The Doc said this can't happen!???

Specialties Critical

Published

I was recently taking care of a younger adult patient who has been intubated for about 3 weeks. The patient is maxed out on a paralytic, maxed on propofol, has an additional anesthetic, and an opioid drip. The response to Train of Four is four twitches, when oral suctioning (not deep) is done, the pts eyebrows wiggle. Pt also wiggles eyebrows in response to discussions of traveling out of the country.

I asked the doctor if the patient could be developing a resistance or tolerance to the current meds, specifically the paralytic. The doctor told me, 'nobody develops a tolerance to a neuromuscular blocker'.

Really? Can anyone confirm or refute this? I have Googled the subject and seen a few articles, but I am more interested in actual nurse experiences.

Thank you

Specializes in Family Practice, Mental Health.

Well......I haven't seen anyone develop a resistance to a neuromuscular blockade. However, I have seen patients be under-dosed. Some people are able to metabolize that med a lot quicker than most.

Why 4/4 TOF? Why not 2/4 TOF?

Is this patient in ARDS?

qaqueen

308 Posts

Thanks for the info.

Yes, ARDS. In the beginning TOF was 2/4, but for the last week 4/4.

Specializes in Family Practice, Mental Health.

Gack!!!! A WEEK?! Ohhhhhhmygoodness.....

What paralytic are you having to use ?!?!

qaqueen

308 Posts

​cisatracurium

offlabel

1,561 Posts

​cisatracurium

Tachyphylaxis, or acquired resistance over a prolonged exposure to a medication has been described several times with cisatricurium. Usually happens over several days or weeks.

Just use something else. Should work fine.

Have your doctor Google cisatricurium tachyphylaxis. You can teach him/her something.

sapphire18

1,082 Posts

Specializes in ICU.

WOW that's a long time to be paralyzed...

qaqueen

308 Posts

Offlabel, Thank you so much for the information. As I am new to ICU, I was not comfortable challenging the doctor.

Hopefully, I will grow into that kind of confidence :sarcastic:

qaqueen

308 Posts

WOW that's a long time to be paralyzed...

Being new to ICU, I know less is better, but I do not know what constitutes "a long time", but it seems long to me.

Kitiger, RN

1,834 Posts

Specializes in Private Duty Pediatrics.

I know a man who was AWAKE during open heart surgery! He could tell the doctors what they had been talking about during surgery. At one point, he managed to wiggle his big toe. Someone noticed it, commented on it, and then it was ignored, because "it couldn't happen".

He says he will NEVER have any kind of surgery again.

qaqueen

308 Posts

I know a man who was AWAKE during open heart surgery! He could tell the doctors what they had been talking about during surgery. At one point, he managed to wiggle his big toe. Someone noticed it, commented on it, and then it was ignored, because "it couldn't happen".

He says he will NEVER have any kind of surgery again.

I couldn't like this because...oh my gosh!

This is horrible!

MYSTICOOKIEBEAR

144 Posts

Specializes in Cardiac/Transplant ICU, Critical Care.

The Doctor has either A) Never experienced a patient on long term Neuromuscular blockers (which shouldn't even be a thing but sometimes there are extenuating circumstances) B) Too proud to admit that they didn't know.

Per our hospital policy and pharmacy protocol cisatracurium (Nimbex) should only be on for 24 hours, and 48 hours maximum to maintain vent synchrony. I recently had a patient who was on cisatracurium for 2 weeks straight with that first week being maxed out in order to maintain vent synchrony. This is also the same patient that was 100% on VV ECMO , 100% on the vent, 40 of Nitric with an spO2 of 91% and a PO2 of 52.

By first hand experience, we were all in agreement that prolonged use of that neuromuscular blocker led to decreased efficacy over time since it was on for longer than the recommended and protocol guidelines. There is no doubt in my mind that this patient will become a case study because my specific Thoracic Surgeon is both brilliant and inquisitive and loves to push the boundaries of known and accepted medicine.

I never checked a TOF on my patient because I knew for a fact that the cisatracurium was started before they did an appropriate TOF and finding the threshold for 4 vigorous twitches. In any case, no matter how low the ouput was, it was always 4. In any case the patient was completely synchronous with the vent so even if there were 4 twitches there is no true indication to increase the dose since we are getting the desired results of vent synchrony.

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