NMBs and muscle twitching w/ Bovie

[Hork Bajir]

Long time lurker, first time poster. Been really enjoying all the excellent case discussions on here, so thought I'd jump in with my own question:

Thoracic surgeon at my shop insists he can tell when a patient is "inadequately relaxed" b/c the muscle fibers jump more when he bovies, even though the patient has 0 twitches (checked at facial nerve, which should be even more sensitive for 'inadequate' blockade). I tried explaining to him that no amount of NMB can abolish direct muscle stimulation from a supra-maximal stimulus (monopolar cautery), but he doesn't buy it. Am I missing something here? Obviously the bovie might be stimulating small nerve fibers in the muscle as well, and so in theory the radius of the area that's affected might be larger when neuromuscular transmission is intact, but even with 100% receptors blocked, the muscles still seem to jump when buzzed. He insists otherwise. Any thoughts on this topic? (Whether a surgeon should really need 1000% muscle relaxation for a straightforward VATS case is another topic, but I digress...)

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[Psai]

So I've actually seen the muscles jumping slightly with bovie despite zero twitches on the face during a plastics case. I switched from bolusing to a vec drip which seemed to solve the problem and the surgeons were happy. I think for vats it doesn't matter although they say if the patient bucks they have to take out the robotic arms. But I see no reason for less than zero twitches.

 

[Radetzky]

Tell him to review his medical school physiology again.

 

[caligas]

Don’t argue. Give 5mg of Roc and then tell him “I gave five thousand mikes of roc.” Repeat as necessary.

 

[ZzzPlz]

Where is @womansurg? She could probably clear this up for us!

 

[ZzzPlz]

Patients waking during surgery?

 

[TheLoneWolf]

In residency, we had a thoracic surgeon who would pull this regularly. He would say "I dont trust the monitor (with zero twitches), I can see the diaphragm moving." Oh really, that's from my ventilator you dingus.

 

[ZzzPlz]

One VA thoracic surgeon complained to me that the heartbeat was interfering with her ability to operate. She wasn’t sure what she wanted me to do about it.

 

[deleted875186]

I love it.

It does seem to differentiate really good surgeons from others. Really good surgeons never complain about this stuff, as long as the patients not breathing or moving.

 

[Psai]

One VA thoracic surgeon complained to me that the heartbeat was interfering with her ability to operate. She wasn’t sure what she wanted me to do about it.

One of our crap thoracic fellows asked me to hold the lungs so that she could close the skin at a small thoracotomy site. I nearly blew an aneurysm at the incompetence. Obviously a really awful surgeon, wouldn't let her touch me if I was actively dying from triple vessel disease.

 

[NICMAN]

Muscle is an excitable tissue just like nerves.

 

[GravelRider]

One word: Sugammadex.

You likely have a cr@ppy surgeon on your hands, but with the aforementioned drug you can give as much rocuronium as you want (or as much as the surgeon thinks he wants) and still wake up on a dime.

 

[Psai]

One word: Sugammadex.

You likely have a cr@ppy surgeon on your hands, but with the aforementioned drug you can give as much rocuronium as you want (or as much as the surgeon thinks he wants) and still wake up on a dime.

I've had surgeons complain about relaxation when patients were given hefty doses of paralytic. Like dawg I just gave 20 of roc five minutes ago, it ain't the relaxation, you're doing something wrong.

 

[GravelRider]

I've had surgeons complain about relaxation when patients were given hefty doses of paralytic. Like dawg I just gave 20 of roc five minutes ago, it ain't the relaxation, you're doing something wrong.

Oh I know. There’s only so much you can do. Eliminate the possibility that you are causing their suckage and get back to that crossword you were working on while they struggle with their horrendous lack of skills.

 

[Hork Bajir]

Psai- I think you mean "20,000 mics of roc"

 

[deleted162650]

While you’ll never be able to eliminate the twitching from direct muscle stimulation, having dense paralysis onboard definitely limits the amount of twitching. Without NMB, the Bovie current will spread out over adjacent NMJ’s and you’ll see bigger/more widespread twitches. This is easy to see if you peek over the drapes emote and after you give more paralytic.

If they still bitch then I break out one of my favorite lines (which I’m pretty sure I stole from @Il Destriero): If he were any more relaxed he’d be in a hammock.

 

[Iso4ane]

If they still bitch then I break out one of my favorite lines (which I’m pretty sure I stole from @Il Destriero): If he were any more relaxed he’d be in a hammock.

If he were any more relaxed he’d be dead.

 

[d9sccr]

If he were any more relaxed he’d be dead.

Sounds like someone the aforementioned VA surgeon could operate on

 

[Laryngophed]

If they still bitch then I break out one of my favorite lines (which I’m pretty sure I stole from @Il Destriero): If he were any more relaxed he’d be in a hammock.

I can't wait to return to the OR to drop that little nugget.

 

[deleted171991]

People also tend to forget that the rocuronium that sits in the cart is, by far, not as potent as the one that sits in the fridge. Get your muscle relaxants fresh from the fridge every morning, and then the 20 mg of roc will not behave like 5.

 

[jwk]

While you’ll never be able to eliminate the twitching from direct muscle stimulation, having dense paralysis onboard definitely limits the amount of twitching. Without NMB, the Bovie current will spread out over adjacent NMJ’s and you’ll see bigger/more widespread twitches. This is easy to see if you peek over the drapes emote and after you give more paralytic.

If they still bitch then I break out one of my favorite lines (which I’m pretty sure I stole from @Il Destriero): If he were any more relaxed he’d be in a hammock.

Anesthesia makes surgery possible - not easy.

 

[MTGas2B]

I do recall the residents of old at my internship institution had secret book of humorous stories about attending. The prolonged lap chole turned the first laparoscopic autopsy was always a favorite.


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[dhb]

I do recall the residents of old at my internship institution had secret book of humorous stories about attending. The prolonged lap chole turned the first laparoscopic autopsy was always a favorite.


Sent from my iPhone using SDN

You ain't seen nothing 'til you've seen a laparoscopic case convert to laparotomy then convert back to laparoscopic!

 

[deleted875186]

You ain't seen nothing 'til you've seen a laparoscopic case convert to laparotomy then convert back to laparoscopic!

How about a laparoscopic case get one hand port, than later get another hand port.