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?

never on an unintubated pt. you are right on.

i float to icu and er. in the er, we sedate people with diprovan all the time. it is the best drug imo. i have never seen a problem after using it yet. in the unit, we stop all sedatives 12 hours before extubation. we stop the diprovan 1 hour before if it is being used. after extubation, if the pt is restless and confused, i certainly would say that very well could be a sign of hypoxia and if there was an a line, i certainly would check a gas. no harm no foul if the a line is there. if all you had was a pulse ox, i would do a gas if the pt's pox was >97 before extubation, and now less than 92. an abg was a reasonable intervention. if hypoxia wasn't the cause and the pt was on 100%nrb mask with good effort, i would consider haldol or ativan (as low as .25 iv increments) to calm the patient if he could keep his sat > than 92 and his rate > than 14.

i would always keep the pts ability to maintain a sat > 92 and rate > 14 no matter what. once those numbers are compromised (imo) it's time to rethink your plan. if you have to retube... you have to retube.

in addition, i would be concerned with his neuro status on admission. if he continues to remain confused to the point where you have to sedate him (thus compromising his resp status), i would then consult with the primary regarding ms change.

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?

Dang. I'm just an OR nurse, and I don't particularly like doing conscious sedation (they don't pay me enough, and I'm not trained as an anesthesia provider) but to me conscious sedation, by definition, is moderate sedation--if someone needs paralytics, that's deep sedation and requires general anesthesia via an LMA or ET tube.

Conscious sedation--good ol' Fentanyl and Versed, in dosages titrated to avoid having to slip in even an oral airway--and produce amnesia. I know people who use a technique in free standing surgery centers of Ketamine and Valium via EJ (EJ started by the circulator, using appropriate precautions to avoid air embolus--Trendelenberg, have patient hold their breath and do a Valsalva.) Ketamine alone can produce combativeness--you've probably all seen it in Vietnam vets or other people with PTSD after it's been used--but, for some reason when combined with Valium and given EJ, it does not.

Can't say I've ever used MS for conscious sedation, not with Fentanyl so readily available. Don't think I've ever signed it out for an anesthesia provider doing MAC, either--or for general anesthesia, for that matter.

you don't paralyze people for conscious sedation.... if you want to use a paralytic have an anesthesiologist there to secure the airway

i would think a CRNA could be there and handle the airway?!?!?!

respiratory muscles (diaphragm) are the last to be blocked and the first to come back from paralysis.... so loisane, you are wrong. and by the way, how does a patient "look" fully reversed???

even w/ a full TOF, eye opening and purposeful movement - 70% of the receptors can still be blocked and sufficient enough to make a patient floppy during recovery (i know you know all this...) as well as SOME providers reverse when there is a mediocre first twitch and none to follow - these patients can "look" sufficient after reversal but quickly become floppy in recovery....

a patient wakes up and is confused... sedating him with morphine is the wrong thing to do, it will worsen the confusion (unless he is in sooo much pain that he has become confused, very unlikely).... you want to use something that will sedate him without compromising his respiratory effort even more: choices include: clonidine, dexmedetomidine, haldol, seroquel, risperdal.... Don't use narcotics, don't use benzos, and wouldn't recommend benadryl as it can sometimes make people even more agitated (especially the elderly) - due to its histamine-effects

i disagree - you are going to give a confused patient haldol, seroquel or risperdal - the antipsychotic drugs w/ the most side effects?!?!?! small amounts of versed (in my small experience) make confused patients very pliable. and although i disagree - i know you have more experience - however - i still have my opinion.

Diprivan/vented - i concur that paralytics are not a good idea in those who are not intubated - a small amt of versed and perhaps 25mcgs of fent may have been enough to give you the time you needed to fix the problem...

Just my 2 cent

Gotosleepy

When would it ever be appropriate to use a paralytic on somebody who is not intubated if your goal is not to immediately intubate them? When would it ever be a safe practice to use a paralytic on a patient with the intention of allowing them to maintain their own airway? Please give examples.

Gotosleepy

When would it ever be appropriate to use a paralytic on somebody who is not intubated if your goal is not to immediately intubate them? When would it ever be a safe practice to use a paralytic on a patient with the intention of allowing them to maintain their own airway? Please give examples.

One would never use a muscle relaxant with the intention of allowing them to maintain their own airway. Anesthesia providers may provide airway support with other devices than an endotracheal tube. We may occasionally elect to use muscle relaxants during anesthetics where we are maintaining the airway by mask or LMA. Of course, gotsleepy may clarify directly, but I believe this is what the comment referred to.

loisane crna

Loisane

Maybe gotosleepy meant what is you explained above, but that it is not the impression I was getting at first , and that is why I wanted an example. It is just that the thought of giving a paralytic without intending to intubate immediately scares the heck out of me!

i said that you can paralyze a patient just as long pt is sedated (and won't be aware of paralysis) and just as long as there is an anesthesia provider at the bedside to maintain/secure the airway.... whether this is with an ETT/LMA or just a mask airway... it doesn't matter.... what matters is having an expert to manage the airway, not an ER conscious sedation nurse, not an ER doc...etc...

actually you can use paralytics in somebody who isn't intubated... but they need to be sedated as well, and you need an anesthesia provider there

Yeah, BUT---in my opinion, paralyzing a patient simply because he is agitated, confused and/or combative qualifies as a CHEMICAL RESTRAINT.

And if you want him to be able to cough and deep breathe, as Diprivan/Vented was instructing him to do, well, MS is a pretty potent respiratory depressant--but you know that.

And, having to put in an airway if respiratory depression ensues from the MS means he's so obtunded that he won't be able to cough and deep breathe without instruction and stimulation ANYWAY--which is what Diprivan/vented was in the middle of instructing him to do--and which means you might end up having to give Narcan for the respiratory depression and he gets agitated all over again!

Then there's still the dilemma of having to reverse the paralytic if need be--and what if he gets agitated and combative AGAIN once THAT takes place?

Seems to me a simple dose of Versed, (possibly even enough to have to reverse with Romazicon to get the degree of sedation you needed to make this patient co-operative and amnesic) or even IV Valium n a pinch would have been the trick here.

I, too, remember the days when patients like this would get p.o. Valium, Benadryl or even Chloral Hydrate with a small sip of water before a bedside bronch or other invasive procedure, and they'd be relaxed and compliant and sometimes have to be stimulated to follow commands because they slept peacefully through it. Of course, that was back in the days before pulse oximeters, too! We (the nurses; there was no anesthesia provider) would watch their nail beds and eyelids for duskiness, and stimulate them as needed.

Maybe I am missing the point here, but why would I want to paralyze somebody with the intention of maintaining their airway with a mask, or with the intention of using an LMA. The beauty of an LMA is to have the patient breath spontaneously. So I am still waiting for Gotosleepy to give an example of when it would be appropriate to give a paralytic without intending to intubate.

oh the list goes on and on...

recent tracheal resection and reconstruction for dilation...

suspension microlaryngoscopy...

TURP w/ obturator nerve stimulation (and you don't want the patient to kick the urologist)

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....

i thought about avoiding this thread as most everything seemed to be covered.

however to specifically reply to london, one treatment option for laryngospasm is to give a dose of succs that is 1/4 the intubation dose, since spasm is usually a result of 1. post extubation cord stimulation, the purpose was to extubate so you dont really want ot reintubate.

2. cord stimluation from someone who was getting conscious sedation and they get too deep. again this is not a full paralyzing dose, but enough to break the spasm so you can ventilate.

again the dose of succs is not full paralysis.

however to titrate paralytics in someone NOT to be intubated doesnt make much sense to me either. we're taught if you paralyze someone, they for obvious reasons no longer control their airway and are at risk for aspiration. the gold standard for protection of the airway in an oett.

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.

ya have to know why, when, how much and is it appropriate for the situation for every drug you use.

i think athomas said it, but to reiterate, if you do train of 4 and the last twitch is 90% as strong as the first twitch you can have up to 70% of you receptor sites still blocked. this is significant paralysis. you may say however that even so, they are still breathing with adequate tidal volumes. this is true to an extent, but drugs like vec and pavulon have metabolites that can cause paralysis (a percentage strength of the parent dose). this means when they go to recovery of back to their room, significant paralysis can take hold and they stop breathing. i believe some literature says even roc has this property (postop resp depression.)

just my little input.

d

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....

i read where this is done in england (birthplace of lma) but is this recognized as a standard in the US. i was under the impression it was still a no no to mechanically ventilate through lma for risk of insuflating the abd and aspiration risks?

also you mentioned a turp w/ opturator stim. i assume your doing this under spinal, then giving some paralytic....can you elaborate please.

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