Nursing Grand Rounds Present new clinical scientific information

Nursing Grand Rounds Present new clinical scientific information, enhance nursing knowledge- improve patient care

Care of the patient receiving NMBA o Neuromuscular transmission

Muscle relaxants o o Block transmission of nerve impulses at the neuromuscular junction Two types of muscle relaxants n n Non-depolarizing muscle relaxants Depolarizing muscle relaxants

Depolarizing Muscle Relaxants o o o Hold open the channel for an extended period of time-rendering the muscle flaccid Example: Succinylcholine Rapid onset-less than one minuteduration of action 5 -10 minutes

Usage: Rapid sequence intubation o Fast surgeries (fast surgeons) Concerns: patients with an abnormal variant of the enzyme pseudocholinesterase-delayed awakening Ask family history Contraindicated in pedi pts unless an emergency o

Non-depolarizing muscle relaxants o o Prevent the release of acetycholine(Ach) from binding to the receptor site Examples n n n Pancuronium-Long acting Vecuronium and rocuronium – intermediate acting Onset 1 -2. 5 minutes Duration of action 80 -120 minutes

Vecuronium o o o 75 -80% metabolized by liver 20 -25% metabolized by kidneys No histamine release Cardiovascular stability Can have a cumulative effect Dose for continuous drip 2 mg/hr

Indications of therapeutic paralysis and the desired level of muscular relaxation o o Control of intracranial pressure Control of muscle spasm Control of intractable agitation Reduction in oxygen consumption and to optimize pt. -ventilator synchrony

What depth of NMBA is necessary to achieved desired goal? o o Synchronous respiration-apnea-or complete paralysis Case study-Why? Opened abdomen n n Return to the OR next day Block bucking on tube/prevent cough response

Cough response o o o Neurophysiologic protection of the upper airway is a critical function of the laryngeal cough reflex Coordinated contraction of thoracic, abdominal, and pelvic muscles Coughing increases intra-abdominal pressure displaces the diaphragm upwards and generates the expiratory force for cough & airway clearance

Nursing considerations o o Maintain adequate NMBA & to avoid using higher doses of a drug then necessary TRAIN OF FOUR n n Produces a muscle contraction Four consecutive stimulations are applied to the nerve and the number of twitches are counted

o o Deliver a dose of NMBA that will produce 1 -2 twitches out of four A positive and a negative electrode is attached to the nerve stimulator n n The negative electrode generates its action potential by depolarizing the membrane The positive electrode causes hyperpolarization-easier to stimulate the nerve

o Ulnar nerve- most commonly used n Adductor policis muscle

o Facial nerve

o Posterior tibial nerve

Nursing considerations o Adequate pain control n n Difficult to assess Round the clock pain meds

Adequate sedation o o Must be sedated-extremely frightening Steady infusion of sedative n n n Diprivan (milk of amnesia) Knocks respiratory drive Although sedated- Must always speak to patient and explain what is happening

Anesthesia awareness o Unintended intra-operative awareness n Occurs during general anesthesia, on the operating room table, when a pt. has not had enough general anesthetic or analgesia to prevent consciousness or waking up during surgery

o Anesthesia Awareness can also occur in the PACU or the ICU n Pts. Are kept sedated, tranquilized, and paralyzed hooked to life support systems, awaiting normalization of their physiology

o o Awareness occurs in 20, 000 -40, 000 pts. Out of every 20 million surgeries The pt. is unable to communicate any distress If awareness occurs-42% feel the pain of surgery, 94% experience panic/anxiety, 70% experience lasting psychological symptoms In rare cases post traumatic stress disorder occurs

Posttraumatic stress disorder o o Can Lead to long lasting after effects Nightmares, night terrors, flashbacks, insomnia and in some cases suicide

BISS MONITOR o o o Allows anesthesia professionals to access processed EEG information as a measure of the effect of certain anesthetics during the care of pts. Monitor changes in the EEG that correlate with drug induced changes in the clinical state Used as a guide that may be associated with reduction of the incidence of awareness and recall

Thank You