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PLACE LABEL HERE NEUROMUSCULAR BLOCKING AGENT (NMBA) ORDERS The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage). 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Mechanical Ventilation Initiation Orders (form # 18389) are required Mechanical Ventilation Sedation Critical Care Orders (form # 15395) are required Maintain RASS: -5 Central intravenous access preferred or a minimum of 2 peripheral intravenous sites 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. Adjust the rate of NMBA continuous infusion based on response from peripheral nerve stimulator and neuromuscular assessment to achieve 90% block = 1 twitch response 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 Physical therapy to provide L’Nard boot. Rotate boot q 2 hrs between feet. Tape eye lids closed Patient weight ______ kg MEDICATIONS 11. NMBA Loading Dose: Norcuron (vecuronium) 0.1 mg/kg IV Push x 1 dose Nimbex (cisatracurium) 0.2 mg/kg IV Push x 1 dose 12. NMBA Continuous Infusion Dose: 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: 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. _______________ Date ________________ Time _____________________________ Physician Signature _____________ PID Number Copy to pharmacy *1-15396* FORM 1-15396 REV. 12/2014 Page 1 of 1