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• Peripheral nerve stimulation use in the Emergency Department
  Leo T Urquhart, Vincent Perkins
  Published on: 21 January 2018

• Published on: 21 January 2018

  Peripheral nerve stimulation use in the Emergency Department

  • Leo T Urquhart, Anaesthetics Core Trainee NHS Dumfries and Galloway
  • Other Contributors:
    • Vincent Perkins, Consultant Anaesthetist

  We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.

  Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.

  We recognise that some Em...

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  We would like to comment of the use of waveform capnography (WC) as an adjunct to help determine adequate paralysis during rapid sequence induction (RSI). The article used recognition of apnoea by loss of WC as an early indicator of muscle paralysis and evidence was presented that this method improved first pass success rates and reduced time to intubation for RSI in an emergency setting.

  Although apnoea can be a useful indicator for the presence of paralysis we would suggest that use of a peripheral nerve stimulator is a more accurate tool for determining when muscle relaxants have produced an adequate effect. The use of this simple and relatively inexpensive machine is standard practice for anaesthetists in determining the level of paralysis. It is also viewed as a standard for provision of anaesthesia outside of the operating theatre environment (Association of Anaesthetists of Great Britain and Ireland: Recommendations for standards of monitoring during anaesthesia and recovery, 2015, Page 8). We suggest from clinical experience that apnoea alone does not always reflect adequate muscle relaxation to allow for optimal intubating conditions. Reactive vocal cords may be present despite apparent correct dosing and timing of muscle relaxants. In addition, apnoea and loss of WC could possibly be a reflection of respiratory depression due to administration of the anaesthetic induction agent, opiods or a deteriorating clinical condition.

  We recognise that some Emergency Medicine doctors may not be familiar with the use of nerve stimulators and that they may not be readily available within all Emergency Departments. We suggest that Emergency Departments should consider keeping a peripheral nerve stimulator as standard equipment. We would argue that this would then permit clinicians who are familiar with their use to have a more objective ability to determine depth of muscle relaxation during RSI, leading to improved intubating conditions.

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  Conflict of Interest:
  None declared.

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