Paralytic and Sedation

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Generally how long are you waiting to turn down sedation after an IV paralytic had been discontinued and turned off? Specifically Nimbex and Roc?

I'm travel nursing during the pandemic and have ran into a bunch of issues with this. So I’m trying to get some opinions. 

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Specializes in Burn, ICU.

How are you monitoring the paralytic? I'd wait to turn down sedation until I was back to the patient's baseline Train-of-Four.  We also use BIS monitoring for sedation so I would titrate down if the BIS showed they were over-sedated (and obviously no other clinical signs of under-sedation.)

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I normally use BIS or the Sed lines but at this facility they aren’t, and they don’t even have the devices to do train of 4 here. 
so I’m just kind of looking for a time frame from once paralytics are stopped, for us to start titrations down on sedation to wake the patient. 
 

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Specializes in Burn, ICU.

I've never done it that way either...but based on patients coming out of paralysis from the OR, I'd say bolus doses wear off in an hour or two. Obviously it will depend on the patient's metabolism if they've been on a drip for a long time. But maybe start slowly weaning after a couple of hours? (Or sooner if you start to see spontaneous respirations on the vent.)

I'll be interested to see what others say from facilities where this is the normal practice!

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These are all sick covid, so they’ve been on paralytics for a minute. Honestly outside of covid crisis I’ve never ever seen it done this way!

but this all came up because I refused to titrate down my patients sedation and transition to Dex while the patient was still on a paralytic drip, with nothing to monitor sedation. There was this whole big blow out by the doctor because I refused. Getting angry, yelling, being a smartass and reminded me I don’t have MD behind my name. ?? Still didn't titrate my sedation down.

But due to that, I’d like to be more prepared and informed. As far as the half life, typical time it takes to wear off I guess.. just generally. 
I know to look for spontaneous breaths, but even then not all have the ability to move limbs... which can still cause distress in my patients. 

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Specializes in ICU.
1 hour ago, Tabitha871 said:

These are all sick covid, so they’ve been on paralytics for a minute. Honestly outside of covid crisis I’ve never ever seen it done this way!

but this all came up because I refused to titrate down my patients sedation and transition to Dex while the patient was still on a paralytic drip, with nothing to monitor sedation. There was this whole big blow out by the doctor because I refused. Getting angry, yelling, being a smartass and reminded me I don’t have MD behind my name. ?? Still didn't titrate my sedation down.

But due to that, I’d like to be more prepared and informed. As far as the half life, typical time it takes to wear off I guess.. just generally. 
I know to look for spontaneous breaths, but even then not all have the ability to move limbs... which can still cause distress in my patients. 

Wow, wonder how he would feel if we stuck a tube down his throat, turned him over on his belly, paralyzed him, and then didn’t make sure he was sedated and pain controlled. Absolutely terrifying! I’m not sure about the pharmacokinetics of paralytics especially with these sick people whose acidosis may potentiate a paralytic, but Roc, Vec, and Nimbex appear to be intermediate blockades lasting up to 90 min. So perhaps 2 hours or so after it’s off just to be safe titrate down sedation? Precedex doesn’t address analgesia, so I don’t understand the desire for sedation alone, especially in a paralyzed patient! Is there any chance this patient was on an oral (OG or NG) cocktail of opioid and benzo analgesia and sedation? If so perhaps transitioning to dex would be effective but without using a BIS I just wonder how anyone expects to be able to keep a person paralyzed, I’d be so worried we couldn’t figure out that the patient was in distress internally.

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No, no oral or IV pain meds at all. 
Almost every paralyzed patient I’ve gotten here... I walk in and they’re tachycardic and  having pressure/oxygenation issues and they can’t figure out why..... I turn up sedation and they’re fine. I’ve been pushing for BIS monitors but nothing. 
Very frustrating bc covid patients in general are very hard to sedate, which makes monitoring it while on a paralytic so much more important. 

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Specializes in ICU.

Oh wow that is so scary. I get that the hospital may not have the resources for BIS monitors, but then I would think they should be extra careful with making sure people are sedated. I, too, have noticed these patients are difficult to sedate. One thing to consider is that some places, mine included, stopped paralyzing everyone and for some patients, even tubed and prone, would just use sedation and titrate to no or few spontaneous breaths. If we were successful in that, we wouldn’t necessarily paralyze, or sometimes we would just push a small amount of paralytic PRN before flipping or head turns without needing a gtt. It gives us the ability to know that a patient is adequately sedated since they aren’t paralyzed, and we knew the sedation is keeping them from taking spontaneous breaths. 

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On 12/29/2020 at 2:05 AM, 0.9%NormalSarah said:

Wow, wonder how he would feel if we stuck a tube down his throat, turned him over on his belly, paralyzed him, and then didn’t make sure he was sedated and pain controlled. Absolutely terrifying! I’m not sure about the pharmacokinetics of paralytics especially with these sick people whose acidosis may potentiate a paralytic, but Roc, Vec, and Nimbex appear to be intermediate blockades lasting up to 90 min. So perhaps 2 hours or so after it’s off just to be safe titrate down sedation? Precedex doesn’t address analgesia, so I don’t understand the desire for sedation alone, especially in a paralyzed patient! Is there any chance this patient was on an oral (OG or NG) cocktail of opioid and benzo analgesia and sedation? If so perhaps transitioning to dex would be effective but without using a BIS I just wonder how anyone expects to be able to keep a person paralyzed, I’d be so worried we couldn’t figure out that the patient was in distress internally.

Precedex does have analgesics effects by potentiating alpha 2 receptors. 

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On 12/28/2020 at 11:40 PM, Tabitha871 said:

These are all sick covid, so they’ve been on paralytics for a minute. Honestly outside of covid crisis I’ve never ever seen it done this way!

but this all came up because I refused to titrate down my patients sedation and transition to Dex while the patient was still on a paralytic drip, with nothing to monitor sedation. There was this whole big blow out by the doctor because I refused. Getting angry, yelling, being a smartass and reminded me I don’t have MD behind my name. ?? Still didn't titrate my sedation down.

But due to that, I’d like to be more prepared and informed. As far as the half life, typical time it takes to wear off I guess.. just generally. 
I know to look for spontaneous breaths, but even then not all have the ability to move limbs... which can still cause distress in my patients. 

That doc is a grade 1 gaping a-hole. Could you have transitioned to high dose Dex (barring bradycardic S/E) while simultaneously titrating down paralytic? Without a ToF, you'd have to ask your patients to open up eyes and lift their head up. Additionally you can look at their CO2 waves and see if they have a curare notch which indicates that the diaphragm is contracting ergo paralytics are wearing off. I don't know if that would have been feasible. We still do that in addition to ToF during emergence of anesthesia. 

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Specializes in ACNP-BC, Adult Critical Care, Cardiology.

It's assinine that a physician would ask to wean sedation that quickly after stopping paralytics.  You really have to make sure the patient is no longer paralyzed and only objective measures such as train of fours, spontaneous movements, over-breathing the set rate on the vent, etc are cues that this is happening.  Patients are not all going to metabolize the paralytic in the same time frame.

Another thing to remember if you're not sure that the paralytic has worn off is to keep the drip that induces amnesia on board at all times.  Only propofol and the benzodiazepines have this property so keep these drips running. 

Opioid drips work for analgesia but they don't induce amnesia.  Precedex does not have that amnesia effect either but it does have analgesic effect once combined with opioids.  You will run the risk of a patient completely paralyzed and being aware of the ordeal...similar to the "awake during surgery" scenarios anesthesiologists can get sued for.

Lastly, weaning sedation would not be your go to after stopping the paralytic on an ARDS patient. In fact, you may need to go up on your sedation as the patient starts moving and fighting your low tidal volume settings on the ventilator.  That would lead to vent dysynchrony and desaturations then you will be struggling and wanting to paralyze again.

 

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Specializes in ICU.
7 hours ago, cynical-RN said:

Precedex does have analgesics effects by potentiating alpha 2 receptors. 

Ah yes I stand corrected. What I should have said is that precedex is typically used alongside other analgesic medications in intubated patients, at least that’s how I had come to understand it. But perhaps there are places where that is the only gtt being used for both sedation and pain control?

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