Caring for the paralysed: A quality-improvement project

2021 
The COVID-19 pandemic has seen increased neuromuscular blocking (NMB) agent use in our intensive care unit (ICU) Varying practice and poor monitoring was noticed during this period In addition to the newly recruited ICU staff, other non-ICU staff were drafted in to help us during the crises, leading to unfamiliarity in use of NMB Due to this gap in practice, there was a requirement for a guideline for the safe and effective use of continuous NMB Methods A quick survey was conducted amongst ICU nurses and junior doctors about the use of NMB agents It was found that although most of the staff had baseline knowledge about the use of NMB agents in ventilated patients, i e , name of the drugs and supportive care needed, many were unsure of the target train-of-four (TOF) and bispectral index (BIS) readings in these patients Titration of NMB drug infusions to achieve a desired response proved to be an especially challenging task and was attributed to the lack of clear instructions while prescribing these drugs Discussion Based on the results of the survey, a guideline was developed to facilitate the appropriate management of continuous infusions of NMBAs and to delegate the authority of titration to nurses This guideline includes a quick reference flowchart, which will serve as an easy bedside reference for the multidisciplinary teams working in the intensive care It informs about decision-making by the responsible consultant, level of sedation required, placement of electrodes (BIS and TOF monitor) and dosage of drug (first choice being atracurium for continuous infusions) The flowchart guides the team how to titrate the drug infusions in order to achieve a target BIS of 40-60 and TOF of two twitches In addition, it also emphasises on supportive nursing care needed whilst the patient is sedated and paralysed Furthermore, focusing on target level of paralysis has been emphasised in the guideline to aid decision-making This guideline was approved at ICU Clinical Governance The next step will involve training nursing staff The guideline will be reviewed after 6 months and thereafter every 2 years
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