Starting neuromuscular blockers

[pharmd8888]

HI, I am an ICU pharmacist and I have a question for you awesome ICU nurses. Seriously, love you all.

I am new to the ICU and have a question about starting a neuromuscular blocker drip on a patient. How do I know they are not aware? What is the RASS score you aim for in these patients? Any guidance is appreciated.

This is especially for SICU patients who have brain injuries. I don't know how to assess their level of awareness by just looking at the MAR

[VANurse2010]

Though I must add to my previous post, this thread has got me interested. I've seen BIS monitoring used in the operating theatre as part of a research trial, but not routinely. A quick search has shown a bit of NICE guidance on it's use in surgery where there's risk of awareness (so patients with high ETOH intake etc) but nothing on critical care.

Looks like I'm going to be asking some questions tomorrow and seeing what I can find out :)

Glad I found this discussion, thanks OP

To my knowledge, BIS monitoring is not EBP outside the OR, which is why it's not used in any of the ICUs at my facility.

[VANurse2010]

Thank you for this, it brings up a question I have as a new to service icu RN. When using the TOF, if you see 2 strong twitches and a hint of a third do you count the last wimpy "near twitch"? Sounds crazy, but I have been told so many different things by multiple peers, I would really like an outside opinion. Thank you

I don't really understand of the point of TOF when paralyzing in the MICU (say for ARDS). You're mostly paralyzing for vent synchrony; it's not like giving a paralytic for therapeutic hypothermia.

[offlabel]

I don't really understand of the point of TOF when paralyzing in the MICU (say for ARDS). You're mostly paralyzing for vent synchrony; it's not like giving a paralytic for therapeutic hypothermia.

Paralyzing patients with acute lung injury is for maximizing mechanical ventilation support and minimizing peak pressures and barotrauma in addition to ablation of native respiratory effort. The least amount of motor tone will add to peak pressures.

[VANurse2010]

Paralyzing patients with acute lung injury is for maximizing mechanical ventilation support and minimizing peak pressures and barotrauma in addition to ablation of native respiratory effort. The least amount of motor tone will add to peak pressures.

You don't need TOF to check for ablation of native effort, nor do you need it to monitor peak pressures.

[calivianya, BSN, RN]

You don't need TOF to check for ablation of native effort, nor do you need it to monitor peak pressures.

Agreed! We always do TOF in the hypothermia patients, but it's 50/50 or less with ARDS for this very reason. It really depends on the physician who's ordering the drip whether or not they want TOF with the nimbex or they're okay with just titrating for vent synchrony.