Paralytics

[militarymd]

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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?"

One stick.

 

[Tenesma]

silver - here are a few recs:

1) only one narcotic and one benzo should be used - don't escalate their dose. this woman is going to be intubated for a while...

2) the ideal thing would be to play with the vent to find a comfortable breathing pattern - if she overbreaths then fine...

3) stop worrying what she looks like... dysfunctional breathing looks weird, and can look weird to the family... so when the family comes by just bolus her w/ PRN narc/benzo. just cause somebody has goofy breathing doesn't mean they are suffering...

4) if she is on dialysis/anuric why is she on Bumex gtt??? that doesn't make sense

5) stop the propofol - use it only for when you need it...

6) mivacron is a dumb choice - for many reasons... you should be either on vec or cisatracurium (i prefer cis cause it is a nicer drug and our hospital gets it cheap) if at all.

7) why are you on continuous dialysis... that doesn't make sense- you should be on CVVH instead if it is a fluid management issue...

8) lactate level is useless information - even if it is slightly elevated what are you going to do about it? it only has a prognostic value- nothing else

9) steroids - there is some literature to support low-dose steroid use - but i would make sure the patient meets the criteria..

 

[UTSouthwestern]

silver - here are a few recs:

1) only one narcotic and one benzo should be used - don't escalate their dose. this woman is going to be intubated for a while...

2) the ideal thing would be to play with the vent to find a comfortable breathing pattern - if she overbreaths then fine...

3) stop worrying what she looks like... dysfunctional breathing looks weird, and can look weird to the family... so when the family comes by just bolus her w/ PRN narc/benzo. just cause somebody has goofy breathing doesn't mean they are suffering...

4) if she is on dialysis/anuric why is she on Bumex gtt??? that doesn't make sense

5) stop the propofol - use it only for when you need it...

6) mivacron is a dumb choice - for many reasons... you should be either on vec or cisatracurium (i prefer cis cause it is a nicer drug and our hospital gets it cheap) if at all.

7) why are you on continuous dialysis... that doesn't make sense- you should be on CVVH instead if it is a fluid management issue...

8) lactate level is useless information - even if it is slightly elevated what are you going to do about it? it only has a prognostic value- nothing else

9) steroids - there is some literature to support low-dose steroid use - but i would make sure the patient meets the criteria..

Was wondering when someone was going to mention cis. Low infusion rates prevent accumulation of metabolites and once it's off, the effect is off in one hour max unless the patient's pH is way off.

 

[supahfresh]

oh man am i wasted tonight.

 

[UTSouthwestern]

oh man am i wasted tonight.

Try some Zantac, Zofran, lemon juice with water, and of course some Cis.

 

[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.

I might have spoken too soon about this....look in the April 20, 2006 issue of New England Journal.

 

[militarymd]

I might have spoken too soon about this....look in the April 20, 2006 issue of New England Journal.

There were enough adverse events related to neuromuscular weakness that a special review was requested by the safety monitoring board..........

 

[supahfresh]

Try some Zantac, Zofran, lemon juice with water, and of course some Cis.

Cis?

 

[rn29306]

Cis?

Cisatracurium, the purified form of one of the 10 stereoisomers of atracuruim.