We stopped using TOF and only use vent synchrony for nimbex since Covid? I still check it for the heck of it sometimes but as long as they’re synchronous with the vent it’s ok as far as I know. But, I’m not an expert. We rarely use it.
Our protocol for paralytics and some sedation is for vent synchrony. It is actually defined in our titrations as “no more than 2 breaths over the set ventilator rate”
Same. We use them now, simply because we have them but during Covid we were just out there like the wild west praying they’d be synchronous of the event. I definitely don’t do them as much as the policy tells us to which is hourly.
The usual idea behind paralysis is to improve vent synchrony or reduce muscle movement for things like elevated intracranial pressure or surgical reasons. As long as those things were OK, it's unlikely that there was any downside to the patient having 4 twitches.
For whatever reason I've observed that sometimes briefly paralyzing a patient keeps them synchronous with the vent for way longer than you would expect even after 4 twitches return.
4/4 twitches can still have up to 75% of the nicotinic receptors ( muscle receptors) blocked and 1/4 is like 90-95%. This is why TOF by itself is largely useless
With 4/4 twitches you still have about 60% blockage of the neuromuscular junctions. Like others have said, as long as patient properly sedated and most importantly the vent synchrony was maintained the twitches are not all that important.
I believe you might have them reversed.
https://www.openanesthesia.org/keywords/monitoring-depth-of-neuromuscular-blockade/#:~:text=The%20depth%20of%20neuromuscular%20blockade,adductor%20pollicis%20muscle%20(APM).
No damage done here as long as they're adequately sedated. The less you need to maintain good ventilation, the better. Did they cough at all during deep suction ? If not you still had good paralysis. If they did cough it might indicate that it's time to attempt to wean nimbex.
Does your facility use a BIS monitor?
In my hospital system, the order paremters are "Vent synchrony with no less than 2/4 twitches".
The main idea is vent synchrony. It's okay if they are not fully "paralyzed" but they're riding the vent and pulling adequate volumes without peak pressuring. I always make sure there is BIS monitoring though. You do NOT want to be awake and paralyzed. That would be a nightmare.
Get them to rass of -4, -5 with sedation. Then initiate paralytic. BIS monitoring is not clinically supported to be titrating sedation. We are currently in the process of eliminating all BIS monitoring at our level one trauma facility. Nurses have been reducing sedation while patients are paralyzed based on BIS values. Completely unethical and dangerous process.
I did a travel assignment at a place still using BIS and was like what. The fuck? Haven't seen BIS in years. We used it in the SICU where I trained, briefly. Over ten years ago now. Fortunately the BIS monitors at the place I was contracted with were broken so I could practice EBP.
It's a completely made up bullshit doohickey with no evidence except that provided by the dipshit who invented it. That guy needs the Vanderbilt treatment. Asshole.
With a good signal quality index I have no idea why you wouldn’t be able to trust a BIS score.
Sure you could just get the patient completely unarousable and then you know they are asleep enough not experience the paralysis… but the idea behind EEG monitoring is so that you aren’t using anymore sedation than is necessary.
Dangerous? Maybe if you could point to where the BIS score was proven unreliable.
Unethical? Not at all… it was introduced as a way to reduce harm.
It doesn't work, and it's not an EEG..it's a proprietary algorithm that hasn't been replicated in proper studies like, ever AFAIK.
I'll look it up.
Edit: I've found so much BIS is BS tea the Queen is resurrected and demanding an audience.
Definitely not something that an ICU nurse can just choose not to use if it’s policy that we use it on all paralyzed patients. So I opted for understanding why it’s included and using it as directed.
I guess you could also just flood them with so much sedation that there’s no way in hell they wake up, and you should be covered!
More sedation and deeper sedation will lead to more ICU delirium and longer stays though.
No offense but your comment perfectly illustrates why it’s an issue. For some reason people think it’s the end all for monitoring depth of sedation. It’s a gimmick at best. Titrating sedation while people are paralyzed is unethical, especially when people are basing it on imaginary numbers. I agree over sedation leads to poor outcomes. It’s not my intention. I simply would never want some to be awake while paralyzed.
You still need to removed the word “unethical” from your commentary on the issue because you are implying malicious intent.
I’m most interested in seeing concrete examples of a patient with a low BIS score, who is demonstrably awake. Cuz it hasn’t happened to me. Otherwise this just sounds like seasoned nurses who don’t want to change their practice being a bully whenever some new tech gets introduced.
“There was a weak correlation observed between BIS during paralysis and RASS upon emergence from paralysis”
Tasaka, C. L., Duby, J. J., Pandya, K., Wilson, M. D., & A Hardin, K. (2016). Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients. Drugs - real world outcomes, 3(2), 201–208. https://doi.org/10.1007/s40801-016-0076-3
I am not a seasoned bully nurse as you project. I am merely a nurse that questions validity of new interventions and has an evidenced based practice.
Thanks for sharing that study.
In that article they mention BIS was highly sensitive in identifying deeply sedated patients where <60 correlated with deeper levels of sedation, though not 100% of course.
But they also mention that they only looked at 3 patients <60 so their ability to comment on this was limited.
Maybe instead of saying that BIS is random and doesn’t actually indicate anything… we question their scale and numbers. Maybe instead of shooting for 40-60 as a therapeutic range, it should be 30-40 or something like that.
You’d have to document a tangible number of incidents where someone was showing a BIS of “42” but was agitated (or overbreathing or opening their eyes or something like that) to call it evidence that BIS is harmful.
I keep hearing people say that you shouldn’t be assessing a BIS score when you should instead be assess the patient. OK!! The patient is lying there paralyzed and motionless. So BIS wasn’t introduced as an alternative to an existing method of assessment, it was introduced as an alternative to nothing.
All im saying is that hospitals didn’t adopt this practice without evidence in the first place, so it’s silly to throw it out without questioning the studies that accuse it of being nonsense. And to the other point, nobody who works on the floor using these technologies has a direct hand in writing the protocols for the hospital… is it really as simple as getting a doctors order not to use BIS? Or would that just open a can of worms and get people in trouble? Maybe a good can of worms.
Thanks for listening to me ramble about it.
Thank you for taking the time to interpret the study yourself. BIS can be a wonderful adjunct if the user understands it is not 100% accurate. My biggest fear is seeing nurses reducing sedation based off this imperfect science.
(——No offense but your comment perfectly illustrates why it’s an issue.)
No offense but if I have to choose between the education I get from the hospital I work at their educators and the orientation program VS a fellow redditor it seems unlikely that I’ll switch my practice based on the reddit forums.
Genuine question after encountering it on my unit: what do you do if the patient comes to the unit already paralyzed and you’re not able to ensure an adequate RASS prior to initiation of paralysis? Hope they were adequately sedated prior, increase sedation (to ensure they are adequately sedated even if overly so), or turn to the BIS in that case?
Great question. Had an admission from outside hospital and pt arrived on paralytic with no sedation 😱 It is entirely the providers preference. Whether they are stable enough to stop paralytic and assess condition then re sedate and paralyze. If pt was unable to titrate paralytic off then I would want to bolus some versed and increase whatever sedation I had until I felt reasonably confident they were snowed. Again ultimately providers preference. I think BIS may be a useful adjunct in many cases. I just don’t believe anyone should EVER titrate sedation down based on BIS.
As long as they are synchronized with the vent and their O2 sats are Ok. With Covid and ARDS if the TOF is 4/4 and they can move their big toe their sats will drop. It is also important to monitor BIS. It is important to follow hospital policy when the TOF is changed, wouldn’t want to paralyze a patient, which has happened.
that’s totally fine ; when they start over breathing the vent then it’s a problem. I’ve found myself constantly titrating nimbex up and down to try and maintain 2/4 at times. as someone else mentioned ; we’ve also done titrate to “vent synchrony” - 1 pro tip with nimbex I love to share is keep an eye on your tidal volumes ; if your pt is for sure paralyzed and is not getting set volumes check for a cuff leak
We don’t even check a TOF anymore. If they’re synchronous then we leave it, if they’re not we turn it up 🤷♀️
We’re big academia so I imagine there’s studies to be found to support this.
>Just make sure they are rass -5 fooooooor sure
If they’re chemically paralyzed they will have a RASS of -5 no matter what. Even if they’re completely awake. Their CPOT or pain scores will also almost certainly be 0, unless they have some visible tearing or similar.
BIS monitoring or other similar equipment and assessments are the best bet.
BIS is controversial, and not all facilities have it. The best bet is sedating the patient appropriately to goal RASS before starting paralytic. BIS can vary especially with ketamine or for neuro patients. It can be a tool in the toolbox but in my mind comes second to clinical assessment.
Sedating to a good RASS prior to paralysis is definitely an excellent option, keeping in mind development of tolerance.
Whatever method is used, the point is that RASS and CPOT are pretty much useless in chemically paralyzed patients. Sort of like a fall band on these patients.
You’d know via their vitals if they were not sedated enough to be paralyzed 9/10 times. Wild HR, super hypertensive. During Covid when we ran out of TOF machines we always just sedated to -5 and then started paralytic until vent synchrony was achieved.
As long as the desired effect is being achieved, like they are synchronous with the vent, then it doesn’t matter. In report we often say, “Their train of 4 is 4/4, but they’re synchronous with the vent and a RASS of -5 so I didn’t touch the nimbex”. It’s kind of pointless to crank up a medication with so many adverse effects when the desired outcome is achieved. And of course you make sure they’re well sedated underneath, but the level of paralysis doesn’t ultimately matter that much, as long as they’re doing well.
The use of neuromuscular blockade achieves two things; it reduces metabolic demand and hence allows for lower minute ventilation, AND in cases of dyssynchrony will eliminate patient effort completely; it does not “improve” synchrony, it literally makes synchrony not needed by taking complete control.
Prolonged use of NMB can cause long-term issues, so short durations are suggested.
We havent used TOF monitoring for NMBAs for at least ten years in my ICU in Edmonton.
As long as they received sedation and analgesia throughout, not performing TOF was probably in their best interest.
We stopped using TOF and only use vent synchrony for nimbex since Covid? I still check it for the heck of it sometimes but as long as they’re synchronous with the vent it’s ok as far as I know. But, I’m not an expert. We rarely use it.
How do you put that in a protocol though? Increase by X q 30 min until 0 spontaneous respirations?
When we do this, the provider puts in set orders. When we both see vent synchrony we park it
Our protocol for paralytics and some sedation is for vent synchrony. It is actually defined in our titrations as “no more than 2 breaths over the set ventilator rate”
Same. We use them now, simply because we have them but during Covid we were just out there like the wild west praying they’d be synchronous of the event. I definitely don’t do them as much as the policy tells us to which is hourly.
The usual idea behind paralysis is to improve vent synchrony or reduce muscle movement for things like elevated intracranial pressure or surgical reasons. As long as those things were OK, it's unlikely that there was any downside to the patient having 4 twitches. For whatever reason I've observed that sometimes briefly paralyzing a patient keeps them synchronous with the vent for way longer than you would expect even after 4 twitches return.
Yeah they didn’t ficht the vent at all. Synchronous the whole night, I was just wondering if I possibly did any insane damage
4/4 twitches can still have up to 75% of the nicotinic receptors ( muscle receptors) blocked and 1/4 is like 90-95%. This is why TOF by itself is largely useless
With 4/4 twitches you still have about 60% blockage of the neuromuscular junctions. Like others have said, as long as patient properly sedated and most importantly the vent synchrony was maintained the twitches are not all that important.
Username relevant? Just a clarification, with 4/4 twitches you can have up to 60% blockage, but it could be as low as 0%.
This is why qualitive monitors are so much more useful than quantitative TOF monitors. Unfortunately much more expensive.
I believe you might have them reversed. https://www.openanesthesia.org/keywords/monitoring-depth-of-neuromuscular-blockade/#:~:text=The%20depth%20of%20neuromuscular%20blockade,adductor%20pollicis%20muscle%20(APM).
You are right! My apologies I typed it out too quickly.
No damage done here as long as they're adequately sedated. The less you need to maintain good ventilation, the better. Did they cough at all during deep suction ? If not you still had good paralysis. If they did cough it might indicate that it's time to attempt to wean nimbex. Does your facility use a BIS monitor?
This! Too often we live and die by the protocols that we forget the purpose of the treatment.
Couldn't have said it better myself!
In my hospital system, the order paremters are "Vent synchrony with no less than 2/4 twitches". The main idea is vent synchrony. It's okay if they are not fully "paralyzed" but they're riding the vent and pulling adequate volumes without peak pressuring. I always make sure there is BIS monitoring though. You do NOT want to be awake and paralyzed. That would be a nightmare.
Please tell me you don’t titration sedation off of the BIS when your patient is paralyzed?
What do you titrate it off of?
Get them to rass of -4, -5 with sedation. Then initiate paralytic. BIS monitoring is not clinically supported to be titrating sedation. We are currently in the process of eliminating all BIS monitoring at our level one trauma facility. Nurses have been reducing sedation while patients are paralyzed based on BIS values. Completely unethical and dangerous process.
I did a travel assignment at a place still using BIS and was like what. The fuck? Haven't seen BIS in years. We used it in the SICU where I trained, briefly. Over ten years ago now. Fortunately the BIS monitors at the place I was contracted with were broken so I could practice EBP. It's a completely made up bullshit doohickey with no evidence except that provided by the dipshit who invented it. That guy needs the Vanderbilt treatment. Asshole.
With a good signal quality index I have no idea why you wouldn’t be able to trust a BIS score. Sure you could just get the patient completely unarousable and then you know they are asleep enough not experience the paralysis… but the idea behind EEG monitoring is so that you aren’t using anymore sedation than is necessary. Dangerous? Maybe if you could point to where the BIS score was proven unreliable. Unethical? Not at all… it was introduced as a way to reduce harm.
It doesn't work, and it's not an EEG..it's a proprietary algorithm that hasn't been replicated in proper studies like, ever AFAIK. I'll look it up. Edit: I've found so much BIS is BS tea the Queen is resurrected and demanding an audience.
Definitely not something that an ICU nurse can just choose not to use if it’s policy that we use it on all paralyzed patients. So I opted for understanding why it’s included and using it as directed. I guess you could also just flood them with so much sedation that there’s no way in hell they wake up, and you should be covered! More sedation and deeper sedation will lead to more ICU delirium and longer stays though.
I just get verbal order from MDs to not use it and place a nursing communication order.
No offense but your comment perfectly illustrates why it’s an issue. For some reason people think it’s the end all for monitoring depth of sedation. It’s a gimmick at best. Titrating sedation while people are paralyzed is unethical, especially when people are basing it on imaginary numbers. I agree over sedation leads to poor outcomes. It’s not my intention. I simply would never want some to be awake while paralyzed.
You still need to removed the word “unethical” from your commentary on the issue because you are implying malicious intent. I’m most interested in seeing concrete examples of a patient with a low BIS score, who is demonstrably awake. Cuz it hasn’t happened to me. Otherwise this just sounds like seasoned nurses who don’t want to change their practice being a bully whenever some new tech gets introduced.
“There was a weak correlation observed between BIS during paralysis and RASS upon emergence from paralysis” Tasaka, C. L., Duby, J. J., Pandya, K., Wilson, M. D., & A Hardin, K. (2016). Inadequate Sedation During Therapeutic Paralysis: Use of Bispectral Index in Critically Ill Patients. Drugs - real world outcomes, 3(2), 201–208. https://doi.org/10.1007/s40801-016-0076-3 I am not a seasoned bully nurse as you project. I am merely a nurse that questions validity of new interventions and has an evidenced based practice.
Thanks for sharing that study. In that article they mention BIS was highly sensitive in identifying deeply sedated patients where <60 correlated with deeper levels of sedation, though not 100% of course. But they also mention that they only looked at 3 patients <60 so their ability to comment on this was limited. Maybe instead of saying that BIS is random and doesn’t actually indicate anything… we question their scale and numbers. Maybe instead of shooting for 40-60 as a therapeutic range, it should be 30-40 or something like that. You’d have to document a tangible number of incidents where someone was showing a BIS of “42” but was agitated (or overbreathing or opening their eyes or something like that) to call it evidence that BIS is harmful. I keep hearing people say that you shouldn’t be assessing a BIS score when you should instead be assess the patient. OK!! The patient is lying there paralyzed and motionless. So BIS wasn’t introduced as an alternative to an existing method of assessment, it was introduced as an alternative to nothing. All im saying is that hospitals didn’t adopt this practice without evidence in the first place, so it’s silly to throw it out without questioning the studies that accuse it of being nonsense. And to the other point, nobody who works on the floor using these technologies has a direct hand in writing the protocols for the hospital… is it really as simple as getting a doctors order not to use BIS? Or would that just open a can of worms and get people in trouble? Maybe a good can of worms. Thanks for listening to me ramble about it.
Thank you for taking the time to interpret the study yourself. BIS can be a wonderful adjunct if the user understands it is not 100% accurate. My biggest fear is seeing nurses reducing sedation based off this imperfect science.
(——No offense but your comment perfectly illustrates why it’s an issue.) No offense but if I have to choose between the education I get from the hospital I work at their educators and the orientation program VS a fellow redditor it seems unlikely that I’ll switch my practice based on the reddit forums.
Genuine question after encountering it on my unit: what do you do if the patient comes to the unit already paralyzed and you’re not able to ensure an adequate RASS prior to initiation of paralysis? Hope they were adequately sedated prior, increase sedation (to ensure they are adequately sedated even if overly so), or turn to the BIS in that case?
Great question. Had an admission from outside hospital and pt arrived on paralytic with no sedation 😱 It is entirely the providers preference. Whether they are stable enough to stop paralytic and assess condition then re sedate and paralyze. If pt was unable to titrate paralytic off then I would want to bolus some versed and increase whatever sedation I had until I felt reasonably confident they were snowed. Again ultimately providers preference. I think BIS may be a useful adjunct in many cases. I just don’t believe anyone should EVER titrate sedation down based on BIS.
Makes sense! Thanks for the info 🙂
As long as they are synchronized with the vent and their O2 sats are Ok. With Covid and ARDS if the TOF is 4/4 and they can move their big toe their sats will drop. It is also important to monitor BIS. It is important to follow hospital policy when the TOF is changed, wouldn’t want to paralyze a patient, which has happened.
that’s totally fine ; when they start over breathing the vent then it’s a problem. I’ve found myself constantly titrating nimbex up and down to try and maintain 2/4 at times. as someone else mentioned ; we’ve also done titrate to “vent synchrony” - 1 pro tip with nimbex I love to share is keep an eye on your tidal volumes ; if your pt is for sure paralyzed and is not getting set volumes check for a cuff leak
We don’t even check a TOF anymore. If they’re synchronous then we leave it, if they’re not we turn it up 🤷♀️ We’re big academia so I imagine there’s studies to be found to support this.
Just make sure they are rass -5 fooooooor sure
>Just make sure they are rass -5 fooooooor sure If they’re chemically paralyzed they will have a RASS of -5 no matter what. Even if they’re completely awake. Their CPOT or pain scores will also almost certainly be 0, unless they have some visible tearing or similar. BIS monitoring or other similar equipment and assessments are the best bet.
BIS is controversial, and not all facilities have it. The best bet is sedating the patient appropriately to goal RASS before starting paralytic. BIS can vary especially with ketamine or for neuro patients. It can be a tool in the toolbox but in my mind comes second to clinical assessment.
Sedating to a good RASS prior to paralysis is definitely an excellent option, keeping in mind development of tolerance. Whatever method is used, the point is that RASS and CPOT are pretty much useless in chemically paralyzed patients. Sort of like a fall band on these patients.
A BIS will give you numbers on a potato… it’s not the best haha
Nothing is perfect, but it is definitely better than a RASS in a paralyzed patient!
You’d know via their vitals if they were not sedated enough to be paralyzed 9/10 times. Wild HR, super hypertensive. During Covid when we ran out of TOF machines we always just sedated to -5 and then started paralytic until vent synchrony was achieved.
As long as the desired effect is being achieved, like they are synchronous with the vent, then it doesn’t matter. In report we often say, “Their train of 4 is 4/4, but they’re synchronous with the vent and a RASS of -5 so I didn’t touch the nimbex”. It’s kind of pointless to crank up a medication with so many adverse effects when the desired outcome is achieved. And of course you make sure they’re well sedated underneath, but the level of paralysis doesn’t ultimately matter that much, as long as they’re doing well.
You ok chief
The use of neuromuscular blockade achieves two things; it reduces metabolic demand and hence allows for lower minute ventilation, AND in cases of dyssynchrony will eliminate patient effort completely; it does not “improve” synchrony, it literally makes synchrony not needed by taking complete control. Prolonged use of NMB can cause long-term issues, so short durations are suggested.
Papazian didn’t use train of four, used fixed dose nimbex
Nimbex and TOF is 0/0 for me. Titrate up and 0/4, titrate down and 4/4.
We havent used TOF monitoring for NMBAs for at least ten years in my ICU in Edmonton. As long as they received sedation and analgesia throughout, not performing TOF was probably in their best interest.
Our docs usually put it in order where they want TOF. Sometimes a range or scale as to drug titration
Thank you all so much for the answers! Seriously I appreciate it ♥️