why?

[troutslayer1]

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i have a question. i am a rn who recovered open hearts, i am now in a nurse anesthesia program, before the boos, i just want to hear your professional opinion. everytime an anestheslogist brought a pt over to our unit, they always paralized them for the eight minute walk. why is this. i also saw this when an anesthesia provider would bring a pt back from ir, etc. i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

 

[coprolalia]

i have a question. i am a rn who recovered open hearts, i am now in a nurse anesthesia program, before the boos, i just want to hear your professional opinion. everytime an anestheslogist brought a pt over to our unit, they always paralized them for the eight minute walk. why is this. i also saw this when an anesthesia provider would bring a pt back from ir, etc. i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

I never do this. (And, it's "paralyzing"... or, more appropriately, giving them a muscle relaxant. Never tell family members you are "paralyzing" their loved one.)

-copro

 

[troutslayer1]

sorry, did not use spell check, plus i have had a few drinks(just had our first test)

 

[coprolalia]

sorry, did not use spell check, plus i have had a few drinks(just had our first test)

Are you a female? PM me a picture if you are. Preferably topless.

-copro

 

[Jeff05]

my favorite part of transport is when the patient starts bucking and self extubates in the elevator. that's why i never paralyze.

 

[deleted126335]

.

 

[deleted50478]

i have a question. i am a rn who recovered open hearts, i am now in a nurse anesthesia program, before the boos, i just want to hear your professional opinion. everytime an anestheslogist brought a pt over to our unit, they always paralized them for the eight minute walk. why is this. i also saw this when an anesthesia provider would bring a pt back from ir, etc. i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

The nurses get pissed if the patient moves around and tries to self-extubate before they've had time to finish their charting.
Thank the government and their representative, JCAHO. Medicine and nursing are now about the paper work, not the patient.

 

[coprolalia]

I think I'd like to slay her trout...

-copro

 

[troutslayer1]

sorry copro, i am a dude. i just dont understand why you would not just give versed and a painkiller, instead of a vec, versed, and a painkiller.

 

[coprolalia]

sorry copro, i am a dude.

Uh-oh... a.... MURSE!???!??!????!!

AGGGHAHAHHAHGGAHGHHHGGGGGGHHHHHHHHH!!!!!!!!!!!!!!



-copro

 

[pie944]

Uh-oh... a.... MURSE!???!??!????!!

AGGGHAHAHHAHGGAHGHHHGGGGGGHHHHHHHHH!!!!!!!!!!!!!!



-copro

I spit out water and started laughing after reading this one. I guess this is how in life one goes from lurker to poster.

thanks for the laugh copro.

 

[Robert Loblaw]

sorry copro, i am a dude. i just dont understand why you would not just give versed and a painkiller, instead of a vec, versed, and a painkiller.

not being pejorative or sarcastic here...if the goal is to not have the patient move (and incidentally do something calamitous) then give a nmb.

don't fool yourself into thinking that induction or coming off bypass are the most dangerous parts of a cardiac anesthetic--transport is. when you are inducing or coming off bypass you are in the controlled, familiar, and well-equipped (with both equipment and extra hands) surrounds of an operating room. during transport you are in the elevator with a bag mask, an o2 tank, and a limited supply of drugs--with a patient who's just had cardiac surgery. the downside of another few hours of nmb in the icu pales in comparison to the potential downside of the disasters that can transpire in transport.

 

[pgg]

sorry copro, i am a dude. i just dont understand why you would not just give versed and a painkiller, instead of a vec, versed, and a painkiller.

A patient who is asleep enough to be still and comfortable while laying motionless in a bed may or may not be asleep enough to be still and comfortable when being heaved from one bed to another. Hallways and the ICU immediately upon arrival are bad times and places for the patient to be bucking or moving. People are distracted (whether nurses charting 🙂, or doctors begging nurses to stop the goddamn charting and look at the patient, or techs untangling lines, or RTs messing with the ventilator) and having a line or tube pulled are risks.

Many of my attendings preferred to err on the side of relaxation to guarantee a limp, pliable, non-bucking patient.

I always tried to be mindful of the ICU's plan - if early extubation was the goal, I would use a small amount of muscle relaxant before transport (enough to keep them around 1-2 twitches) and I'd reverse the patient before I left the ICU.

Hallway disasters are memorable. I don't much care if extubation is delayed 30 minutes, so my patients go to the unit relaxed.

 

[coprolalia]

Hallway disasters are memorable. I don't much care if extubation is delayed 30 minutes, so my patients go to the unit relaxed.

Depends on how much **** you're dragging along. If you have a standard ICU ventilator, a balloon pump, a CVVH machine, nitric oxide infuser, a crappy bed with a broken wheel, two IV poles, and an ECMO machine, then... well... yeah, relax the f*cker.

-copro

 

[troutslayer1]

thanks for all the replies.

 

[Licoricestick]

my favorite part of transport is when the patient starts bucking and self extubates in the elevator. that's why i never paralyze.

This is invariably followed by the lift breaking down. 😱

My patient's saftey in transport (which definitely includes minimising the number of things that can go wrong) is definitely my first priority and the convenience of the receiving staff is somewhere further down my priority list.

For further information you could just read the chapter on transporting critically ill patients that can be found in every ICU textbook and most anaesthetic texts.

 

[Frank Rizzo]

i have a question. i am a rn who recovered open hearts, i am now in a nurse anesthesia program, before the boos, i just want to hear your professional opinion. everytime an anestheslogist brought a pt over to our unit, they always paralized them for the eight minute walk. why is this. i also saw this when an anesthesia provider would bring a pt back from ir, etc. i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

Ever see how much bloods pours out of the neck when the cordis is pulled out by the patient? It sucks, and makes a big fukn mess. They get some relaxant from me.

 

[dhb]

I always say the best drug for transport is nimbex 😀

 

[monchi]

i have a question. i am a rn who recovered open hearts, i am now in a nurse anesthesia program, before the boos, i just want to hear your professional opinion. everytime an anestheslogist brought a pt over to our unit, they always paralized them for the eight minute walk. why is this. i also saw this when an anesthesia provider would bring a pt back from ir, etc. i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

All anyone who "knows" seems to care about is what is going on the minute the patient is on their hands.
You didn't understand why they were paralyzed for the eight minute transport, so you thought it was excessive. You never considered what transport might be like. I bet you never asked why, either. But, you went ahead and bitched and made the judgement that it was "excessive".
Yeah. Troutslayer, you'll be a great CRNA - because you'll always know best, since everyone else, esp the doctors supervising you, are *****s. I bet you were an awesome ICU nurse.

 

[geogil]

All anyone who "knows" seems to care about is what is going on the minute the patient is on their hands.
You didn't understand why they were paralyzed for the eight minute transport, so you thought it was excessive. You never considered what transport might be like. I bet you never asked why, either. But, you went ahead and bitched and made the judgement that it was "excessive".
Yeah. Troutslayer, you'll be a great CRNA - because you'll always know best, since everyone else, esp the doctors supervising you, are *****s. I bet you were an awesome ICU nurse.

It seems that the OP was being pretty diplomatic and humble in their request for information. Unless this is Armygas the 4th, i say we cut him just a little slack.

 

[pgg]

I always say the best drug for transport is nimbex 😀

?

Why? Just because cis is magically metabolized in a non-liver non-renal manner doesn't mean an excessive dose won't cause prolonged weakness, or that it never needs to be reversed.

It seems that the OP was being pretty diplomatic and humble in their request for information. Unless this is Armygas the 4th, i say we cut him just a little slack.

I agree, when we treat polite SRNAs like this, it's no wonder that only the trolls stick around.

 

[monchi]

It seems that the OP was being pretty diplomatic and humble in their request for information. Unless this is Armygas the 4th, i say we cut him just a little slack.

Yes, you're right. Just letting out frustration - I've seen so many stupid things happen in my few years of residency. I'm glad that he asked.

 

[Arch Guillotti]

Sounds like a reasonable question.

When I would do hearts I would invariably end up pushing some relaxant before going to the ICU. Not a ton but enough to keep things settled down for the ride upstairs. Usually was nimbex, maybe 10 mg or so (or whatever was left in the syringe). Always had a free flowing IV and some sedation going (prop or precedex) so the paralytic was just a little extra insurance. Or maybe if I was running an infusion of nimbex I would just leave it on until we headed out of the OR. Always had a stick of induction agent handy as well. If I had redosed pavulon I usually wouldn't give any more relaxant.

I think the question is a valid one if pts are given very large doses of relaxant that is lasting an unreasonable amount of time (pushing a stick of pavulon before leaving the OR).

 

[troutslayer1]

All anyone who "knows" seems to care about is what is going on the minute the patient is on their hands.
You didn't understand why they were paralyzed for the eight minute transport, so you thought it was excessive. You never considered what transport might be like. I bet you never asked why, either. But, you went ahead and bitched and made the judgement that it was "excessive".
Yeah. Troutslayer, you'll be a great CRNA - because you'll always know best, since everyone else, esp the doctors supervising you, are *****s. I bet you were an awesome ICU nurse.

i was asking because i have routinely transported pts before on two pressors, vented, with lines and i did not use a paralytic. one pt was even a fresh heart who had to go back because of a clots around the heart. usually pts i received from an anesthesiologist were heavily sedated and had received a paralytic. it made it harder to extubate pts as quickly as possible. this was also the case for several pts who were taken to ir for procedures by me, and were brought back by an anesthesiologist. i understand the need for a pt to be "relaxed" for transport, but i found it overkill to use a paralytic. i wanted to know from your perspective why was that the case, if there was a really great reason for this that i am missing. thank you to the drs who responded with serious posts.

 

[troutslayer1]

ps. monchi, i respected the mds i worked with greatly, as did they to me. all of my references to school were from drs i worked with. plus they respected the fact that i always wanted to learn more, as i respected them for always teaching anyone, rn or dr, who wanted to learn.

 

[Jeff05]

ps. monchi, i respected the mds i worked with greatly, as did they to me. all of my references to school were from drs i worked with. plus they respected the fact that i always wanted to learn more, as i respected them for always teaching anyone, rn or dr, who wanted to learn.

just because you have never seen a problem without paralysis doesn't mean it can't happen. anesthesia is a game of numbers. bad things don't happen frequently, but when they happen, they are really bad.

ex: having a patient after liver transplant who got 25 units/20ffp/5PL, etc self extubate on way to sicu = death. i would rather needlessly paralyze 10,000 patients than have ONE box on me in the elevator. it's a personal philosophy.

 

[Bertelman]

i was asking because i have routinely transported pts before on two pressors, vented, with lines and i did not use a paralytic. one pt was even a fresh heart who had to go back because of a clots around the heart. usually pts i received from an anesthesiologist were heavily sedated and had received a paralytic. it made it harder to extubate pts as quickly as possible. this was also the case for several pts who were taken to ir for procedures by me, and were brought back by an anesthesiologist. i understand the need for a pt to be "relaxed" for transport, but i found it overkill to use a paralytic. i wanted to know from your perspective why was that the case, if there was a really great reason for this that i am missing. thank you to the drs who responded with serious posts.

With the exception of the bring-back, the examples you mentioned were (relatively) clinically stable patients who had been chilling on your unit for some amount of time since the insult wielded upon their sternum by the CT surgeon. You had demonstrated they were stable and tolerating the ventilator by watching them for hours on the unit, getting signout, etc.

We're talking about someone fresh off sternotomy, with a fragile heart, just disconnected from the vaporizer scrambling his brain. More importantly, we are transporting our patient from a very controlled atmosphere with the tools, technology and personnel to perform a multitude of invasive, life-saving procedures, through an environment with none of the above, to land in a destination with the technology and personnel to monitor the recovering patient, but not much else.

In your case where you transported the patient to the OR, you were actually taking him to a safer destination. We, on the other hand, need to pack for a long trip, because the weather might get turbulent. If our patient bucks the tube or pulls lines out on the way to the ICU, I'm not convinced the materials will be immediately available to repair the damage. As a matter of fact, if it happened on the way to the elevator, I may just turn around and head right back to the OR, because that's where I feel safe.

 

[proman]

Different practices I guess. I'm doing a month at a local community hospital. Best cardiac outcomes of the state. They reverse the patient when the sternum is closed and transport with a propofol drip. Many patients get extubated within 2-4 hours. But, their ICU is across the hall from the ORs. At our main hospital we normally don't reverse but leave the patient with twitches. Again, no elevator ride. The ICU delayed reversing patients until all the paperwork was done etc, many hours. So those patients get reversed by us as soon as we get to the unit. Even 10 mg of vec will be reversible before the chest xray comes back.

 

[troutslayer1]

thank you proman, good response. by the way the pt i transported was to ct not the or. i did that later.

 

[drccw]

Fresh hearts when I transport to ICU never get additional paralytic. My practice is more in line to proman. I typically carry a stick of reversal with me to the ICU and reverse when I get there. If you are paralyzing your hearts before transport then you've ruined fast tracking... However, if you are in a Uni setting doing hearts most likely those guys aren't fast tracked. The goal should be to have most of the fresh hearts extubated within 90 minutes of ICU arrival.

However, if I have a patient that requires direct ICU admission after an OR case then they need prolonged ventilation. Then yes, I give them a little something to relax them for transport..

So real world (ie not sick heart world) goal should be to fast track most hearts...

 

[G4 BOS]

Are you a female? PM me a picture if you are. Preferably topless.

-copro

That, undoubtedly, is a refined response.
You display fine character and caliber "Crap-o".

It’s too bad that Jet and Mil decided to depart - they were great mentors, they are men of integrity and strength.

 

[jennyboo]

Some people think if you paralyze for transport then you minimize the risk of the patient suddenly deciding to self-extubate.

Other people think that if you don't paralyze you maximize the chance that if you lose your tube, the patient still has some potential to breathe for himself.

When I was a first-year resident, I used to paralyze all the time. Now, I paralyze sometimes, and other times (especially when the patient is semi-awake and cooperative on pressure support and I have a transport ventilator at hand) I neither paralyze nor sedate.

Whatever is appropriate to the situation at hand, and beyond that whatever floats your boat.

 

[coprolalia]

That, undoubtedly, is a refined response.
You display fine character and caliber "Crap-o".

It's too bad that Jet and Mil decided to depart - they were great mentors, they are men of integrity and strength.

Like I f***ing care what you think about me.

You obviously haven't been around for very long if you don't remember some of the "integrity and strength" displayed by those two in some of the more classic flame wars of this entire forum.

Lighten up, Francis. This forum ain't the real world. A lot of people get that confused from time to time. You're forgiven.

-copro

 

[coprolalia]

When I was a first-year resident, I used to paralyze all the time. Now, I paralyze sometimes, and other times (especially when the patient is semi-awake and cooperative on pressure support and I have a transport ventilator at hand) I neither paralyze nor sedate.

👍

Whatever is appropriate to the situation at hand...

Yes. But...

and beyond that whatever floats your boat.

... you should've stopped previously.

We shouldn't, as practitioners, do things simply because they "float our boat". I see far too much of that, and sometimes such "boat-floating" could even be potentially construed as dangerous practice.

What you should always do is provide safety and comfort to the patient, and in that order. If it is safer to give a relaxant (i.e., they're a "thrasher"), then do it.... with the concurrent risk of under-sedation, potential for loss of airway, and recall during transport.

That's the trade-off.

-copro

 

[dhb]

?

Why? Just because cis is magically metabolized in a non-liver non-renal manner doesn't mean an excessive dose won't cause prolonged weakness, or that it never needs to be reversed.

Thanks for the lesson Prof.

 

[jennyboo]

We shouldn't, as practitioners, do things simply because they "float our boat". I see far too much of that, and sometimes such "boat-floating" could even be potentially construed as dangerous practice.

What you should always do is provide safety and comfort to the patient, and in that order. If it is safer to give a relaxant (i.e., they're a "thrasher"), then do it.... with the concurrent risk of under-sedation, potential for loss of airway, and recall during transport.

That's the trade-off.

This is like the age-old argument of, "Which is better, general or regional?"

A smart clinician makes up for the disadvantages of each method. I challenge you to find a study which demonstrates that neuromuscular blockade during transport has better outcomes than adequate sedation during transport.

 

[Jeff05]

This is like the age-old argument of, "Which is better, general or regional?"

A smart clinician makes up for the disadvantages of each method. I challenge you to find a study which demonstrates that neuromuscular blockade during transport has better outcomes than adequate sedation during transport.

sometimes common sense works too. there is 0% chance of a paralyzed patient self extubating, bucking, pulling lines in elevator. i am SURE that there is a higher chance of a patient who is NOT paralyzed doing that. don't need a study for that.

how many times do you have a patient move in the OR when you're not expecting it? more than once a year? too much in my book.

 

[pillowhead]

If our patient bucks the tube or pulls lines out on the way to the ICU, I'm not convinced the materials will be immediately available to repair the damage. As a matter of fact, if it happened on the way to the elevator, I may just turn around and head right back to the OR, because that's where I feel safe.

I actually had a Neurosurg patient self-extubate once on the way to the ICU. I was just so thankful we hadn't gotten on the elevator yet (though were waiting for it to come). Turned around and went right back to the OR as fast as humanly possible for reintubation and paralysis.

Now I don't routinely paralyze every patient for ICU transport since that event though I have a lower threshold to do so now. This guy had been liberally juicy and drooly despite frequent, repetitive suction and had bad coronary artery disease, so we didn't want to give him glyco. The copious secretions coupled with some movement in a guy at least twice my size (not a patient that was easy to just physically keep from moving) equaled tube out despite a pretty good tape job. Hindsights 20/20, but if I have much doubt at all, I paralyze these guys now. I can only imagine what kind of horrible nightmare that would have been if we had gotten in the elevator. I also always carry a laryngoscope with me now and not just a face mask.

 

[coprolalia]

I challenge you to find a study which demonstrates that neuromuscular blockade during transport has better outcomes than adequate sedation during transport.

I love this challenge! This is a favorite game of people with predilections that they don't want to let go of.

"I challenge you to show me a study where pink fuzzy bunnies are demonstrably shown to be cuter than brown fuzzy bunnies."

Most intelligent people can see right through this ruse, Jenny. Have a tube come out of a paralyzed patient with a difficult airway in the middle of the hallway sometime while you're transporting. You'll learn quickly to tolerate a little movement and spontaneous respirations. That's all I'm saying. And, no, that will never be "studied".

-copro

 

[fakin' the funk]

i thought it was an excessive move, especially when we were trying to get the pt extubated as soon as possible for most pts. i bitched at the time, but i also understand that i might not be looking at it right. so what would be a good reason for paralizing a pt just for transport. thank you in advance for people who take it seriously.

Is there a meaningful difference between getting the pt extubated n hours after ICU arrival and n + time of resolution of NMB effect hours after ICU arrival? I'm not sure there is.