CARE OF THE PATIENT ON A NEUROMUSCULAR BLOCKING AGENT
( for the benefit of all junior doctors & nurses )
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.
REASON Patients on neuromuscular blocking agents are unable to breathe or move and are dependent on mechanical ventilation.
Sedation and Analgesia
Maintain continuous sedation and analgesia.
REASON 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.
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.
REASON 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.
REASON 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 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.
REASON 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.
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. Traction weight should be reduced during paralysis.
REASON 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.
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.
REASON 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.
DVT Prophylaxis
Maintain DVT prophylaxis with TED/SCDs and/or prophylactic anticoagulant therapy.
REASON Paralysis of leg muscles, vasodilating nature of drug and patient immobility decreases venous return and increase risk for thrombosis.
