thoughts on only Paralytic while intubated....

MassED, BSN, RN · Aug 4, 2008

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.

oh, god... this guy's hx: (at about 30 yrs old too) MI, COPD, HTN, Crohn's, Depression... I think that's it. I can only imagine the stress... that would be the most horrific experience - like a nightmare.

TiredMD · Aug 4, 2008

Why in God's name did they give a paralytic in the first place? Are we talking "paralyzed after RSI" or were they intentionally paralyzing the guy?

Regardless, I've never heard of such an insane, irresponsible practice. That's the kind of crap that novice paramedics do in the field, then they get yelled at when they get to the hospital.

Funny thing about Fentanyl + Versed, once you give enough you usually don't need the paralytic.

Next time you see that doc, punch him/her right in the face for me.

neneRN, BSN, RN · Aug 4, 2008

NEVER NEVER NEVER give a paralytic without sedation FIRST!!!! EVER! That's a cardinal rule.

In my 8 years in the ED, I've never given any paralytic without sedation first. As a nurse, this is something you flat out refuse to do and you raise a big stink if any doc wants you to.

There are times when you're struggling to keep the BP up, and you may have to try some different things to maintain the BP and keep them sedated, but there's always something that works.

As far as documenting that you notified the doc or were refused orders for sedation, that's not really going to save yourself either, because in a court, the first thing the lawyer would be asking you is why you didn't go up the chain of command and be an advocate for your patient, knowing how cruel administering a paralytic without sedation is....ALWAYS involve your charge/supervisor in this situation...

beachbum3 · Aug 4, 2008

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.

Maybe there was worry about interaction between sedation and the drugs? (I have no idea if they would, just came to mind) I'm going to look it up...

beachbum3 · Aug 4, 2008

So my drug book says its contraindicated in acute alcohol intoxication, also says alcohol/CNS depressants can increase hypotensive effects of the drug.

Still seems completely unacceptable.

flightnurse2b, LPN · Aug 4, 2008

Maybe there was worry about interaction between sedation and the drugs? (I have no idea if they would, just came to mind) I'm going to look it up...

according to nursing 2008 drug handbook:

vec interacts with the following: aminoglycosides, bacitracin, beta blockers, clindamycin, mag salts, enflurane, halothane, isoflurane, polymyxin abx, quinidine, quinine, sux, tetracyclines, tegretol and dilantin.

vec is incompatible with: alkaline solutions, amphotericin B, diazepam, lasix and thiopental.

then there is a bolded blue alert that reads: Drug has no known effect on conciousness, pain threshold, or cerebration. To avoid pt distress, don't induce neuromuscular block until patient is unconcious.

SFRN · Aug 4, 2008

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.

This is completely unethical---when a person is paralyzed---they MUST be given sedation and pain meds. Propofol is GREAT but not enough...because it has no analgesic properties.....you would need some Fent. and propofol.........wow i am amazed at this story.

GilaRRT · Aug 4, 2008

This is a pretty serious problem. If a patient was awake during this experience and found out that they were paralyzed without sedation or analgesia, they would have a very good civil case against the hospital or providers involved.

There are special situations where giving a paralytic without sedation or analgesia is indicated. For example, if you are attempting to intubate a crash airway and encounter problems such as trismus, you can give a bolus of sux without sedation. Remember, a crash airway is defined as an unresponsive patient who is near death. This is not your typical RSI scenario. Nor does this apply to the patient who is already intubated.

kmoonshine, RN · Aug 4, 2008

Following RSI, the only times that I've used paralytic + sedation/analgesia are times when we induce hypothermia following cardiac arrest (you don't want them to shiver, as it increases oxygen demand). I've also used a vec drip on someone receiving versed who was intubated due to severe asthma attack & pneumonia. We added a vec drip to keep her from fighting the tube as we continued to titrate her versed and other drips. There's a few other patients when a dose of paralytic was given, but sedation was always on board.

I think that the ability to determine proper sedation/analgesia for the vented patient is an artform. Its can be really complex and there isnt a magic formula for everyone - and I commend those nurses who have mastered this technique!

SmilesHeal101 · Aug 4, 2008

I am so sorry to hear that this happened to a patient. I am a nursing student and from a patient standpoint this is not ethical. Patients that are intubated are highly anxious, probably unable to breathe, and paranoid something is going to happen. There is a lot I need to learn and understand about nursing, and what to do in this situation.

BaRNs · Aug 4, 2008

Holy #&*$^%! Valium or versed at the VERY LEAST! Paralytics with nothing else on board tugs the fringes of incompetence on that physicians part. I would bring that event up with your charge AND dept/unit manager. That will make for excellent staff meeting dialogue to prevent that from occuring again. I have seen docs do some crazy things during intubation in the OR and ICU over the last several years, and have seen almost this exact incident happen before. You need to get in this MD's face and advocate immediately, if he fails to respond you get your charge nurse involved and call his attending or his medical director ASAP! He will be Johnny-on-the-spot with versed at a minimum after that.

I can't imagine a medical condition that would allow for a paralytic and contraindicate some type of sedative. I seriously doubt this MD had a specific, justifiable reason for not scripting you some kind....

APRN., DNP, RN, APRN, NP · Aug 4, 2008

Holy Cow Batman! Any nurse who follows through on an order to sustain a patient on a paralytic without sedation is hell bent on getting a chance to check out how well their malpractice insurance coverage is.