Induction on a 23 y/o male with a "full stomach" for a hand ORIF. Versed preop 2mg, in OR 100 mcg fentanyl, 10 mg defasc dose of roc, 200 mg propofol, sux 100 mg. Pt had small fasiculations, intubated easily but was coughing as the tube slid into trachea. I pushed 30 mg Roc without checking twitches. I then preceded to get reamed for the next 10 minutes. My staff was telling me that you should NEVER give NDNMB before suxs has worn off as evidenced by nerve stimulator. In my mind the patient was coughing so I assumed that either I didn't achieve a complete block, or he just metabolized the 100 mg really fast. That's neither here nor there. The point she was making was that you could induce a phase II block from giving NDNMB on top of sux. I bent over and took it like a man....but in the back of my head I was doubting that that is true. So when I got home today I looked up how a phase II block can be induced. Miller talks about 2 situations which it can occur. 1) repeated prolonged exposure to sux; 2) giving ACHE inhibitor to someone who has been paralyzed with sux and has psuedocholine esterase deficiency. I also remember reading in another text a long time ago about overdosing on Neostigmine can also cause a channel block, inducing a phase II block. I have found nothing in my text books that says giving a NDNMB on top of sux can cause this. Can anyone chime in with info?