Residual NMBA in cellsaver

Tenesma · Oct 30, 2003

this is an excellent point.... and many forget about this....

as a general rule for me, i only use cell-saver during the case or towards the end of the case - and if i am not extubating it is a moot point.... i make a point of not using the cell-saver on transport to the PACU or in the PACU --- those extra 100-250 cc of rehashed blood aren't that big of a life-or-death difference in that setting....

incidentally my favorite use of a cell-saver so far has been in the ICU - i had an encephalopathic, end-stage liver disease, intubated guy s/p TIPS procedure where they had "unknowingly" torn the hepatic artery (of all things) and he was bleeding 400cc of blood out of his chest tube every 15 minutes!!! so i brought the cell-saver up from the OR (along with the cell-saver nurse) and we re-transfused the chest tube blood back into his Cordis!!! it was fantastic!!! of course, i was written up by the ICU charge nurse because there is no policy allowing cell-savers in the ICU

versatile_kat · Oct 30, 2003

Well, Tenesma, shame on you for helping to save that patient's life! I hope you learned your lesson by being written up .

Thanks for the clinical question, Sam, and the clinical insight, Tenesma. I always enjoy these posts. Keep it up!

gaspassah · Oct 31, 2003

i apologize for my ignorance up front since i never worked with cell savers but i would like to ask a question.

1. during the use of a cell saver is the concentration of paralytic in the volume of blood in the cell saver so concentrated that the reinfusion causes paralysis.

2. what kind of time length are we talking, shouldnt the amount of paralytic "in" the patient metabolized or partially so.., and thusly shouldnt the reinfused amount be subtherapeutic concidering total blood volume.

thanks,

again i have no experience here yet.

ok i asked 2 questions

Tenesma · Oct 31, 2003

the cell-saver collects aspirated blood - so if the patient suddenly loses a decent amount of blood then chances are they lost some unmetabolized paralytic - and usually in cases with high blood loss you usually overdose with paralytics anyway on purpose....

so even though the patient might very well have metabolize his own paralytics, while transporting them to the PACU (for example) or even in the PACU it is an inopportune time for them to be presented with more paralytic... while it may be subtherapeutic (meaning they won't become paralyzed), it could easily disable pharyngeal muscles (usually first to be lost and last to return) thus leading to a poorly protected airway...

on a different but related note - did you know that neostigmine can act as a muscle relaxant ?... that would be an interesting thread for conversation

stevierae · Oct 31, 2003

Originally posted by Tenesma
this is an excellent point.... and many forget about this....

as a general rule for me, i only use cell-saver during the case or towards the end of the case - and if i am not extubating it is a moot point.... i make a point of not using the cell-saver on transport to the PACU or in the PACU --- those extra 100-250 cc of rehashed blood aren't that big of a life-or-death difference in that setting....

incidentally my favorite use of a cell-saver so far has been in the ICU - i had an encephalopathic, end-stage liver disease, intubated guy s/p TIPS procedure where they had "unknowingly" torn the hepatic artery (of all things) and he was bleeding 400cc of blood out of his chest tube every 15 minutes!!! so i brought the cell-saver up from the OR (along with the cell-saver nurse) and we re-transfused the chest tube blood back into his Cordis!!! it was fantastic!!! of course, i was written up by the ICU charge nurse because there is no policy allowing cell-savers in the ICU

Good save, Tenesma.

Wonder why they (surgeons) didn't connect his chest tube to one of those Pleurevacs that is capable of autotransfusing in the first place? You know, the kind they use on open hearts?

Or, is that what "Cordis" refers to in this case? What is a TIPs?

Now, what you did was just a stop-gap measure to buy him time until he could get back to the OR for emergency repair of his hepatic artery, right?

Jesus, don't you just love these supervisor/manager/charge nurse types who can't function or think or expect anyone else to do so without a "policy" in place!!! Did she also want to wait until his family came in and signed a consent for him to go back to the OR, because that's what "policy" dictates in her black-and-white-no-gray-areas world?

stevierae · Oct 31, 2003

Originally posted by Tenesma
on a different but related note - did you know that neostigmine can act as a muscle relaxant ?... that would be an interesting thread for conversation

I would like to see that thread, too--would be interesting--as well as this one:

Did you know that Ancef (Kefzol) potentiates neuromuscular blockade? Or--does it?

I was taught that many years ago in a nursing pharmacology class, and since it is usually the antibiotic du jour for most every case, I wonder if its effect on neuromuscular blockade is :

A. So minimal that anesthesia doesn't give it a second thought

B. Significant, so anesthesia plans accordingly around it

C. The stuff of urban legend, or no longer thought to be true, as it was in the '80s

I love this (CRNA) discussion area--always something new to learn from folks who do this every day!

g8rlimey · Oct 31, 2003

Thanks for your post, Tenesma. Good example of thinking on your feet!

You also validated my feeling on the topic of risky autotransfusion. I assume this happens rarely, but as you stated, why risk it for such a miniscule amt. of volume?

Stevierae:

There is risk of neuromuscular blockade with antiBx, but from what I have read, it is generally with aminoglycosides, such as Gent or Tobra. Cephalosporins and PCN are known to have no effects on the neuromuscular blockade, one of the many reasons Kefzol is used so much in the OR.

Anybody know if Vanco shows any interactions with NMBA's?

g8rlimey · Oct 31, 2003

Originally posted by Tenesma
on a different but related note - did you know that neostigmine can act as a muscle relaxant ?... that would be an interesting thread for conversation

I looked this up on basis of disbelief and was pleasantly suprised to see it sitting right these in Stoelting's Pharm & Phys., 3rd ed., p.225, "Anticholinesterase drugs have also been reported to produce some form of neuromuscular blockade, but doses far greater than those administered clinically are required to produce this effect."

My question to you, Tenesma, is how useful is this? Concomitant adminstration of glycopyrrolate must be at least in the liter range?

gotosleep · Oct 31, 2003

perhaps this may be more applicable to the patient taking an anticholinesterase (MG, glaucoma, etc...) preoperatively and the administration of a depolarizing muscle relaxant.

Tenesma · Nov 1, 2003

regarding neostigmine - the reason why this is important to keep in mind is because of the trouble you can sometimes run into... here are a few scenarios:

1) running a succinylcholine drip for a super-quick lap chole - and for some reason you reverse with neostigmine (or your student or whatever) - you can easily go into a very long phase II block

2) pt has 4 twitches and gets reversed with full dose (70mcg/kg/min) prior to going to PACU - just to make patient a bit stronger! some of those patients will actually experience some weakness and SOB about 7-10 minutes after neostigmine administration - (by the way, edrophonium is a better choice for those kinda situations (3-4) twitches but it is too expensive and too few people understand how to use it)

deepz · Nov 1, 2003

Originally posted by Tenesma
... a succinylcholine drip for a super-quick lap chole ....

**** PLEASE, please tell me no one does this anymore. Even as an academic curiosity, sux drip is so 1950s as to seem unethical. --- deepz

.... edrophonium is a better choice ... but ... too few people understand how to use it)

**** And that would be how exactly ...?

deepz