PLACE LABEL HERE

NEUROMUSCULAR BLOCKING AGENT (NMBA)

ORDERS

The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1.  Mechanical Ventilation Initiation Orders (form # 18389) are required

2.  Mechanical Ventilation Sedation Critical Care Orders (form # 15395) are required

3.  Maintain RASS: -5

4.  Central intravenous access preferred or a minimum of 2 peripheral intravenous sites

5.  Monitor twitch response and percent of blockade with peripheral nerve stimulator q 2 hrs. If not within goal range, titrate infusion q 15 min until goal range achieved.

6.  Adjust the rate of NMBA continuous infusion based on response from peripheral nerve stimulator and neuromuscular assessment to achieve 90% block = 1 twitch response

7.  When “wake up” assessment is ordered by physician

·  Nurse and Respiratory Therapist to coordinate, as needed

·  Stop NMBA for 1 hr q 12 hrs if approved by the physician

·  Restart at same or less rate when Train-of-Four equals 4 twitches and/or patient becomes hemodynamically/neurodynamically unstable

·  Notify physician if unable to obtain a Train-of-Four or block recovery

8.  Physical therapy to provide L’Nard boot. Rotate boot q 2 hrs between feet.

9.  Tape eye lids closed

10.  Patient weight ______kg

MEDICATIONS

11.  NMBA Loading Dose:

q Norcuron (vecuronium) 0.1 mg/kg IV Push x 1 dose

q Nimbex (cisatracurium) 0.2 mg/kg IV Push x 1 dose

12.  NMBA Continuous Infusion Dose:

q Norcuron (vecuronium) 50 mg in 250 ml normal saline. Begin at 1 mcg/kg/min then adjust to

maintain 90% suppression of twitch response. (Infusion range 0.8-1.2 mcg/kg/min)

Renal/Liver failure patients:

q Nimbex (cisatracurium) 200 mg in 200 ml normal saline. Begin at 3 mcg/kg/min then adjust

to maintain 90% suppression of twitch response. (Infusion range: 0.5-10 mcg/kg/min)

13. Lacrilube (mineral oil/petrolatum) apply ointment to both eyes q 6 hrs. DC Isopto Tears (hypromellose) if previously ordered.

14. Sedation Continuous Infusion Dose:

Patient must have continuous Anxiolytic AND Analgesic infusions prior to starting on paralytics.

PRN Medications

15. Emergency Reversal Agent:

Neostigmine methylsulfate 1 mg slow IV Push. May repeat q 5 minutes prn up to max total dose of 5 mg.

Atropine 0.02 mg/kg IV Push with each dose of Neostigmine.

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Date Time Physician Signature PID Number

Copy to pharmacy

*1-15396* FORM 1-15396 REV. 12/2014 Page 1 of 1