GRADIENT PRESENTATION

Administration of Neuromuscular Blockers and use of Peripheral Nerve Stimulator

Neuromuscular blocking agents must be administered to a non-intubated patient, even immediately prior to intubation, by the physician, Advance Practice Nurse (CRNP) or CRNA.

These medications include but are not limited to:Succinylcholine- (Anectine)Pancuronium- (Pavulon)Vecuronium- (Norcuron)Cisatracurium- (nimbex)Atracurium- (tracium)Etomidate (amidate)Rocuronium- (zemuron)Mivacuriuim (mivacron)Curare

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Purpose: To establish a standardized procedure for the admninistration of neuromuscular blocking agents prior to intubation and in the management of a ventilator dependent patient.

Thomas Hospital Policy

1. Completion of a unit specific competency in neuromuscular blockers including documented clinical practice by a preceptor or participation in an annual skills fair. 2. Patient must be intubated, mechanically ventilated, and have sedation BEFORE administration of the medication.3. Patient must have a written medical order (no standing or unit orders permissible.4. Medication must be administered in accordance with the manufacure's guidelines. 5. Competency in administration of neuromuscular blockers must be reviewed annually.

Registered Nurses may administer a neuromuscular blocking agent for the managment of a ventilator dependent patient within the following guidelines.

In accordance with the Alabama Board of Nursing's Standards of Practice, it is prohibited for the RN to administer these medication in the non-intubated patient, even in the circumstance of immediately prior to intubation.

Paralytic Titration Peripheral Nerve StimulatorTrain of Four

Best to get baseline on the patient BEFORE neuromuscular blocker is started. This is not always possible if the patient was given a blocker in ED, before admission to us.
Start with the lowest mA or energy to elicit 4 twitches (this is your patients's baseline).
Once the neuromuscular blockade infusion is initiated, you should retest the patient about every 10-15 minutes to determine effectiveness. Retest the patient every 1-2 hours until clinically stable, and a satisfactory level of blockade is achieved.
The normal goal for an adequate level of paralyzation of a patient is for the patient to twich 2/4 with the train of four.
If they twitch 4/4 times the paralytic needs to be increased, because their muscles are still too responsive (AKA need to be more paralyzed.
If they twitch 0/4 times the patients muscles are too paralyzed (you need to decrease the paralytic).
In most cases, one or two twitches will be evidence of adequate blockade.
ONLY in those cases that the physician states they don't want the patient to move at all, would you need to increase the blockade so that no twithces are seen.
Once the "sweet spot" of blockade is achieved, continue to retest the patient every 2 hours durin the NMB infusion per Thomas Hospital policy.

Measuring PNS is ONLY used if the patient is on continuouos neuromuscular blockade (not when receiving intermittent pushes).

***** If patient is on a high amount of peep, verify with Pulmonary before turning off paralytic*****EXTREME caution must be excercised to prevent the PNS lead wires from contacting a pacing catheter or pacing lead wires. Microshock hazard may be a risk to patient with external pacing catheters.

Ulnar nerve- not radial nerve,

people always point to the radial by mistake- thumb is the area that should twitch.

Facial Nerve- watch for twitches above the eyebrow.

Posterial Tibial- obsserve for plantar flexion of the great toe.

Refer to Validation Criteria for the locations that we can use the peripheral nerve stimulator.

Place electrodes in the right location.

Wash hands
Extend the patient's arm, palm up, in a relaxed position
Apply two gelled electrodes over the path of the ulnar nerve. Place the distal electrode on the skin at a flexor crease on the ulnar surface of the wrist. Place the second electrode approximately 1-2 cm proximal to the first, parallel to the flexor carpi ulnaris
Attach lead wires to the electrode
Turn on the PNS selecting low mA
Depress the TOF key and observe twitching, counting the number of twitches of the thumb only.

Testing the Ulnar nerve

Wash hands
Extend the patient's arm, palm up, in a relaxed position
Apply two gelled electrodes over the path of the ulnar nerve. Place the distal electrode on the skin at a flexor crease on the ulnar surface of the wrist. Place the second electrode approximately 1-2 cm proximal to the first, parallel to the flexor carpi ulnaris
Attach lead wires to the electrode
Turn on the PNS selecting low mA
Depress the TOF key and observe twitching, counting the number of twitches of the thumb only.

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Transcript

Administration of Neuromuscular Blockers and use of Peripheral Nerve Stimulator

Paralytic Titration Peripheral Nerve StimulatorTrain of Four

Testing the Ulnar nerve

Testing the Ulnar nerve

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