CARE OF THE PATIENT ON A NEUROMUSCULAR BLOCKING AGENT
STANDARDS OF NURSING CARE IN CCTC (SONC)

1. Safety
2. TOF Monitoring
3. Sedation and Analgesia
4. Neurological Monitoring

5. Temperature Monitoring
6. Corneal Protection
7. Joint/Limb Protection
8. Pulmonary Care
9. DVT Prevention
   

STANDARD OF NURSING CARE

 1.

Safety Monitoring

Ensure patient is fully ventilated on a controlled rate of breathing (not on Pressure Support) before administration of a Neuromuscular Blocker (NMB).

Ensure ECG, oxygen saturation and arterial pressure alarms are on with appropriate alarm settings.

Monitor and document vital signs q1h and prn.

1.

Patients on neuromuscular blocking agents are unable to breathe or move and are dependent on mechanical ventilation.

 2.

TOF Monitoring

Connect Peripheral Nerve Stimulator and measure baseline Train of Four (TOF) prior to initiation of initial dose of NMB, whenever possible. Place two ECG electrodes along ulnar nerve (baby finger side of palmer surface of wrist) and assess for thumb twitch. Facial nerve can be tested if no ulnar response.

Assess TOF q 1 h following initiation of drug. The goal is 2-3 twitches out of 4 stimulations (2-3/4) and adequate control of ventilation. Bolus or adjust infusion to maintain these goals.

If ventilation and/or metabolic rate is adequately controlled and the TOF is 4/4, do not increase the drug dose. Conversely, if the patient is breathing above the ventilator and the TOF is 0/4, titrate the drug to achieve ventilation goals.

Risk for critical illness polyneuropathy or myopathy increases when NMBs are used in conjunction with steroids or aminioglycocides.

 2.

Critically ill patients may not respond to peripheral nerve stimulation for a variety of reasons. Baseline testing helps to differentiate the cause for any subsequent decrease in responsiveness to TOF (e.g., differentiate whether 0/4 is due to excessive drug dosing or pre-existing problem).

Although TOF provides a guideline for drug dosing, it does not always correlate to drug effect. If the patient is breathing above the ventilator with a TOF of 0/4, the peripheral nerve stimulator is likely underdetecting the true response and drug effect.

 3.

Sedation and Analgesia

Maintain continuous sedation and analgesia.

Continue to explain all procedures to the patient.

 3.

NMBs produce temporary paralysis without any analgesic or sedative effect. It should be assumed that the patient is awake and alert; analgesics and sedatives should be given accordingly.

Lacrimation, hypertension and tachycardia may be a sign of awareness/awakefullness.

 4.

Neurological Monitoring

Assess pupil size and reactivity q1-4h. Do not assess for responsiveness to pain, or perform cold caloric testing (oculovestibular reflex).

Note: NMB agents will mask seizures by paralysis of muscle activity but do not prevent seizures from happening.

 4.

Pupils reactivity is preserved with NMBs and provides the only method for neurological assessment. Eye movement is paralyzed with NMBs, blocking the oculovestibular response. Patients could potential experience discomfort/nausea despite an inability to respond. Motor function is paralyzed but pain is sensation preserved.

Temperature Monitoring

Monitor temperature q1h. Assess core temperature (rectal, pulmonary artery, bladder or esophageal) if oral temperature is <36 or if a cooling blanket is in use.

NMBs paralyze muscle activity and decrease heat production. They may be used to control metabolic rate, prevent shivering and/or facilitate hypothermia.

When used for other purposes, hypothermia may develop as a result of decreased heat production and inability to shiver. The use of a cooling blanket increases the potential for rapid and precipitous temperature drop.

Provide Corneal Protection

Obtain order for eye lubricant q 2 h and prn. Keep eyelids closed at all times. Lubricating ointments (e.g., lacrilube) may be sufficient to keep eyelids closed and corneas moist.

If eyes must be patched to maintain a closed position, caution is required to ensure the lids remain closed at all times under any patch.

Blink reflex is paralyzed and lacrimation blocked.. If eyelids are open or partially open,

If eyes should open under a patch, the dry gauze would come in contact with the cornea, causing further injury.

 7.

Protect Against Joint/Limb Injury

Maintain careful alignment of joints and spine. Use spinal precautions during turning. Use pillows to maintain lateral neck alignment and hip abduction during repositioning.

Passive range of motion should be provided by a physiotherapist only.

If NMB is required during skeletal traction, notify ortho/trauma. Traction weight should be reduced during paralysis.

 7.

Paralysis decreases joint and limb protection and increases risk for joint dislocation or spinal trauma.

The lack of muscle resistance increases risk to conduct range of motion beyond normal range.

 8.

Pulmonary Care

Provide oral care per procedure q 2 h and prn and keep HOB elevated > 30 degrees as tolerated.

Suction a minimum of q6h using an assisted cough technique. If abdominal surgery/contraindication to diaphragm pressure, provide assisted cough through rib cage support. Please refer to the Interdisciplinary Suctioning Guidelines

 8.

Paralysis of swallowing and gag reflex increases collection of oral secretions and risk for aspiration.

Paralysis of the diaphragm suppresses the cough reflex and ability to clear secretions.

 9.

DVT Prophylaxis

Maintain DVT prophylaxis with TED/SCDs and/or prophylactic anticoagulant therapy.

Suction a minimum of q6h using an assisted cough technique. If abdominal surgery/contraindication to diaphragm pressure, provide assisted cough through rib cage support.

 9.

Paralysis of leg muscles, vasodilating nature of drug and patient immobility decreases venous return and increase risk for thrombosis.