Anesthesia

allnurses Guide · Dec 5, 2009

I was just reading the thread about why patients are to void before a surgery, and I saw a mention of paralytics. Are they used in most surgeries with general anesthesia, or is it case by case? Why would it be used in one situation and not another? It never occured to me that one could have surgery without it, I guess. Or maybe I just thought the sedation was enough to essentially *cause* paralysis during the operation. Hm.
Anyway, what's the deal with anesthesia?

We use paralytics quite frequently to assist with intubation after that point it depends on the operation whether we choose to use paralytics or not.

Paralytics can be used to assist the surgeon in muscle relaxation ie. for abdominal cases. It is sometimes used more for patient safety where any patient movement could be potentially be disastrous ie. brain surgery or laparscopic surgery when the instruments are in the abdomen.

Just some examples but I am sure you get the idea.

cmonkey · Dec 5, 2009

Interesting. I'm having a procedure this month and now I'm going to pepper the anesthesiologist with questions. They love that, right? :bugeyes:

Wait, though, that brings up a question. Why use them during intubation? That is, if you aren't using paralytics, why do you need to intubate in the first place? I can see needing to if you *are* using paralytics because, hello, paralyzed; but if not, is the sedation so effective that respirations are diminished and that necessitates intubation?

PolandM · Dec 5, 2009

Airway protection mainly. Yes, sedatives can/will greatly affect respirations. You always sedate before you paralyze. As far as I know even if a paralytic isn't maintained through a case you would normally give a bolus for intubation to relax the airway to help facilitate visualization and what not.

FOCKER0014 · Dec 5, 2009

just because you sedate a patient does not mean their cough/gag reflex goes away....paralytics will knock this reflex out and allow for easier and safer intubation.....They will also relax the musculature of the neck and jaw for easier manipulation.....

just my five cents....

allnurses Guide · Dec 5, 2009

Interesting. I'm having a procedure this month and now I'm going to pepper the anesthesiologist with questions. They love that, right?
Wait, though, that brings up a question. Why use them during intubation? That is, if you aren't using paralytics, why do you need to intubate in the first place? I can see needing to if you *are* using paralytics because, hello, paralyzed; but if not, is the sedation so effective that respirations are diminished and that necessitates intubation?

We use paralytics on intubation to help prevent laryngospasm.

dmc_rrt · Dec 5, 2009

the answer from focker0014 says it best. :up:

allnurses Guide · Dec 5, 2009

It is not that simple. I can knock out anyone's gag/cough reflex with enough sedation. That is why we don't normally use paralytics when placing an LMA. We just give them a large dose of propofol right before we place the LMA, and the propofol we keep the patient from coughing/gagging for the initial insertion. You can gain adequate relaxation with enough sedation, but it comes at a cost to your hemodynamics, so using sedation with a paralytic offers a decent compromise between hemodynamic stability and relaxation. It is not uncommon to intubate peds without using any paralytics.

PostOpPrincess, BSN, RN · Dec 5, 2009

This place isn't big enough to go into all the intricacies. Suggest you look at books.

FOCKER0014 · Dec 5, 2009

can't argue with that....merely implying that paralytics make for a safer intubation...

GilaRRT · Dec 5, 2009

It is not that simple. I can knock out anyone's gag/cough reflex with enough sedation. That is why we don't normally use paralytics when placing an LMA. We just give them a large dose of propofol right before we place the LMA, and the propofol we keep the patient from coughing/gagging for the initial insertion. You can gain adequate relaxation with enough sedation, but it comes at a cost to your hemodynamics, so using sedation with a paralytic offers a decent compromise between hemodynamic stability and relaxation. It is not uncommon to intubate peds without using any paralytics.

I think your point should be expanded upon because many people confuse what happens in the OR with what happens outside of the OR. Paralytics are common place in a procedure known as rapid sequence intubation (RSI). It is understandable to assume RSI is ~ to a "typical" OR induction. However, a paralytic has a very special place in RSI.

RSI is something we typically do in a crisis or potential crisis situation outside of the OR. In this environment it is reasonable to assume a non fasting patient who would not meet the criteria for an elective OR case. A major and often overlooked rationale for giving a paralytic in RSI is to decrease the risk of aspiration. Of course, paralysis may produce better intubating conditions; however, aspiration prevention is often regarded as one of the major traditional reasons for going down the path of RSI. However, do not always assume paralysis will make for an easier intubation. In addition, not every patient who is "critical" will require RSI. RSI is but one tool and should be used only on people who will benefit and meet strict criteria. For example, an unresponsive person who is near death would not be a RSI candidate in spite of their condition. Likewise, a morbidly obese person with spinal trauma, a Mallampati score of IV, and limited jaw mobility would also not be a good RSI candidate.

A little diversion from the OP; however, still a good topic to define in the hopes of understanding.

cmonkey · Dec 6, 2009

This is really interesting, thanks. Another question for you: as I understand it, sedation is fairly easy to reverse; is it the same case with paralytics?