Monitoring ICU Paralytics and Patient Care

All right you guys welcome back to another video lesson from ICU Advantage. In our lesson here today we're going to continue our discussion that we've been having on our ICU drips and specifically here our paralytics. And we're going to continue this discussion with a pretty short lesson in which we're going to be talking about the different monitoring that we do for these patients and the care that we want to provide for these patients. So make sure that you guys keep watching in order to get all of this great info that we have for you. And before we get too far in here, if this is your first time here to our channel and watching one of our videos, and you'd really be interested in more of these critical care educational content topics such as this one here, then I do invite you guys to subscribe to our channel below. When you do, head down, hit that bell icon, and make sure and select all notifications. That way you won't miss out as soon as a new lesson becomes available. As always, a special shout-out to all of our awesome subscribers who continue to come back here, watching our videos, liking our videos, and leaving us awesome comments. We really appreciate you guys, and I do want to thank you. Also, make sure you head over to Facebook. Instagram and Twitter and make sure and follow us over there. And for those of you who don't know me, my name is Eddie Watson and this is ICU Advantage. All right, so let's go ahead and get into our lesson here. Like I said, this is going to be a pretty short one. The last two lessons, the first one we went through did a really good overview of the anatomy and physiology and how it is that our paralytics actually work. And then in our second lesson, we went through and did a breakdown of... All the different paralytics that are available to us talked about some of the key differences between those, as well as which ones you would expect to find in a continuous infusion. And if you haven't watched those lessons already, I'm going to link to them up above as well as down in the show notes. But let's go ahead and get into this lesson here. Like I said, we're going to be talking about the monitoring that we want to do for these patients as well as some of the care we need to make sure and provide to them. So the first and foremost thing that I want to mention is with... With paralytics, as well as a lot of these medications that we talk about, we want to make sure that we're providing the least amount of the drug that we need in order to achieve the effect that we're looking to achieve. And really, the whole reason for this is when we discontinue these medications, we want our patient's recovery to be as quick as possible. And so in order to be able to do this, we have to have some way to monitor the amount of paralysis that we're achieving in our patients with these medications. And the way that we typically do this is something that we call the peripheral nerve stimulation. And the most common way that we do this is through something that we call the train of four. And essentially what this is doing is we're going to provide four quick electrical signals to our patient, usually about a half a second apart. And then based on the proper placement of these electrodes. we would expect to see some sort of muscle twitching. Now, in order to see this muscle twitching, we have to make sure we have these electrodes in the proper place. And so a couple of the common sites that we use are going to be the ulnar nerve, which is going to be located on the ulnar side of the wrist. And by stimulating this nerve, we're going to see the patient adduct their thumb and flex their fingers. Now, we also can use the patient's facial nerve. And this is going to be just outside of the outer part of the eye. And by stimulating this nerve, what we're looking for is a closed eyelid or furrowed brow. And then finally, we can use the posterior tibial nerve. And if we use this one, we're looking for flexing of the big toe. Usually the two most common ones are going to be either the ulnar or the facial nerve. So like I said, in order to have this effect, we're going to send four pretty quick electrical impulses and look for that muscle twitching. Now based on the number of twitches you see out of the four signals that we give, this will give us an indication of how much blockage we have going on. So to kind of give you an idea and put this in perspective, let me break it down for you and really show you for so many twitches that you see. What does this actually equate to in terms of our blockage? So now out of the four signals that we send, if we only see one twitch, that tells us that we're probably blocking about 90% of our patient's receptors. If you only see two of the four twitches, then this tells us that we have probably around 80% of those receptors blocked. But even if you see three of the four twitches, this still is going to tell us that we're probably about 75% blocked for our patient. Obviously, if you see four of the twitches, that's going to be hard to kind of quantify how much we have blocked because it could be anywhere from just under 75% to really not blocking any and you should see four twitches. So when you have a patient that's on this medication, you're going to want to have a goal set for how many twitches you should be seeing to give you an idea of how much blockage that we want. Obviously, this goal is going to be dependent on the reason that we're having to paralyze this patient in the first place. But generally, for most critically ill patients, we're shooting for a goal of either 2 or 3. Now, one of the most common mistakes that comes up with using paralytics and getting the train of 4 is sometimes we're in that rush to get everything going. Our patient's pretty sick. We want to get all this stuff happening as quickly as we can. And then we just forget to get an initial train of 4. And this is really a vital step because One, you want to confirm that you have your electrodes in the proper place, but you also want to slowly increase the voltage in order to find the sweet spot to be able to get the effect that we're looking for without having to apply too much electricity. Because if you haven't tested this out on yourself, and you're anything like me and you really don't like getting shocked, it's really not a comfortable feeling, especially as you start to crank some of those voltages up higher. So really important before you guys start the paralytic, make sure you guys get a baseline train of four. Now to kind of add to this, if your patients are on this medication either for extended periods of time or if they've just built up a decent amount of edema, that this can really reduce the effect of the stimulation that we're giving them. And so what this means is that you may need to actually increase the output on it over time if you start to see... decreasing or diminishing twitching, but you really haven't made any changes to your medication, especially for those patients that have kind of been cruising with a good twitch at a good set rate, achieving the therapeutic goal that you want from the medication. And so now you guys hopefully have an understanding of how we objectively, quantifiably assess how much paralytic our patients need. So now when it comes to the care of these patients, one of the biggest concerns that we have, especially if these patients are on these medications for a period of time, is going to be muscle weakness. And so it is important to know that as we turn these medications off and the patients begin to recover, we're actually going to see that their larger muscles are going to recover quicker than their smaller muscles. And so some of the things that we want to do to really kind of test and make sure that... our patients are coming back from this medication without any issue, is we want to check things like a sustained head lift or leg lift, opening their eyes, a strong hand squeeze, see if they can stick out their tongue, do they have purposeful movements in what they do, do they have a strong cough, are they able to maintain a sustained strong bite, and do they have an ability to swallow? All of these things are going to be good indicators to really show you that those smaller muscles are recovering as we would expect to see for our patient. But again, as I had mentioned, patients who are on prolonged infusions can really expect to see prolonged weakness as a result. And so one of the big concerns that we get for with this is one of the side effects can be myopathy and really disuse atrophy. So it's going to be vital that we're checking this stuff in our patients, especially those who've been on these infusions for a long period of time, as well as patients who are on concurrent steroids, that we have noticed that this can also contribute to this myopathy. and this disuse atrophy. So really make sure that you guys are checking this stuff and that you're checking it thoroughly because we want to have a really good assessment of how they're coming back off of the paralytics. Now another thing to really keep in mind with these patients, like I had talked about in the previous lesson, none of these paralytics do anything for analgesia, amnesia, sedation. The only effect they have is on the paralytic effect. And so one thing that's absolutely necessary with these patients is we must sedate them when we're using these drugs. So it's absolutely essential that we're doing this for our patients because it can be quite terrifying if you really think about if you're not sedated but completely paralyzed and not having any ability to move or communicate or have any idea of what's going on. And so really for these patients, we want to make sure that we have deep sedation going on. And one of the best ways that we've found to really be able to do this at the bedside for these ICU patients is through the use of a monitor like the biz monitor. But if you don't have that available to you, then you just really want to be using high levels of sedation medication with the goal of ensuring that these patients are deeply sedated. So please definitely don't disregard the fact that your patient is laying there. not moving, they seem calm and totally fine, they're paralyzed. So we don't have any way to truly assess the sedation that's going on without the use of some extra device. So in cases like these, we really should be erring on the side of caution to ensure that we're not creating a horrific experience for our patients. All right, so two last things that I just want to mention here real quick that are important to keep in mind when we have our patients paralyzed. And the first is that we really want to be using some sort of prophylactic eye care or eye ointment. And so again, these patients are not able to move, so they're not able to blink and refresh in their eyes. So we're typically going to be giving them this ointment to ensure that their eyes stay moist and to really help to prevent corneal abrasions. And then the last thing that I want to mention to you guys is one very interesting thing of these medications. Obviously, they don't have any kind of effect on our cardiac muscle because clearly we can paralyze our patients and we don't end up killing them. But in addition to that, generally the muscles in our pupils are not going to be affected by these medications either. And so what this means is you can still check for pupillary reaction in your patients. All right, so that's going to finish this lesson here talking about paralytics. If you found this lesson useful, please leave us a like down below. As well as if we earned your trust with this video, feel free to subscribe to our channel below. Make sure and keep an eye out for the next lesson in this series, or feel free to check out another one of our awesome videos right here. As always, thank you guys so much for watching, and just have a great day!

So make sure that you guys keep watching in order to get all of this great info that we have for you. And before we get too far in here, if this is your first time here to our channel and watching one of our videos, and you'd really be interested in more of these critical care educational content topics such as this one here, then I do invite you guys to subscribe to our channel below. When you do, head down, hit that bell icon, and make sure and select all notifications. That way you won't miss out as soon as a new lesson becomes available.

As always, a special shout-out to all of our awesome subscribers who continue to come back here, watching our videos, liking our videos, and leaving us awesome comments. We really appreciate you guys, and I do want to thank you. Also, make sure you head over to Facebook.

Instagram and Twitter and make sure and follow us over there. And for those of you who don't know me, my name is Eddie Watson and this is ICU Advantage. All right, so let's go ahead and get into our lesson here. Like I said, this is going to be a pretty short one.

The last two lessons, the first one we went through did a really good overview of the anatomy and physiology and how it is that our paralytics actually work. And then in our second lesson, we went through and did a breakdown of... All the different paralytics that are available to us talked about some of the key differences between those, as well as which ones you would expect to find in a continuous infusion. And if you haven't watched those lessons already, I'm going to link to them up above as well as down in the show notes.

But let's go ahead and get into this lesson here. Like I said, we're going to be talking about the monitoring that we want to do for these patients as well as some of the care we need to make sure and provide to them. So the first and foremost thing that I want to mention is with...

With paralytics, as well as a lot of these medications that we talk about, we want to make sure that we're providing the least amount of the drug that we need in order to achieve the effect that we're looking to achieve. And really, the whole reason for this is when we discontinue these medications, we want our patient's recovery to be as quick as possible. And so in order to be able to do this, we have to have some way to monitor the amount of paralysis that we're achieving in our patients with these medications. And the way that we typically do this is something that we call the peripheral nerve stimulation. And the most common way that we do this is through something that we call the train of four.

And essentially what this is doing is we're going to provide four quick electrical signals to our patient, usually about a half a second apart. And then based on the proper placement of these electrodes. we would expect to see some sort of muscle twitching.

Now, in order to see this muscle twitching, we have to make sure we have these electrodes in the proper place. And so a couple of the common sites that we use are going to be the ulnar nerve, which is going to be located on the ulnar side of the wrist. And by stimulating this nerve, we're going to see the patient adduct their thumb and flex their fingers. Now, we also can use the patient's facial nerve. And this is going to be just outside of the outer part of the eye.

And by stimulating this nerve, what we're looking for is a closed eyelid or furrowed brow. And then finally, we can use the posterior tibial nerve. And if we use this one, we're looking for flexing of the big toe. Usually the two most common ones are going to be either the ulnar or the facial nerve. So like I said, in order to have this effect, we're going to send four pretty quick electrical impulses and look for that muscle twitching.

Now based on the number of twitches you see out of the four signals that we give, this will give us an indication of how much blockage we have going on. So to kind of give you an idea and put this in perspective, let me break it down for you and really show you for so many twitches that you see. What does this actually equate to in terms of our blockage?

So now out of the four signals that we send, if we only see one twitch, that tells us that we're probably blocking about 90% of our patient's receptors. If you only see two of the four twitches, then this tells us that we have probably around 80% of those receptors blocked. But even if you see three of the four twitches, this still is going to tell us that we're probably about 75% blocked for our patient.

Obviously, if you see four of the twitches, that's going to be hard to kind of quantify how much we have blocked because it could be anywhere from just under 75% to really not blocking any and you should see four twitches. So when you have a patient that's on this medication, you're going to want to have a goal set for how many twitches you should be seeing to give you an idea of how much blockage that we want. Obviously, this goal is going to be dependent on the reason that we're having to paralyze this patient in the first place.

But generally, for most critically ill patients, we're shooting for a goal of either 2 or 3. Now, one of the most common mistakes that comes up with using paralytics and getting the train of 4 is sometimes we're in that rush to get everything going. Our patient's pretty sick. We want to get all this stuff happening as quickly as we can. And then we just forget to get an initial train of 4. And this is really a vital step because One, you want to confirm that you have your electrodes in the proper place, but you also want to slowly increase the voltage in order to find the sweet spot to be able to get the effect that we're looking for without having to apply too much electricity. Because if you haven't tested this out on yourself, and you're anything like me and you really don't like getting shocked, it's really not a comfortable feeling, especially as you start to crank some of those voltages up higher.

So really important before you guys start the paralytic, make sure you guys get a baseline train of four. Now to kind of add to this, if your patients are on this medication either for extended periods of time or if they've just built up a decent amount of edema, that this can really reduce the effect of the stimulation that we're giving them. And so what this means is that you may need to actually increase the output on it over time if you start to see...

decreasing or diminishing twitching, but you really haven't made any changes to your medication, especially for those patients that have kind of been cruising with a good twitch at a good set rate, achieving the therapeutic goal that you want from the medication. And so now you guys hopefully have an understanding of how we objectively, quantifiably assess how much paralytic our patients need. So now when it comes to the care of these patients, one of the biggest concerns that we have, especially if these patients are on these medications for a period of time, is going to be muscle weakness.

And so it is important to know that as we turn these medications off and the patients begin to recover, we're actually going to see that their larger muscles are going to recover quicker than their smaller muscles. And so some of the things that we want to do to really kind of test and make sure that... our patients are coming back from this medication without any issue, is we want to check things like a sustained head lift or leg lift, opening their eyes, a strong hand squeeze, see if they can stick out their tongue, do they have purposeful movements in what they do, do they have a strong cough, are they able to maintain a sustained strong bite, and do they have an ability to swallow?

All of these things are going to be good indicators to really show you that those smaller muscles are recovering as we would expect to see for our patient. But again, as I had mentioned, patients who are on prolonged infusions can really expect to see prolonged weakness as a result. And so one of the big concerns that we get for with this is one of the side effects can be myopathy and really disuse atrophy. So it's going to be vital that we're checking this stuff in our patients, especially those who've been on these infusions for a long period of time, as well as patients who are on concurrent steroids, that we have noticed that this can also contribute to this myopathy. and this disuse atrophy.

So really make sure that you guys are checking this stuff and that you're checking it thoroughly because we want to have a really good assessment of how they're coming back off of the paralytics. Now another thing to really keep in mind with these patients, like I had talked about in the previous lesson, none of these paralytics do anything for analgesia, amnesia, sedation. The only effect they have is on the paralytic effect. And so one thing that's absolutely necessary with these patients is we must sedate them when we're using these drugs.

So it's absolutely essential that we're doing this for our patients because it can be quite terrifying if you really think about if you're not sedated but completely paralyzed and not having any ability to move or communicate or have any idea of what's going on. And so really for these patients, we want to make sure that we have deep sedation going on. And one of the best ways that we've found to really be able to do this at the bedside for these ICU patients is through the use of a monitor like the biz monitor. But if you don't have that available to you, then you just really want to be using high levels of sedation medication with the goal of ensuring that these patients are deeply sedated.

So please definitely don't disregard the fact that your patient is laying there. not moving, they seem calm and totally fine, they're paralyzed. So we don't have any way to truly assess the sedation that's going on without the use of some extra device. So in cases like these, we really should be erring on the side of caution to ensure that we're not creating a horrific experience for our patients.

All right, so two last things that I just want to mention here real quick that are important to keep in mind when we have our patients paralyzed. And the first is that we really want to be using some sort of prophylactic eye care or eye ointment. And so again, these patients are not able to move, so they're not able to blink and refresh in their eyes.

So we're typically going to be giving them this ointment to ensure that their eyes stay moist and to really help to prevent corneal abrasions. And then the last thing that I want to mention to you guys is one very interesting thing of these medications. Obviously, they don't have any kind of effect on our cardiac muscle because clearly we can paralyze our patients and we don't end up killing them.

But in addition to that, generally the muscles in our pupils are not going to be affected by these medications either. And so what this means is you can still check for pupillary reaction in your patients. All right, so that's going to finish this lesson here talking about paralytics. If you found this lesson useful, please leave us a like down below. As well as if we earned your trust with this video, feel free to subscribe to our channel below.

Make sure and keep an eye out for the next lesson in this series, or feel free to check out another one of our awesome videos right here. As always, thank you guys so much for watching, and just have a great day!

Transcript for:Monitoring ICU Paralytics and Patient Care

Transcript for:
Monitoring ICU Paralytics and Patient Care