thoughts on only Paralytic while intubated....

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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.

Specializes in cardiac ICU.

Our standard is to begin with propofol as sedation for intubated patients, even in the ER. It almost follows an algorithm. Propofol first, then it will get combined with fentanyl if it appears that pain is an issue. If mechanical ventilation is anticipated to be longer term, then a combo of ativan & fentanyl is ordered. Neuromuscular blockade (such as atracurium) is added only if there is a problem with ventilating/oxygenating the patient. It's pretty much a given that we will use a paralytic when the patient is bad enough that we are using a rotoprone bed.

It's actually part of our P&P that sedation is used alongside NMB. The sedation is to be monitored with BIS monitoring (single lead EEG) with the BIS goal set by the MD. NMB is monitored using "train of four". I can't imagine the level of terror it would induce to be paralyzed, but awake and wondering if something had happened to paralyze me - and if it was permanent!

I don't know if the MD in this particular scenario realizes he could actually guilty of a criminal offense. He was using a chemical restraint by not having used sedation first. I hope HIS documentation shows why it was a legitimate decision to use only a chemical paralytic for intubation and mechanical ventilation. Being "Devil's Advocate", I'm thinking the doc may have had the "I'll teach him a lesson" approach to having the guy more aware of what was going on - but unable to move/fight. However, that's not our purpose as medical professionals - no matter how tempting the idea is.

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Specializes in SICU.

We use dilaudid, versed and etomidate for urgent intubation on the unit. We string up the propofol after the patient has shown they are not vent compliant (love love love propofol) I have heard of them using roc /NMB agents for difficult intubations in emergent situations down in EC. I wish everyone just did RSIs, but that is obviously a scope of practice issue with the meds required. After watching an anesthetist intubate I was in awe of how smooth and quick an RSI is. Running joke is: the reason I want to go back to school is because I can't stand to watch residents intubate any longer after watching the pros...lol :D

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Specializes in ER, ICU,.

in my opinion...you should paralize and intubate the person who said no diprivan!!! See how fast they get that rule changed

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Specializes in ER.
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.

Thanks for the comment. This doc is from the UK... but has been here a bit. The thing is, I know the doc has MS, so I don't know if that's influencing his practice at all. ?? I assumed care for him around 1945, he came in at 1920 hrs. I did see they did an RSI with him on arrival.

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Specializes in Emergency & Trauma/Adult ICU.

I have seen this done twice, on patients with enough multiple chemicals on board PTA that further sedating them became a nasty game of chase the BP vs. sufficient sedation to not fight the vent.

I'm not defending the practice.

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Specializes in Neuro ICU and Med Surg.

I was in a similar situation. I need to take a pt to MRI, and she wouldn't tolerate sedation, her BP would drop and I had to put her on Neo, would get her off Neo and she would need more sedation to tolerate MRI vent, then the cycle bagan with neo and fentanyl and versed. I called the resident on call to have MRI put on hold and he told me to give nimbex and no sedation. I refused. I flat out told him that he would induce MI if he did that. He put the MRI on hold and she was extubated the next day and went the next night. I had no problem telling him how cruel he was wanting to take a pt to MRI and paralyze them with no sedation and pain med.

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It's my understanding that a paralytic is NEVER used alone. The doc should always prescribe a sedative such as propofol. I can't imagine being completely awake but unable to move or speak. It would be a truly horrifying experience. This doc needs to be written up so this doesn't happen again.

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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....

I agree. This is a perfect example of why we HAVE to be advocates. We can't just defer to the doc and if the doc doesn't respond to a nurses concerns then we should go over their head.

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Specializes in Neonatal ICU (Cardiothoracic).

That's why in every RSI algorithm, paralytics are the LAST thing you give.

What about etomidate? Fentanyl/versed? These have always worked very well together, and usually eliminate the need for paralytics by the 2nd dose.

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Specializes in Pediatric Psychiatry, Home Health VNA.

Honestly OP, it sounds like the physician was punishing the patient for using drugs. It's an awful thing but I've unfortunately seen it happen a few times.

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Specializes in Emergency, outpatient.

Mass ED, why didn't the doc tell you why? I'm sure it was obvious to the other staff (both nurses and other docs?) that you were in a pickle trying to get sedation orders for your patient; no reason for the doc not to make it clear why he was choosing this route. I'm sorry this happened to the patient and to you.

I agree; this needs to be addressed pronto before it happens again, with your manager and especially with the medical director and other physicians.

I noticed you said you didn't want to take the pt up to ICU like that, but maybe that would have been the only way to get the needed sedation.

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Specializes in icu, er, transplant, case management, ps.
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.

I don't know how long your fellow was intubated for but any patient who is on a paralytic, needs to be sedated. No patient has a nurse with him/her every minute. If you are awake, you are aware of it. And staff tends to forget you are still alert and talks with family about your paralytic. Then the patient starts thinking about becoming disconnected and what can happen. It puts such fear into you, that even I, as a professional nurse, was afraid of being intubated again. I told everyone, when I even thought I might be, I wanted sedation if intubated on put on a vent. I was intubated once more and the fear in my voice and my eyes was enough to convince the residents. And I made it my mission to ensure every patient got sedation as well.

Woody:twocents:

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