When the patient arrives in the operating
room, they have a blood pressure
cuff placed on them. A cardiogram's placed,
pulse oximetry, and end-tidal carbon dioxide
level are always done. And in the United States,
it's a required monitor to put a temperature probe on
the patient or in the patient's mouth or nose.
Make sure an intravenous is in place, give a small
dose of a drug such as Fentanyl,
1-3 micrograms/kg is what I normally use.
The induction drug in a healthy individual who's
hemodynamically stable, my preferred drug
is Propofol. I use 2-2.5 milligrams/kg and I follow
this immediately with Rocuronium,
0.6 milligrams/kg, which is a moderate but not
large dose of Rocuronium. When I'm doing
a patient that requires neuromuscular
blockade, I often use a nerve stimulator
such as the one shown in this picture.
It's hooked up to the forearm. The current
is adjusted through the stimulator and
you examine the thumb for twitches,
as stimulations occur. And the usual
rate of stimulation is 4 twitches over 2 seconds.
This is called the Train of Four.
And the assessment of the Train of Four can
give us some indication of how deeply
paralyzed the patient is, whether it's safe to proceed
with intubation, whether it's safe to proceed with
with surgery, or at the end of the case, whether it's safe
to attempt to reverse the patient.