muscle relaxants

yoga crna · May 4, 2006

I don't do anything routinely in anesthesia, except maintain an airway, support circulation and keep the patient anesthetized. Rarely, if ever have I reversed the muscle relaxants you mentioned. I generally use nimbex for intubations and mivacron, on the occasional case where I need muscle relaxation for a short time during the procedure. Understand that my cases are usually long and rarely need muscle relaxation after intubation. Just got some new edrophonium for the drawer, threw out the one with the expired date. The top was never opened in three years. However, if a patient needs reversal, they get it. It is always best to individualize each anesthetic.

yoga crna

Isuhd8u · May 4, 2006

Thanks for your response. I don't have any experience w/ edrophonium yet. At the institution where I am doing clinicals at, the neostigmine/robinol combo is used (in adults). In your experience, what seems to work best? Which is used more commonly? I'd like to get different perspectives. Thanks a bunch!

athomas91 · May 4, 2006

edrophonium is rarely used due to its short duration of action...

deepz · May 4, 2006

edrophonium is rarely used due to its short duration of action...

It is short relative to neostigmine, yes ... BUT ... edrophonium can be a valuable adjunct (rarely) if a patient proves to be slow to reverse. I will occasionally pile on a bit of Enlon to speed the return of 4/4 when the TOF demonstrates the neostigmine/glyco is marginally adequate. A top-up usually brings them right around to 4/4 and a sustained headlift.

My favorite reversal is pyridostigmine actually; it's reputed to have a duration of action more closely matched to that of Robinul. Few places outside the military stock Regonol or Mestinon any more. Most places still stock Enlon.

deepz

crnateach · May 4, 2006

I personally have very little experience with mivacurium, although I do know there is a lot of debate surrounding antagonism of its blockade.

One of the reasons mivacurium is so short acting is because it is rapidly hydrolyzed by plasma cholinesterase. Neostigmine (and possibly edrophonium) also inhibit plasma cholinesterase (although there is conflicting evidence as to whether or not edrophonium inhibits plasma cholinesterase).

So, the debate is whether or not to antagonize a moderately deep mivacurium block with an anticholinesterase - because it could actually prolong the block- or to let the naturally rapid process of elimination occur.

Since I practice in a large teaching facility - the word "short" is relative, and there is hardly ever an indication for mivacurium (other than for teaching purposes, which is a very valid reason). Cisatracurium is a very popular neuromuscular blocker at my institution, and for many cases, muscle relaxation is continued until the very end. So, unless used for intubation only, cistatracurium blocks are commonly antagonized with neostigmine and glycopyyrolate.

deepz · May 4, 2006

I personally have very little experience with mivacurium......

I'll say it again about this useless drug: by the time Mivacron reaches peak effect, it's already half worn off.

?!

jwk · May 4, 2006

edrophonium is rarely used due to its short duration of action...

Maybe it's rarely used at your facility. We use it quite often because of it's faster onset of action compared to neostigmin.

Movacron (as we call it) is not good for much of anything. Use sux for short cases - for those who still have it available and appreciate the ART of anesthesia, sux drips are great.

Regonol - haven't seen that in years. I didn't know it was still available.

Isuhd8u · May 5, 2006

Use sux for short cases - for those who still have it available and appreciate the ART of anesthesia, sux drips are great.
Good point...tell me more! I have only heard about sux gtts but have never seen one. How would you go about using one? How do you titrate it, etc?

athomas91 · May 5, 2006

one of the CRNA's i trained under uses a sux gtt here and there and taught me how to do it well...i think it is a wonderful and unappreciated technique - i think many don't use it because it requires a little more work (continually monitoring your TOF to ensure your block isn't getting too deep....) but anyway...

i was taught.... ( :) ) that pyridostigmine wasn't used due to its long duration of action ( and potential SE in PACU or on the floor)

is this the case or is that bull hockey...

deepz · May 5, 2006

Kudos. You were lucky to have had a mentor who wasn't afraid to show you a largely discredited technic. Why discredited? 'Cause back in The Day there were folks who used no nondepolarizers -- none, Sux Gtt for everything -- every case all day long, every patient same bag, whether an 8 minute D&C or an 8 hour Cranie. Beyond the obvious cross-contamination idiocy, Sux Gtt led to many problems: overdose, cholinesterase depletion with dual-blockade, delayed emergence, hours on the vent, etc. And hypoxic brain damage. It CAN be a very elegant technic, when employed with finesse and close monitoring -- i.e., the Art of Anesthesia. Unfortunately Sux Gtt was also a favorite technic for the criminally lazy, and widely abused.

Ah ... Memory Lane.

(BTW pyrido's duration was well-matched with Robinul)

one of the CRNA's i trained under uses a sux gtt here and there and taught me how to do it well...i think it is a wonderful and unappreciated technique - i think many don't use it because it requires a little more work (continually monitoring your TOF to ensure your block isn't getting too deep....) but anyway...
i was taught.... ( :) ) that pyridostigmine wasn't used due to its long duration of action ( and potential SE in PACU or on the floor)
is this the case or is that bull hockey...

London88 · May 6, 2006

I also worked with a CRNA who used a sux drip for a short procedure. I thought it was awesome. Like athomas91 mentioned we used a continuous twich monitor to ensure that we were not going into a phase 2 block. However I thought this CRNA was awesome in general. Off the topic for a second I watched this same CRNA do a blind nasal intubation on a pt with parkinsons disease in the ER who was in resp distress from aspirating and had difficulty opening her mouth. He sat her up at 90 degrees and had the tube in 5 seconds. Our ologist was most impressed.