What are the protocol orders for paralyzing and proning in patients with severe Acute Respiratory Distress Syndrome (ARDS)?

Protocol Orders for Paralyzing and Proning in Severe ARDS

For patients with severe ARDS who require deep sedation to facilitate lung-protective ventilation or prone positioning, a neuromuscular blocking agent (NMBA) infusion for up to 48 hours is recommended over intermittent boluses. 1, 2

Patient Selection Criteria

• Consider NMBA use and prone positioning in patients with:
  • Severe ARDS (PaO₂/FiO₂ ≤100 mmHg) 1, 2
  • Persistent hypoxemia despite optimized ventilation
  • Patient-ventilator dyssynchrony despite deep sedation
  • Inability to maintain lung-protective ventilation with deep sedation alone
  • Elevated plateau pressures (>30 cmH₂O) despite optimization

Step-by-Step Protocol for NMBA Administration

1. Before initiating NMBA:

   • Ensure adequate sedation (Ramsay sedation score of 6)
   • Optimize mechanical ventilation (low tidal volume 4-8 mL/kg PBW)
   • Set plateau pressure <30 cmH₂O and optimize PEEP

2. NMBA Administration:

   • Agent of choice: Cisatracurium 1, 2
   • Initial dosing: 15 mg IV bolus followed by 37.5 mg/h infusion 1, 2
   • Alternative approach: Train-of-Four (TOF) guided titration starting at lower doses (11-15 mg/h) 3, 4
   • Duration: Up to 48 hours 1, 2

3. Monitoring during NMBA therapy:

   • Ensure deep sedation before and during paralysis
   • Monitor adequacy of paralysis using Train-of-Four (TOF) assessment 1, 3
   • Target TOF of 0 twitches at the ulnar site for profound block 3
   • Monitor ventilator parameters for patient-ventilator dyssynchrony
   • Assess oxygenation parameters (PaO₂/FiO₂ ratio) regularly

Prone Positioning Protocol

1. Indications:

   • Severe hypoxemia (PaO₂/FiO₂ <150 mmHg) 2
   • Failure to improve with standard ventilation strategies

2. Preparation:

   • Ensure adequate NMBA effect before proning
   • Secure all lines, tubes, and catheters
   • Assemble a team of 4-5 healthcare providers
   • Use appropriate positioning aids (face cushions, pillows for chest/pelvis)

3. Procedure:

   • Maintain prone position for 12-16 hours per day 2
   • Return to supine position for 6-8 hours
   • Continue cycles until oxygenation improves and can be maintained in supine position
   • Monitor for complications (pressure injuries, facial edema, endotracheal tube displacement)

4. Contraindications to prone positioning:

   • Unstable spine or pelvic fractures
   • Open abdominal wounds
   • Hemodynamic instability
   • Increased intracranial pressure
   • Recent sternotomy or cardiac surgery

Ventilation Management During Paralysis and Proning

• Use lung-protective ventilation strategy:
  • Tidal volume: 6 mL/kg predicted body weight
  • Plateau pressure: <30 cmH₂O
  • PEEP: Higher titrated levels (typically 10-15 cmH₂O) for severe ARDS 2
  • Target PaO₂: 70-90 mmHg 2
  • Target SpO₂: 88-95% 5

Weaning Protocol

1. NMBA Discontinuation:

   • Limit duration to 48 hours when possible 1, 2
   • Assess for return of neuromuscular function after discontinuation
   • Monitor for ICU-acquired weakness

2. Return to Supine Position:

   • Consider return to supine when PaO₂/FiO₂ >150 mmHg for >4 hours
   • Continue lung-protective ventilation strategies

Important Considerations and Pitfalls

• TOF-guided dosing: Recent evidence suggests TOF-guided titration can reduce cisatracurium consumption by up to 60% while maintaining efficacy 3, 4
• Conflicting evidence: While earlier studies showed mortality benefit with NMBA use 5, 6, the more recent ROSE trial showed no difference in 90-day mortality 7
• ICU-acquired weakness: Monitor for muscle weakness after NMBA discontinuation, though studies have not shown increased incidence with 48-hour use 5
• Avoid prolonged paralysis: Limit NMBA use to 48 hours when possible to minimize complications
• Cardiovascular events: Be vigilant for increased adverse cardiovascular events during NMBA therapy 7

By following this protocol for paralyzing and proning in severe ARDS, clinicians can optimize oxygenation while minimizing potential complications associated with these interventions.