Therapeutic Paralysis: The Patient’s Perception
Abstract & Commentary
Little is known about the experience of critically ill patients or family members when neuromuscular blocking agents (NMBAs) are used to achieve therapeutic paralysis. To better understand this experience, Johnson and colleagues interviewed 11 patients who received NMBAs while in a Level I trauma center and a family member for each patient who was present on a consistent basis while the patient was paralyzed. The patients spent 36.2 ± 21.7 days in the trauma ICU, including 33.2 ± 21.5 days on mechanical ventilation. The interviews were conducted after the patients were discharged from the ICU, but before hospital discharge. When interviewed, all patients had a Glasgow Coma Scale score of 15 and were oriented to person, place, and time. Mean age was 32.5 ± 12.0 years. NMBAs were administered for 13.1 ± 13.5 days and included pancuronium (n = 8), vecuronium (n = 2), or both drugs (n = 1).
When asked what they remembered, all patients described the experience with vagueness (e.g., "I was asleep for a long time and woke up"). Many patients had difficulty distinguishing dreams from reality (e.g., "I tried to tell people to do things, but they wouldn’t do them in my dreams"). However, one patient described dreams that included details from conversations at the bedside. When asked about the experience of paralysis, none of the patients remembered being unable to move, being in pain, or specific events (e.g., procedures, alarms, or mechanical ventilation). However, some recalled hearing voices. Six patients recalled their mother talking to them and five recalled nurses talking to them (e.g., "I knew I could not move; my mom and my nurses told me"). When asked what could be done to make things better, family members stressed the importance of being informed about events, continuity of care (having the same nurses), and being told about the patient’s reactions when paralysis was discontinued. Patients stressed the importance of having someone present to provide support, and not being tightly restrained. (Johnson KL, et al. Am J Crit Care 1999;8:490-498.)
COMMENT BY LESLIE A. HOFFMAN, PhD, RN
NMBAs induce paralysis, but do not alter consciousness, reduce pain, or relieve anxiety. Patients are left fully conscious but unable to move. Consequently, additional medications (e.g., analgesics and sedatives) must be administered when NMBAs are required. Few studies have attempted to document recollections of patients and family members about therapeutic paralysis. Consequently, little is known about the effectiveness of current approaches to manage pain and sedation during use of these drugs.
In this study, patients were interviewed approximately six days after ICU discharge. The interview included probes designed to prompt recollection of the experience. The patient and family member were asked to describe what the experience was like and to share what they remembered about the experience. Most patients described the experience with vagueness, as if they had been sleeping. Some patients recalled events, but they were unsure if they were real or part of a dream. In contrast to prior reports, patients in this study did not recall pain or relate any terrifying experiences while receiving NMBAs. Consequently, it appears that unit protocols were effective in managing pain and suppressing awareness of unpleasant events.
In this study, peripheral nerve stimulation (train-of-4) was used to ensure consistent and safe levels of blockade, and adequacy (3 of 4 twitches) was assessed every four hours. All patients received a loading dose and a maintenance dose of morphine or fentanyl. Morphine (5-30 mg/h IV) or fentanyl (300-1000 mcg/h/IV) was administered according to a schedule, not "as needed." In addition, all patients received lorazepam 2-4 mg IV every hour while on NMBAs. Thus, the protocols used a proactive approach for managing pain and sedation and suppressing awareness of unpleasant events. The unit had a liberal (24-hour access) visitation policy that encouraged family interaction.
Several findings of this study have important implications for health care providers. Frightening, painful experiences associated with the use of NMBAs may potentially be averted by protocols that entail monitoring the level of paralysis and schedule administration of medications to relieve pain, provide sedation, and decrease awareness. Because the patients were aware of being touched and of individuals present at the bedside, it is important to provide emotional support, explain procedures, and monitor what is said in bedside conversations. Critical care physicians and nurses should discuss the experience of therapeutic paralysis with patients to better understand how well protocols minimize adverse effects of this experience.
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