Why not paralyze??

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by Ketofol Ketofol (New) New Nurse Student

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maji2002

maji2002

40 Posts

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

Ketofol

Ketofol

6 Posts

@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. 

subee, MSN, CRNA

Specializes in CRNA, Finally retired. Has 50 years experience. 4,139 Posts

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

BigPappaCRNA

270 Posts

On 8/8/2022 at 5:02 PM, 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.

 

Edited by BigPappaCRNA

BigPappaCRNA

BigPappaCRNA

270 Posts

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

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.

 

No.  No only is it not common sense, your opinion is not evidenced based and not supported by a mountain of literature.  Never paralyzing someone with an LMA is old school dogma, passed on through the years with no research to back it up.  There are countless citations about the efficacy and safety of NDMR use with the LMA.  Hell, even LMA literature from the manufacturers says it is OK to do.  Hell, even the worlds leading airway expert, Dr. Benumof says it is appropriate.

Now if you choose not to do so, that is fine, and reasonable.  We should all practice at our own levels of comfort, but since students are reading this, I just had to correct your grossly incorrect statement.

 

BigPappaCRNA

BigPappaCRNA

270 Posts

On 7/29/2022 at 1:20 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?

I think it is just a practice that has been handed down through time.  When I first started practicing anesthesia in 1992, we didn't even have End Tidal agent monitoring.  We just turned the Forane dial to 1% and hoped and prayed that they were getting the appropriate amount of vapor, but we never actually knew if they were.  It wasn't until the late 1990s that end tidal agent monitoring became more common.  Then the BIS came out (not saying it is good, or bad, just that it now existed) giving an additional layer of measuring.  Now there are cerebral oximetry platforms and more importantly direct frontal lobe EEG monitors ( Sedline by Masimo) that have completely taken the guess work out of the equation.  I would be far, far more comfortable doing a case with 1% Sevo if I could see the raw EEG waves and see they were going in and out of burst suppression.  Then, I would paralyze.  Just no good reason not to do so.  The aversion is really from a bygone era. It likely won't go away for another generation (like Swan Lines, or test ventilating before giving muscle relaxants, or avoiding LR and only giving Normal Saline in ESRD, and countless others.).  It will just take some time.

offlabel

offlabel

1,396 Posts

On 8/17/2022 at 12:46 PM, BigPappaCRNA said:

No.  No only is it not common sense, your opinion is not evidenced based and not supported by a mountain of literature.  Never paralyzing someone with an LMA is old school dogma, passed on through the years with no research to back it up.  There are countless citations about the efficacy and safety of NDMR use with the LMA.  Hell, even LMA literature from the manufacturers says it is OK to do.  Hell, even the worlds leading airway expert, Dr. Benumof says it is appropriate.

Now if you choose not to do so, that is fine, and reasonable.  We should all practice at our own levels of comfort, but since students are reading this, I just had to correct your grossly incorrect statement.

 

Just did that a couple of days ago...liter and a half blood loss, 3 u prbcs, renal failure patient...did great...