An Awake Paralysis Victim in An Awake Paralysis Victim in SICU and Cardiac AnesthesiaSICU and Cardiac Anesthesia

R1 R1 胡念之胡念之

Patient ProfilePatient Profile

Age: 47 y/oAge: 47 y/o Sex: maleSex: male Weight: 87.5 KgWeight: 87.5 Kg Height: 177.6 cmHeight: 177.6 cm P.H: DM under insulin control for 10+ yrsP.H: DM under insulin control for 10+ yrs HTN under Renitec control for 7+ yrsHTN under Renitec control for 7+ yrs Chronic renal insufficiency (Cre level around Chronic renal insufficiency (Cre level around

2.5) for several yrs2.5) for several yrs HyperlipidemiaHyperlipidemia

He received scheduled OPCAB on 94/1/23 He received scheduled OPCAB on 94/1/23 due to CAD, 3-vessel disease.due to CAD, 3-vessel disease.

He was admitted to 4A1 SICU for post-op He was admitted to 4A1 SICU for post-op observation and care at 10 pm on 1/23.observation and care at 10 pm on 1/23.

Pre-op

Heart Echo (1/10)Heart Echo (1/10)

LVEF: 30 % +/-LVEF: 30 % +/- Dilated LVDilated LV

Impaired LV contractilityImpaired LV contractilityMR , mildMR , mildMinimal amount pericardial effusionMinimal amount pericardial effusion 　 　

Pavulon

1st 4mg 2nd 4mg

A-line

CVP

4th 4mg3rd 4mg

10pm

5th 4mg

The adequate dosage of Pavulon for this patient sThe adequate dosage of Pavulon for this patient should be 1.75~2.625 mg/hrhould be 1.75~2.625 mg/hr

The operation was over at 10pm on 1/23The operation was over at 10pm on 1/23 No limbs movement or eye opening at 8am on 1/2No limbs movement or eye opening at 8am on 1/2

44 Mild tremor over four distal limbs was noted at 9aMild tremor over four distal limbs was noted at 9a

mm TOF on 10am: 0 %TOF on 10am: 0 % Head control recovered at 2pmHead control recovered at 2pm Fully recovered at 3~4pmFully recovered at 3~4pm Extubated at 5pmExtubated at 5pm

Topic discussionTopic discussion

Risk factors of prolonged paralysisRisk factors of prolonged paralysis Monitor of neuromuscular blockMonitor of neuromuscular block Muscle relaxant and fast track anesthesiaMuscle relaxant and fast track anesthesia Guidelines for the intrahospital transport of cGuidelines for the intrahospital transport of c

ritically ill patientsritically ill patients

Risk Factors of Prolonged ParalysisRisk Factors of Prolonged Paralysis

Chronic hypertension Chronic hypertension — alters cerebral bloo— alters cerebral blood flow autoregulationd flow autoregulation

Liver diseaseLiver disease Kidney diseaseKidney disease DMDM Reduced serum albuminReduced serum albumin level level — increased f— increased f

ree drug containree drug contain Severe hypothyrodism — altered metabolisSevere hypothyrodism — altered metabolis

mm

Evaluation of Neuromuscular Evaluation of Neuromuscular Function Function

Single-twitchSingle-twitch Train-of-four (TOF)Train-of-four (TOF) Tetanic stimulationTetanic stimulation Double- burst stimulation (DBS) Double- burst stimulation (DBS)

Single TwitchSingle Twitch

peripheral motor nerve at frequencies peripheral motor nerve at frequencies ranging from 1.0 Hz (once every second) to ranging from 1.0 Hz (once every second) to 0.1 Hz (once every 10 seconds)0.1 Hz (once every 10 seconds)

Increasing block results in decreased Increasing block results in decreased evoked response to stimulationevoked response to stimulation

Train-of-four (TOF)Train-of-four (TOF)

four supramaximal stimuli are given every 0.four supramaximal stimuli are given every 0.5 seconds (2 Hz) 5 seconds (2 Hz)

partial nondepolarizing blockpartial nondepolarizing block: the ratio decre: the ratio decreases (fades), inversely proportional to the deases (fades), inversely proportional to the degree of blockadegree of blockade

partial depolarizing blockpartial depolarizing block: no fade occurs in t: no fade occurs in the TOF response he TOF response

Clinical relaxation usually requires 75~95% Clinical relaxation usually requires 75~95% neuromuscular blockadeneuromuscular blockade

the degree of block can be read directly frothe degree of block can be read directly from the TOF response m the TOF response

less painful than tetanic stimulation, generallless painful than tetanic stimulation, generally does not affect the degree of neuromusculy does not affect the degree of neuromuscular blockade ar blockade

Tetanic StimulationTetanic Stimulation

Very rapid (e.g., 30-, 50-, or 100-Hz) deliverVery rapid (e.g., 30-, 50-, or 100-Hz) delivery of electrical stimuli y of electrical stimuli

50-Hz stimulation given for 5 seconds 50-Hz stimulation given for 5 seconds Normal neuromuscular transmission and a pNormal neuromuscular transmission and a p

ure depolarizing block: the response is sustaure depolarizing block: the response is sustainedined

Nondepolarizing block and a phase II block Nondepolarizing block and a phase II block after injection of succinylcholine: the responafter injection of succinylcholine: the response will not be sustained se will not be sustained

Disadvantages:Disadvantages:

very painful very painful

may produce a lasting antagonism of may produce a lasting antagonism of neuromuscular blockade in the stimulated neuromuscular blockade in the stimulated musclemuscle

Double- burst stimulation (DBS)Double- burst stimulation (DBS)

two short bursts of 50-Hz tetanic stimulation separtwo short bursts of 50-Hz tetanic stimulation separated by 750 msec, duration of each square wave iated by 750 msec, duration of each square wave impulse in the burst is 0.2 msec mpulse in the burst is 0.2 msec

most commonly used: DBS3,3most commonly used: DBS3,3 Nonparalyzed muscle: the response is two short mNonparalyzed muscle: the response is two short m

uscle contractions of equal strengthuscle contractions of equal strength Partly paralyzed muscle: the second response is wPartly paralyzed muscle: the second response is w

eaker than the first (i.e., the response fades) eaker than the first (i.e., the response fades)

allowing manual (tactile) detection of small allowing manual (tactile) detection of small amounts of residual blockade under clinical amounts of residual blockade under clinical conditions conditions

during recovery and immediately after during recovery and immediately after surgery: superior to tactile evaluation of the surgery: superior to tactile evaluation of the response to TOF stimulation response to TOF stimulation

What is “Fast Track Cardiac What is “Fast Track Cardiac Anesthesia”Anesthesia”

Early tracheal extubation ( within 1~8 hrs) and decreased length of ICU and hospital stay with subsequent cost reduction and to limit the risk of ventilator-induced complications

Short-acting hypnotic drugs Reduced doses of opioids, or the use of ultr

ashort-acting opioids

The choice of muscle relaxant—The choice of muscle relaxant—

Duration (min)Duration (min) Maintenance Maintenance Dosage (mg/Kg)Dosage (mg/Kg)

EliminationElimination

PancuroniumPancuronium

(Pavulon)(Pavulon)

60-9060-90 0.01-0.015 in ev0.01-0.015 in every 20-40 minsery 20-40 mins

70% renal

15-20% hepatic

RocuroniumRocuronium

(Esmeron)(Esmeron)

20-3520-35 0.1-0.150.1-0.15 50-70% biliary

10-20% hepatic

10-25% renal

CisatracuriumCisatracurium

(Nimbex)(Nimbex)

6060 0.01-0.020.01-0.02 Hofmann elimination

Hofmann elimination: spontaneous degradation in plasma and tissue at normal body pH and temperature

Methods to reduce the risk of Methods to reduce the risk of residual neuromuscular blockaderesidual neuromuscular blockade

the use of the use of intermediate-acting NMBDsintermediate-acting NMBDs intra-op and post-op intra-op and post-op neuromuscular monitoringneuromuscular monitoring routine examinationsroutine examinations for clinical signs of muscle for clinical signs of muscle

weakness before extubationweakness before extubation pharmacological pharmacological reversalreversal whenever pancuroniu whenever pancuroniu

m is used m is used shorter-acting muscle relaxants: improvements ishorter-acting muscle relaxants: improvements i

n neuromuscular recovery and fewer signs and sn neuromuscular recovery and fewer signs and symptoms of muscle weaknessymptoms of muscle weakness

Recovery of Neuromuscular Function After Cardiac Surgery: Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium Pancuronium Versus Rocuronium AnesthesiaAnesthesia & & AnalgesiaAnalgesia. 96(5):1301-7. 96(5):1301-7

A different opinion….A different opinion….

Residual paralysis is common after cardiac Residual paralysis is common after cardiac surgery, and requires continuous postoperative surgery, and requires continuous postoperative sedation sedation

if anesthetic depth is well maintained throughout if anesthetic depth is well maintained throughout surgery, there is no need for continuous surgery, there is no need for continuous neuromuscular blockadeneuromuscular blockade

in fast-track cardiac surgery, it seems in fast-track cardiac surgery, it seems unnecessary to maintain paralysis by repetitive unnecessary to maintain paralysis by repetitive bolus injection or continuous infusion of bolus injection or continuous infusion of neuromuscular blockers neuromuscular blockers

Is muscle relaxant necessary for cardiac surgery Is muscle relaxant necessary for cardiac surgery AnesthesiaAnesthesia & & AnalgesiaAnalgesia. . 99(5):1330-3 99(5):1330-3

Intrahospital Transport of Critically Ill Patients

Pretransport Coordination and Communication

Accompanying Personnel Accompanying Equipment Monitoring During Transport

Guidelines for the inter- and intrahospital transport of critically illpatientsCrit Care Med 2004 Vol. 32, No. 1

Pretransport Coordination and Communication

Continuity of patient care by communication to review patient condition and the treatment plan in operation

Receiving location confirms: timing of the transport & equipment support

Documentation: indications for transport patient status throughout the time away

from the unit of origin

Accompanying Personnel

A minimum of two people should accompany a critically ill patient

A physician with training in airway management and ACLS, and critical care training or equivalent, accompany unstable patients

Accompanying Equipment

Blood pressure monitor Pulse oximeter Cardiac monitor/defibrillator A memory-capable monitor Oxygen source of ample supply to provide f

or projected needs plus a 30-min reserve (1 atm = 15 PSI)

Oxygen concentration: for neonates and for those patients with congenital heart disease who have single ventricle physiology or are dependent on a right-to-left shunt to maintain systemic blood flow

Basic resuscitation drugs Supplemental medications, such as

sedatives and narcotic analgesics,

Monitoring During Transport

Electrocardiographic monitoring Continuous pulse oximetry Periodic measurement of BP, pulse rate, an

d respiratory rate

Special Recommendation of Cardiac Special Recommendation of Cardiac Surgery PatientSurgery Patient

NTG infusion: for p’t with LIMA graft (reduce NTG infusion: for p’t with LIMA graft (reduce vasospasm risk)vasospasm risk)

Low-dose dopamine infusion: at least the first 24 hours post-operatively, irrespective of a good BP or diuresis.

Intensive Care Unit, Prince of Wales Hospital, Chinese University of Hong Kong

Thanks for Your Attention!!Thanks for Your Attention!!