We had a pt one time with very high PEEP (~20) and I remember the nurse giving NMBA to aid in the process. My question is, what exactly is the relation of giving a NMBA to PEEP? My colleague told me but totally forgot as this wasn't exactly my pt. Thanks for any info.
I would guess that this is an ARDS patient? NMBA reduce the ability to contract muscle so a patient who is sedated but still fighting the vent, is dyssynchronous, or has overall high muscle tone may be given a drug like Vec to allow us to better control their ventilation. If they cannot contract their own diaphragm, intercostal muscles, or other accessory muscles they will not be increasing their PEEP from that. This is also not the only thing that can contribute to a high PEEP so it may have been more of a trial compared to changing vent settings or giving other medications.
Aggressive ventilator settings like that imply that the PO2 and PCO2 are at thresholds that strongly stimulate the patients respiratory drive. As the above poster noted, this creates ventilator asynchrony and worsening respiratory failure. Paralysis takes that element out of the picture.
TBH, I don't think the pt was in vent dyssynchrony / auto PEEP. I just wanted to make sure I'm not missing any other reason for why this drug is used aside from better controlling the pt's ventilation (ie. minimizing shivering in a hypothermic pt). Thanks for your input, guys.
Do you mean high peak airway pressures? Generally PEEP is something you set, not something patients "have", and it's not really related to NMBAs. More as described above, it's to reduce peak inspiratory pressures in ARDS patients.
You didn't provide much detail but from my experience, patients on 20 of PEEP are usually in ARDS and also have higher FI02 requirements. We sedate and paralyze them to decrease their oxygen demand as they have very little oxygen reserve. The more they do on their own the more they deplete their oxygen reserve hence the need to paralyze. Hopefully that makes sense.
You didn't provide much detail but from my experience, patients on 20 of PEEP are usually in ARDS and also have higher FI02 requirements. We sedate and paralyze them to decrease their oxygen demand as they have very little oxygen reserve. The more they do on their own the more they deplete their oxygen reserve hence the need to paralyze. If that doesn't help to bring up their PaO2 then we prone them. Hopefully that makes sense.
I agree with what everyone above is saying. You would use an NMBA for total control of a patients respiratory drive so that they are not fighting the ventilator. If a pt has a PEEP of 20 set on the vent then they are most likely in ARDS. If they have a high PEEP on their own then they may be auto-peeping because they can't get their breaths out. I've had this happen before on a pt and we either decreased their I-Time so that their inspiration was shorter or we unhooked the vent for a few seconds to released trapped air.
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