•Botulinum toxin has become the number one minimal invasive cosmetic procedure in the United States.

•Botox injections are easily obtained in the outpatient setting

•Botulinum toxin blocks the release of acetylcholine from the neuromuscular junction

•The ability of assessing the depth and recovery of neuromuscular blockade is impacted by the denervation from Botox injections

 

Case Study:

 

• 32 year-old female classified as ASA 2 presented for elective diagnostic laparoscopy. Patient’s past medical history included hypertension, hyperlipidemia, and bipolar disorder.

• Preoperative anesthesia evaluation was unremarkable and the patient endorsed no prior surgical procedures.

• General anesthesia with intravenous induction of propofol, lidocaine, fentanyl, and 50 mg rocuronium for neuromuscular blockade was completed.

• 60 minutes post-induction the patient had 0/4 TOF and weak post tetanic twitch at the facial nerve. Based on the pharmacokinetics of rocuronium, the patient was re-dosed with 20 mg of rocuronium.

• Upon completion of the case, the patient’s arms were untucked, and ulnar nerve TOF was utilized for confirmation of adequate reversal with sugammadex. Notably the twitches at the ulnar nerve were 2/4 vs 0/4 at the facial nerve. 

• In PACU the patient endorsed recently undergoing Botox injections.