thoughts on only Paralytic while intubated....

[MassED, BSN, RN]

I am just wondering how common and cruel the practice is of using only paralytics while a person is intubated in the ER. I took care of a guy last night that we gave Norcuron 10 mg which wore off in 30 minutes each time... and the doc never ordered anything else, despite my asking.... they don't use Diprivan where I work, which I find odd... only in the units.

So, my question being... how common do ER nurses see this occur? Wouldn't this make for a horror story for the patient, once extubated, being paralyzed and aware??? Yikes... my poor guy. I kept talking to him - I saw tears... really made me mad.

[beachbum3]

Wow... thats terrible!

I've only seen it done with paralytic and sedation.... I can't imagine not having both.

Is it always this way, or was there some reason he couldn't have sedation as well?

[MassED, BSN, RN]

Wow... thats terrible!

I've only seen it done with paralytic and sedation.... I can't imagine not having both.

Is it always this way, or was there some reason he couldn't have sedation as well?

that's a good question - I don't know if that is common practice here, as this guy was really tough keeping him under for the vent so I had to go back and forth to the ER doc to request more meds.

Any other intubated patient that I've cared for at this facility hasn't had solely a paralytic...not that I recall.... usually they get up to the unit so fast, but we were trying to get him settled prior to getting him up to the unit, but I did find it odd... maybe this doc had his reasons.. I don't know.

The hospitalist had ordered an Ativan titration for the unit, which would have required an act of god to get started in the ER (and he was biting and gagging on the tube meanwhile). They'd go nice and slow on the 5th floor, bring it down on their next run.... not the most expeditious process. I did give him some Ativan IV (6mg, which did NOTHING) prior to his 5th Norcuron, though. We did suction a big old chunk of meat around his ET tube, the NG appeared clogged, wouldn't flush... so maybe he had choked prior to EMS arriving and attempting intubation x3 without success. I think they shoved that piece of meat so far into his lungs... the secretions were so copious that is was vomit-like amounts. After the chunk, that backed off. Anyway, off on a tangent. But the paralytic only issue (prior to the Ativan) was pretty mean. I know this doc did say "well it should hold him until he gets to the unit" but that is crappy to leave this patient in that state even for a short time. I can only imagine what this guy was going through. He was trying to mouth words to me too... why we didn't extubate after that, it's beyond me...

[flightnurse2b, LPN]

yikes!!

i always always do paralytic with sedation/amnestic. i cant imagine being fully alert while being intubated and paralyzed. why couldnt he just give a little versed or valium??

that sounds really uncalled for on the MD's part....

[RazorbackRN, BSN, RN]

There is something seriously wrong with that. As a matter of fact, I would've had a problem administering the paralytic without sedation.

Sounds to me like the Ethics Committee needs to be involved with this practice.

[cardiacRN2006, ADN, RN]

How sad!

Drs have tried this with me. After intubation I say, "so, do you want fentanyl or versed?"

If they ask why I need sedation, I usually say something like, "because we don't paralyze without sedation here". If I get any static, then I start busting out words like, 'standards of care' ..... If the Dr still says no my next question will be, "who is your attending?"

This is actually one thing I really will go up the chain for. My pts will not be without sedation while paralyzed.

[leslie :-D]

that is just outright barbaric.

time to vent this md and give him a taste of his own medicine.

leslie:twocents:

[woody62, RN]

I don't know about ER's. I was once tubed, for three days, on a paralytic, without sedation. When I was extubated, I told the senior resident, who I knew, I would kill him if he ever did it to me again. For a patient it is one of the most frightening things that can happen. You are able to think and worry about all the bad things that can happen. I can't imagine anything worse being done to a patient. And it certainly puts a fear into them, the next time they are to undergo it.

Woody

[kmoonshine, RN]

I agree with everyone else - how cruel! I often find that docs will only order sedation for vented patients; at times, I have to ask them for a paralytic. But I've never had it the other way around. Of course, in the ED your main focus is to stabalize the patient and get them up to ICU ASAP. You usually don't have the time play around with titrating optimal sedation settings, but to not even attempt to GIVE sedation? That's awful.

You should see if there's a P&P regarding this issue. I would have charted "Pt appears uncomfortable, biting ETT, movement noted. Writer notified Dr. Jones regarding pt's appearance and need for sedation; no orders received from Dr. Jones."

[MassED, BSN, RN]

I don't know about ER's. I was once tubed, for three days, on a paralytic, without sedation. When I was extubated, I told the senior resident, who I knew, I would kill him if he ever did it to me again. For a patient it is one of the most frightening things that can happen. You are able to think and worry about all the bad things that can happen. I can't imagine anything worse being done to a patient. And it certainly puts a fear into them, the next time they are to undergo it.

Woody

thank you - just reinforces from a patient's viewpoint. I knew he'd hear me, so I continued to talk to him and tell him the vent was breathing for him and not to bite, etc. But no amount of reassurance could help, I kept thinking... I'd panic too. Then to have that darn chunk of meat come up... he likely felt it and knew it was there and that was the reason why he went unresponsive.... how that would have sucked also. He did appear relieved once it came up, though. A small slice of a reprieve.

I know it won't change this particular guy's style of practice if I confront him. Damn sure won't go the mgmnt route, since they have nothing to do with the docs. I just don't get why he would only order the paralytic after my repeated attempts for sedation requests... he's a great doc, but this really puzzled and angered me. Could there have been a fear to sedate? His Head CT was normal.... his urine tox was positive for Cocaine, THC... Barbituates... I think that's it.

[MassED, BSN, RN]

I agree with everyone else - how cruel! I often find that docs will only order sedation for vented patients; at times, I have to ask them for a paralytic. But I've never had it the other way around. Of course, in the ED your main focus is to stabalize the patient and get them up to ICU ASAP. You usually don't have the time play around with titrating optimal sedation settings, but to not even attempt to GIVE sedation? That's awful.

You should see if there's a P&P regarding this issue. I would have charted "Pt appears uncomfortable, biting ETT, movement noted. Writer notified Dr. Jones regarding pt's appearance and need for sedation; no orders received from Dr. Jones."

I did write a note similar to that -"MD notified of movement, biting tube, Norcuron 10 mg ordered and administered."

I know he wanted the guy to get up to ICU, but I explained to him that I couldn't transfer him in that state.... still no sedation order.

I will look next weekend for any P&P on that.... hmmm... of course I'm keeping the patient's name, in case he comes back!

[BelleKat, BSN, RN]

I know of one pt who just received just a paralytic when he was intubated all night,he had an MI in the morning from the outrageous stress. I don't know why Drs don't always want to order sedation and/or analgesia. It's a cruel thing to do to someone.