Muscle relaxants and tourniquets

[jetproppilot]

OK folks, heres another useless topic I'm going to propose. We have an old, ricketty orthopedic surgeon who insists we put all his total knees to sleep for whatever reason, even though we use regional with every other surgeon unless contraindicated. And he's one of those control freak- whiners who is constantly complaining- particularly about lack of muscle relaxation. He swears that once the tourniquet is up, our muscle relaxants don't do any good. Now as I see it, doesn't the non-depolarizer still work at the muscles origin ABOVE the tourniquet which would facilitate muscle relaxation? This guy is crazy, folks, and lord knows why he complains about muscle relaxation when every other ortho dude I've worked with hasn't. "HOW MANY TWITCHES DO YOU HAVE???", he'll ask the CRNA. blah blah blah. Was it my mom that told me a little knowledge is dangerous?

Is there any basis to his complaint? Or can I end this for good, drag him out into the parking lot and settle this gangster style? haha

Anyway, point me in the direction of a paper that'll refute this old dude and I'll buy you dinner in New Orleans.

[Hossam]

do you give ms.relaxant after torniquet is on?

[ivorflem]

Muscle relaxants have been added to Bier Blocks for many years in small doses with big effects. Once the tourniquet is up there should be no significant clearance of the muscle relaxants out of the compartment.  The addition of more antibiotic, anti-inflammatories, or muscle relaxants to the other side of an inflated tourniquet makes no sense.
The rare reduction of a prosthesis or joint has been greatly assisted by brief use of muscle relaxant in my practice but the surgeons layout of the butt joints on bone has never improved with relaxants.
The real issue is what possible good does the surgeon achieve by distracting his care to a pharmacology about which he has no knowledge or liability. The behaviour needs to be extinguished and the nerve stimulator put away.

[Matthew Parsons]

Muscle relaxant work at the neuromuscular junction. The muscle fibre it innervates, however, may extend well below the torniquet. While I have no data about this, I would imagine that once a torniquet is up, extra muscle relaxant may have a small effect on the muscle below the torniquet as long as they are long muscle fibres that extend below the torniquet. I doubt that it would be a significant effect.

Remember the study of awareness where a limb was isolated from the rest of the body by the use of a torniquet. Despite a general anesthetic, some patients could obey verbal commands (lifting hand). Thus the torniquet effectively protected the limb from the relaxant.