Enfermería de urgencias en la intubación de secuencia rápida a pacientes COVID-19 / Cuidados de enfermagem de emergência para intubação de sequência rápida em pacientes com COVID-19 / Emergency Nursing Care for Rapid Sequence Intubation in COVID-19 Patients

Introducción: La inducción de secuencia rápida modificada es la sugerida para la intubación orotraqueal a pacientes COVID-19 que presentan distrés respiratorio en urgencias. El objetivo de esta revisión es plantear el proceso de atención de enfermería durante las fases de planificación, preparación, pretratamiento y sedación con parálisis neuromuscular. Materiales y Métodos: artículo de reflexión acerca de elementos conceptuales en la valoración, diagnóstico, planeación, ejecución y evaluación del cuidado de enfermería, a partir de la revisión de literatura de consensos y protocolos nacionales e internacionales y publicaciones de cuidado de enfermería a pacientes COVID-19. Resultados: los medicamentos recomendados por la literatura en la inducción de secuencia rápida a pacientes COVID-19 son: en la fase de pretratamiento, las benzodiacepinas necesarias para disminuir la ansiedad del paciente, la lidocaína que controla el reflejo de la tos y el fentanilo que contribuye con la analgesia; en la fase de sedación inductores como etomidato y ketamina están indicados en pacientes con inestabilidad hemodinámica y propofol en pacientes estables; en la fase de parálisis neuromuscular el rocuronio es el recomendado como primera opción antes que la succinilcolina y los vasopresores tipo norepinefrina, epinefrina, vasopresina y/o dopamina, son necesarios en todas las fases para el manejo de la inestabilidad hemodinámica. Conclusiones: aplicar el proceso de atención de enfermería durante las fases de inducción de secuencia rápida contribuye con la organización de los medicamentos requeridos para la intubación orotraqueal, lo cual, disminuye la ansiedad del paciente y el riesgo de contaminación del personal de salud.

Introduction: Modified rapid sequence induction is suggested for orotracheal intubation in COVID-19 patients with respiratory distress in the emergency department. The objective of this review is to discuss nursing care during the phases of planning, preparation, pretreatment and sedation with neuromuscular paralysis. Materials and Methods: A reflection article was written on conceptual elements in nursing care assessment, diagnosis, planning, implementation and evaluation based on the literature review of national and international standards and protocols, and publications on nursing care in COVID-19 patients. Results: Drugs recommended by rapid sequence intubation in COVID-19 patients are benzodiazepine for reducing patient's anxiety, lidocaine for cough control and fentanyl for analgesia in the pretreatment phase; inducers such as etomidate and ketamine are suggested in hemodynamic unstable patients and propofol in stable patients in the sedation phase; rocuronium is recommended as the first-choice neuromuscular blocking agent before vasopressors such as succinylcholine and norepinephrine, epinephrine, vasopressin and/or dopamine which are needed in all phases for managing hemodynamic instability. Conclusions: Applying a nursing care plan during rapid sequence induction phases contributes to a more organized medication regimen required for orotracheal intubation, which reduces patient's anxiety and the risk of contamination for healthcare personnel.

Introdução: A indução de sequência rápida modificada é sugerida para intubação orotraqueal em pacientes com COVID-19 com problemas respiratórios no departamento de emergência. O objetivo desta revisão é discutir os cuidados de enfermagem durante as fases de planejamento, preparação, pré-tratamento e sedação com paralisia neuromuscular. Materiais e métodos: Um artigo de reflexão foi elaborado sobre elementos conceituais na avaliação, diagnóstico, planejamento, implementação e avaliação da cuidados de enfermagem com base na revisão da literatura de normas e protocolos nacionais e internacionais, e publicações sobre cuidados de enfermagem em pacientes com COVID-19. Resultados: As drogas recomendadas pela intubação de sequência rápida em pacientes com COVID-19 são benzodiazepinas para reduzir a ansiedade do paciente, lidocaína para controle da tosse e fentanil para analgesia na fase de pré-tratamento; indutores como etomidato e cetamina são sugeridos em pacientes com instabilidade hemodinâmica e propofol em pacientes estáveis na fase de sedação; o rocurônio é recomendado como o bloqueador neuromuscular de primeira opção frente a vasopressores como succinilcolina e norepinefrina, epinefrina, vasopressina e/ou dopamina, que são necessários em todas as fases para o manejo da instabilidade hemodinâmica. Conclusões: A aplicação de um plano de cuidados de enfermagem durante as fases de indução de sequência rápida contribui para a organização dos medicamentos necessários para a intubação orotraqueal, o que reduz a ansiedade do paciente e o risco de contaminação para o pessoal de saúde.

Peristalsis and propulsion of colonic content can occur after blockade of major neuroneuronal and neuromuscular transmitters in isolated guinea pig colon.

We recently identified hexamethonium-resistant peristalsis in the guinea pig colon. We showed that, following acute blockade of nicotinic receptors, peristalsis recovers, leading to normal propagation velocities of fecal pellets along the colon. This raises the fundamental question: what mechanisms underlie hexamethonium-resistant peristalsis? We investigated whether blockade of the major receptors that underlie excitatory neuromuscular transmission is required for hexamethonium-resistant peristalsis. Video imaging of colonic wall movements was used to make spatiotemporal maps and determine the velocity of peristalsis. Propagation of artificial fecal pellets in the guinea pig distal colon was studied in hexamethonium, atropine, ω-conotoxin (GVIA), ibodutant (MEN-15596), and TTX. Hexamethonium and ibodutant alone did not retard peristalsis. In contrast, ω-conotoxin abolished peristalsis in some preparations and reduced the velocity of propagation in all remaining specimens. Peristalsis could still occur in some animals in the presence of hexamethonium + atropine + ibodutant + ω-conotoxin. Peristalsis never occurred in the presence of TTX. The major finding of the current study is the unexpected observation that peristalsis can occur after blockade of the major excitatory neuroneuronal and neuromuscular transmitters. Also, the colon retained an intrinsic polarity in the presence of these antagonists and was only able to expel pellets in an aboral direction. The nature of the mechanism(s)/neurotransmitter(s) that generate(s) peristalsis and facilitate(s) natural fecal pellet propulsion, after blockade of major excitatory neurotransmitters, at the neuroneuronal and neuromuscular junction remains to be identified.

Monitoring neuromuscular blockade in the intensive care unit: the peripheral nerve stimulator.

Traditionally, neuromuscular blocking agents (NMBAs) have been administered in the operating room as an adjunct to anesthetics. Recent studies in the United States have indicated that 98% of the anesthesiologists and critical care nurses surveyed use NMBAs at least occasionally. When monitoring the use of NMBAs, a combination of clinical monitoring and peripheral nerve stimulator monitoring has been recommended. However, the most effective techniques have yet to be described. Understanding the complexities of NMBAs and the absolute need for accurate monitoring techniques is imperative for clinicians. The purpose of this literature review is to evaluate current literature regarding monitoring techniques of NMBAs and to guide the advanced practice nurse's role in critical care.

Development of a policy for patients receiving neuromuscular blocking agents.

PURPOSE: To develop a policy to standardize the care of patients paralyzed with neuromuscular blocking agents (NMBAs). METHODS: Criteria were developed to assess adherence to the policy. Categorical and continuous data were collected and analyzed. RESULTS: Deficiencies were identified in frequency of train-of-four monitoring and in carrying out daily discontinuation of NMBAs to allow effects of paralysis to dissipate. CONCLUSIONS: The policy was useful as an educational tool. A NMBA order form should be developed to improve adherence to the policy.

Reversal agents to counteract muscle relaxation: nursing considerations.

Advances in pharmacology and technology over the last decade have fostered expanded use of muscle relaxants in critical care units and emergency departments. The neuromuscular blockade facilitated by these agents may be reversed pharmacologically, or may be spontaneously reversed endogenously. To ensure appropriate patient management, the critical care nurse, clinical nurse specialist, and acute care nurse practitioner must have a comprehensive understanding of the pathophysiology of neuromuscular blockade and reversal, the medications involved in this process, and the critical patient assessment and management skills necessary to assure a positive patient outcome.

Applied pharmacology of common neuromuscular blocking agents in critical care.

While all neuromuscular blocking agents (NMBAs) effectively interrupt neuromuscular transmission, it must be emphasized that these drugs are completely devoid of analgesic, sedative, or amnestic properties. The increasing use of NMBAs in the ICU requires familiarity with their basic pharmacologic properties, as well as an appreciation of potential problems associated with chronic (> 24 hrs) neuromuscular blockade. Although NMBAs possess an impressive safety record, the majority of recommendations for neuromuscular blocker use in the ICU are extrapolated from short-term perioperative studies in healthy patients. NMBAs are structurally related to acetylcholine and their main site of action is the postjunctional nicotinic acetylcholine receptor, although prejunctional interaction may be an important component of total activity. These drugs act to either sustain a depolarization at the postjunctional membrane (succinylcholine), or they inhibit neuromuscular transmission by a competitive (non-depolarizing) blocking mechanism. Adverse hemodynamic consequences may result from concurrent stimulation of muscarinic receptors, autonomic ganglia, histamine, or catecholamine release associated with some agents. The metabolism and excretion of NMBAs may be altered in ICU patients with end-organ dysfunction, concurrent medications, electrolyte, acid-base, and nutritional abnormalities, along with underlying nervous system and muscle pathology. Prolonged weakness after discontinuation of NMBAs is increasingly recognized after these agents are used for extended periods. This phenomenon may be related to alterations in the pharmacokinetics and pharmacodynamics, along with altered physiology of the neuromuscular junction, nervous system, or muscle, or other undefined toxic effects. A sound knowledge of the basic physiology of the neuromuscular junction, neuromuscular blocker pharmacology, and standard techniques to assess the degree of neuromuscular blockade provides the rationale for drug selection when paralysis is indicated in ICU patients.

Neuromuscular blockade in adult intensive care.

Neuromuscular blocking agents are powerful drugs that are being used with increasing frequency in critical care medicine. The choice of a particular muscle relaxant is influenced by the patient's underlying condition and the side-effects of the drugs. Many factors influence an individual's response to neuromuscular blocking agents, and therefore, each patient's response should be monitored with a nerve stimulator. When muscle relaxants are used, common complications are patient awareness secondary to inadequate analgesia and sedation, and overdose of the neuromuscular blocking agents. Prolonged paralysis for days to weeks after the discontinuation of neuromuscular blocking agents is an uncommon but devastating complication, the etiology of which is poorly understood. Physicians in critical care medicine should receive formal training in the use of neuromuscular blocking drugs.

Powerlessness and the patient under neuromuscular blockade.

The patient under neuromuscular blockade is dependent on members of the interdisciplinary team for all physical and psychological needs. Loss of control leads to feelings of powerlessness and helplessness which can adversely affect the patient's ability to cope. The nurse caring for this patient must be able to effectively combine clinical expertise with compassion in order to most effectively help the patient cope with the period of powerlessness. An individualized approach to restore control helps curtail the progression of powerlessness to hopelessness and limit the associated depression and anxiety.