NMBA reversal

[jetproppilot]

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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.

So lets say you're finishing up an ACL on a twenty year old Tulane football star.

You did it under general because you're a member of S.A.R.A.

He's reversed....holding a pretty good tidal volume, but you arent quite ready to extubate.

And he is sleepier than you anticipated, since he's received only 150ug fentanyl for a 2 hour case.

Regardless, despite his good ventilatory pattern, you feel like waiting to pull the tube.

ETCO2 holding steady at 58.

Orthopedist has 4 knee scopes to go. Has to follow himself....no other rooms available.

Will you T piece him to the PACU?

 

[urgewrx]

So lets say you're finishing up an ACL on a twenty year old Tulane football star.

You did it under general because you're a member of S.A.R.A.

I have worked with a lot of top end professional athlete stars. They always get GA. You don't want to risk a nerve injury and ruin their career. Not even by chance.

In this case I don't thinks it's a whim to do GA.

 

[jetproppilot]

I have worked with a lot of top end professional athlete stars. They always get GA. You don't want to risk a nerve injury and ruin their career. Not even by chance.

In this case I don't thinks it's a whim to do GA.

Thats not the point of my post though, Urge.

INTUBATE has raised issues about ETCO2 monitoring.

And the lack of said monitoring in the PACU.

So I posed the above clinical situation....

ASA 1, ventilating as described, ETCO2 in the high fifties....

orthopedist with cases to follow....

CAN WE T PIECE IT TO THE PACU??????

 

[Intubate]

Thats not the point of my post though, Urge.

INTUBATE has raised issues about ETCO2 monitoring.

And the lack of said monitoring in the PACU.

So I posed the above clinical situation....

ASA 1, ventilating as described, ETCO2 in the high fifties....

orthopedist with cases to follow....

CAN WE T PIECE IT TO THE PACU??????

This isn't the same situation as before, but I'll give my answer...
You CAN t-piece it to the PACU, but I wouldn't. I'd assist the guy for a few more minutes until he was awake enough to ventilate himself out of his acidemia and awake enough to be extubated. Is it going to hurt him to go to the PACU with a pH of 7.2? Probably not. But its not ideal. Would you just "t-piece it" to the pacu if it was your wife having surgery, or would you try to normalize her physiology and wake her up? The surgeon can wait.
I don't really want to argue with you, and you seem to be getting angry. It comes down to a matter of style, I guess.

 

[urgewrx]

Thats not the point of my post though, Urge.

Attempted thread hijack FAILED!!

 

[jetproppilot]

This isn't the same situation as before, but I'll give my answer...
You CAN t-piece it to the PACU, but I wouldn't. I'd assist the guy for a few more minutes until he was awake enough to ventilate himself out of his acidemia and awake enough to be extubated. Is it going to hurt him to go to the PACU with a pH of 7.2? Probably not. But its not ideal. Would you just "t-piece it" to the pacu if it was your wife having surgery, or would you try to normalize her physiology and wake her up? The surgeon can wait.
I don't really want to argue with you, and you seem to be getting angry. It comes down to a matter of style, I guess.

No anger here.

Just posed a clinical scenerio that occurs very frequently, where a T piece can help you.

My wife could handle an ETCO2 in the fifties/sixties without an issue.

 

[fakin' the funk]

you add nothing to this discussion.

No crap, but I find that "doctoer" guy hilarious.

 

[leaverus]

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.

Hi, sorry to resurrect this thread as it's been a few days, but i'm curious about this post and have a question. I'm a resident and as i understand it, reversal doesn't do anything to the NMB; it just provides more ACh to compete against the antagonist. To me this means that Neostigmine only makes the patient strong enough at emergence to be extubated. Which means that in the PACU, the patient can still turn to floppy **** after the hour or so that reversal lasts if there's still vec/roc hanging around, yes? So why should it matter if your patient meets extubation criteria with or without reversal?

 

[urgewrx]

ABSENCE OF "RECURARIZATION" IN PATIENTS WITH DEMONSTRATED PROLONGED NEUROMUSCULAR BLOCK

CHINGMUH. LEE, M.D., MARTIN. S. MOK, M.D., ANGELINE. BARNES, M.D. and RONALD. L. KATZ, M.D. Department of Anesthesiology, Harbor General Hospital Campus, UCLA School of Medicine Los Angeles, California 90024, U.S.A.
The possibility of "recurarization" after antagonism of the competitive neuromuscular block with anticholinesterases was studied. Observations were made on the time-course of the block in five patients at risk from recurarization because of multiple organ failure and who demonstrated unusually prolonged blockade. In none of these patients did the block recur. We conclude that, provided spontaneous recovery of neuromuscular transmission has made progress before the antagonism, and that the patient does not deteriorate or become exhausted afterwards, recurarization is unlikely.

 

[urgewrx]

Recurarization is a theoretical possibility, but under study conditions it has never been observed. Authorities in the subject will say it never happens.

There are a few case reports of weak patients on PACU where recurarization has been blamed, but you know how reliable case reports can be.

 

[Laurel123]

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.

Hi Dr. Doze and others,

During residency, I had some attendings tell me that if you give 'too much' neostigmine, as in a 5 mg dose when a patient does not have any residual NMB on board, that patients can actually develop weakness later. I remember looking through my textbooks at the time and not finding anything about that. I know that there is cholinergic crisis that can result from NDNMB taken by myasthenic patients that can result in weakness.

Anyhow, I had a patient recently that has some sort of nose surgery. He was obese with OSA, DM and HTN, and I gave him 5 of vec and intubated him. After two hours, I had him breathe on his own, and the twitch moniter showed a good tetanus, but I reversed him anyways, because I wanted to give him every chance to not have respiratory issues. He held his head up, followed commands and I extubated him. In the PACU, he was really drowsy and even after two hours in the PACU he just layed there, maintaining his sats, but taking smallish breaths. So I went to go look at him, and he was floppy - 3/5 strength in all four extremities and blurry vision. Drowsy, but arousable. This is now five hours since 5mg of vec.

Any thoughts?

I ended up sending him to the hospital via ambulance to get lytes and CBC, but they were all normal.

 

[rmh149]

Hi Dr. Doze and others,

During residency, I had some attendings tell me that if you give 'too much' neostigmine, as in a 5 mg dose when a patient does not have any residual NMB on board, that patients can actually develop weakness later. I remember looking through my textbooks at the time and not finding anything about that.

Too much neostigmine could actually cause an excess of acetylcholine produced by the inhibition of AChE at the NMJ causing desensitization (acetylcholine-induced block). Depending on what you read...you have to give way more than you would ever need in the clincal setting. Others say that clinical doses can produce this effect.

 

[CremeSickle]

Yup

We call it a "floppy" patient where im at.

I tailor my neostigmine/glyco for every pt specifically. I dont believe in mixing them since the glyco takes up to 3 minutes to kick in. I am especially careful in the pt with slow HR due to BBlockers.