Anaesthetic management of oberlin nerve transfer without NMN-Depolarising muscle relaxants

Karthi V*

Anaesthesia Technician, OT Department, Kauvery Hospital, Hosur, Tamil Nadu

*Correspondence

Abstract

Surgical procedures requiring precise nerve identification often mandate the avoidance of neuromuscular blocking agents (NMBAs), especially in patients with pre-existing nerve injury. We report a case of a 53-year-old female with left brachial plexus injury who underwent Oberlin I & II nerve transfer with canaloplasty under general anaesthesia without non-depolarising muscle relaxants. Successful intraoperative nerve mapping using Stimpod NMS 410 allowed accurate localization and transfer of functioning nerve fascicles. Anaesthesia was maintained using total intravenous anaesthesia (TIVA) and opioid infusion with sevoflurane inhalation support. The patient recovered uneventfully with stable hemodynamic, minimal pain, and favourable post-operative outcomes. This case highlights the multidisciplinary coordination required for surgeries involving nerve monitoring without muscle relaxation.

Key words: Neuromuscular blocking agents (NMBAs); Total intravenous anaesthesia (TIVA); Anaesthesia

Introduction

Neuromuscular blocking agents are routinely used to facilitate endotracheal intubation and provide surgical relaxation. However, in nerve reconstruction surgeries particularly in patients with pre-existing nerve damage the use of non-depolarising muscle relaxants is contraindicated as they interfere with intraoperative nerve stimulation and mapping. In such situations, anaesthetic management relies heavily on TIVA and opioid-based techniques to ensure adequate depth of anaesthesia while preserving neuromuscular function.

This article describes a successful nerve transfer procedure performed at Kauvery Hospital, Hosur, using intraoperative nerve monitoring without non-depolarising muscle relaxants.

Case presentation

A 53-year-old female presented with a history of a road traffic accident (lorry vs two-wheeler) four months prior. She had undergone wound debridement and suturing under general anaesthesia at that time. Subsequently, the patient developed left upper limb paresis. MRI studies revealed a left brachial plexus injury requiring surgical intervention.

Diagnosis

Clinical Diagnosis: Left brachial plexus injury with functional motor impairment.

Investigations

  • MRI demonstrating nerve root injury involving segments requiring reconstruction using Oberlin nerve transfer.
  • MRI studies revealed a left brachial plexus injury requiring surgical intervention.

Preoperative Laboratory Investigations

Lab testResults
Blood GroupB Positive
Hb13.4mg/dl
Platelets302000
RBS93mg/dl
Urea21.4mg/dl
Creatinine0.5mg/dl
Sodium142mmol/L
Potassium4.5mmol/L
INR0.92
TSH4.022
T31.12
T48.28

All values were within acceptable limits for anaesthesia.

Anaesthetic and Surgical management

Preoperative Planning

  • Procedure: Oberlin nerve I & II transfer with canaloplasty via left post-aural approach.
  • Stimpod NMS 410 for intraoperative nerve mapping.
  • Anaesthetic Plan: General anaesthesia without non-depolarising NMBAs to preserve nerve response.

Intraoperative Anaesthesia

Induction

  • Glycopyrrolate 0.2 mg.
  • Midazolam 1 mg.
  • Lignocaine 2 mL.
  • Fentanyl 100 mcg.
  • Propofol 100 mg.
  • Depolarising NMBA used only for intubation: Inj. Succinylcholine 50 mg.
  • Intubation performed nasally with 6.5 mm flexo-metallic ETT using fibreoptic awake intubation.

Maintenance

TIVA regimen

  • Propofol infusion: 10 mL/hr.
  • Fentanyl infusion: 5 mL/hr.
  • Paracetamol 1 g IV.

Inhalation agent à Sevoflurane (minimal concentration)

Access a Drugs administered via right internal jugular CVC.

Intraoperative Vitals

SpO₂100%
BP110/70 mmHg
HR86/min
EtCO₂28 mmHg
RR16/min
Tidal Volume425 mL
ECGNormal sinus rhythm

Surgical course

  • Duration: 7 hours.
  • Procedure completed successfully with continuous nerve stimulation and fascicular identification.
  • No non-depolarising muscle relaxants used.

Immediate recovery

  • Anaesthetic infusions tapered at the end of surgery.
  • Smooth emergence from anaesthesia.
  • Extubated when fully awake, breathing adequately.
  • Pain score: 2/10.
  • Shifted to ICU hemodynamically stable.

POD 1

  • Plastic Surgery: Mild pain over operative site → IV analgesics started.
  • ENT: Mastoid dressing removed; wound healthy.

POD 2

  • Plastic Surgery: Dressing intact; catheter removed.
  • ENT: Pain over operative ear site; dressing removal; wound healthy.

POD 3

  • Sterile dressing changed.

Postoperative nursing management

Pain and comfort management

  • Assessed pain using a validated scale and administered IV analgesics as ordered.
  • Ensured comfortable positioning of the limb and surgical site.

Neurological monitoring

  • Observed motor strength, sensation, and any new deficits.
  • Recorded changes in limb movement and nerve function, ensuring early detection of complications.

Wound care

  • Performed sterile dressing changes for:
    • Mastoid incision.
    • Brachial plexus operative site.
  • Monitored for signs of infection (redness, discharge, swelling).
  • Coordinated dressing procedures with ENT and Plastic Surgery teams.

Medication administration

  • Administered postoperative medications including:
    • Antibiotics.
    • Analgesics.
    • Ulcer protectives.
    • Vitamin supplements.
    • Antiemetics.
  • Observed for side effects and ensured adherence to dosing schedule.

Education and Discharge preparation

  • Educated patient and family on:
    • Wound care at home.
    • Pain management.
    • Medication adherence.
    • Activity restrictions.
    • Signs of complications requiring medical attention.
  • Provided instructions for follow-up with ENT and Plastic Surgery teams.

Outcome

The patient tolerated the 7-hours procedure well without any intraoperative complications. Anaesthesia was maintained successfully using TIVA and opioid infusion without the administration of non-depolarising muscle relaxants, allowing effective intraoperative nerve mapping. Hemodynamic parameters remained stable throughout the surgery, and the patient was smoothly extubated after the reversal of sedation.

Postoperatively, the patient demonstrated:

  • Stable vital signs with no respiratory or cardiovascular instability.
  • Minimal pain (pain score 2/10) effectively managed with IV analgesia.
  • Healthy wound healing, with dressing changes showing no signs of infection or dehiscence.
  • Improved comfort and mobility, assisted by appropriate positioning and analgesia.
  • No neurological deterioration, with preserved nerve responses for postoperative rehabilitation.

By postoperative day 3, both ENT and Plastic Surgery teams confirmed satisfactory wound status and provided discharge clearance. The patient was discharged with oral medications and follow-up rehabilitation advice.

Overall, the outcome was excellent, demonstrating that major nerve reconstruction surgery can be safely performed without non-depolarising muscle relaxants when supported by careful anaesthetic management, precise nerve monitoring, and coordinated postoperative care.

Discussion – Medical aspects

Avoidance of non-depolarising NMBAs is essential in nerve repair surgeries because:

  • They eliminate muscle responses required for nerve mapping.
  • They interfere with the identification of functional fascicles.
  • They compromise the surgical accuracy of nerve transfer.

Anaesthetic considerations included:

  • Use of succinylcholine only for intubation, as it has a short duration and no effect on later nerve stimulation.
  • Maintaining anaesthesia using TIVA and opioid infusion.
  • Ensuring adequate depth using sevoflurane supplementation.
  • Vigilant monitoring due to prolonged procedure duration.

This case highlights the importance of:

  • Proper equipment procurement.
  • Interdepartmental planning.
  • Skilled airway management using fiberoptic techniques.

Discussion – Nursing aspects

Nursing team responsibilities included:

  • Preoperative preparation and psychological reassurance.
  • Maintaining sterility for long-duration surgery.
  • Assisting in equipment setup (Stimpod, fibreoptic, CVC lines).
  • Continuous intraoperative monitoring of vitals.
  • Pressure point care during the 7-hour procedure.

Postoperative:

  • Pain assessment and management.
  • Wound care.
  • Monitoring for neurological improvement.
  • Providing emotiaonal and family support.

Conclusion

This case demonstrates that major nerve reconstruction surgeries can be safely and effectively performed without the use of non-depolarising muscle relaxants. Successful perioperative outcomes were achieved through meticulous planning, advanced nerve monitoring, TIVA-based anaesthetic strategy, and coordinated multidisciplinary teamwork. The patient recovered well with stable vitals, minimal pain, and optimal postoperative care, underscoring the value of collaborative, empathetic, and evidence-based clinical practice.

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment