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Acetylcysteine

Posted

Specializes in Psych nurse. Has 7 years experience.

I swear we learned in school that when Mucomyst is adminstered to have suction on standby.

Well, a patient was given it, started coughing profusely, blocked his airway with phlegm or whatever, fell off the bed, hit his head, lost consciousness, and fractured a rib.

I questioned staff about why wasn't suction on standby. All said no, never heard of that practice. Anybody have an opinion here?

SycamoreGuy

Has 1 years experience.

Nope, haven't heard of that. Perhaps it was a protocol at a hospital your nursing faculty worked at.

MedTrans68, ASN

Specializes in Psych nurse. Has 7 years experience.

Mucomyst has this warning attached to it. It says "When cough is inadequate, the airway must be maintained open by mechanical suction if necessary." Am I missing something here?

[h=2]Warnings[/h]After proper administration of Mucomyst (acetylcysteine), an increased volume of liquified bronchial secretions may occur. When cough is inadequate, the airway must be maintained open by mechanical suction if necessary. Where there is a mechanical block due to foreign body or local accumulation, the airway should be cleared by endotracheal aspiration, with or without bronchoscopy. Asthmatics under treatment with Mucomyst should be watched carefully. Most patients with bronchospasm are quickly relieved by the use of a bronchodilator given by nebulization. If bronchospasm progresses, the medication should be discontinued immediately.

My son used mucomyst when he was a baby. My understanding of the drug was that it breaks down the disulfide bonds making the mucus very watery and easier to cough up. If the patient doesn't have a spontaneous cough then the mucus needs be suctioned. I do know that mucomyst is very irritating and it is recommended that albuterol is given before or with the mucomyst.

applewhitern, BSN, RN

Specializes in ICU. Has 30 years experience.

It just seems like common sense would prevail; I mean if someone needs Mucomyst for their lungs you would want suction readily available, whether protocol or not.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Mucomyst has this warning attached to it. It says "When cough is inadequate, the airway must be maintained open by mechanical suction if necessary." Am I missing something here?

Warnings

After proper administration of Mucomyst (acetylcysteine), an increased volume of liquified bronchial secretions may occur. When cough is inadequate, the airway must be maintained open by mechanical suction if necessary. Where there is a mechanical block due to foreign body or local accumulation, the airway should be cleared by endotracheal aspiration, with or without bronchoscopy. Asthmatics under treatment with Mucomyst should be watched carefully. Most patients with bronchospasm are quickly relieved by the use of a bronchodilator given by nebulization. If bronchospasm progresses, the medication should be discontinued immediately.

First if cough/gag reflex is diminished in ANY WAY mucomyst should NOT be administered PO. Peroid. End of story.

So for example...a patient comes in with a Tylenol with codeine over dose...their acetaminophen levels are toxic and they need mucomyst...but they are somnolent or obtunded. The drug would be administered through the NGT or given IV. If their level of consciousness was low enough they would be intubated then treated. Remember the ABC's.

If a patient was givein mucomyst PO and was lethargic (again I wouldn't give it by drinking with ANY altered LOC) and began vomiting (the stuff is DISGUSTING!) of course AGAIN your priority is ABC. Suctioning the airway and rolling the patient on their side to prevent aspiration IS the treatment of choice.

IN the case of bronchospasm...mucomyst is given as a respiratory nebulized treatment in patients with, in my experience, think tenacious secretions and it can cause bronchospasm. If this occurs it is reversible by stopping the mucmyst nebulized treatment and an albuterol/atovent treatment is administered.

I am confused how anyone can cough themselves out of a bed, fall to the floor, breaking a rib, and losing consciousness if they were being properly observed and monitored.

What type of healthcare setting is this that suction was not on the wall and easily accessible.

MedTrans68, ASN

Specializes in Psych nurse. Has 7 years experience.

All my points exactly. This is a hospital with suction on the wall. RT Department is in charge of administering all nebulized treatments and was standing there watching him the whole time. I don't get it either. I really don't. I don't get why staff of however-many years in practice do not know these procedures. Two other staff rushed in and immediately HOISTED him up onto the bed. I was yelling to clear his airway and get the O2 sat monitor on him. A 25+ year RN yelled back at me that we are not concerned with his O2 sat. Oh but throwing him on the bed is important? The patient is full code. I was going with ABCs, not getting him back in bed. These people scare me, and I have no say because I've been an LPN for 1 year and these people have been RNs for 20+ years.

Lack of a good cough reflex is not a contraindication nor an absolute contraindication. For mucomyst, it is recommended that suction be available to maintain the air away. The only recommendations that I'm aware of is that asthmatics use albuterol either before or with a nebulized treatment of mucomyst and to not mix with antibiotics.

I'm not sure exactly what happened with your patient, but it seems to me that a lot went wrong if the patient was able to fall out of bed with medical personnel at the bedside. I would agree with what you are saying as far as breathing comes first and the head trauma a very close second. Maybe the RN felt that O2 check wasn't as important as to getting the patient back to breathing properly? I'm not really sure what was going on at that point. It seems you have good reason to be upset, but is it specifically because of the mucomyst? Do you feel it was inappropriately given? Or the person giving it didn't understand how to properly maintain patient safety? Since it was a doctor's order, do you feel someone should have spoken to the doctor about concerns with this patient?

I am only asking because I'm learning new things every day and this case is very interesting with all the things that went wrong. It's puzzling that people just stood around as this patient began coughing so hard that they fell out of bed and did nothing to help the patient until they were on the floor.

One more question.... Was it a nebulized treatment or orally given?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

All my points exactly. This is a hospital with suction on the wall. RT Department is in charge of administering all nebulized treatments and was standing there watching him the whole time. I don't get it either. I really don't. I don't get why staff of however-many years in practice do not know these procedures. Two other staff rushed in and immediately HOISTED him up onto the bed. I was yelling to clear his airway and get the O2 sat monitor on him. A 25+ year RN yelled back at me that we are not concerned with his O2 sat. Oh but throwing him on the bed is important? The patient is full code. I was going with ABCs, not getting him back in bed. These people scare me, and I have no say because I've been an LPN for 1 year and these people have been RNs for 20+ years.
Is this acute care? to the inexperienced eye I can see how you viewed this. I can see why the nurses acted this way without being there. Just a word of advice...in an emergency...never "yell" it adds to the chaos...((HUGS))

I hear what you are saying...let me try to glean a little out of this situation. It sounds as if the patient was dangling on the side of the bed while receiving the treatment. The RT was there and it appears so were you. The patient had severe coughing/gagging and fell onto the floor...maybe they were too weak to be dangling.....I don't know for I was not there. The patient sustained an injury that is not good under any circumstances. A real cluster of panic.

I know in some facilities they have gone to cost saving measures and not setting you the suction canisters in every room. IMHO this can be a costly one in the long run...but that is for them to figure out.

I cannot not offer any insight as to the RT apparent lack of response. Maybe they were new and inexperienced. The nurses were focused on getting the patient off of the floor and at that moment running around looking for the pulse ox is not a priority...at THAT particular moment. The priority is... are they breathing? Do they have a pulse? Then getting the patient safe and oxygen on...then worry about the O2 sat. So I see where the nurses would say that they were not concerned with the O2 sat....at that moment.

I am an ER nurse so my focus , after the patient had already fallen, would have been to lie the patient on the floor, be sure they are breathing, had a pulse, maintain c-spine precautions as best I could, get some O2 and call for help. Even if the patient was not coding a code could have been called to get necessary personnel present quickly.

Mucomuyst CAN cause this sort of reaction in patient but it is by no means "common". I think unopened suction supplies should be in every occupied patient room by the wall suction apparatus. Why this is not done in your facility I have no idea.

Does this help?

Edited by Esme12

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Lack of a good cough reflex is not a contraindication nor an absolute contraindication. For mucomyst, it is recommended that suction be available to maintain the air away. The only recommendations that I'm aware of is that asthmatics use albuterol either before or with a nebulized treatment of mucomyst and to not mix with antibiotics.

I'm not sure exactly what happened with your patient, but it seems to me that a lot went wrong if the patient was able to fall out of bed with medical personnel at the bedside. I would agree with what you are saying as far as breathing comes first and the head trauma a very close second. Maybe the RN felt that O2 check wasn't as important as to getting the patient back to breathing properly? I'm not really sure what was going on at that point. It seems you have good reason to be upset, but is it specifically because of the mucomyst? Do you feel it was inappropriately given? Or the person giving it didn't understand how to properly maintain patient safety? Since it was a doctor's order, do you feel someone should have spoken to the doctor about concerns with this patient?

I am only asking because I'm learning new things every day and this case is very interesting with all the things that went wrong. It's puzzling that people just stood around as this patient began coughing so hard that they fell out of bed and did nothing to help the patient until they were on the floor.

The lack of a good cough/gag IS a contraindication to orally administered mucomyst in the presence of Tylenol overdoses. If someone cannot cough or has a poor gag orally administered medication is contraindicated due to risk of aspiration.

Edited by Esme12

The lack of a good cough/gag IS a contraindication to orally administered mucomyst in the presence of Tylenol overdoses. If someone cannot cough or has a poor gag orally administered medication is contraindicated due to risk of aspiration.

Ok. My dealings with mucomyst has been purely nebulized treatments. That is good to know in the future. :-)

If he was coughing hard enough to cough himself out of the bed, it sounds like his cough WAS adequate that suction wasn't needed.

vampiregirl, BSN, RN

Specializes in Hospice. Has 10 years experience.

What type of healthcare setting is this that suction was not on the wall and easily accessible.

I work LTC, we have suction on the crash cart for each unit.

I have occasionally had orders for mucomyst. On the several patients I've administered it to, I've always first administered an albuterol tx. Our protocol requires nurses to remain with a patient during a neb tx (any neb tx). It usually is very effective - just smells horrible!

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Ok. My dealings with mucomyst has been purely nebulized treatments. That is good to know in the future. :-)
IN the presence of Tylenol overdose it can also be given IV.

MedTrans68, ASN

Specializes in Psych nurse. Has 7 years experience.

It was given by nebulizer. RT was at doorway. Watching him. Watching the halls. watching him. Watching the halls. I was about 15 feet away in a nurse station unaware of exactly what she was giving him. RT always just comes on the floor and does their thing then leaves. Suction is on the wall with canister. It is bagged unless hooked up and on standby. O2 sat is right there at bedside on a long cord because there is an MP5. I work on telemetry. The RT staff is very much older, early 60s. Not sure of years of experience but assume not nearly a newbie.

Pt just kept saying afterwards that something felt stuck in his throat and he couldn't breathe to the point he like passed out. I dunno. It was just chaotic and I am trying to work smarter and learn from it. The suction part stood out for me from school because they kept reiterating that but i just don't get why RT never heard of it, especially when it is clearly a bolded warning on the clinical pharmacology paper for mucomyst.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

It was given by nebulizer. RT was at doorway. Watching him. Watching the halls. watching him. Watching the halls. I was about 15 feet away in a nurse station unaware of exactly what she was giving him. RT always just comes on the floor and does their thing then leaves. Suction is on the wall with canister. It is bagged unless hooked up and on standby. O2 sat is right there at bedside on a long cord because there is an MP5. I work on telemetry. The RT staff is very much older, early 60s. Not sure of years of experience but assume not nearly a newbie.

Pt just kept saying afterwards that something felt stuck in his throat and he couldn't breathe to the point he like passed out. I dunno. It was just chaotic and I am trying to work smarter and learn from it. The suction part stood out for me from school because they kept reiterating that but i just don't get why RT never heard of it, especially when it is clearly a bolded warning on the clinical pharmacology paper for mucomyst.

Right... I can't answer for the RT. Having suction available does not mean having it open and ready to go. But do you see where the nurse reacted?

The nurse hears a commotion...runs in finds the patient on the floor unconscious. She assesses. Ok he is breathing and has a pulse, he is not blue...lets get him off the floor. Lets get him up in the bed....now lets Get him some O2..ok still breathing...so airway is OK...no need to suction right now...lets get some vitals.

Scrambling for the pulse ox in the midst of chaos isn't a priority. All you want to know is are they breathing? Do they have a pulse? ARE THEY BLUE?

You don't want to start blindly sticking suction cath in his mouth in case he has an upper airway obstruction...lets say he had a cough drop in his mouth that he sucked into his throat with the breathing treatment because mucomyst tastes so bad....because you will just jam it further down his throat and really obstruct the airway. If they are moving air leave it alone until you have a better handle in the situation. If they don't have vomit pouring out of their mouth leave it until you have a better assessment.

Now the patient could have very well had a mucous plug. Coughed until he passed out probably not from a lack of O2 but from vagal response. If he was able to talk after the incident without deep suctioning his airway was fine all along.

Do you see what I mean? Does this help?

IN the presence of Tylenol overdose it can also be given IV.

Or PO if you want the person to think twice next time they decide to take a bottle of tylenol.