Assessment of Neuromuscular Function in Patients With Prior Cosmetic Procedures: A Case Report.

The use of Botulinum toxin type A (Botox) for cosmetic procedures has become so prevalent that many patients do not always consider it to be a past surgical procedure, and it goes excluded from the medical record. Without the knowledge of prior Botox use, interpretation of facial nerve train-of-four testing may be inaccurate. We describe a 61-year-old woman with a history of multiple cosmetic procedures whose postoperative course was complicated by multiorgan system failure, requiring neuromuscular blockade while on mechanical ventilatory support. Gauged by facial nerve stimulation, adequate neuromuscular blockade was assumed. However, patient-ventilator dyssynchrony motivated the decision to move the peripheral nerve stimulator to the ulnar nerve, where muscle twitches were observed. This indicated inadequate paralysis. This case report highlights the importance of monitoring neuromuscular function with ulnar nerve testing in patients with a history of cosmetic Botox procedures.