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Muscle relaxants in critically ill (Indications (Controlling ventilation…
Muscle relaxants in critically ill
Routine use of MR to facilitate sedation is not recommended. If used should be for short period with regular monitoring.
Indications
Intubation
Controlling ventilation
Resp failure
Head injury
Transfer patients e.g. for imaging
Prevention of shivering with therapeutic hypothermia
Infection control and prevention of coughing e.g. in TB for staff protection during bronch.
Short surgical procedures in ICU (e.g. trache)
Treat tetanus and muscle spasm
Problems
Airway
Increased risk of aspiration and vent associated pneumonia
Loss of airway in difficult airway scenario
Breathing
Impair resp effort (must have MV and may require prolonged MV until return function)
Implicated in development of critical illness polyneuropathy (prolongs ventilation, delays rehab, prolongs ICU stay)
Require expertise and eqpt. to deal with difficult intubation / accidental extubation
Circulation
Increases electrode drift in LIDCO
Neurological
Complicates neurological assessment
Mask seizure activity and may not recognise status epilepticus
Apparent decreased consciousness
Unable to perform brain death testing
Complicates management of certain conditions
Myasthenia Gravis
Preeclampsia, HELLP
Risk of awareness when paralysed can lead to PTSD
Other
Allergic reaction
Sux problems after prolonged immobility, burns (prejunctional ACh receptors)
Depolarizing NMB implicated in MH
Loss of protective reflexes (cough, blink, repositioning) may increase risk of incidental or pressure injury
Muscle relaxant choice
Caution using depolarising MR if:
Multiple injuries
Renal failure and risk severe hyperkalaemia
Immobility
Burns
Particular caution using NDMR if:
Risk accumulation in setting of hepatic or renal failure
Histamine release in cardiac unstable
Electrolyte disturbance