Paralytics

[SilverStreak]

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I have a question about the choice of drug my intensivist ordered on my pt last night. I asked him, but didn't get the full answer I was looking for. The pt was a CAB post op day 6, came in full blown cardiogenic shock, on IABP in cath lab, had multiple organ systems failing, on continous dialysis, multiple pressors, headed for the septic train, you get the idea.

She was on AC mode on the vent (ARDS) with tidal volume 600, rate 20, breathing in the 30-40 times a minute. I asked him at that point about APRV mode on vent but he didn't want it. We tried pain control, increasing sedation, ativan, all to no avail. I called him back because after all of the above he wanted given, she's still tachypneic.

He came in and evaled her, wanted Mivacron one time bolus of 5 mg, which I gave, worked for about an hour, then she's huffing and puffing again on the vent. Finally, this morning, he let me start a Mivacron gtt on her. My question about the drug is why Mivacron over Norcuron, which is what we typically use. He said it had to do with her renal decline. But, when I looked up mivacron, it can cause hypotension, hypoxia, and a whole list of other things. Plus, we're on continuous dialysis, so the machine should clear the drug anyway, as long as it's not a large molecule.

I don't understand the patho behind these possible side effects, but it doesn't make sense to me. If we're paralyzing the muscles, the vent should be able to work more effectively, and she should have improving PO2, right?

Another question is what paralytics do you guys typically use in the OR? I'm guessing you use a combo of drugs based on the type of case. We've had a few of our hearts wake up and be paralyzed, and it scares the s hit out of them, we have them on light sedation, but since we try to fast track extubation, we start weaning off the sedation right away. A few have woke up with paralytics still on board and raise hell about it when they get extuabed. Does anybody else see this on a routine basis? We've got some new anesthesia students, and lately we're seeing pts get hammered with drugs (versed, fentanyl,etc.) and take forever to wake up. Where are their preceptors when they're loading granny with crappy renal clearance with all this stuff I dunno... I'm wondering if this may not be the case with the paralytics also that they are overdosing it. Any oppinions?

 

[jetproppilot]

I have a question about the choice of drug my intensivist ordered on my pt last night. I asked him, but didn't get the full answer I was looking for. The pt was a CAB post op day 6, came in full blown cardiogenic shock, on IABP in cath lab, had multiple organ systems failing, on continous dialysis, multiple pressors, headed for the septic train, you get the idea.

She was on AC mode on the vent (ARDS) with tidal volume 600, rate 20, breathing in the 30-40 times a minute. I asked him at that point about APRV mode on vent but he didn't want it. We tried pain control, increasing sedation, ativan, all to no avail. I called him back because after all of the above he wanted given, she's still tachypneic.

He came in and evaled her, wanted Mivacron one time bolus of 5 mg, which I gave, worked for about an hour, then she's huffing and puffing again on the vent. Finally, this morning, he let me start a Mivacron gtt on her. My question about the drug is why Mivacron over Norcuron, which is what we typically use. He said it had to do with her renal decline. But, when I looked up mivacron, it can cause hypotension, hypoxia, and a whole list of other things. Plus, we're on continuous dialysis, so the machine should clear the drug anyway, as long as it's not a large molecule.

I don't understand the patho behind these possible side effects, but it doesn't make sense to me. If we're paralyzing the muscles, the vent should be able to work more effectively, and she should have improving PO2, right?

Another question is what paralytics do you guys typically use in the OR? I'm guessing you use a combo of drugs based on the type of case. We've had a few of our hearts wake up and be paralyzed, and it scares the s hit out of them, we have them on light sedation, but since we try to fast track extubation, we start weaning off the sedation right away. A few have woke up with paralytics still on board and raise hell about it when they get extuabed. Does anybody else see this on a routine basis? We've got some new anesthesia students, and lately we're seeing pts get hammered with drugs (versed, fentanyl,etc.) and take forever to wake up. Where are their preceptors when they're loading granny with crappy renal clearance with all this stuff I dunno... I'm wondering if this may not be the case with the paralytics also that they are overdosing it. Any oppinions?

Nice post.

Your intensivist is obviously professing an expertise he doesnt possess.

Using mivacurium over vecuronium is an expensive joke.

Vecuronium has enough hepatic clearance that your intensivist's opinion doesnt hold water.

And for various inconsistencies in ICU sedation, with potential concominant long-wakeups,

heres one word for ya:

DEXMETATOMIDINE.

 

[VolatileAgent]

was this truly ARDS? that's the fundamental question i have reading your scenario. if so, then you need specific reasons why not APRV? i don't know if cardiogenic shock is all that associated with ARDS, and that seems like pretty big volumes to boot. but, if she's septic (which is associated with ARDS) then you need to ask that question before anything else. nonetheless, if you have ARDS, paralysis ain't gonna help much anyway.

you ask a lot of good questions, though. typically if we relax someone in our units they get a vec drip. this is mostly a cost issue.

 

[militarymd]

Critical Illness Polyneuropathy....


Steroidal type NMBs, intermediate action type NMBs, in combo with steroids, antibiotics puts patients at significant risk of the above condition...

Never paralyze critically ill patients unless you have exhausted every other avenue of care...and then ...with only the shortest acting drug you have available...for the shortest duration of time necessary.

 

[Idiopathic]

DEXMETATOMIDINE.

I love what Ive seen of Precedex. Nice posts, all.

 

[VolatileAgent]

precedex is an okay unit drug, sucks as an anesthetic. just my $.02.

 

[jetproppilot]

precedex is an okay unit drug, sucks as an anesthetic. just my $.02.

With an extensive history of dex-anesthesia-plan-based CABGs, thoracotomies, craniotomies, big back cases, CEAs,

I adamantly disagree with you.

And I'm not a paid dex-representative.

 

[sdn1977]

From my perspective, cost is a major issue since drug purchases are often bundled. Sometimes what appears as more expensive is not if tied to other drugs with higher usage. Therapeutically they are equivalent. However, he/she may have been coming from the perspective of how it is metabolized. You mentioned your patient was in multiple organ failure. Mivaron is metabolized to inactive metabolites while Norcuron is not. There is data to suggest that recovery may increase in patients with cirrhosis or cholestasis due to slower clearance of vencuronium so it could happen if the liver started to slow down. From an academic standpoint, you could make a case for having to consider potentially active metabolites (one metabolite has potentially 50% of the vencuronium potency - animal studies only..) Both are cleared similarly from the kidneys, you just have to allow for the metabolites as well.

Now, therapeutically, would this make a difference? Probably not with titration - either agent might have been useful. He may have been in the mode of shooting from the hip - trying anything.

 

[SilverStreak]

Yep it was ARDS, the night before when I had her I took over her care, vent settings were SIMV TV 800 rate 10 fiO2 50% PEEP 5 with PO2 60's. Her sats suck and she's breathing 40-50 times a minutes, peak pressures on the vent are in the 70's. The dayshift nurse had let this go on for HOURS, at least 5 or 6. I was so pissed, we are in ICU with one patient for a reason. If they're that labored on the vent, something is wrong. So, I called our intensivist/pulmonologist and he wanted to add PS and increase PEEP to 8. So, we did, with no change in her at all. The RT and I discussed the vent, the patient, and made vent settings to AC rate 20 TV 600 (b/c stiff lungs don't need big volumes), immediately she's chilled RR 20-22, peak pressures down 40's, PO2 up to 75 on our gases. So, I called him back and told him what we did and how she looked now, and he said fine.
The next night I come in, same story. The vent settings she had looked good on 12 hours ago now ain't cutting it. She's tachypneic, tachycardic, increasingly hypotensive, febrile (102.5),hypoxic po2 61 on 60% o2 now, I told the dayshift nurse I was gonna call pulmonary back, and says "well, what are you gonna tell him, she hasn't changed" It was a totally different patient that what I had the night before I had weaned off all pressors (norepinephrine and vasopressin), and we had good bp even on CRRT, SR 80's, temp 98. People kill me that they don't pick up on these things when you have one Freakin' patient, but anyway I'll quit ranting.
I call him twice on her in 3 hours, and he tells me get a CXR and he'll come in (I think he realized I wouldn't leave alone at this point). He comes in and says he doesn't want her on APRV because she won't tolerate it with her heart function, my last CI was 2.7, bp 100's at this point with my gtts, so I said to him "Is it that or do you just not like the APRV mode?" At this point he says, no I don't like it and she's not going on it. It's so frustrating in these situations. People at work at like I'm way too anal retentive but what the hell are we doing in the ICU if we're not treating the patient appropriately, just watching her be miserable like that. It kills me.

 

[militarymd]

Yep it was ARDS, the night before when I had her I took over her care, vent settings were SIMV TV 800 rate 10 fiO2 50% PEEP 5 with PO2 60's. Her sats suck and she's breathing 40-50 times a minutes, peak pressures on the vent are in the 70's. The dayshift nurse had let this go on for HOURS, at least 5 or 6. I was so pissed, we are in ICU with one patient for a reason. If they're that labored on the vent, something is wrong. So, I called our intensivist/pulmonologist and he wanted to add PS and increase PEEP to 8. So, we did, with no change in her at all. The RT and I discussed the vent, the patient, and made vent settings to AC rate 20 TV 600 (b/c stiff lungs don't need big volumes), immediately she's chilled RR 20-22, peak pressures down 40's, PO2 up to 75 on our gases. So, I called him back and told him what we did and how she looked now, and he said fine.
The next night I come in, same story. The vent settings she had looked good on 12 hours ago now ain't cutting it. She's tachypneic, tachycardic, increasingly hypotensive, febrile (102.5),hypoxic po2 61 on 60% o2 now, I told the dayshift nurse I was gonna call pulmonary back, and says "well, what are you gonna tell him, she hasn't changed" It was a totally different patient that what I had the night before I had weaned off all pressors (norepinephrine and vasopressin), and we had good bp even on CRRT, SR 80's, temp 98. People kill me that they don't pick up on these things when you have one Freakin' patient, but anyway I'll quit ranting.
I call him twice on her in 3 hours, and he tells me get a CXR and he'll come in (I think he realized I wouldn't leave alone at this point). He comes in and says he doesn't want her on APRV because she won't tolerate it with her heart function, my last CI was 2.7, bp 100's at this point with my gtts, so I said to him "Is it that or do you just not like the APRV mode?" At this point he says, no I don't like it and she's not going on it. It's so frustrating in these situations. People at work at like I'm way too anal retentive but what the hell are we doing in the ICU if we're not treating the patient appropriately, just watching her be miserable like that. It kills me.

Goto ARDS network and look at their published trials of mechanical ventilation...then come back and tell which modes of ventilation are used.

 

[jetproppilot]

From my perspective, cost is a major issue since drug purchases are often bundled. Sometimes what appears as more expensive is not if tied to other drugs with higher usage. Therapeutically they are equivalent. However, he/she may have been coming from the perspective of how it is metabolized. You mentioned your patient was in multiple organ failure. Mivaron is metabolized to inactive metabolites while Norcuron is not. There is data to suggest that recovery may increase in patients with cirrhosis or cholestasis due to slower clearance of vencuronium so it could happen if the liver started to slow down. From an academic standpoint, you could make a case for having to consider potentially active metabolites (one metabolite has potentially 50% of the vencuronium potency - animal studies only..) Both are cleared similarly from the kidneys, you just have to allow for the metabolites as well.

Now, therapeutically, would this make a difference? Probably not with titration - either agent might have been useful. He may have been in the mode of shooting from the hip - trying anything.

See that???

I didnt know all that s hit.

Thanks for your post.

Please keep it up and we'll all learn.

 

[SilverStreak]

Critical Illness Polyneuropathy....


Steroidal type NMBs, intermediate action type NMBs, in combo with steroids, antibiotics puts patients at significant risk of the above condition...

Never paralyze critically ill patients unless you have exhausted every other avenue of care...and then ...with only the shortest acting drug you have available...for the shortest duration of time necessary.

We were already at this point of polyneuropathy before giving the NMB. I know that he wanted to exhaust every possibility b/f giving me the order for the paralytic, so he ordered ativan, fentanyl. However, we had already been giving versed and morphine, so if those were gonna fix the problem, I would think you would see some response from her (decreased HR, RR) if it's a pain/anxiety issue. Plus in my mind, if he won't give me the okay for APRV b/c he's worred about heart/bp tolerating it, why are we loading her up with benzo and 100 mcg of fentanyl an hour?

 

[jetproppilot]

Yep it was ARDS, the night before when I had her I took over her care, vent settings were SIMV TV 800 rate 10 fiO2 50% PEEP 5 with PO2 60's. Her sats suck and she's breathing 40-50 times a minutes, peak pressures on the vent are in the 70's. The dayshift nurse had let this go on for HOURS, at least 5 or 6. I was so pissed, we are in ICU with one patient for a reason. If they're that labored on the vent, something is wrong. So, I called our intensivist/pulmonologist and he wanted to add PS and increase PEEP to 8. So, we did, with no change in her at all. The RT and I discussed the vent, the patient, and made vent settings to AC rate 20 TV 600 (b/c stiff lungs don't need big volumes), immediately she's chilled RR 20-22, peak pressures down 40's, PO2 up to 75 on our gases. So, I called him back and told him what we did and how she looked now, and he said fine.
The next night I come in, same story. The vent settings she had looked good on 12 hours ago now ain't cutting it. She's tachypneic, tachycardic, increasingly hypotensive, febrile (102.5),hypoxic po2 61 on 60% o2 now, I told the dayshift nurse I was gonna call pulmonary back, and says "well, what are you gonna tell him, she hasn't changed" It was a totally different patient that what I had the night before I had weaned off all pressors (norepinephrine and vasopressin), and we had good bp even on CRRT, SR 80's, temp 98. People kill me that they don't pick up on these things when you have one Freakin' patient, but anyway I'll quit ranting.
I call him twice on her in 3 hours, and he tells me get a CXR and he'll come in (I think he realized I wouldn't leave alone at this point). He comes in and says he doesn't want her on APRV because she won't tolerate it with her heart function, my last CI was 2.7, bp 100's at this point with my gtts, so I said to him "Is it that or do you just not like the APRV mode?" At this point he says, no I don't like it and she's not going on it. It's so frustrating in these situations. People at work at like I'm way too anal retentive but what the hell are we doing in the ICU if we're not treating the patient appropriately, just watching her be miserable like that. It kills me.

If I'm ever in need of ICU care I hope you are taking care of me.

 

[militarymd]

We were already at this point of polyneuropathy before giving the NMB. I know that he wanted to exhaust every possibility b/f giving me the order for the paralytic, so he ordered ativan, fentanyl. However, we had already been giving versed and morphine, so if those were gonna fix the problem, I would think you would see some response from her (decreased HR, RR) if it's a pain/anxiety issue. Plus in my mind, if he won't give me the okay for APRV b/c he's worred about heart/bp tolerating it, why are we loading her up with benzo and 100 mcg of fentanyl an hour?

Modes of mechanical ventilation (aprv, oscillator, partial liquid, etc.) do not make patients better.

You appear to be under the impression that changing a mode of ventilation will help the patient recover....or that paralyzing a patient will help them recover.....The modalities that you are suggesting only makes the patient look better to you.

Mechanical ventilation only serves one purpose....oxygenation to a minimal acceptable level....that is usually SAO2 . 92%....and ventilation to a minimal acceptable level....that is usually whatever the CO2 needs to be to keep systemic pH >7.1 or 7.2

So...the things that you are concerned about don't amount to anything other than making the patient "look" cosmetically better to the untrained eye.

 

[SilverStreak]

Modes of mechanical ventilation (aprv, oscillator, partial liquid, etc.) do not make patients better.

If they don't make patients better, why do we put them on the vent? I agree with you that we reach a point where the patient will not get better no matter what we do, however, because I know that is the point you are trying to make to me.
You appear to be under the impression that changing a mode of ventilation will help the patient recover....or that paralyzing a patient will help them recover.....The modalities that you are suggesting only makes the patient look better to you.
No, they made her a DNR today, I called the family this morning and told them she was looking more and more like she may not survive this hosptilization, mind you, none of the physicians at this point had been so honest with the family. I paved the way for them to accept and understand her condition today so that they felt a DNR was appropriate. I had no illusions that changing vent mode would ultimately help her recover.
My question on the use of paralytics was purely because we rarely do use them, why we used one particular drug over another.
Mechanical ventilation only serves one purpose....oxygenation to a minimal acceptable level....that is usually SAO2 . 92%....and ventilation to a minimal acceptable level....that is usually whatever the CO2 needs to be to keep systemic pH >7.1 or 7.2

So...the things that you are concerned about don't amount to anything other than making the patient "look" cosmetically better to the untrained eye.

The things I was concerned about were that she looked terrible. If you walked in and saw your mom on the vent gasping for air, you're telling me you don't think trying different therapies-be it pharmacological, or mechanical ventilation would cross your mind? If she was a full code and you did not have your medical background, and had not been told by the surgeon and ICU doctor that she was going to die? Forgive me if it upsets me as a nurse to see my patient suffer and no one address it. To me, it was unacceptable and inhumane to let her continue on that way. If I could possibly make it better for her, that was all I wanted.

BTW, Thanks for the ARDS network info. I went and looked at their data. You know at this point, no one knows the best approach of how to treat/recover from ARDS. That is why there is so much ongoing research to determine if what we are intuitively thinking by treating these patients can be determined to have a definitive outcome.

From the ARDS network site you sent me to:

-lower tidal volumes show improved survival rates
-no further improvement in survival rates with addition of higher peep
-studies done on the AC mode
-goal O2 is PO2 of 55-80 or sat of 88-95
I questioned the use of the APRV mode because I know some studies have been done on it's usefullness with ARDS patients.

MilMd, you seem a bit hostile to me, or am I taking it personal? I sense an attitude with you towards me. I am sincerely interested in learning and understanding whatever I can to make my patients better. Please don't take my posts in any other way. I tend to overthink, and maybe I worry about things other nurses wouldn't, but would you want a nurse who just plods along during thier shift, writes the numbers down, gives the meds, and don't use thier brains to give input into the care of the patient? Remember, I spend 12 hours at that bedside, I hardly left her room last night, I see minute to minute what's going on. When I call to suggest a treatment to the MD, if you don't want to do it, that's fine, just don't get upset that I question why we're not doing this or that. It's more for my learning than trying to be know it all pushy nurse.

 

[SilverStreak]

If I'm ever in need of ICU care I hope you are taking care of me.

Thanks jet 🙂

 

[SilverStreak]

With an extensive history of dex-anesthesia-plan-based CABGs, thoracotomies, craniotomies, big back cases, CEAs,

I adamantly disagree with you.

And I'm not a paid dex-representative.

Have to say I agree with jet. Our OR runs Dex gtts on all the hearts and it seems to be an excellent drug, both intra and post operatively. We use much less pain meds with it also, and the patients get a better sleep because it mimics your natural sleep. I really don't think the wake ups I see have to do with Dex, because in some cases, they wake up just fine, they're pissed because they can't move anything and don't know why, makes me think the NMB was used a little to heavy by the newbies. I could be wrong, just throwing it out as a possibility.

 

[AJM]

Modes of mechanical ventilation (aprv, oscillator, partial liquid, etc.) do not make patients better.

You appear to be under the impression that changing a mode of ventilation will help the patient recover....or that paralyzing a patient will help them recover.....The modalities that you are suggesting only makes the patient look better to you.

Mechanical ventilation only serves one purpose....oxygenation to a minimal acceptable level....that is usually SAO2 . 92%....and ventilation to a minimal acceptable level....that is usually whatever the CO2 needs to be to keep systemic pH >7.1 or 7.2

So...the things that you are concerned about don't amount to anything other than making the patient "look" cosmetically better to the untrained eye.

Ahhh, a person after my own heart! 😀

Silverstreak, I don't think changes in paralytics or modes of ventilation will necessarily help this patient. What will help, however, is optimizing your lung protective ventilatory strategy. If you feel this patient has ARDS, you should consider placing her on the ARDSnet ventilation protocol. I'm particularly referring to the high tidal volumes that she's on. In ARDS, you would want to drop the tidal volumes to 6-8cc/kg of ideal body weight, calculated based on age, height, and sex. In her case, she would have to have an ideal body weight of 75kg in order to be getting 8cc/kg TV, (since she's at 600cc) which would mean that she would be a heck of a tall woman.

It's okay if her RR is high - it's preferable to have a high RR rather than a high TV. Permissive hypercapnia is okay, too.... as far as the concern with how she looks, often you need to sedate these patients very heavily in order for them to tolerate these 'unnatural' ventilatory strategies.

 

[militarymd]

There's no hostility at all...I'm not sure where you're getting that from.

I'm just giving you the scoup on ARDS as I would any medical student or resident.

I've been taking care of patients with ards since 1998...have kept up with the literature on the disease process quite religiously until last year, so I'm aware of the concerns you've brought up...and have heard them a bizillion times.

Let me just say again....APRV is just another mode of ventilation that may cosmetically make the patient look better....definitive end points are improvement in pO2...and PCO2...and ventilator free survival at 30, 60, 90 days.
APRV has not been demonstrated to do that....Things that have been demonstrated...are listed in the ARDS Network. And as you can see...all the modes of ventilation used are some type of AC( simv, cmv, etc.) APRV is just a gimick perpetrated on the medical community by the ventilator makers.

The patient IS NOT sufferring.

 

[jetproppilot]

The things I was concerned about were that she looked terrible. If you walked in and saw your mom on the vent gasping for air, you're telling me you don't think trying different therapies-be it pharmacological, or mechanical ventilation would cross your mind? If she was a full code and you did not have your medical background, and had not been told by the surgeon and ICU doctor that she was going to die? Forgive me if it upsets me as a nurse to see my patient suffer and no one address it. To me, it was unacceptable and inhumane to let her continue on that way. If I could possibly make it better for her, that was all I wanted.

BTW, Thanks for the ARDS network info. I went and looked at their data. You know at this point, no one knows the best approach of how to treat/recover from ARDS. That is why there is so much ongoing research to determine if what we are intuitively thinking by treating these patients can be determined to have a definitive outcome.

From the ARDS network site you sent me to:

-lower tidal volumes show improved survival rates
-no further improvement in survival rates with addition of higher peep
-studies done on the AC mode
-goal O2 is PO2 of 55-80 or sat of 88-95
I questioned the use of the APRV mode because I know some studies have been done on it's usefullness with ARDS patients.

MilMd, you seem a bit hostile to me, or am I taking it personal? I sense an attitude with you towards me. I am sincerely interested in learning and understanding whatever I can to make my patients better. Please don't take my posts in any other way. I tend to overthink, and maybe I worry about things other nurses wouldn't, but would you want a nurse who just plods along during thier shift, writes the numbers down, gives the meds, and don't use thier brains to give input into the care of the patient? Remember, I spend 12 hours at that bedside, I hardly left her room last night, I see minute to minute what's going on. When I call to suggest a treatment to the MD, if you don't want to do it, that's fine, just don't get upset that I question why we're not doing this or that. It's more for my learning than trying to be know it all pushy nurse.

Listen Silver,

And take this from a down to earth dude.

MilMD's posts are to the point.

BOOM.

Factual data. Experience. Literature to back up the posts.

IN YOUR FACE posts.

May seem harsh at times.

But the dude's got it going on.

Smartest dude on this forum, and probably one of the smartest anesthesiologists on the planet.

Treat him like a resource. Dude has a wife, a cuppla kids, a crotch rocket.

In other words he (like all of us) has many other things they could be doing with their time.

Don't take the bluntness personal.

We will all be blunt sometimes.

Learn from his posts.

I do.

 

[rn29306]

From my perspective, cost is a major issue since drug purchases are often bundled. Sometimes what appears as more expensive is not if tied to other drugs with higher usage. Therapeutically they are equivalent. However, he/she may have been coming from the perspective of how it is metabolized. You mentioned your patient was in multiple organ failure. Mivaron is metabolized to inactive metabolites while Norcuron is not. There is data to suggest that recovery may increase in patients with cirrhosis or cholestasis due to slower clearance of vencuronium so it could happen if the liver started to slow down. From an academic standpoint, you could make a case for having to consider potentially active metabolites (one metabolite has potentially 50% of the vencuronium potency - animal studies only..) Both are cleared similarly from the kidneys, you just have to allow for the metabolites as well.

Now, therapeutically, would this make a difference? Probably not with titration - either agent might have been useful. He may have been in the mode of shooting from the hip - trying anything.

Given the CV potential side effects and relatively short duration of mivacron (thus redosing on a continual basis), would atracurium (w/ Hoffman and nonspecific esterases metabolism) have been a better choice given his mode of thinking of organ failure?

 

[militarymd]

Listen Silver,

And take this from a down to earth dude.

MilMD's posts are to the point.

BOOM.

Factual data. Experience. Literature to back up the posts.

IN YOUR FACE posts.

May seem harsh at times.

But the dude's got it going on.

Smartest dude on this forum, and probably one of the smartest anesthesiologists on the planet.

Treat him like a resource. Dude has a wife, a cuppla kids, a crotch rocket.

In other words he (like all of us) has many other things they could be doing with their time.

Don't take the bluntness personal.

We will all be blunt sometimes.

Learn from his posts.

I do.

You're waaaayyy too kind....I'll just take "smartest" guy in the very northern tip of Alabama😉 where the hillbillies have no teeth.

 

[militarymd]

Given the CV potential side effects and relatively short duration of mivacron (thus redosing on a continual basis), would atracurium (w/ Hoffman and nonspecific esterases metabolism) have been a better choice given his mode of thinking of organ failure?

I don't know

 

[rn29306]

Let me just say again....APRV is just another mode of ventilation that may cosmetically make the patient look better....definitive end points are improvement in pO2...and PCO2...and ventilator free survival at 30, 60, 90 days. And as you can see...all the modes of ventilation used are some type of AC( simv, cmv, etc.) APRV is just a gimick perpetrated on the medical community by the ventilator makers.

FINALLY. Someone speaks the truth about APRV.

All the CRNAs and RTs in a city in TN will be celebrating with a hospital-wide party when we quit this damned study on APRV vs other methods of ventilation.

You are all invited.

 

[jetproppilot]

You're waaaayyy too kind....I'll just take "smartest" guy in the very northern tip of Alabama😉 where the hillbillies have no teeth.

OHHHHHHH No, Bro.

As I've always been, for better or worse,

just calling a spade a spade.

You are one gifted dude.

 

[rn29306]

I don't know

I think the pharmacist was right - the internist was shooting from the hip. I have never heard of ICU paralysis with mivacron. Of course, that doesn't mean it is wrong, but there seem to be better alternatives than mivacrap...But if that was his line of thinking (organ failure), it would seem that atracurium would be a better choice. Interesting.

 

[rn29306]

.........a crotch rocket.

Hey Mil, didn't I see where there is going to be one of those superbike races in AL soon?

 

[AJM]

FINALLY. Someone speaks the truth about APRV.

All the CRNAs and RTs in a city in TN will be celebrating with a hospital-wide party when we quit this damned study on APRV vs other methods of ventilation.

You are all invited.

I gotta tell you, I never understood this APRV craze some centers have. Out of the hospitals I've worked at, the vast majority of them never use that mode. But there's this one hospital where everyone is practically militant about putting as many patients on APRV as they can....

I'd be curious to see whether APRV would actually result in improved mortality or fewer ventilator days compared with other modes. But so far no mode has been proven to be superior or inferior, except for SIMV, which has been shown to be associated with a larger number of days on mechanical ventilation than the other modes.

 

[sdn1977]

Given the CV potential side effects and relatively short duration of mivacron (thus redosing on a continual basis), would atracurium (w/ Hoffman and nonspecific esterases metabolism) have been a better choice given his mode of thinking of organ failure?

I'm not a forensic pharmacist, so I can't comment on what might have been a better choice, particularly on a forum. In addition, I'm not able to assess all the clinical parameters which are involved so I'd never assume the impact of organ failure on drug metabolism was greater than the clinical condition which they were trying to treat. I was speculating on choice of drug - which could just be as simple as personal preference! I'd be very impressed if one of the intensive care physicians I work with would have come up with this. But, if he/she had read about it, been to a CE or have gone to a dinner put on by Organon recently, it may have been something which could have swayed him. As I said, therapeutically, either or would have worked & not have impacted the eventual outcome, IMO.

As for the pain/anxiety issue - the switch from midazolam/morphine to lorazepam/fentanyl was probably just a P&T compliance issue. It appears the physician decided long term pain/anxiety control issues were going to be required. Fentanyl has a longer half-life than morphine (likewise lorazepam longer than midazolam) when infused continuously. It requires less nursing titration. Fentanyl has less itching (if the pt is ever arousable enough to itch) than morphine & midazolam is far less expensive than lorazepam. The physician was probably already getting heat from the pharmacist about the expense so the timing of the switch was irrelevant to the change in condition of the pt. Just my opinion.

 

[rn29306]

I gotta tell you, I never understood this APRV craze some centers have. Out of the hospitals I've worked at, the vast majority of them never use that mode. But there's this one hospital where everyone is practically militant about putting as many patients on APRV as they can....

I'd be curious to see whether APRV would actually result in improved mortality or fewer ventilator days compared with other modes. But so far no mode has been proven to be superior or inferior, except for SIMV, which has been shown to be associated with a larger number of days on mechanical ventilation than the other modes.

We are a level 1 trauma center with several research items currently being conducted. Not exactly sure which service is conducting the APRV study, but my guess is one of the couple Surgery CCM fellows running around. Can find out details and shoot you a copy or link when all the numbers are cruched.

One of the studys that should be out this year by the surg/ccm fellows is about using single-shot induction of etomidate and drawing consecutive interval cortisol levels on patients vs other agents for intubation. Will keep posted.

 

[SilverStreak]

There's no hostility at all...I'm not sure where you're getting that from.

I'm just giving you the scoup on ARDS as I would any medical student or resident.

Sorry, maybe I'm just oversensitive. I haven't been on here long enough to know all the personalities yet. I just thought I was sensing you think I'm a pain in the butt asking dummy questions. I appreciate all the time you've taken to answer my questions. Maybe I do have a touch of I'm a nurse- don't hate me syndrome because of all the recent happenings on here. But, I hope you all will come to know me as inquisitive and wanting to bounce ideas off you all and not trying to start trouble.

 

[rn29306]

I'm not a forensic pharmacist, so I can't comment on what might have been a better choice, particularly on a forum. In addition, I'm not able to assess all the clinical parameters which are involved so I'd never assume the impact of organ failure on drug metabolism was greater than the clinical condition which they were trying to treat. I was speculating on choice of drug - which could just be as simple as personal preference! I'd be very impressed if one of the intensive care physicians I work with would have come up with this. But, if he/she had read about it, been to a CE or have gone to a dinner put on by Organon recently, it may have been something which could have swayed him. As I said, therapeutically, either or would have worked & not have impacted the eventual outcome, IMO.

As for the pain/anxiety issue - the switch from midazolam/morphine to lorazepam/fentanyl was probably just a P&T compliance issue. It appears the physician decided long term pain/anxiety control issues were going to be required. Fentanyl has a longer half-life than morphine (likewise lorazepam longer than midazolam) when infused continuously. It requires less nursing titration. Fentanyl has less itching (if the pt is ever arousable enough to itch) than morphine & midazolam is far less expensive than lorazepam. The physician was probably already getting heat from the pharmacist about the expense so the timing of the switch was irrelevant to the change in condition of the pt. Just my opinion.

Damnit Jet, you beat me to it on the other thread, and at the risk of sounding like a JPP yes-man:

sdn1977 please post on here some 'mo.

You guys are such a resource in the OR. I stop by and talk to our OR pharmacist a couple of times a day - some to shoot the shiznit and a couple to just run some things by, be it either cost, opinions on different ways of doing something, timing, etc.

Thanks for your unique insight. 👍

 

[SilverStreak]

I'm not a forensic pharmacist, so I can't comment on what might have been a better choice, particularly on a forum. In addition, I'm not able to assess all the clinical parameters which are involved so I'd never assume the impact of organ failure on drug metabolism was greater than the clinical condition which they were trying to treat. I was speculating on choice of drug - which could just be as simple as personal preference! I'd be very impressed if one of the intensive care physicians I work with would have come up with this. But, if he/she had read about it, been to a CE or have gone to a dinner put on by Organon recently, it may have been something which could have swayed him. As I said, therapeutically, either or would have worked & not have impacted the eventual outcome, IMO.

As for the pain/anxiety issue - the switch from midazolam/morphine to lorazepam/fentanyl was probably just a P&T compliance issue. It appears the physician decided long term pain/anxiety control issues were going to be required. Fentanyl has a longer half-life than morphine (likewise lorazepam longer than midazolam) when infused continuously. It requires less nursing titration. Fentanyl has less itching (if the pt is ever arousable enough to itch) than morphine & midazolam is far less expensive than lorazepam. The physician was probably already getting heat from the pharmacist about the expense so the timing of the switch was irrelevant to the change in condition of the pt. Just my opinion.

Thanks for your posts. I wish our pharmacist was as cool as you. We call ours jack a ss jack (his name is jack) because I think his sole reason for being on this earth is to make a nurses night living hell when you've already got enough going on without his input.

I like hearing drugs from your prospective. You're a very valuable resource here.

 

[sdn1977]

Damnit Jet, you beat me to it on the other forum, and at the risk of sounding like a JPP yes-man:

sdn1977 please post on here some 'mo.

You guys are such a resource in the OR. I stop by and talk to our OR pharmacist a couple of times a day - some to shoot the shiznit and a couple to just run some things by, be it either cost, opinions on different ways of doing something, timing, etc.

Thanks for your unique insight. 👍

You're welcome! Stop by anytime (even those of us who have to rotate to the ICU or downstairs too!). We can usually offer you candy to keep your blood sugar up! 😀

 

[MDEntropy]

Critical Illness Polyneuropathy....


Steroidal type NMBs, intermediate action type NMBs, in combo with steroids, antibiotics puts patients at significant risk of the above condition...

Never paralyze critically ill patients unless you have exhausted every other avenue of care...and then ...with only the shortest acting drug you have available...for the shortest duration of time necessary.

Hey Mil,
Can you site some evidence for long term moribidity - either CIPN or myopathy - due to an NMB used alone, that is, NOT in combination with, for example, steroids? I am not referring to a patient with, let's say, renal insufficiency who takes 7-10 days to clear drug X and get return of twitches, as this is simply an overdose not an adverse reaction. I am well aware of the evidence for serious trouble when steriods are combined with NMBs but I haven't seen proof that these serious long term problems happen with NMB's alone although I have seen this written but with no data to support the claim.
Paralysis without adequate amnesia aside, if the patient is not on steriods (or perhaps aminoglycosides etc.) and the NMB is constantly being titrated to a monitored endpoint (TOF), is long term use (days to weeks) really that risky?

 

[jetproppilot]

I'm not a forensic pharmacist, so I can't comment on what might have been a better choice, particularly on a forum. In addition, I'm not able to assess all the clinical parameters which are involved so I'd never assume the impact of organ failure on drug metabolism was greater than the clinical condition which they were trying to treat. I was speculating on choice of drug - which could just be as simple as personal preference! I'd be very impressed if one of the intensive care physicians I work with would have come up with this. But, if he/she had read about it, been to a CE or have gone to a dinner put on by Organon recently, it may have been something which could have swayed him. As I said, therapeutically, either or would have worked & not have impacted the eventual outcome, IMO.

As for the pain/anxiety issue - the switch from midazolam/morphine to lorazepam/fentanyl was probably just a P&T compliance issue. It appears the physician decided long term pain/anxiety control issues were going to be required. Fentanyl has a longer half-life than morphine (likewise lorazepam longer than midazolam) when infused continuously. It requires less nursing titration. Fentanyl has less itching (if the pt is ever arousable enough to itch) than morphine & midazolam is far less expensive than lorazepam. The physician was probably already getting heat from the pharmacist about the expense so the timing of the switch was irrelevant to the change in condition of the pt. Just my opinion.

Dude,

I've been in this business ten years.

And some of the things you are posting I've never heard.

So I'm again respectfully requesting that you continue to post freely here.

You will educate all of us.

 

[sdn1977]

Thanks for your posts. I wish our pharmacist was as cool as you. We call ours jack a ss jack (his name is jack) because I think his sole reason for being on this earth is to make a nurses night living hell when you've already got enough going on without his input.

I like hearing drugs from your prospective. You're a very valuable resource here.

Hahahahaha ! I can do that too! If you can't account for 15mg of MS on your shift or if you don't draw that gentamicin level when it was ordered, I can do that (make your night a living.....). I'd like to say all of us are willing to help, unfortunately, thats not always the case. Stop by the ICU pharmacy just to chat & you can have candy too!!! 😀

 

[militarymd]

Sorry, maybe I'm just oversensitive. I haven't been on here long enough to know all the personalities yet. I just thought I was sensing you think I'm a pain in the butt asking dummy questions. I appreciate all the time you've taken to answer my questions. Maybe I do have a touch of I'm a nurse- don't hate me syndrome because of all the recent happenings on here. But, I hope you all will come to know me as inquisitive and wanting to bounce ideas off you all and not trying to start trouble.

If I thought you were a pain in the butt, I would just ignore you.

 

[militarymd]

Hey Mil,
Can you site some evidence for long term moribidity - either CIPN or myopathy - due to an NMB used alone, that is, NOT in combination with, for example, steroids? I am not referring to a patient with, let's say, renal insufficiency who takes 7-10 days to clear drug X and get return of twitches, as this is simply an overdose not an adverse reaction. I am well aware of the evidence for serious trouble when steriods are combined with NMBs but I haven't seen proof that these serious long term problems happen with NMB's alone although I have seen this written but with no data to support the claim.
Paralysis without adequate amnesia aside, if the patient is not on steriods (or perhaps aminoglycosides etc.) and the NMB is constantly being titrated to a monitored endpoint (TOF), is long term use (days to weeks) really that risky?

I don't know...My practice pattern here is definitly not evidence based...just good sense based....

However, there are very few ICU patients in this situation where they are not on all the other comorbid meds...so it is kind of something that I have not thought about.

 

[militarymd]

As for ATivan and morphine....the SCCM recommends using these drugs for long term sedation...although recent data would suggest that ativan may not be the benzo to use....longer vent days..


So SCCM may change its recommendations...it may have changed already, and I just don't know about it.

 

[militarymd]

Hey Mil,
Can you site some evidence for long term moribidity - either CIPN or myopathy - due to an NMB used alone, that is, NOT in combination with, for example, steroids? I am not referring to a patient with, let's say, renal insufficiency who takes 7-10 days to clear drug X and get return of twitches, as this is simply an overdose not an adverse reaction. I am well aware of the evidence for serious trouble when steriods are combined with NMBs but I haven't seen proof that these serious long term problems happen with NMB's alone although I have seen this written but with no data to support the claim.
Paralysis without adequate amnesia aside, if the patient is not on steriods (or perhaps aminoglycosides etc.) and the NMB is constantly being titrated to a monitored endpoint (TOF), is long term use (days to weeks) really that risky?

I think I remember a case report in NEJM a number of years ago where a SINGLE dose of vec led to persistent and prolonged paralysis in a critically ill patient....

 

[SilverStreak]

As for ATivan and morphine....the SCCM recommends using these drugs for long term sedation...although recent data would suggest that ativan may not be the benzo to use....longer vent days..


So SCCM may change its recommendations...it may have changed already, and I just don't know about it.

I was very hesitant to give the ativan for the very reason that I know benzos hang around longer. I actually didn't give any ativan even though he had ordered it prn, until he specifically said "give her ativan and fentanyl now". I had continued to up her diprivan as well, but she was a morbidly obese lady and I was hesitant to continue increasing it because it is stored in the fat cells and can also cause more days on the vent. The night before, she had looked like she was slowly making improvement, and we'd hoped with the continous dialysis, she'd get to a point where extubation was possible. I guess in a nutshell, I know there's nothing we're gonna do for her to prevent the inevitable, but I felt since she was a full code that we should continue to treat her aggresively until the family was told it was a hopeless cause.

 

[SilverStreak]

If I thought you were a pain in the butt, I would just ignore you.

Okay, forgive me for taking you the wrong way then. Thanks for all your input. Sometimes I question what we do in treating our patients, but physcians tend to get defensive and don't realize I'm just asking why this or why that to learn beyond the obvious what we're doing. I've come of the oppinion though that sometimes they may be treating and know some things I don't know, and then again, sometimes, they may be treating without really knowing what to do.

 

[dogbone65]

👍 Great thread!

 

[militarymd]

Okay, forgive me for taking you the wrong way then. Thanks for all your input. Sometimes I question what we do in treating our patients, but physcians tend to get defensive and don't realize I'm just asking why this or why that to learn beyond the obvious what we're doing. I've come of the oppinion though that sometimes they may be treating and know some things I don't know, and then again, sometimes, they may be treating without really knowing what to do.

there is a lot of both........hopefully most of the time it is the former, but unfortunately I know that it is frequently the latter.

 

[SilverStreak]

I don't know...My practice pattern here is definitly not evidence based...just good sense based....

However, there are very few ICU patients in this situation where they are not on all the other comorbid meds...so it is kind of something that I have not thought about.

I also suggested we order a lactate and cortisol level (because no one had thought to it yet 🙁 ). Cortisol was > 40, intensivist ordered me to start a steriod if cortisol was less than 25, so she was not on steriod, nor had she ever gotten any, unless the OR gave some I didn't look at the OR med record for a steriod.

Just for clarity, drugs we were on:
IV gtts-
insulin
bumex
levophed
vasopressin
diprivan
tpn

IV push/abx meds-
1 dose vanco
zosyn q 6
reglan (don't know why this was ordered gi was working fine)
spa
morphine/ativan/fentanyl/versed combo
mivacron

Any concerns with the above mil in relation to the paralytic?

BTW, I don't get the concern about renal decline either she was clearing fine, just wasn't peeing. am labs creatinine was 1.1-creatinine was 1.6 when we started dialysis to help pull fluid off not really to help her clear, liver function normal per labs, so hepatic clearance on drugs should not have been an issue either.

 

[SilverStreak]

Ahhh, a person after my own heart! 😀

Silverstreak, I don't think changes in paralytics or modes of ventilation will necessarily help this patient. What will help, however, is optimizing your lung protective ventilatory strategy. If you feel this patient has ARDS, you should consider placing her on the ARDSnet ventilation protocol. I'm particularly referring to the high tidal volumes that she's on. In ARDS, you would want to drop the tidal volumes to 6-8cc/kg of ideal body weight, calculated based on age, height, and sex. In her case, she would have to have an ideal body weight of 75kg in order to be getting 8cc/kg TV, (since she's at 600cc) which would mean that she would be a heck of a tall woman.

It's okay if her RR is high - it's preferable to have a high RR rather than a high TV. Permissive hypercapnia is okay, too.... as far as the concern with how she looks, often you need to sedate these patients very heavily in order for them to tolerate these 'unnatural' ventilatory strategies.

She weighed 100 kg on admit, and put on a good 20 pounds I think in 6 days from fluid overload. I understand ideal body weight is preferable in regards to tidal volume, but her ideal body weight (she was short) was probably in the ball park of 60 kg, so I would think it would make more sense to set tidal volume based on her dry weight. She has probably never been anywhere close to her ideal body weight, so why am I wrong to think we should base tidal volume on her actual weight? We do drugs this way.
Her other parameters on the abg looked good co2 mid 40's.
And again, my concern with how she looked was that 12 hours ago, she was very comfortable with these vent settings and was hemodynamically much more stable. From an ICU nurse perspective, I have to recognize these changes and notify the MD and let him decide their significance. He was obviously concerned since he came in to see her at almost midnight.

 

[militarymd]

check out data that Meduri published on ARDS and steroids.

Steroids in intermediate doses given over a prolonged course is significantly associcated with altering the disease course of ARDS.,....patients get better. I always used corticosteroid in ARDS especially after 3 days of the disease.

You want to avoid paralyzing the patient, but you have to do what you have to do....sometimes the best path of care has treatment options that are undesirable.

 

[militarymd]

Marik and Zaloga??? I think they're the guys in DC.

They talk about "relative" adrenal insufficiency in critically ill patients who need supraphysiologic doses of steroids for vasopressor requiring hypotension.

Another reason to start steroids despite paralyzing the patient.

 

[iron]

When the patient got fat, her lungs didn't get bigger. Hence set tidal volume toward ideal body weight (surrogate for lung size) instead of true body weight.

We dose many drugs to body weight but not all. Dosing to body weight on induction agents would probably lead to overdoses. There are drug delivery systems in use in Europe that dose drugs to target concentrations taking in to account volume of distribution and the like. In the US, it's more of an academic discussion, "How much propofol should I give this woman with a BMI of 50?"