1. An Awake Paralysis Victim in SICU and Cardiac Anesthesia R1 胡念之

2. 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 HTN under Renitec control for 7+ yrs Chronic renal insufficiency (Cre level around 2.5) for several yrs Chronic renal insufficiency (Cre level around 2.5) for several yrs Hyperlipidemia Hyperlipidemia

3.  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.

4. Pre-op

5. Heart Echo (1/10)  LVEF: 30 % +/-  Dilated LV Impaired LV contractility MR, mild Minimal amount pericardial effusion  Dilated LV Impaired LV contractility MR, mild Minimal amount pericardial effusion

6. Pavulon 1st 4mg2nd 4mg A-line CVP

7. 4th 4mg3rd 4mg

8. 10pm 5th 4mg

9.  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

10. 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

11. Risk Factors of Prolonged Paralysis  Chronic hypertension — alters cerebral blood flow autoregulation  Liver disease  Kidney disease  DM  Reduced serum albumin level — increased free drug contain  Severe hypothyrodism — altered metabolism

12. Evaluation of Neuromuscular Function  Single-twitch  Train-of-four (TOF)  Tetanic stimulation  Double- burst stimulation (DBS)

13. 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

14. 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

15.  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

16. 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

17.  Disadvantages: very painful very painful may produce a lasting antagonism of neuromuscular blockade in the stimulated muscle may produce a lasting antagonism of neuromuscular blockade in the stimulated muscle

18. 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)

19.  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

20. 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

21.  The choice of muscle relaxant— Duration (min) Maintenance Dosage (mg/Kg) Elimination Pancuronium(Pavulon)60-90 0.01-0.015 in every 20-40 mins 70% renal 15-20% hepatic Rocuronium(Esmeron)20-350.1-0.1550-70% biliary 10-20% hepatic 10-25% renal Cisatracurium(Nimbex)600.01-0.02Hofmann elimination Hofmann elimination: spontaneous degradation in plasma and tissue at normal body pH and temperature

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

23. 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

24. 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

25. 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

26. 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

27. 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)

28.   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,

29. Monitoring During Transport   Electrocardiographic monitoring   Continuous pulse oximetry   Periodic measurement of BP, pulse rate, and respiratory rate

30. 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

31. Thanks for Your Attention!!