Is it possible to titrate paralytics?

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Is it possible to titrate paralytics so that they can still breathe but remain immobilized?

like i said earlier paralytics in an unintubated patient should only be provided by an anesthesiologist/CRNA.... and definitely should not be used as a means to manage confusion/restlessness in the ICU.

the gold standard for airway protection is an awake, cooperative patient who has full airway reflexes :) otherwise the next best thing is an ETT... but like i said there are quite few circumstances where an ETT isn't always the solution

there was a study last year that looked at TOF ratios in patients in the PACU, and they found that a ratio of 0.7 to 0.8 was very common in the PACU.... so it is evident that many anesthesiologists/CRNA extubate and deliver to the PACU patients who clearly still are very weak, but aren't aware of it due to the haze of anesthesia. There was another recent study that looked at healthy volunteers who received no sedation whatsoever and then received a mivacurium drip with airway support as needed.... with a ratio of 0.8 or less, they felt god-awful... even with 0.9 they felt like crap.... in fact, another study looking at post-op PACU course of paralytics, it showed that it can take up to 45 minutes after TOF=4 w/ ratio of 0.8 before a patient will feel that their strength is back to baseline...

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Thank you for the information Gotosleepy. I am always willing to expand my limited knowledge. Most anesthesia providers I have come into contact with shy away from mechanically ventilating the patient with an LMA. As far as the tracheal stenosis and dilation etc. An ETT of advancing sizes is being used to dilate the trachea with anesthesia ventilating the patient in between via the ETT, at least that is the way I have particpitated in such cases. As far as the direct microlaryngoscopy we use a very short acting muscle relaxant with a small ETT. Infact the surgeon tells us what size tube to use. I am sure there are many other ways to do these procedures but this is what I have seen and participated in. However back to Diprivan's original question I think it referred to a paralytic outside of the OR setting in a non intubated patient. I cannot think of any situation where it would be appropriate to use a paralytic in such a situation w/out the intent to intubate.

Gaspassah

I know that low dose succs can be used to break a laryngospam just like you give a priming dose of a paralytic as a defasiculator, but I think this is a completely different context to what Gotosleepy is saying.

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london, i agree, it was just the only case i could think of to use a paralytic on someone you werent planning to intubate.

the gold standard for airway protection is an awake, cooperative patient who has full airway reflexes otherwise the next best thing is an ETT.

i agree here also, my statement as i'm sure you were aware was for the patient not able to do so. :p

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The other day I was doing conscious sedation on a patient with morphine. He was agitated, trying to get out of bed, trying to leave the hospital, but completely confused (didn't know place or date). They had just extubated him, a bit prematurely, and he was having a hard time keeping his airway clear. I tried to educate him on coughing and deep breathing, but he was too confused. So I sedated him on morphine. His breathing dropped from 30's to mid teens, O2 sat remained in the low 90's, so I kept him on 2L NC, and nasally suctioned him, but even then, he could still move as I inserted the catheter. A few hours after I suctioned him, his temp dropped from 38.1 to around 37.2. Oh yeah, and some dumb RT said he might be retainin C02 and suggested I do an abg. His abg was fine.

That answer your question as to why?

I'm glad "some dumb RT" told you to do an ABG!!!. It might have been normal...but that should be the first thing you think of when someone is confused, with low or normal sats, and who is breathing in the 30s!!! That is what I was taught as an RN in the ICU and that is what i have been told as an SRNA. Once you've ruled out hypoxia and hypercarbia you can begin working on other things. And why would you want a patient to not move even with suctioning...that will only dispose him to hypoxia. And as someone stated earlier..the only reason a muscle relaxant should EVER be used on someone who does not have a secured airway is if you are going to intubate or when you are breaking a laryngospasm with a little bit of succs. Even then an ANESTHESIA provider, respiratory therapist, or a physician needs to be available to secure the airway. Muscle relaxants should never be used on someone without a secured airway or an airway security person standing RIGHT there. Yikes!! And an even scarier phenomenon is that 50% of your neuromuscular junctions can still be blocked even when a patient has a TOF without fade!!! Recurarization is a very real phenomenon. Fortunately, the respiratory muscles are quite resistant to NMBAs. Anyway..that's my 2 cents.
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paralytic and no secured airway.... sounds like what we do to prisoners in Texas... something called the death penalty.... or ....'lethal injection'?

Seriously, thank you all for taking the time to write in such detail. I am learning SO much from this board. I cannot wait for school to start!

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actually the lethal part of the injection is a bolus of Potassium Chloride - the paralytic is just to make the patient look at peace for the witnesses...

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and the beauty of an LMA is that you can paralyze them, mechanically ventilate them, and not have to deal with the increased risk of bronchospasm/tracheal irritation that you see w/ ETT....

Dangerous road to go down - I don't care what the LMA sales rep tells you about what they do in England.

We have had patients aspirate with LMA's in place. We have had patients bite the LMA tube in half. We have had patients suffer laryngospasm with LMA's. Although I have come to like them, it has taken a long time for me to do so. They have their place - and they have their limitations.

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jwk.... show me the literature that shows that there is an increased incidence of documented aspiration in mechanically ventilated patients by LMA vs ETT.... in fact, if you look at the literature (if you eliminate ICU patients, pre-existing pulmonary disease and pre-existing GERD) there is no statistical difference between the two...

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i know of a case where someone was not trained in airway management, patient previously ventilated, recently extubated, icu nurse took the patient to ct, pt became agitated wouldnt lay still, so the nurse "sedated" the patient with vecuronium since that was what they were doing while the patient was on a ventilator. needless to say the outcome in ct was not good, especially for the patient.

No ICU nurse who is 'really' an ICU nurse would do this... unfortunately in today's 'warm body' staffing mode, inexperienced nurses can get to 'play' ICU nurse too easily in facilities that have this mentality. :angryfire

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jwk.... show me the literature that shows that there is an increased incidence of documented aspiration in mechanically ventilated patients by LMA vs ETT.... in fact, if you look at the literature (if you eliminate ICU patients, pre-existing pulmonary disease and pre-existing GERD) there is no statistical difference between the two...

I'm sorry - did I say in any of this in my post?

It takes positive pressure to ventilate someone on an LMA if they're not breathing spontaneously. Common sense would tell you that you could use the same amount of positive pressure from a ventilator safely.

Common sense would also tell you that an LMA will not seal the airway as completely as an ETT. Most of the time, it does fine. Sometimes it doesn't. If it wasn't a safe device, none of us would be using them.

And to be perfectly honest, I hate reading a lot of the literature. Why? Take your example - if you eliminate enough classifications of patients, you can get to the point of no statistical difference in just about anything you want to study.

We've had plenty of LMA reps come through quoting literature and telling us how things are done in other countries. Laparoscopies with LMA's? Not in my OR. Sitting position shoulder cases with the table turned away from me? Go right ahead with your LMA - they'll have an ETT if I do the case. LMA's certainly have their place - I use them every day, but I don't use them indiscriminately.

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i agree with you jwk... they should definitely not be used indisciminately... in fact, i had two silent aspirations in no-risk factor young patients (both were okay after all), but still LMA isn't perfect. I just want point out that it is an alternative airway, and statistically it provides everything an ETT does minus the airway protection and high pressures... if you look at england where they have FAR more LMA experience, they use them for c-sections!!!! with success!!! i still can't stomach that literature :)

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i agree with you jwk... they should definitely not be used indisciminately... in fact, i had two silent aspirations in no-risk factor young patients (both were okay after all), but still LMA isn't perfect. I just want point out that it is an alternative airway, and statistically it provides everything an ETT does minus the airway protection and high pressures... if you look at england where they have FAR more LMA experience, they use them for c-sections!!!! with sucess!!! i still can't stomach that literature :)

And in my mind, that would be one of the worst cases to use them in. What's the point? It's not like an ETT is an expensive thing to use.

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