Use of Muscle Relaxants in Feline Ophthalmic Anesthesia/Surgery

August 1, 2019 (published)

Nancy Brock, DVM, DACVAA

These agents reversibly paralyze the patient, rendering the eye immobile, thus reducing the risk of
ocular movement during surgery.

Requirements
Means to provide continual manual or mechanical IPPV
Atracurium or rocuronium muscle relaxant
Neostigmine reversal agent
Atropine
A nerve stimulator is also required to monitor the degree of muscle relaxation, the timing of repeat
doses, and the adequacy of reversal of paralysis upon completion of surgery.

Step by Step Instructions

1. Anesthetize the patient and prepare for surgery.

 
2. Initiate manual or mechanical IPPV before administering the relaxant.

 
3. Place two nerve stimulator leads over the anterior tibial nerve, which is palpable as it travels
over the caudal lateral aspect of the tibial crest: Insert two hypodermic needles through the
skin on either side of the nerve and attach the alligator clips to their metal parts.

 
4. Ensure that the stimulator functions properly by generating four twitches to the tibial nerve,
known as the “Train of Four” (TOF), and observing that the distal limb extends with each
stimulus. If the response is weak, try repositioning the leads to generate strong contractions.

 
5. Ensure that this stimulus is not associated with motion of the rest of the body—particularly
the face (unlikely)—as this motion may interfere with the surgery.

 
6. After all the monitors are in place and 5 minutes prior to the beginning of surgery, administer
atracurium 0.2 mg/kg IV OR rocuronium 0.5 mg/kg IV over 90 seconds. This provides 20–30
minutes of globe immobilization after a 2–4 minutes onset of action.

 
7. Monitor the onset of paralysis by observing the weakening and, eventually, the complete
disappearance of the muscle responses to the nerve stimulator over the 5 minutes that
follow relaxant injection. Adequate ocular paralysis is achieved once all four muscle twitches
are absent, and should persist for 20–30 minutes after an initial dose.

 
8. Continue monitoring the TOF response every 5 minutes. (I like to maintain one visible twitch)

 
9. Administer a repeat dose of atracurium 0.1 mg/kg IV OR rocuronium 0.16 mg/kg IV upon
return of the second muscle twitch response to the TOF test with a nerve stimulator as
described above. This will provide ±10 minutes of paralysis. Repeat doses of atracurium can
be reduced to 0.05 mg/kg if there was prolonged effect from the initial dose.

 
10. In order to facilitate reversal, administer only small doses of muscle relaxant if less than 10
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minutes of surgical time remain.

  
11. Prior to awakening the patient, administer atropine 0.005 mg/kg IV, followed in 3 minutes
of neostigmine 0.02–0.06 mg/kg IV titrated very slowly in 10% increments over 3–5 minutes
until the TOF has returned to normal, whereby all four contractions are of equal strength.

 
12. Once the TOF has returned to normal, apply a titanic stimulus and verify that muscle
contraction cane sustained for 3–5 seconds. If the muscle contraction fades, keep the
patient asleep for a few more minutes then repeat the tetanic stimulus test. Or you can
titrate additional reversal agent if you prefer.
It is best to have at least one muscle twitch present before initiating reversal. If no muscle twitch
response can be elicited, paralysis is still intense and full reversal may necessitate additional
neostigmine.

Warning
Bolus neostigmine injection may result in severe bradycardia to the point of cardiac arrest.

Signs of incomplete reversal of paralysis in the intubated patient include:

TOF response that has not returned to full strength

Presence of fade in muscle contraction when a tetanic stimulation is applied
Weak palpebral reflex
An etCO2 value >45 mm Hg with spontaneous ventilation
Decreased chest wall motion during spontaneous breathing (diaphragmatic motion
predominates)
Signs of incomplete reversal of paralysis in the awake, extubated patient include:

Weak response to toe pinch

Voice change if vocalizing
Inability to lift the head
Decreased chest wall motion during spontaneous breathing (diaphragmatic motion
predominates)
The situation may require administration of a further dose of neostigmine 0.02 mg/kg slowly over 5
minutes, with careful monitoring for bradycardia.

Most Common Causes of Persistent Paralysis Despite Reversal

Agent Administration
Deep plane of anesthesia
Extreme hypothermia
Concurrent use of aminoglycoside or polymixin antibiotics

Monitoring Anesthesia in the Paralyzed Patient

Blood pressure and heart rate changes are the best indicators of changing anesthetic depth, due
to respiratory rate/depth, jaw tone, and ocular reflexes being unavailable for use as anesthetic
depth monitors during paralysis.

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Paralyzed patients that are lightly anesthetized can make attempts to breathe on their own, as the
diaphragm is one of the first muscles to recover from the effects of muscle relaxants.

The surgeon may also comment that a change in ocular tone or ocular movement is occurring,
indicating the need for a deeper plane of anesthesia and/or a further incremental dose of muscle
relaxant, depending on remaining surgical time.

URL: https://www.vin.com/doc/?id=8990229&pid=20311