Critical Care: Neuromuscular Blockers Flashcards
What is the typical use of neuromuscular blockade in ICU
- Intubated patients with severe respiratory failure
2. Despite optimization of analgesia, sedation and ventilator management
List two common kinds of severe respiratory failure in the ICU
- Acute respiratory distress syndrome
2. status asthmaticus
Recent data suggest that early empiric neuromuscular blockade in patients with severe ____ is beneficial
ARDS
Neuromuscular blockers are also used as adjunctive agents to control ________ in patients with neurologic injury
Neuromuscular blockers are also used as adjunctive agents to control SEVERE INTRACRANIAL HYPERTENSION in patients with neurologic injury (e.g. traumatic brain injury)
What is the role of neuromuscular blockers in ventilators
- Neuromuscular blockers are typically used once efforts to facilitate ventilation have failed
What are modes of ventilation failure (3)
- Poor oxygenation
- Dyssynchrony
- High intrathoracic pressures that put the patient at risk for barotrauma
Summarize uses of NMBs in critical careq1.
- Help with ventilators
- Help with intracranial hypertension
- Help with shivers for therapeutic hypothermia
- Tetanus
- Decrease movement during procedures
NMB should only be used once __ and ___ goals are met
- Analgesia
2. Sedation
What dosing strategy should be used for sedatives used in conjunction with an NMB
Continuously infused sedative
What properties should sedatives that are used with NMB have?
Amnestic (e.g. benzodiazepines, propofol)
What sedative does not provide depth of s edation required for NMB infusion?
Dexmedetomidine
What is role of analgesics in NMB
- Analgesics can also be used as needed in patients with pain
- Many practitioners insist on the combination of a sedative and an analgesic in paralyzed patients
Patients should be provided with ______ while paralyzed
Lubricating eye drops
List four neuromuscular blocking agents
- Pancuronium
- Vecuronium
- Atracurium
- Cisatracurium
List six concerns with neuromuscular blockade
- Can mask seizure activity
- Critical illness poly-neuromyopathy
- Mask insufficient analgesia and sedation
- Increase risk of VTE
- Increase risk of skin breakdowna nd decubitus
- Corneal abrasions
How to prevent corneal abrasions
Apply ophthalmic ointment or drops to eyes every 6-8 hours
Why is it important for therapeutic paralysis must be carefully considered and reevaluated every day?
Risk of critical illness poly-neuromyopathy (prolonged muscle weakness)
What is a strategy to reevaluate NMB?
- Regularly discontinue the drug (e.g. once daily)
- assess sedation / sedative dose
- Assess need for continued blockade (does it meet a ventilator failure condition?)
- Assess dose of paralytic (did it wear off at expected time?)
What NMBs is it more imporant to assess dose of paralytic?
- Pancuronium and vecuronium
2. Longer half-life AND dependence on end organ clearance.
What is TOF used for with NMB?
To guide dosing
How is TOF performed for NMB?
- four electrical impulses applied to ulnar or facial nerves
- Obatin baseline TOF: usually one twitch per impulse (4/4 twitches)
- Goal TOF is 1-2/4 twitches which indicates 85%-90% receptor blockade.
What are two technical problems that limit accuracy of TOF
- Perspiration
2. Tissue edema
Pancuronium, vecuronium, atracurium, cistracurium, prolonged in renal failure?
- Pancuronium: Yes
- Vecuronium: Yes
- Atracurium: No
- Cisatracurium: No
Pancuronium, vecuronium, atracurium, cistracurium, prolonged in hepatic failure?
- Pancuronium: Yes
- Vecuronium: Yes
- Atracurium: No
- Cisatracurium: No
