Why not paralyze??

I'm a senior SRNA and gonna be graduating soon. I have a question that I have to ask because I can never get a straight answer. 

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?

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.

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.

Specializes in Anesthesia.
On 8/12/2022 at 7:35 AM, 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. 

Why not paralyze? The two most common causes of allergic reactions for anesthesia drugs are Sugamadex (the #1) and Rocuronium (#2). A spontaneously ventilating patient that isn’t getting positive pressure ventilation isn’t going to be subjected to loss of venous return from ppv. It’s difficult to have recall on a patient that isn’t fully paralyzed/paralyzed, because they will move long before they are actually awake. 
I would suggest that if someone routinely needs paralytics to have a stable patient and use less drugs then they aren’t doing their anesthesia correctly. 

There are multiple ways to do anesthesia and each case should be tailored for the patient and procedure.

@Nurse Pompom

The level of sedation/analgesia that's needed to prevent awareness and block nociception is so much less than what's needed to block reflexive muscle movements (or reflexive autonomic actions such as aspiration and spasm). For example, a cysto, bronch, or breast biopsy is actually not super painful AFTER the surgery is done. No much sedation and pain meds are needed, but a significant amount of "sedation " of some sort is required to prevent movement. 

Sorry, just trying to figure this out and it's bothering me. Clearly im wrong because its a thing haha. Completely appreciate any and all responses 

@offlabel

Setting up a Neo gtt also takes more work as well haha

Paralyze, 0.6-0.7 Mac of Volatile, a little dilaudid and Precedex/ketamine, PCV-VG on the vent w/ necessary PEEP, open Sodoku and put feet up LOL.

@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. 

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...

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