during COVID19 surge Critical Care Department Cooper University Health Care April 2020 Background Patients with COVID19 may progress to ARDS requiring use of NMB to manage oxygenation and ventilator ID: 911594
Download Presentation The PPT/PDF document "Protocol for use of continuous neuromusc..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Protocol for use of continuous neuromuscular blockade (NMB)during COVID-19 surge
Critical Care Department
Cooper University Health Care
April 2020
Slide2Background
Patients with COVID-19 may progress to ARDS, requiring use of NMB to manage oxygenation and ventilator
dyssynchrony
During COVID-19 surge,
bispectral
index (BIS) monitor may not be available to monitor level of sedation for all patients who require NMB therapy
Slide3Indications for NMB
Severe ARDS with ongoing hypoxia due to ventilator
dyssynchrony
Severe status
asthmaticus
with ventilator
dyssynchrony
Shivering preventing achievement of targeted temperature management
Surgical request (e.g. open abdomen, returning to OR)
Slide4Contraindications for NMB
Any condition requiring accurate neurologic monitoring, neurological status is the primary concern, and neurological changes would prompt emergent intervention
Inability to achieve or contraindication to deep sedation
Brain-death testing
(absolute)
End-of-life care, comfort care, or compassionate
extubation
(absolute)
Cardiogenic hemodynamic instability
(relative)
High dose steroids
(relative
)
Slide5Protocol
Titrate sedation, using established protocols and multimodal
analgosedation
, to achieve a RASS of -5. Aim to use the minimum amount of medications to achieve a RASS of -5 and NVPS <3.
Once the minimal rates of continuous infusions of
analgosedation
are established to achieve RASS of -5/ NVPS <3, change the orders in EPIC to
non-
titratable
. This includes eliminating the titration parameters in the administration instructions and the dose range within the EPIC orders.
Initiate neuromuscular blockade agent (NMBA) per protocol.
Titrate NMBA to desired peripheral nerve stimulation via train of four (TOF), as well as elimination of
overbreathing
the respiratory rate set on the ventilator.
When
used for shivering, NMBAs should titrate to BSAS of
0
Slide6Protocol, continued
Treating
physicians should reassess
need
for continued NMB daily during interdisciplinary rounds. If there is no clear contraindication, a “paralytic vacation” should be trialed to assess the
following:
The
need for the continuous infusion the
NMBA
To
allow titration of
analgosedation
to goal RASS -5/ NVPS <3, as patient needs may have changed due to
tachyphylaxis
Perform
a neurologic
examination
Slide7Protocol, continued
If
the patient triggers the ventilator, titrate
analgosedation
to attempt achievement of ventilator synchrony through deep sedation without NMB.
If unable to achieve synchrony, or decompensation occurs, notify the treating physician.
Analgosedation
should be titrated to RASS -5/ NVPS <3 prior to
reinitiation
of NMB (starting with bolus) per
orderset
.
Analgosedation
orders should be updated to be
non-
titratable
.
For ANY adjustments to
analgosedation
the patient must be able to be assessed using RASS/NVPS and thus not be paralyzed.
Exception
: bolus analgesics and/or sedatives should be used for expected painful and/or stimulating procedures (central lines, wound dressing changes,
proning
/ supinating
etc
)
Slide8Clinical Checklist Items
Reassess daily for need for continued NMB (and document in note)
VTE chemical and mechanical prophylaxis
Passive range of motion exercises BID ± PT consult
Serum glucose <180 mg/
dL
NO
sedation vacations or SBT while paralyzed (absolute contraindication)
Lubricating eye drops at least
twice daily
Slide9Patient Care Recommendations
DO
continue to talk to patients as if they were responsive, explain any and all procedures that are going to be done
DO
use local anesthetic for painful procedures (central lines, LP, chest tubes, para/thoracentesis,
etc
)
DO
consider bolus dose analgesia/ sedation before procedures.
Use
continuous infusions of sedative(s) capable of achieving deep sedation such as
propofol
or
midazolam
Dexmedetomidine
does NOT have a role in achieving deep
sedation
Avoid prolonged infusions of NMBAs (>48 hours) if possible
Avoid concomitant
steroids
Steroids increase the risk of critical illness myopathy, neuropathy and
VAP
Slide10Key Learning Points
If BIS is available, use standard protocol, however BIS should be prioritized on patients on ECMO.
Without BIS, do NOT attempt to titrate
sedation while on NMBA.
Change orders in EPIC to reflect that sedation/ analgesia drips are non-
titratable
. Boluses are still ok.
Do daily checks off
NMBA (
if safe to do so) to see if
NMB is
still needed and to see if
sedation
/ analgesia
needs to be titrated up or down.
9