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An Awake Paralysis Victim in SICU and Cardiac Anesthesia

An Awake Paralysis Victim in SICU and Cardiac Anesthesia. R1 胡念之. Patient Profile. Age: 47 y/o Sex: male Weight: 87.5 Kg Height: 177.6 cm P.H: DM under insulin control for 10+ yrs HTN under Renitec control for 7+ yrs

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An Awake Paralysis Victim in SICU and Cardiac Anesthesia

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  1. An Awake Paralysis Victim in SICU and Cardiac Anesthesia R1 胡念之

  2. Patient Profile • Age: 47 y/o • Sex: male • Weight: 87.5 Kg • Height: 177.6 cm • P.H: DM under insulin control for 10+ yrs HTN under Renitec control for 7+ yrs Chronic renal insufficiency (Cre level around 2.5) for several yrs Hyperlipidemia

  3. He received scheduled OPCAB on 94/1/23 due to CAD, 3-vessel disease. • He was admitted to 4A1 SICU for post-op observation and care at 10 pm on 1/23.

  4. Pre-op

  5. Heart Echo (1/10) • LVEF: 30 % +/- • Dilated LVImpaired LV contractilityMR , mildMinimal amount pericardial effusion

  6. Pavulon 1st 4mg 2nd 4mg A-line CVP

  7. 3rd 4mg 4th 4mg

  8. 5th 4mg 10pm

  9. The adequate dosage of Pavulon for this patient should be 1.75~2.625 mg/hr • The operation was over at 10pm on 1/23 • No limbs movement or eye opening at 8am on 1/24 • Mild tremor over four distal limbs was noted at 9am • TOF on 10am: 0 % • Head control recovered at 2pm • Fully recovered at 3~4pm • Extubated at 5pm

  10. Topic discussion • Risk factors of prolonged paralysis • Monitor of neuromuscular block • Muscle relaxant and fast track anesthesia • Guidelines for the intrahospital transport of critically ill patients

  11. Risk Factors of Prolonged Paralysis • Chronic hypertension — alters cerebral blood flow autoregulation • Liver disease • Kidney disease • DM • Reduced serum albuminlevel — increased free drug contain • Severe hypothyrodism — altered metabolism

  12. Evaluation of Neuromuscular Function • Single-twitch • Train-of-four (TOF) • Tetanic stimulation • Double- burst stimulation (DBS)

  13. Single Twitch • peripheral motor nerve at frequencies ranging from 1.0 Hz (once every second) to 0.1 Hz (once every 10 seconds) • Increasing block results in decreased evoked response to stimulation

  14. Train-of-four (TOF) • four supramaximal stimuli are given every 0.5 seconds (2 Hz) • partial nondepolarizing block: the ratio decreases (fades), inversely proportional to the degree of blockade • partial depolarizing block: no fade occurs in the TOF response • Clinical relaxation usually requires 75~95% neuromuscular blockade

  15. the degree of block can be read directly from the TOF response • less painful than tetanic stimulation, generally does not affect the degree of neuromuscular blockade

  16. Tetanic Stimulation • Very rapid (e.g., 30-, 50-, or 100-Hz) delivery of electrical stimuli • 50-Hz stimulation given for 5 seconds • Normal neuromuscular transmission and a pure depolarizing block: the response is sustained • Nondepolarizing block and a phase II block after injection of succinylcholine: the response will not be sustained

  17. Disadvantages: very painful may produce a lasting antagonism of neuromuscular blockade in the stimulated muscle

  18. Double- burst stimulation (DBS) • two short bursts of 50-Hz tetanic stimulation separated by 750 msec, duration of each square wave impulse in the burst is 0.2 msec • most commonly used: DBS3,3 • Nonparalyzed muscle: the response is two short muscle contractions of equal strength • Partly paralyzed muscle: the second response is weaker than the first (i.e., the response fades)

  19. allowing manual (tactile) detection of small amounts of residual blockade under clinical conditions • during recovery and immediately after surgery: superior to tactile evaluation of the response to TOF stimulation

  20. What is “Fast Track Cardiac Anesthesia” • Early tracheal extubation ( within 1~8 hrs) and decreased length of ICU and hospital stay with subsequent cost reduction and to limit the risk of ventilator-induced complications • Short-acting hypnotic drugs • Reduced doses of opioids, or the use of ultrashort-acting opioids

  21. The choice of muscle relaxant— Hofmann elimination: spontaneous degradation in plasma and tissue at normal body pH and temperature

  22. Methods to reduce the risk of residual neuromuscular blockade • the use of intermediate-acting NMBDs • intra-op and post-op neuromuscular monitoring • routine examinations for clinical signs of muscle weakness before extubation • pharmacological reversal whenever pancuronium is used • shorter-acting muscle relaxants: improvements in neuromuscular recovery and fewer signs and symptoms of muscle weakness Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium Anesthesia & Analgesia. 96(5):1301-7

  23. A different opinion…. • Residual paralysis is common after cardiac surgery, and requires continuous postoperative sedation • if anesthetic depth is well maintained throughout surgery, there is no need for continuous neuromuscular blockade • in fast-track cardiac surgery, it seems unnecessary to maintain paralysis by repetitive bolus injection or continuous infusion of neuromuscular blockers Is muscle relaxant necessary for cardiac surgery Anesthesia & Analgesia. 99(5):1330-3

  24. Intrahospital Transport of Critically Ill Patients • Pretransport Coordination and Communication • Accompanying Personnel • Accompanying Equipment • Monitoring During Transport Guidelines for the inter- and intrahospital transport of critically illpatients Crit Care Med 2004 Vol. 32, No. 1

  25. Pretransport Coordination and Communication • Continuity of patient care by communication to review patient condition and the treatment plan in operation • Receiving location confirms: timing of the transport & equipment support • Documentation: indications for transport patient status throughout the time away from the unit of origin

  26. Accompanying Personnel • A minimum of two people should accompany a critically ill patient • A physician with training in airway management and ACLS, and critical care training or equivalent, accompany unstable patients

  27. Accompanying Equipment • Blood pressure monitor • Pulse oximeter • Cardiac monitor/defibrillator • A memory-capable monitor • Oxygen source of ample supply to provide for projected needs plus a 30-min reserve (1 atm = 15 PSI)

  28. Oxygen concentration: for neonates and for those patients with congenital heart disease who have single ventricle physiology or are dependent on a right-to-left shunt to maintain systemic blood flow • Basic resuscitation drugs • Supplemental medications, such as sedatives and narcotic analgesics,

  29. Monitoring During Transport • Electrocardiographic monitoring • Continuous pulse oximetry • Periodic measurement of BP, pulse rate, and respiratory rate

  30. Special Recommendation of Cardiac Surgery Patient • NTG infusion: for p’t with LIMA graft (reduce vasospasm risk) • Low-dose dopamine infusion: at least the first 24 hours post-operatively, irrespective of a good BP or diuresis. Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong

  31. Thanks for Your Attention!!

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