Patient movement is a normal, reflexive response to a stimulus not completely blunted by a “light” anesthetic. This does NOT mean the patient is aware of what is happening. These are two entirely different concepts and unfortunately something which many of our surgical colleagues do not understand. That being said, patient movement is undesirable for obvious reasons and can even be dangerous in certain circumstances.
Prevention is the best form of treatment. As you get more experience with particular surgeries and the surgeons, you can establish a timeline and estimate the duration of the case. If paralysis is acceptable, go for it! Moreover, in situations like Mayfield head pins, robot-assisted surgeries, and prone positioning… err on the side of immobility! These are a few circumstances in which I’m extra cautious about patient movement as it can put the patient’s well-being at serious risk. I’m more paranoid about checking for signs of neuromuscular relaxation and redosing paralytics as needed. Takes a little longer to wake up? So what – the risk isn’t work it!
So what if your intubated patient starts to move? The very first step is to tell the surgeons to hold up and take the patient off mechanical ventilation. In other words, put them on manual mode. Yes, they’re likely going to be apneic, but often times they’re coughing due to normal airway reflexes against the endotracheal tube. Dyssychrony with the ventilator will only exacerbate the stimulus. Take them off the ventilator and plan your pharmacologic intervention.
Is the case almost over? This is where having a little extra propofol drawn up comes in handy! Bolus some and resume mechanical ventilation. Rinse and repeat as needed.
Are you still in the middle of the case? If paralysis is permitted, bolus your choice of nondepolarizing neuromuscular blocker (most commonly rocuronium, vecuronium, or cisatracurium) and have some form of objective assessment (train-of-four monitoring, low trigger thresholds on the ventilator, etc.) to gauge your depth of relaxation. If paralysis is not permitted (motor evoked potentials, nerve monitoring) then deepen the anesthetic with propofol, consider titrating additional narcotic, uptitrate volatile agents and reassess the case.
Oh, and never forget to put them back on the ventilator. 😀