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sb439@gre.ac.uk's picture
by on Sun, 2018-04-08 00:19

I think I'm asking this in a very roundabout way below, but in short, critical care practitioners; is paralysis without sedation ever, under any circumstances an admissible course of action if sedatives are available?
Currently I think not, but I am not an anaesthetist or by any means an expert.
A discussion on social media and a confusing attempt at a literature search has led me to pursue some opinions here!
The discussion was a theoretical case of out-of-hospital management of a peri arrest stab victim. The suggestion of paralysis without sedation to facilitate intubation was made given the presence of profound hypotension.
Obviously there are enormous ethical issues with this and it would not be an action to take lightly. It seems to me that this used to be considered a very improbable course of action only to be taken in absolute extremis, but now I wonder whether this is the case at all with the rise of ketamine in the management of trauma patients. Hypotension is listed as a possible side effect and hypovolaemia a caution in the BNF, but with adequate fluid/blood resuscitation, is ketamine always going to be safe for these patients?
Thank you for sharing your thoughts!
Ben

CraigR's picture
by on Thu, 2019-04-11 15:36

Depending on the specifics of the case one could consider giving some pressor support prior to using some mild amount of sedative or pain medication.  ie getting the hemodynamics to a place that would support the drop from your pain or sedation meds.  Ketamine is mentioned in some website and sources for intubation circumstatnce.  I have also used it before for intubations.  However,  I have found that (at least in USA hospitals) if sometimes takes time to get from pharmacy.  This may limit its use in extremis. If you are in a forced to act situation to save a life, you may have limited ideal choices to render care. 

ChristopherS's picture
by on Thu, 2019-04-11 20:36

Opinion based without hard facts but, my thoughts are:
Is NMB without any sedation acceptable? No. I think the reasons for not doing this are well discussed.
Ketamine is great in this situation but is ketamine always safe? No. But then again positive pressure ventilation is also prone to upset grossly hypovolaemic patients! I’d always be sure to question if the plastic tube is the Immediate priority. If it’s needed now then the FKR combination is demonstrated as probably the best of a bad bunch thanks to the armed forces and evolving trauma practices at home. Either way, if you’re going to be doing PPV in a hypovolameic patient, be prepared for cardiovascular deterioration after the tube.

CharlesH's picture
by on Sat, 2019-05-18 02:49

The answer is entirely circumstantial and subject to clinical judgement.
Ketamine is not "always safe".  It is a negative inotrope.  However, that effect is usally masked by its indirect sympathetic effects.  If a person in extreme shock is already fully sympathetically activated, then the negative inotropic effects predominate.
If a person is truly peri-arrest and the reason for not giving a sedative (even in low dose) is concern for precipitating arrest and death, then:
(1) It is likely that the person is already so shocked as to be unconscious and will not have memory of the event.  If they do have memory of the intubation, then intubation will be the least traumatic thing happening to them.
(2) Paralysis without sedation is justifiable, and may in fact assist their survival by both facilitating intubation and reducing their metabolic load.  In depends on just how impaired the person already is: one is juggling the risk of cardiovascular collapse and death, against the future risk of PTSD.
So as regards paralysis without hyponosis, I would "never say never".  However, that is also the sort of person that will also require immediate damage control surgery if they are going to have any chance of survival.
Having said all of that, one would need to be quite certain that the person is truly peri-arrest and that hyponosis is truly too high a risk to that person's life.  That would essentially mean unrecordable cardiac output.  In the vast majority of trauma cases, a little volume preload, a small adrenaline bolus, a small ketamine bolus, paralysis and an apology will be safe, survivable and provide adequate hypnosis.  
I would not include the "no hypnosis" option in any pre-hospital guideline: it would only be an exception to be exercised in extremis.  And I wouldn't base that clinical decision on an online forum, but only on the basis of long anaesthetic experience.  It is a serious decision that would probably also give the anaesthetist nightmares.
I hope that helps.