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Treat the PAIN, it’s not about the paralysis!




I wanted to take the time and answer a few listener questions.  Based on an email I received from a very good and passionate critical care provider, I wanted to discuss the treatment and administration of long-acting neuromuscular blocking agents.  As FlightBridgeED has grown to the platform it is now, we have thousands of loyal listeners and followers.  I realized that is the driving forces for our growth and a true testament to all of you.  Based on that, the podcast for many is something that they see as the gold standard and want to follow.  Although this is flattering, I will say that it still puzzles me a bit.  By no means do I think my way is the only way.  I also see now that the podcast and FlightBridgeED have become something I could have never imagined. With that being said, I fully understand the responsibility that comes with that.  I only want to put out the highest quality education that is based on the newest evidence-based research and clinical practice standards.  I also will never put something out that I don’t or wouldn’t employ myself.  

Flight nurses and paramedics have an amazing job that allows them the opportunity to critically think and practice medicine with protocols that are very broad and objective.  The question I received from this listener was based on the use of long-acting paralytics and my overall views for trying to stay away from the administration of these medications.  Although this is my view, I also understand that the use of long-acting paralytics can be given to our patients if needed, with the additional treatment and administration of pain and sedation medications that are essential for continued pain control and sedation.  However, I’ve learned through my role with Air Methods as well as collaboration throughout the world with MD’s, that it’s so much better to manage someone without paralytics if at all possible.  My statement on the podcast regarding Vecuronium and Rocuronium for post-intubation management being “a lazy approach” is something that I’ve witnessed.  I do however understand that my statements may be taken literally and there are excellent clinicians out there like that use the medications with critical thinking as your guide.  

I myself was one of those people about 8 years ago that administered long-acting paralytics to all my intubated patients post-intubation.  It wasn’t because I didn’t want to deal with them (which I’ve been told many times by flight crews as the reason for administration), but because of the culture at the time and how I was taught 17 years ago.  What caused the change?  As I became obsessed with ventilator management years ago and started to read research and published studies, I realized that we as clinicians, despite excellent critical thinking, don’t manage patient’s pain and sedation adequately enough when our patients are lying there paralyzed.  We are human and don’t see these little clues that warrant re-dosing of Fentanyl and Versed.  As I’m sure many of you have witnessed, I too have been on transfer flights and found patients lying there with nothing but paralysis.  That is barbaric care and something that has to be stopped.   

Based on studies and overall clinical practice, I’ve realized that pain management is the biggest thing we need to be doing.  We as an industry had, and still do have a major deficit in this area, with crews not dosing pain and sedation often enough.  My argument is based on that alone. If we can’t get our crews to dose Fentanyl and Versed correctly, why would we want them to paralyze them on top of that?  I believe we would have a much bigger issue.  In addition, couple that with all the studies of delirium and the administration of benzodiazepines, and it makes it clear that we need lots of pain management, and smaller amounts of sedation meds.  

I agree that there are times that patients need to rest and could potentially benefit from long-acting paralysis.  Many can argue that TBI patients could be a candidate for long-acting paralysis. However the biggest aspect that drives up ICP other than the head injury itself is pain.  Pain management is the number one key, not paralysis. Based on that statement, I feel like the patients that would benefit from paralysis are limited and patients do better when they’re allowed to over breath by a few breaths per minute.  This is easily identified with the LTV1000, 1200 and Revel Ventilators.  

I always try to look at things from the perspective of least harm. I feel that based on the data, the least harm is to try to manage patients without long-acting paralytics.  That’s not saying there isn’t a need, but putting that assumption as a last medication in your tool bag is in my opinion best practice.  I also understand that outcomes may not be worse, but I do believe that patients are more comfortable and treated better with regards to pain, by using pain and sedation liberally and attempting to keep long-acting paralysis as the last line medication.

As I’ve stated above, FlightBridgeED has become something I could have never imagined. We have an amazing platform and thousands of doctors, nurses and paramedics as well as other professionals that use the education-based podcasts as their tool for career development.  I love that, and understand the responsibility this carries for myself and the FlightBridgeED team as a whole.  In the end, I want you to critically think and assess the best treatment option for each of your patients.  The old culture was to paralyze every patient post-intubation, however now there’s a massive paradigm shift that warrants looking at this treatment from a different angle and limiting this treatment to patients that absolutely need long acting paralysis instead of prophylactically administering the medication on every patient.  Remember, treat the PAIN, it’s not about the paralysis!

Thanks you for your continued support and for allowing me the oppurtunity to invest in the FlightBridgeED community!



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