At 1330, Mr. Hill’s wife asks for you at the nurses station. She tells you that Mr. Hill seems very anxious, and that she’s been holding his hands so he doesn’t pull out the tube. You follow her to the room and find Mr. Hill with his legs hanging off the side of the bed and his hand on the ventilator tubing. His respiratory rate is 30 and the ventilator is alarming with almost every breath. Per the pulmonologist’s order, you administered 2 mg of Versed at 1200 and 1300, but Mr. Hill’s anxiety seems worse instead of better. He looks at you when you talk to him, but doesn’t respond appropriately or follow commands. Another nurse helps you settle him in bed again and you ensure that his wrist restraints are secure before leaving the room to call the physician.

1.  What do you anticipate the physician will order?

Answer:

A continuous Versed infusion and possibly neuromuscular blockade.

The physician orders a continuous Versed infusion of 1-10 mg/hr, titrated to effect, and a Nimbex infusion with TOF maintained at 90%.

2.  The physician is ready to hang up the phone, but you think of one more crucial thing to ask him about the ventilator settings. What is it?

Answer:

The ventilator mode is currently SIMV, which is used with spontaneously breathing patients. However, the Nimbex infusion will paralyze Mr. Hill’s diaphragm along with the rest of his body, thus the ventilator mode should be changed to completely take over respiratory function. The mode should be changed to control or assist-control ventilation.

3.  Which infusion will you start first, the Versed or the Nimbex?

Answer:

Versed. Remember that NMB’s do not have any sedative or analgesic properties. Always sedate the patient prior to administering a paralyzing agent.

4.  How will you monitor the level of paralysis?

Answer:

Test train-of-four (TOF) with a peripheral nerve stimulator. Remember to test and record the baseline prior to starting the Nimbex. After the infusion is started, test TOF every

15 –30 minutes until steady state is achieved. Then it may be tested every two hours for the first 24 hours, unless the Nimbex is being titrated. The physician ordered 90% blockade, so the goal is one thumb twitch.

5.   How will you explain this change in events to Mr. Hill’s wife and family?

Answer:

Keep the explanation simple but be sure to answer their questions. Keep in mind that the word “paralysis” may frighten them. Important points to include are: the paralysis is caused by medication and is reversible, the paralysis is only a temporary measure to help Mr. Hill breathe better with the ventilator, and his level of paralysis will be closely monitored with the PNS. Tell them that he is sedated, but encourage them to talk to him and touch him. Also reassure them that Mr. Hill’s physical needs such as repositioning, oral care, and bathing will be taken care of by the staff.