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Surgeons and Neuromuscular blockade.

anes

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Nov 9, 2012
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Working in the orthopedic room I frequently get asked by the orthopods "is the patient fully relaxed". If I respond with anything other than "the patient has zero twitches" they ask for more neuromuscular blockade. Frequently I'll just unplug the twitch monitor and say that the patient is fully relaxed, but in reality wont make any changes. All of a sudden they're able to carry on with the procedure with no further issues. Some of the better surgeons never ask for neuromuscular blockade, however some of the younger ones require it for all cases.

The other day we had a case of a patient with an acute distal radius fracture who refused regional anesthesia. We decided to proceed with an LMA. In the middle of the case the orthopod looks up and asks if the patient is fully relaxed. We told them that the patient wasn't relaxed, and wasn't intubated, and if they needed paralysis the patient would require intubation. They replied "We want full relaxation for all of our procedures". After saying this they proceeded and finished the case in 15 minutes.

How do you guys handle this situation? Do you guys cave and paralyze the patient? Do you deepen your gas? Or do you do nothing and pretend like you've made changes?
 

caligas

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You can always just say the pt is relaxed, just be sure they are not going to move: plenty of gas/narcotic. I work with a neurosurgeon who not only wants relaxation, he wants absolutley no muscle response to heavy bovie use in the paraspinal muscles during initial disection for spine fusion cases. Even with no twitches there can still be some localized muscle twitching with the bovie around the spine. Usually I just give in and give more roc since there will be plenty of time for things to wear off before emergence, but the neuromonitoring people hate it.
 

jwk

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WIth the orthopods, just answer "yes". They won't know the difference. As you've noted, "the better surgeons" don't ask.

But your post brings up another interesting concept - why not give NMBs to a patient with an LMA?
 
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pgg

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Just because they ask for it doesn't mean you have to give it. There's nothing wrong or dumb about a surgeon asking us for something that helps them. They don't know the details of our job or all the things we consider when we give drugs; they just want the patient to be floppy. I admit I do have to bite my tongue a bit when they're working distal to a tourniquet and ask for more muscle relaxant.

Saying no doesn't have to be adversarial. A simple "your conditions won't improve with more relaxant, and if I give more, it may delay extubation" ...

If I like the surgeon, I'll respond with "The day you can put an ex-fix on a bottle of roc is the day I'll let you choose the dose" ... and then they will usually say something about about Sudoko or a nurse doing my job.
 

anes

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WIth the orthopods, just answer "yes". They won't know the difference. As you've noted, "the better surgeons" don't ask.

But your post brings up another interesting concept - why not give NMBs to a patient with an LMA?

I know they've used paralytics with LMA's in europe. And it's probably okay... if everything goes well.

However, what happens if the patient is turned away from you and LMA loses its seal? What if the patient develops bronchospasm and cannot be ventilated with PPV through the LMA? What if the patient aspirates?

I think if those things happen (especially in America) you'll have a hard time explaining yourself in court. The reason we don't use paralytics (usually) with LMA's is probably defensive medicine.
 

pgg

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I know they've used paralytics with LMA's in europe. And it's probably okay... if everything goes well.

However, what happens if the patient is turned away from you and LMA loses its seal? What if the patient develops bronchospasm and cannot be ventilated with PPV through the LMA? What if the patient aspirates?

I think if those things happen (especially in America) you'll have a hard time explaining yourself in court. The reason we don't use paralytics (usually) with LMA's is probably defensive medicine.

There is absolutely nothing wrong with using paralytics with LMAs.

If you're worried about a patient being turned away and an LMA losing its seal, you should've put a tube in.

How is a NMB-relaxed MA patient developing bronchospasm worse than a non-NMB-relaxed patient developing bronchospasm?

What does muscle relaxant or lack thereof have to do with bronchospasm risk or aspiration risk in an otherwise properly anesthetized patient?


The reason most people don't use paralytics with LMAs has more to do with losing the primary benefit of the LMA in the first place - a simplified anesthetic with a spontaneously breathing patient.

Actually, as often as not, for LMA cases I just put the patient on the vent anyway. And I use desflurane too. :)
 

nap$ter

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the answer is "yes, no, or i'll check". never mention twitches to a surgeon. it will only complicate your life.

the surgeon doesn't want a lecture on the meaning of x/4 twitches and percent receptor occupancy. what they're really asking you is whether you can do something to further optimize muscular relaxation to facilitate operating conditions. you make the choice about what solution if any you can offer.

neuromuscular blockade isn't the only muscle relaxant - as you pointed out volatile and propofol also work well.

paralytic is not contraindicated with an LMA - all of the "what-ifs" you mentioned exist whether the patient is paralyzed or not - those are the inherent risks of an LMA.

i personally don't lie to surgeons. i pick my battles rarely and carefully, and the timing of those conversations is rarely intraop. lying to a surgeon may get you caught, and is acting like a little kitty-kat IMHO.
 

Idiopathic

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i give my LMA patients pressure support but want them all to be spontaneously breathing. i do not like to place them on mechanical ventilation, because of the likelihood of ventilating the stomach and the possibility of regurgitation of gastric contents. agree that the airway is not protected any better with no paralytic, but if i can reduce the positive pressure to the stomach, i may reduce the risk of regurgitation, PONV, etc.

they want muscle relaxation to help align their fractures, or reduce the bigger ones, i dont see a problem with it. part of our job is helping facilitate the surgical repair. my favorite is when they complain about relaxation when the tourniquet is up - as if anything i gave now or measured elsewhere would have any bearing on the muscle contraction in the ischemic/occluded limb
 

Idiopathic

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Just tell them, "if he was any more relaxed, he'd be in a smoking jacket."
It doesn't really answer the question one way or another. They'll just laugh and keep drilling.

when they ask how many twitches i tell me residents to respond with "fourteen" and wait for the looks.
 

RemyMcswain

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More important question...

What do you do when the OB asks you "Is the patient relaxed?" for the C-section under spinal?

Had that exact situation. And no she was not referring to the Uterus.

I asked the patient, "are you relaxed" and the patient replied earnestly "yes, very relaxed."

Then told the PGY4, "yes patient says shes relaxed." OB blushed.
 

WholeLottaGame7

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Right here.
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Working in the orthopedic room I frequently get asked by the orthopods "is the patient fully relaxed". If I respond with anything other than "the patient has zero twitches" they ask for more neuromuscular blockade. Frequently I'll just unplug the twitch monitor and say that the patient is fully relaxed, but in reality wont make any changes. All of a sudden they're able to carry on with the procedure with no further issues. Some of the better surgeons never ask for neuromuscular blockade, however some of the younger ones require it for all cases.

The other day we had a case of a patient with an acute distal radius fracture who refused regional anesthesia. We decided to proceed with an LMA. In the middle of the case the orthopod looks up and asks if the patient is fully relaxed. We told them that the patient wasn't relaxed, and wasn't intubated, and if they needed paralysis the patient would require intubation. They replied "We want full relaxation for all of our procedures". After saying this they proceeded and finished the case in 15 minutes.

How do you guys handle this situation? Do you guys cave and paralyze the patient? Do you deepen your gas? Or do you do nothing and pretend like you've made changes?

How does the saying go? "Good surgeons don't need paralysis, bad surgeons don't deserve it"?
 

gasp

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Sep 13, 2009
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Working in the orthopedic room I frequently get asked by the orthopods "is the patient fully relaxed". If I respond with anything other than "the patient has zero twitches" they ask for more neuromuscular blockade. Frequently I'll just unplug the twitch monitor and say that the patient is fully relaxed, but in reality wont make any changes. All of a sudden they're able to carry on with the procedure with no further issues. Some of the better surgeons never ask for neuromuscular blockade, however some of the younger ones require it for all cases.

The other day we had a case of a patient with an acute distal radius fracture who refused regional anesthesia. We decided to proceed with an LMA. In the middle of the case the orthopod looks up and asks if the patient is fully relaxed. We told them that the patient wasn't relaxed, and wasn't intubated, and if they needed paralysis the patient would require intubation. They replied "We want full relaxation for all of our procedures". After saying this they proceeded and finished the case in 15 minutes.

How do you guys handle this situation? Do you guys cave and paralyze the patient? Do you deepen your gas? Or do you do nothing and pretend like you've made changes?

Ortho surgeons like to ask this question. There are some procedures which may have better outcomes if the muscles are fully relaxed, in that case its fine. However most of these guys are now asking for almost ANY procedure if the patient is relaxed, which sometimes get ridiculous.

I once had a patient who was getting a procedure done under spinal/mac and the ortho resident was having a hard time cause he sucked so he said (in a real pissy tone) "c'mon man is the f***ing patient relaxed??" The pt was fully awake and said "I am relaxed !! and you best relax too foo.." That was a good day..
 

jwk

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Apr 30, 2004
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I know they've used paralytics with LMA's in europe. And it's probably okay... if everything goes well.

However, what happens if the patient is turned away from you and LMA loses its seal? What if the patient develops bronchospasm and cannot be ventilated with PPV through the LMA? What if the patient aspirates?

I think if those things happen (especially in America) you'll have a hard time explaining yourself in court. The reason we don't use paralytics (usually) with LMA's is probably defensive medicine.

These are problems inherent with LMA use in general, and not really related to PPV.

Do you ever watch and see how much positive pressure you generate by simply masking the patient prior to intubation? It's generally a good bit more than what I'm using if I throw the patient on pressure support with an LMA. If aspiration is truly a concern, then an ETT is the appropriate action.
 
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