The neuromuscular blockade: paralysis on purpose.

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When you're a new RN like me, you don't really know what crazy things you'll be expected to do during the day when you clock in to work. For me over during some recent shifts, it's been keeping a young patient chemically paralyzed.

Chemically-induced total paralysis, or neuromuscular blockade, is a treatment for severely critical pulmonary conditions like ARDS; in other words, anytime you need increased lung compliance or the patient's really fighting the ventilator. They also use it for oscillatory ventilation. These vents were formerly used only in the neonatal ICU, but they're being used for adult trauma and ARDS patients as well. When a patient's put on an oscillator (or jet-vent), their lungs are essentially kept permanently inflated with high pressure, and small, rapid waves or oscillations of oxygenated air are sent into the lungs. The patient's "breaths" are extremely rapid, and the machine is very noisy, grunting away at (if I remember right) something like 180 waves per minute.  Oscillators for adults are kind of a last-ditch effort but I've seen young trauma patients pull through them. It's a very unstable thing, usually requiring the RN to be in the room pretty much the whole time. Let me tell you, hearing the rhythm of an oscillator for 12 hours straight is something you don't easily forget.

Back to paralysis: the obvious first problem with it is that you paralyze the diaphragm, so they'd better be on a ventilator. The second, more clinically important problem is that paralytics don't sedate the patient at all, or treat pain. You can be chemically paralyzed and completely awake. So we always, always sedate first, paralyze second. However, as the nurse you have to be constantly watching for signs that the patient is too awake. Typically we go by heart rate or blood pressure. If you do something to them and their heart rate or BP spikes, you know they're more aware.  I was even in a room with a patient once (not my patient) when the residents were discussing a planned surgery and the patient's heart rate skyrocketed. I tend to err on the side of caution and titrate the sedatives on the high end.

The other problem is the neurological exam is really limited. All you really have to go by is pupillary response. The pupil's muscles are contained within the blood-brain barrier, so paralytic agents don't affect them, and pupils continue to react to light. This is the only really tangible sign that a person's still "in there" when they're paralyzed.

These are things I don't even remember discussing in nursing school. And when we were hired, the pharmacist who reviewed them with us (introduced them, you could say!) alerted us to two things: one, we're going to be better experts on using these drugs than even the physicians are, and two, these are the most dangerous drugs used in the entire hospital.

Pretty wild.