an awake paralysis victim in sicu and cardiac anesthesia l.
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An Awake Paralysis Victim in SICU and Cardiac Anesthesia. R1 胡念之. Patient Profile. Age: 47 y/o Sex: male Weight: 87.5 Kg Height: 177.6 cm P.H: DM under insulin control for 10+ yrs HTN under Renitec control for 7+ yrs

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An Awake Paralysis Victim in SICU and Cardiac Anesthesia

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patient profile
Patient Profile
  • Age: 47 y/o
  • Sex: male
  • Weight: 87.5 Kg
  • Height: 177.6 cm
  • P.H: DM under insulin control for 10+ yrs

HTN under Renitec control for 7+ yrs

Chronic renal insufficiency (Cre level around 2.5) for several yrs


He received scheduled OPCAB on 94/1/23 due to CAD, 3-vessel disease.
  • He was admitted to 4A1 SICU for post-op observation and care at 10 pm on 1/23.
heart echo 1 10
Heart Echo (1/10)
  • LVEF: 30 % +/-
  • Dilated LVImpaired LV contractilityMR , mildMinimal amount pericardial effusion


1st 4mg

2nd 4mg




3rd 4mg

4th 4mg

The adequate dosage of Pavulon for this patient should be 1.75~2.625 mg/hr
  • The operation was over at 10pm on 1/23
  • No limbs movement or eye opening at 8am on 1/24
  • Mild tremor over four distal limbs was noted at 9am
  • TOF on 10am: 0 %
  • Head control recovered at 2pm
  • Fully recovered at 3~4pm
  • Extubated at 5pm
topic discussion
Topic discussion
  • Risk factors of prolonged paralysis
  • Monitor of neuromuscular block
  • Muscle relaxant and fast track anesthesia
  • Guidelines for the intrahospital transport of critically ill patients
risk factors of prolonged paralysis
Risk Factors of Prolonged Paralysis
  • Chronic hypertension — alters cerebral blood flow autoregulation
  • Liver disease
  • Kidney disease
  • DM
  • Reduced serum albuminlevel — increased free drug contain
  • Severe hypothyrodism — altered metabolism
evaluation of neuromuscular function
Evaluation of Neuromuscular Function
  • Single-twitch
  • Train-of-four (TOF)
  • Tetanic stimulation
  • Double- burst stimulation (DBS)
single twitch
Single Twitch
  • peripheral motor nerve at frequencies ranging from 1.0 Hz (once every second) to 0.1 Hz (once every 10 seconds)
  • Increasing block results in decreased evoked response to stimulation
train of four tof
Train-of-four (TOF)
  • four supramaximal stimuli are given every 0.5 seconds (2 Hz)
  • partial nondepolarizing block: the ratio decreases (fades), inversely proportional to the degree of blockade
  • partial depolarizing block: no fade occurs in the TOF response
  • Clinical relaxation usually requires 75~95% neuromuscular blockade
the degree of block can be read directly from the TOF response
  • less painful than tetanic stimulation, generally does not affect the degree of neuromuscular blockade
tetanic stimulation
Tetanic Stimulation
  • Very rapid (e.g., 30-, 50-, or 100-Hz) delivery of electrical stimuli
  • 50-Hz stimulation given for 5 seconds
  • Normal neuromuscular transmission and a pure depolarizing block: the response is sustained
  • Nondepolarizing block and a phase II block after injection of succinylcholine: the response will not be sustained

very painful

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

double burst stimulation dbs
Double- burst stimulation (DBS)
  • two short bursts of 50-Hz tetanic stimulation separated by 750 msec, duration of each square wave impulse in the burst is 0.2 msec
  • most commonly used: DBS3,3
  • Nonparalyzed muscle: the response is two short muscle contractions of equal strength
  • Partly paralyzed muscle: the second response is weaker than the first (i.e., the response fades)
allowing manual (tactile) detection of small amounts of residual blockade under clinical conditions
  • during recovery and immediately after surgery: superior to tactile evaluation of the response to TOF stimulation
what is fast track cardiac anesthesia
What is “Fast Track Cardiac 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 ultrashort-acting opioids
The choice of muscle relaxant—

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

methods to reduce the risk of residual neuromuscular blockade
Methods to reduce the risk of residual neuromuscular blockade
  • the use of intermediate-acting NMBDs
  • intra-op and post-op neuromuscular monitoring
  • routine examinations for clinical signs of muscle weakness before extubation
  • pharmacological reversal whenever pancuronium is used
  • shorter-acting muscle relaxants: improvements in neuromuscular recovery and fewer signs and symptoms of muscle weakness

Recovery of Neuromuscular Function After Cardiac Surgery:

Pancuronium Versus Rocuronium Anesthesia & Analgesia. 96(5):1301-7

a different opinion
A different opinion….
  • Residual paralysis is common after cardiac surgery, and requires continuous postoperative sedation
  • if anesthetic depth is well maintained throughout surgery, there is no need for continuous neuromuscular blockade
  • in fast-track cardiac surgery, it seems unnecessary to maintain paralysis by repetitive bolus injection or continuous infusion of neuromuscular blockers

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

intrahospital transport of critically ill patients
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 illpatients

Crit Care Med 2004 Vol. 32, No. 1

pretransport coordination and communication
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
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
Accompanying Equipment
  • Blood pressure monitor
  • Pulse oximeter
  • Cardiac monitor/defibrillator
  • A memory-capable monitor
  • Oxygen source of ample supply to provide for 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
Monitoring During Transport
  • Electrocardiographic monitoring
  • Continuous pulse oximetry
  • Periodic measurement of BP, pulse rate, and respiratory rate
special recommendation of cardiac surgery patient
Special Recommendation of Cardiac Surgery Patient
  • NTG infusion: for p’t with LIMA graft (reduce 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