangerous management and a lack of situational awareness and critical thinking. Poor judgement, not good CRNA material.
Hopefully you can look at her electronic anesthesia record, pull up the Q1 min recording and see what was really going on immediately prior to extubation.
I would have done a few things to this lady, none of which she seems to have even considered. At least she was bagging her. Was it good form with effective large TV breaths to affect gas exchange and remove CO2?
You really want this person managing your emergencies when you're not in the room? I wouldn't.
Go xerox a page on the differential for delayed emergence and give it to her. That's a good place to start.
Delayed Emergence from Anesthesia



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Il Destriero

 

[Southpaw]

Too easy to knock the CRNA in this case, and politics aside, all I'll say is that I enjoy not working with them. Each and every day I simply look in the mirror to find the person to blame when the anesthetic goes wrong.

This seems like pretty straightforward CO2 narcosis with residual anesthetic on board. Double dosing the neo in a patient who wasn't weak likely made things worse.

You say this wasn't your case, so where was the anesthesioligist? Not being there during emergence is at best poor care, and potentially billing fraud.

 

[Arch Guillotti]

Not being there during emergence is at best poor care, and potentially billing fraud.

It depends on your definition of emergence. Most anesthesiologists I know don't necessarily go to extubation.

 

[GassmanMD]

All very good points. CO2 narcosis could well have been the culprit, I am not sure if she was adequately ventilating the patient and who knows what else was going on before I arrived. We don't have an electronic intra-op record, so yeah....no way to check back and find out what was really happening.

I am newly out of residency and this is my first gig. I do my own cases 80% of the time, so I have not been in a supervisory role too many times. This was my first time experiencing something like this and frankly I was unprepared to deal with someone else's (mis)management. The nurses tend to do an OK job, but they over sedate and over dose the paralytics. Then they depend too much on flumazenil or narcan to recover.

 

[GassmanMD]

Too easy to knock the CRNA in this case, and politics aside, all I'll say is that I enjoy not working with them. Each and every day I simply look in the mirror to find the person to blame when the anesthetic goes wrong.

This seems like pretty straightforward CO2 narcosis with residual anesthetic on board. Double dosing the neo in a patient who wasn't weak likely made things worse.

You say this wasn't your case, so where was the anesthesioligist? Not being there during emergence is at best poor care, and potentially billing fraud.

We do medical supervision not direction. So don't have to be there for induction or emergence.

 

[nimbus]

All very good points. CO2 narcosis could well have been the culprit, I am not sure if she was adequately ventilating the patient and who knows what else was going on before I arrived. We don't have an electronic intra-op record, so yeah....no way to check back and find out what was really happening.

I am newly out of residency and this is my first gig. I do my own cases 80% of the time, so I have not been in a supervisory role too many times. This was my first time experiencing something like this and frankly I was unprepared to deal with someone else's (mis)management. The nurses tend to do an OK job, but they over sedate and over dose the paralytics. Then they depend too much on flumazenil or narcan to recover.

That's interesting because I've never used flumazenil and used narcan maybe 5 times in over 20years.

 

[GassmanMD]

That's interesting because I've never used flumazenil and used narcan maybe 5 times in over 20years.

I have never administered flumazenil either and narcan only once in the ICU. 4mg of versed preop is pretty routine here. And some people will even give versed and fentanyl in preop holding

 

[IlDestriero]

. The nurses tend to do an OK job, but they over sedate and over dose the paralytics. Then they depend too much on flumazenil or narcan to recover.

I supervise a lot of the time, and I give narcan or flumazenil maybe once or twice a year. Usually to undiagnosed OSA folks. If they routinely need it, that's another problem. They both can have significant side effects.


--
Il Destriero

 

[Urzuz]

I have never administered flumazenil either and narcan only once in the ICU. 4mg of versed preop is pretty routine here. And some people will even give versed and fentanyl in preop holding

4 mg of Versed?!?! Am I the only oddball that does NOT give Versed routinely? I use it for MAC cases and very VERY rarely in the super anxious person who is flying off the handles....everyone else gets a syringe full of propofol to calm their nerves.

 

[deleted171991]

4 mg of Versed?!?! Am I the only oddball that does NOT give Versed routinely? I use it for MAC cases and very VERY rarely in the super anxious person who is flying off the handles....everyone else gets a syringe full of propofol to calm their nerves.

Because you didn't go to "anesthesia" school. Amateur! The Versed for the patient is to calm the provider's nerves. Plus it doesn't drop their blood pressure like your propofol. Plus propofol cannot be reversed.

Best anesthesia is with fentanyl + versed + rocuronium. If you get into trouble, you just give narcan + flumazenil + sugammadex (drawn up in one syringe), and the next minute the patient is awake.

 

[IlDestriero]

1 syringe reversal... sweet.
Can we add 4 mg of zofran to it as well?


--
Il Destriero

 

[psychbender]

Best anesthesia is with fentanyl + versed + rocuronium. If you get into trouble, you just give narcan + flumazenil + sugammadex (drawn up in one syringe), and the next minute the patient is awake.

"Anesthesia, off!"


Sent from my SM-G920V using SDN mobile

 

[Southpaw]

We do medical supervision not direction. So don't have to be there for induction or emergence.

When I read this, I have a hard time faulting the nurses for saying they don't need us around. Through one side of our mouth we say we're needed as being in the OR is one of the most critical times of the patient's life, and from the other side of our mouths we say we don't need to be there at the most critical times. I'm not knocking you personally, but no one should question why there are bills all over the place to remove our supervision requirement.

You'll never see a surgeon say 'I don't need to be around when the operation is going on....as long as things are going well the nurse can handle it'.

 

[IlDestriero]

You'll never see a surgeon say 'I don't need to be around when the operation is going on....as long as things are going well the nurse can handle it'.

No they say the resident or PA can do it while they start another case, or get lunch, or surf for the latest M series add ons.


--
Il Destriero

 

[Aether2000]

In most locations (I go to 9) I do my own cases and much prefer that. Working with CRNAs is always a struggle in a surgery center, when they feel it is their duty to narcotize the hell out of patients at the end of a procedure, bring them into the PACU barely ventilating, then go home leaving me stuck trying to wake people up for several hours. Their thinking during surgery is monolithic with an extremely short list (if any at all) differential diagnoses that explain problems they encounter.

 

[fakin' the funk]

I have never administered flumazenil either and narcan only once in the ICU. 4mg of versed preop is pretty routine here. And some people will even give versed and fentanyl in preop holding

4mg of midazolam "routinely" for preop anxiolysis is unnecessary and ridiculous.