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Clinical Case for Discussion: One week before you graduate from anesthesia residency, you lose the peripheral nerve stimulator you use to monitor neuromuscular blockade. Should you bother to purchase another one?
Discussion: Fast forward to your first day in post-residency private practice. Your first case is a colectomy on an obese, 5 foot 2 inch, 100-kilogram male with adenocarcinoma of the sigmoid colon. You bring the patient into the operating room, anesthetize him with propofol, and inject 50 mg of rocuronium into his IV. You wait 90 seconds before intubating the trachea. The surgeon enters the room. After the Timeout, the patient is placed in lithotomy position. The surgeon performs a rectal exam and sigmoidoscopy under anesthesia.
“We’ve got a problem,” the surgeon announces. “The tumor has grown since my last exam, and it’s too close to the anus to treat with simple colectomy. He needs a total proctocolectomy, and I didn’t give him informed consent for that. We need to wake him up and come back another day.” He shrugs his shoulders, and walks out of the room. (Seem like an far-fetched scenario? It’s not–this exact incident happened to me at Stanford about 8 years ago.)
You are stunned. “Come back another day?” The circulating nurse shakes her head. She and the scrub tech are looking at you–waiting for you to wake up the patient. It’s only been twelve minutes since you injected the muscle relaxant, and you have no nerve stimulator. Being a resourceful Stanford graduate, you call another anesthesia attending and ask to borrow her nerve stimulator. When the nerve stimulator is delivered to you, you discover no twitches at either the patient’s facial nerve or ulnar nerve.
The nurse asks, “Is there a problem?”
You answer, “Not really, but I can’t wake up the patient until the muscle relaxant wears off further.” You decide to wait until one twitch returns before you administer neostigmine/glycopyrrolate reversal. You sit down, the nurse sits down, and the scrub tech scrubs out. The operating room seems absurdly quiet for thirty minutes while you wait to reverse the muscle relaxant. Forty minutes later, you extubate the trachea and take the patient to the Post Anesthesia Care Unit.
After you finish your Stanford residency, you need to be prepared for faster surgeons and shorter operative times. Overdosing patients with muscle relaxants is a common mistake when newly-trained anesthesiologists leave residency. The operative time for a laparoscopic appendectomy may be as little as fifteen minutes. A pediatric tonsillectomy may last only twelve minutes. An anterior cruciate ligament repair may last only 45 minutes.
In private practice, you will probably use modest doses of vecuronium or rocuronium when paralysis is necessary. If the surgeon finishes earlier than expected, you always want to be able to reverse muscle relaxation and awaken the patient without delay. Whenever appropriate, you will prefer to use an LMA instead of an endotracheal tube, partly because the LMA insertion does not require a muscle relaxant, and partly because it’s easier for the patient to breath spontaneously with an LMA.
How about the need for a nerve stimulator to monitor neuromuscular blockade? I polled the thirty-three private anesthesiology attendings at Stanford via email, regarding their practices using nerve stimulators and muscle relaxants. I learned the following: Most practitioners do not administer additional muscle relaxant following intubation unless surgical conditions demand it. Most practitioners do not reverse muscle relaxants if no dose was given in the last hour of a case.
Almost every private attending still owns a nerve stimulator. Half of the attendings use a nerve stimulator routinely whenever they administer muscle relaxants, but half the attendings use the device occasionally or rarely, relying on clinical criteria and judgment alone in regards to the level of neuromuscular blockade. Is this practice wise, or not?
The American Society of Anesthesiologists Standards for Basic Anesthesia Monitoring, posted on www.asahq.org, does not list the use of a peripheral nerve stimulator as a standard.
However, in Miller’s Anesthesia, 2008 Edition, Chapter 47 on Neuromuscular Monitoring, author Jørgen Viby-Mogensen makes the following statements:
- “Many anesthesiologists do not agree with extensive use of nerve stimulators and argue that they manage quite well without these devices. However, the question is not how little an experienced anesthetist can manage with but rather how to ensure that all patients receive optimal treatment.”
- “It is difficult and often impossible to exclude with certainty clinically significant residual curarization by clinical evaluation of recovery of neuromuscular function.”
The author further states that the following clinical tests of postoperative neuromuscular recovery are NOT reliable:
- Sustained eye opening
- Protrusion of the tongue
- Arm lift to the opposite shoulder
- Normal tidal volume
- Normal or nearly normal vital capacity
- Maximum inspiratory pressure less than 40 to 50 cm H2O
The author states that the following clinical tests of postoperative neuromuscular recovery ARE reliable:
- Sustained head lift for 5 seconds
- Sustained leg lift for 5 seconds
- Sustained handgrip for 5 seconds
- Maximum inspiratory pressure 40 to 50 cm H2O or greater
The author concludes that “Adequate recovery of postoperative neuromuscular function cannot be guaranteed without objective neuromuscular monitoring.”
In private practice in Palo Alto, most of us use a MiniStim unit Model MS-1B Miniature Nerve Stimulator (Life-Tech, Houston, Texas), a simple device with one red button for Tetanus, and one green button for Twitch. The MiniStim assessment of tetanus or twitch response is done by visual and tactile evaluation of muscle movement, with no quantitation of blockade.
Is there any good reason to avoid using a nerve stimulator? The benefit/risk ratio of using the device approaches infinity. If you ever lose it, you can purchase another one on the Internet for a mere $155. I’ve had my current unit for ten years, during which I’ve administered 7000 anesthetics. The cost of the MiniStim so far works out to be about 2 cents per case.
During residency or during the years afterward, a MiniStim and a stethoscope are arguably the only tools of your own you need to carry into an operating room to conduct a 21st-century general anesthetic.
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Is there a study that shows periodic or regular TOF monitoring over a long case with multiple re-dosing of intermediate acting relaxants affecting the accuracy of TOF monitor or/and other modalities like double burst stimulation together with clinical assessment at the end of the case in deciding if the patient has adequately recovered for extubation? I understand not using nerve stim to guide re-dosing may cause inability to extubate promptly. Time to exubate is not the issue at point. My query is about the reliability of the NM stim monitor at the end of the case prior to extubation without regular use intraop.
Related to this, is the question of when airway problems occur after extubation, does the anesthesia provider carry more legal liability because he/she was not using/ recording NM monitor regularly despite adequate clinical and NM monitoring evidence of full NM recovery at the end. This is the fear most practitioners have who are anal about NM monitoring.
Just as clinical signs are not accurate, NM stim monitors specially non-quantitative devices are not either in predicting with 100% accuracy that patient is fully recovered for extubation. The science is there but application for practical use is not perfect and requiring cumbersome routine use specially in this day and age of high turnover “do as many cases as you can in one day” is just not practical.
I wonder if the studies that cite airway problems because of residual NM blockers after extubation are mostly in Academic/ training hospitals and if the problem would be just as bad with experienced practitioners in private practice.
Usually, NM monitoring is most important at the time of extubation, to determine if the paralysis has been reversed. Yes I believe there is increased medical-legal liability if you’re not using a NM monitor at that time and then a patient has respiratory failure secondary to residual paralysis post-extubation.
I use a non-quantitative NM monitor, and I believe it is sufficiently accurate.
I’ve been very impressed with sugammadex as a reversal agent for paralysis prior to extubation. It should almost eliminate the occurrence of respiratory failure secondary to residual paralysis post-extubation.
I don’t know of any studies comparing private practice vs academic practice regarding respiratory failure secondary to residual paralysis post-extubation, but I know I had more frequent problems in training than I do now, primarily because I used higher doses of paralytic drugs in training. In training I was afraid the patient would move during surgery, and the surgical team would either be angry or would think I was incompetent. Now I rely on sufficient anesthetic depth rather than paralyzing every patient.
Thank you very much for your response but I don’t think my first question was answered adequately. Let me rephrase another way: If I use my NM monitor (non-quantitative) only at the end of the case right before extubation, and do not regularly use it throughout the case (relying on clinical signs and pharmacological knowledge )- Is there an actual study that proves the accuracy of the NM monitor at the end of case is unreliable? Or is this just an assumption by many clinicians and academicians who are medico-legal adverse specially in the US.
Many a times, there are airway issues after extubation that may not be caused by problems with residual muscle relaxant use. However, because on review of the anesthetic record, TOF monitoring was not recorded on a regular basis, although it was used and recorded at the end, before extubation, the blame is attributed to inadequate TOF monitoring.
Is this right?
I am not aware of any study that documents use of the NM only at the end of the case as unreliable.
Most anesthetic records I read or review do not have TOF data marked throughout the case.
If you use TOF monitoring at the time of extubation you are on firm ground. Your TOF result may or may not be documented on your anesthetic record. If you testify or state that the non-quantitative TOF was four strong twitches, that would be be safe, and in my opinion is standard of care.