Some anesthesiologists use time elapsed since last dose and some use patient's clinic (head lift etc.) but some just rely on response to twitch monitor. What is your experience?
I prefer to monitor the effect of muscle relaxant drugs before extubation especially in ambulatory surgery. This approach avoid patient discomfort (inability to move in conscious state).
Although this attitude was possible in my country only the recent years, with the advent of the TOF measurement device. Before, extubation was based on clinical observation and type of medication (non depolarizing muscle relaxant with short or long duration).
However, to avoid a catastrophe, we prefer to keep patients on artificial ventilation still further 30 min-1h (during times of pipecuronium was only available as curare).
My opinion is that we need to monitor the effect of muscle relaxation with TOF, particularly in brief interventions, which allows us to detect residual effect and get more attention, if needed.
Greetings, from Moldova
there's a nice review about NMBAs in the introduction of this article.
Personnally I always use a TOFratio monitor if available - the goal is a ratio of 0.9 - if i have a simple TOFcount machine - I wait for 4 responses and then antigonize.
Acta Anaesthesiol Belg. 2013;64(2):49-60.
A review of the interest of sugammadex for deep neuromuscular blockade management in Belgium.
Dubois PE, Mulier JP.
The TOF method gives you the answer before your patient returns in a conscious state. The monitoring of the muscle relaxant effect helps us provide a good quality anesthesia and prevents from residual effects fenomenon
Unfortunately we do not have TOF in my clinic so our decision to reverse non-depolarising muscle relaxants at the end of the surgery is based solely on the type of surgery, time elapsed from the last dose, duration and extent of the procedure and the patient's haemodynamic and respiratory status during the procedure and ASA status as well. If in doubt about extubating at the end of the procedure, I sometimes choose to reverse the action of the relaxans but keep the patient sedated and intubated for short period of time (definitely shorter than if I did not reverse the relaxants), trying to have the time on the ventilator as short as possible.
I didn't mean when you have doubt about it, I meant for example if you had a spine surgery and you had given single intubation dose of let's say Roc in the morning and now it is 15:00 what would you do
Are you still going with the studies?
TOF is just for induction and the most reliable reversal indicator is 5" sustained tetanus.
I agree with Anthony. However, in developing countries, we are not blessed with ROC/VEC or even nerve stimulator. That's it. You have to stick to your basics. What do I do with my patients? I reverse all! Of course, if there is no contraindication. You should just imagine the turn over of the operations in our centers. There is no real PACU or whatever. I would not want to face any legal problem. No one would condemn you if you use the reverse and the patient dies due to delayed airway compromise. But the opposite: every one will keep asking you why you did not reverse muscle relaxation, no matter how non-scientific their comments are.
Let's put it this way: would you reverse if the patient has 5" sustained tetanus? How much you will give?