Protocol for use of continuous neuromuscular blockade (NMB) - PowerPoint Presentation

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Protocol for use of continuous neuromuscular blockade (NMB)during COVID-19 surge

Critical Care Department

Cooper University Health Care

April 2020

Background

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

Indications 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)

Contraindications 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

)

Protocol

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

Protocol, 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

Protocol, 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

)

Clinical 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

Patient 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

Key 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.

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