Why not paralyze??

[solarex]

On 7/29/2022 at 4:20 AM, Ketofol said:

For cases where paralytic is not needed, but you have an ETT in (d/t airway control, NPO status, etc...) why wouldn't you just paralyze anyways so you use significantly less volatile gas and have better hemodynamics. This is considering that you have sugammadex available. This way you can give narcotics, precedex, ketamine, whatever you want, with plenty of blood pressure to work with? Some preceptor say it's better to not to paralyze if you don't have to, but I don't understand when you have sugammadex?

Preceptors recommend not paralyzing and just turning down the gas for hypotension, yet when I get under 1 MAC, that's when I've had times when patients either move or buck (or laryngospasm with an LMA). I'll try to titrate narcotics in to keep respiratory rate low but there's still NO guarantee that the patient won't flip out.

I feel it's either:

1) Paralyze regardless, use gas for amnesia/unconsciousness, and analgesic meds for HR & BP

2) Don't paralyze but keep patient on more than 1 MAC gas and accept having to give pressors or start a neo gtt a lot!

Sorry for the long question. I just don't understand what I'm missing here. Is the risk of coughing, bucking, spasming, hypotension,  and pissing off the surgeon worth not having to paralyze?

I'm a USAGPAN Grad and will come at your question based on my training.

Question 1. For cases where paralytic is not needed, but you have an ETT in (d/t airway control, NPO status, etc...) why wouldn't you just paralyze anyways so you use significantly less volatile gas and have better hemodynamics?  Answer.....you are arguing to paralyze in order to give LESS of something (gas). That's reasonable, but....Neostigmine and Robinul are 2 drugs, so you aren't giving "less of anything."  as for hemodynamic stability, fluids and pressors are for a reason.  The gas is primarily for memory, recall, to not remember, and shouldn't be strictly based on their BP.  If you have a person who can't tolerate 0.8 MAC or 1.0 MAC without Blood Pressure issues, then fix the Blood pressure issue with a medicine directly designed for Blood pressure issues.

You mentioned Suggamadex.  Think about cost.  I promise you, if you work at a smaller place in the future, which means you are more independent and generally make more money, giving Suggamadex regularily will get you a meeting with the Chief and Pharmacy Director.

You used the word "Regardless" in for or against paralyzing.  Peace of advice, NEVER used all inclusive words in anesthesia.  Noticed how I used the word "Never" in this sentence and the last sentence, this is the only time you use an all inclusive word.  There is no "always, never, 100 percent of the time, absolutely not's."  This is what separates your advanced education and advanced reasoning compared to concrete thinking so common with undergraduate nursing education.  

You mentioned narcotics to keep respiratory rates low and that there is no guarantee the patient will not flip out.  CORRECT.  A guarantee would be in the "all inclusive" categories and those don't exist.  There is also no guarantee the patient will wake up, speak again, or speak 5 languages and become a genius after the anesthetic.  You do what you can to minimize/attentuate risk.

Here's my general rule with paralysis.  Notice I wrote the word "General."  That means....there are exceptions and nothing concrete, but in general, 

1.  If I don't have an ETT in place, I don't paralyze.  That's common sense I hope for everyone on this board.

2.  ETT is in place.....the very first thought is.......what type of surgery/where are we working/gas in the belly?  If I am working around the airway in adults such as tonsils, yes, even tonsils, oral maxifacial procedures with a nasal ETT, thyroid with major vascular organs close by, carotids, I generally paralyze.  Back cases where they are prone.  This also helps the surgeon and helping the surgeon regarding relaxed muscles helps time.  It decreases the time of the surgery and decreases the amount of time under anesthesia and blood loss and in the prone position.  Gas in the belly, gallbladder, appendix.  Procedures in the thoracic cavity.  

3.  Outside of these areas above, paralysis is far more about the patient.  For example, do I have someone with a mild cough, perhaps a very recent onset URI where they are coughing on 1 MAC of gas for a Total Knee or Shoulder Surgery?  I will often paralyze them.  Do they have an incredibly reactive airway where they just love to cough?  Then I will consider relaxing them.

4.  What I generally do not do.  Make my decision to paralyze someone based on wake up time.  I also don't generally base my gas level on wake up time worries.  That's no factor.  I am good enough with gas and paralytic dosage to have 5 minute wake ups with a gas set at 1 MAC or at least 2 of 4 TO4.  One thing I recommend for you.  There is no absolute standard for wake up times, but the general consensus in Anesthesia for many years is 10 minutes from the time the sutures or stressing are on.  I know, we often do it far, far less in time than this, and the OR nurse sometimes will look at you with a 10 minute wake up, but historically, any wake up that is less than 10 minutes is satisfactory, so don't let an RN in the OR who has no concept of what anesthesia standards are rush you or goat you or pressure you to meet their wake up time.  

[Nurse Pompom]

Probably because you can't be sure of their level of sedation if they are paralyzed? Just a guess though. 

[offlabel]

There is no straight answer. Varying levels of stimulation require varying depths of anesthesia. Lot's of times patients cough on the tube during stimulation because the surgical stimulus somewhere else lowers the threshold for airway irritation.

For example, ever notice patients can cough without moving the operative leg during knee surgery? You can mitigate that by using an LTA and/or a bunch of narcotic and/or overdose the volatile agent and a phenylephrine infusion and not need muscle relaxant.

Talk to 10 people get 10 answers.

I use an LTA on everyone I'm going to extubate, keep the end tidal agent to .7 to .8 MAC and usually paralyze. Analgesia as needed. I do this because I extubate everyone awake on the tube right off the ventilator and I want them awake, talking and comfortable leaving the OR.  But with the cases that I do and the age and comorbidity demographic that I anesthetize, I'm still running phenylephrine or norepi to keep a mean pressure over 70. Healthier patients? Not so much. 

That's just me. 

[PaSSiNGaS, MSN]

Unfortunately as a SRNA you have to just "go along" with the CRNA you are with.  My advice is pick up stuff from everyone that you like, that you don't plan on doing, and what is just dangerous or incorrect.  

Like off label said there isn't a right or wrong answer but if I am dealing with hypotension and to fix it I plan on turning down the gas then I will prepare to possibly paralyze because like you said I don't want the patient moving.  Another option could be run them deep enough to avoid movement while running a small phenylephrine gtt.  Many people feel their way is the only way to do anesthesia and that just isn't the case.  

[offlabel]

The bottom line is that paralyzing takes more work, especially if you take full advantage of it by lightening the anesthetic. You have to get out of your chair and check twitches regularly.  Whether someone has free use of sugammadex or not shouldn't  come into the conversation. 

[PaSSiNGaS, MSN]

On 8/2/2022 at 11:59 PM, solarex said:

You mentioned Suggamadex.  Think about cost.  I promise you, if you work at a smaller place in the future, which means you are more independent and generally make more money, giving Suggamadex regularily will get you a meeting with the Chief and Pharmacy Director.

Might want to look up the actual costs.  It is just about identical in price when you compare it to using Neo/Glyco for reversal.  Not to mention there are plenty of studies showing it is far superior for reversal of paralysis.  If admin is giving pushback I recommend bringing them articles and a simple cost analysis.

[solarex]

2 hours ago, PaSSiNGaS said:

Might want to look up the actual costs.  It is just about identical in price when you compare it to using Neo/Glyco for reversal.  Not to mention there are plenty of studies showing it is far superior for reversal of paralysis.  If admin is giving pushback I recommend bringing them articles and a simple cost analysis.

I'm not sure where you are getting your vendor. I do the ordering of anesthesia medications/inventory in my dept and I can assure the cost is 2 times that of neo/stig reversal. When used for high risk post op respiratory complication patients, the long term cost is similar to neo/glyco when recovery time and post oo respiratory events are figured in. Most patients having surgery in the USA are not high risk for post op respiratory complications.

1. As for effective reversal and weakness in PACU, there is zero question that Suggam. Is more effective.  The same applies to Methadone compared to Fentanyl in open heart surgery. We still don't use Methadone for hearts. We know TURPS fair better with Robots, yet we still perform some without them. If you have 2 of 4 TOF with a person without major risk for post op resp. complications, neostig/glyco is a solid option and cost effective. This is not to say we Never use Sugamm. I use it regularly when the cost and risk ratio align to the patient.

2. The data is overwhelmingly clear that when plastic surgeons close a wound, the patients have less residual scar tissue long term and better cosmetic appearance. How come plastic surgeons aren't coming to the ER very much, or the OR for that matter? It's because the Surgeon or FA/PA or ER Doc does an adequate job in closing that is cost effective. Sugamm. is a wonderful drug that has its use, but like anything else, in a specific situation that calls for it, and there are many that do, but there are more that do not until the cost for the average patient and surgery approach the same as neostig/glyco, and that margin has narrowed, but it is still wide.

[subee, MSN, CRNA]

Every student in my program had to mask one case with nothing but gas alone to learn how to measure depth of anesthesia.  I had a young healthy male inguinal hernia repair.  We were allowed to give a dose of pentathol up front but no narcs until the end.  Very useful lesson in the behavior of inhalation anesthetics.  The member became a useful monitor for depth;  keep the member DOWN:)

[Tampa Two]

Another argument for not ALWAYS paralyzing and ensuring your decision to paralyze (muscle relaxation with a paralytic agent) is specific for that patient, surgery, and situation is knowing that historically, of all the allergic reactions (including anaphylaxis) that occurs due to a drug given in the Operating Room by Anesthesia, the category with the highest incidence are paralytics. 

So, because paralytic agents have the highest incidence compared to other anesthesia drugs for causing severe allergic reactions, does that mean we simply NEVER give them?  Of course not, but it again goes back to nearly all things in anesthesia in that there are no absolutes, and each drug given should be patient specific and taking into consideration the type of surgery, case length, comorbidities, etc.  Just multiple factors involved, not simply one.

For the original poster who asked the question, "Why not ALWAYS paralyze?"  If you gave this question to every anesthesiologist and CRNA in the USA who has been practicing for more than 3 years, without knowing anything about the patient, surgery, or situation, the overwhelming majority would cringe at the word "Always" when used in the question.  The word "Always" is an all inclusive word, and those are frowned on in the anesthesia world because their usage and practical application are extremely, extremely Rare.

 

[maji2002]

Paralyzing weakens the muscles used to breathe, so it is harder to wean people making them subject to many more potential complications.

[subee, MSN, CRNA]

4 hours ago, Ketofol said:

@Tampa Two

I understand your concern with NMBD allergic reactions. Definitely something to consider. 

With that said, I've had CRNA preceptors that paralyze everytime there's an ETT in and the anesthetic is smoother, less hypotension, less pressors/fluid, and more room to work with when giving analgesic medications. I don't understand why people would "cringe" at the thought of paralyzing when it's not required.... In the days of superior medications (sugammadex) why not take full advantage of it? Reversal with sugammadex is so fast and residual paralysis is unlikely if dosed appropriately. Side effects are also minimal....Running someone on 1-1.3 MAC or loading them up with a ton of narcotics is so unnecessary when you could just give 30-40 mg of Roc and keep twitches around 2/4. Then work in meds that will help out with postop pain/discomfort instead of battling HoTN with high volatile which does nothing for the patient postop (big source of N/V and delrium). Remember, sedation to prevent movement is significantly more than what is required for amnesia, unconsciousness, and pain. A complete anesthetic is using meds for their intended purpose (amenesia, analgesia, and areflexia).....IDK, maybe I missed something. It just seems people are stuck in the "old mindset", similar to video-blades and qualitative neuro-monitoring. 

I remember the days of Pavulon so I REALLY appreciate the blessing of intermediate-acting muscle relaxants and used them with few issues.  However, you haven't been around long enough to also appreciate how many drug shortages we have been through when our relaxants of choice were not available and propofol was meted out to you PER CASE.  It's good to learn to be flexible.  But maybe that's part of my gloomy perspective on the future that I always was preparing myself to practice in the Third World mode.  It also expands your intellectual horizons to have to use alternatives.  I used to do hysterectomies with spinal-general if the patient would go along.  That way the kishkas keep contracting during surgery so they don't get an ileus, you only need to use enough relaxant so they don't buck and by the end of the case, they've been on inhalation long enough that they can tolerate the tube.  I usually didn't even have to reverse them.  They wake up quickly and comfortably.  But that was just me.  No one else showed much interest in adopting my method:)  I always tried the most elegant method I could, using the least resources.  

[BigPappaCRNA]

PaSSiNGaS said:

Might want to look up the actual costs.  It is just about identical in price when you compare it to using Neo/Glyco for reversal.  Not to mention there are plenty of studies showing it is far superior for reversal of paralysis.  If admin is giving pushback I recommend bringing them articles and a simple cost analysis.

Sorry Solarex, but he is 100% correct.  Sugammadex is actually cheaper, directly compared with the prices of both Neostigmine and Glycopyrolate (both of which have soared since Sugammadex was released).  This is not even taking into account the more difficult costs that are a little more difficult to quantify like weak patients, prolonged PACU stay, aspiration, and NAUSEA.  Bottom line: Sugammadex is both less expensive up front in acquisition costs, and really laps the competition on the overall perioperative experience.