Hospital policy for Paralytics/Train of 4

[SkiRNBABSN]

If it wouldn't be too much trouble...can some of you lovely nurses please attach a copy of your unit's policy and unit competency for monitoring a patient on a paralytic gtt? Including Train of 4 competency also would be extremely helpful.

Also any feedback on what type of equipment you like/dislike to use to monitor your patient would be helpful. Pros/Cons of each type you use.

This is purely for research purposes as our unit is looking into training the nurses on this.

Thanks all.

[BSN16]

Although i dont have a policy i can pull up, i do frequently have patients on vecuronium drips to help with ICP issues or sometimes resp issues. I don't use any special equipment besides a nerve stimulator for the TOF. (And also basic vital monitors lol)

Goal is to achieve 2/4 twitches. This can be done on either the ulnar nerve or facial. (i personally always do facial).

Before initiating a paralytic gtt patients must have a secure airway and be sedated.

thats about it... pretty simple once you do it

[Okami_CCRN, BSN, RN]

Our hospital uses Nimbex as the paralytic of choice/stock. As per our policy a baseline TOF is obtained prior to the commencement of gtt. TOF is to be done q15 minutes until therapeutic based on the orders. TOF is to be done hourly after that, if titrating q15 minutes again until therapeutic.

We often use TOF with patients in ARDS, some intensivists write for 2/4 twitches while others prefer no spontaneous breaths over the set limit on the ventilator.

Things to remember with TOF, you can use the facial or ulnar nerve, I prefer ulnar. Also, the patients acid/base balance affects the TOF.

[marienm, RN, CCRN]

I'm at home & can't get to our policies, but we use TOF as described by Okami (and Nimbex is the primary paralytic that I've used too) as well as a BIS monitor for sedation. TOF measures paralysis, and when the pt is paralysed you can't measure a RASS score, so that's what we use BIS for. It connects to our Phillips monitors with its own special module. Our policy calls for establishing a baseline TOF reading (how many milliamps needed to provoke twitches) and BIS level prior to initiating a paralytic gtt.

I've mostly used this with burn patients, so I will put the TOF electrodes wherever I can get them to stick...facial or ulnar...and usually have to hold them down with one hand while pushing the button with the other hand. I recall trying them on an ankle once too, but I don't think it worked. (An anesthesia resident helped set it up, but honestly it wouldn't have made a difference for that patient anyway.) The BIS monitor only has a forehead strip and when we have bad facial burns I question how well this works.