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Semin Respir Crit Care Med 2001; 22(2): 175-188
DOI: 10.1055/s-2001-13831
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Neuromuscular Blockade in the Intensive Care Unit

Lynne C. Gehr1 , Curtis N. Sessler2
  • 1Department of Anesthesiology, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, Virginia and
  • 2Division of Pulmonary and Critical Care Medicine, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, Virginia
Further Information

Publication History

Publication Date:
31 December 2001 (online)

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ABSTRACT

Neuromuscular blocking agents (NMBA) are frequently utilized in the ICU, primarily to facilitate mechanical ventilation. An ideal NMBA is nondepolarizing, has no propensity to accumulate, is easily titrated, has a rapid onset and offset, does not rely on organ function for metabolism, and has no toxic or active metabolites. Current NMBAs are classified as aminosteroids or benzylisoquinoliniums and have different features, but none are ideal. Selection of the best NMBA is determined by individual patient characteristics. Proper use of these agents includes a comprehensive plan to manage all aspects of care affected by NMBA, as well as monitoring of clinical effect and degree of neuromuscular blockade via periodic peripheral nerve stimulation. There are well-recognized complications of NMBA, including prolonged drug effect and acute quadriplegic myopathy. The latter condition can result in prolonged rehabilitation. The use of an NMBA can be essential for the successful outcome from critical illness; however, cautious use of these agents with a structured approach to minimize complications is urged.

KEYWORD

Neuromuscular blocking agent - peripheral nerve stimulation - prolonged paralysis

REFERENCES

  • 1 Martyr d' Anghera P. (1516) DeOrbe Novo.  English Translation by MacNutt FA New York: Putnam; 1912
    Google Scholar
  • 2 Brodie B C. Experiments and observations on different modes in which death is produced by certain vegetable poisons.  Phil Trans R Soc London. 1811;  194-195
    PubMedGoogle Scholar
  • 3 Gill R C. Curari, the flying death.  Natural History. 1935;  36 279-286
    PubMedGoogle Scholar
  • 4 Feldman S. Neuromuscular Block.  Oxford: Reed Educational and Professional Publishing, Ltd. 1996: 1-6
    Google Scholar
  • 5 Hansen-Flaschen J H, Brazinsky S, Basile C, Lanken P N. Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure: a national survey.  JAMA . 1991;  266 2870-2875
    CrossrefPubMedGoogle Scholar
  • 6 Christensen B V, Thunedborg L P. Use of sedatives, analgesics and neuromuscular blocking agents in Danish ICUs 1996/97: a national survey.  Intensive Care Med . 1999;  25 186-191
    CrossrefPubMedGoogle Scholar
  • 7 Magarey J M. Sedation of adult critically ill ventilated patients in intensive care units: a national survey.  Aust Crit Care . 1997;  10 90-93
    PubMedGoogle Scholar
  • 8 Dasta J F, Fuhrman T M, McCandles C. Patterns of prescribing and administering drugs for agitation and pain in patients in a surgical intensive care unit.  Crit Care Med . 1994;  22 974-980
    PubMedGoogle Scholar
  • 9 Prielipp R C, Coursin D B, Wood K E, Murray M J. Complications associated with sedative and neuromuscular blocking drugs in critically ill patients.  Crit Care Clin . 1995;  11 983-1003
    PubMedGoogle Scholar
  • 10 Strange C, Vaughan L, Franklin C, Johnson J. Comparison of train-of-four and best clinical assessment during continuous paralysis.  Am J Respir Crit Care Med . 1997;  156 1556-1561
    PubMedGoogle Scholar
  • 11 Rudis M I, Sikora C A, Angus E. A prospective, randomized, controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients.  Crit Care Med . 1997;  25 575-583
    CrossrefPubMedGoogle Scholar
  • 12 Mascia M F, Koch M, Medicis J J. Pharmacoeconomic impact of rational use guidelines on the provision of analgesia, sedation, and neuromuscular blockade in critical care.  Crit Care Med . 2000;  28 2300-2306
    PubMedGoogle Scholar
  • 13 Appadu B L, Greiff J M, Thompson J P. Postal survey on the long-term use of neuromuscular block in the intensive care.  Intensive Care Med . 1996;  22 862-866
    CrossrefPubMedGoogle Scholar
  • 14 Shapiro B A, Warren J, Egol A B. Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Society of Critical Care Medicine.  Crit Care Med . 1995;  23 1601-1605
    CrossrefPubMedGoogle Scholar
  • 15 Kleinpell R, Bedrosian C, McCormick L, Kremer M, Bujalski L, Bronsted R. Use of peripheral nerve stimulators to monitor patients with neuromuscular blockade in the ICU.  Am J Crit Care . 1996;  5 449-454
    PubMedGoogle Scholar
  • 16 Klessig H T, Geiger H J, Murray M J, Coursin D B. A national survey on the practice patterns of anesthesiologist intensivists in the use of muscle relaxants.  Crit Care Med . 1992;  20 1341-1345
    PubMedGoogle Scholar
  • 17 Bevan D R, Devan J C, Donati F. Muscle relaxants in clincal anesthesia. Chicago, Year Book Medical Publishers 1988
    Google Scholar
  • 18 Stoelting R, Miller R. Basics of Anesthesia.  Philadelphia: Churchill Livingstone 1994: 83-94
    Google Scholar
  • 19 Bowman W C. Pharmacology of neuromuscular function. 2nd ed. London: Wright; 1990
    Google Scholar
  • 20 Taylor P. Are neuromuscular blocking agents more efficacious in Paris?.  Anesthesiology . 1985;  63 1-3
    PubMedGoogle Scholar
  • 21 Changeux J P. The nicotineic acetylcholine receptor: an allosteric protein prototype of ligand-gated ion channels.  Trends Pharm Sci . 1900;  11 485
    PubMedGoogle Scholar
  • 22 Waud D R. The nature of ``depolarization block''.  Anesthesiology . 1968;  29 1014
    PubMedGoogle Scholar
  • 23 Sokoll M D, Gergis S D. Antibiotics and neuromuscular function.  Anesthesiology . 1981;  55 148-159
    CrossrefPubMedGoogle Scholar
  • 24 Bevan D R, Donati F. Muscle relaxants. In: Barash P, Cullen B, Stoelting R, eds. Clinical Anesthesia Philadelphia: JB Lippincott 1992: 481-484
    Google Scholar
  • 25 Ducharme J, Donati F. Pharmacokinetics and pharmacodynamics of steroid muscle relaxants. In: Partridge B, ed. Anesth Clinics N Am Philadelphia: WB Saunders 1993: 11:283-285
    Google Scholar
  • 26 Bowman W C. Nonrelaxant properties of neuromuscular blocking drugs.  Br J Anesth . 1982;  54 147
    PubMedGoogle Scholar
  • 27 Basta S J. Modulation of histamine release by neuromuscular blocking drugs.  Curr Opin Anaestheiol . 1992;  5 572-576
    PubMedGoogle Scholar
  • 28 Matthey P, Wang P, Finegan B A, Donnelly M. Rocuronium anaphylaxis and multiple neuromuscular blocking drug sensitivities.  Can J Anaesth . 2000;  47 890-893
    PubMedGoogle Scholar
  • 29 Pollard B T. Neuromuscular blocking agents in specific clinical situations. In: Pollard BT, ed. Applied Neuromuscular Pharmacology Oxford: Oxford University Press; 1994
    Google Scholar
  • 30 Caldwell J E, Castagnoli K P, Canfell P C. Pipecuronium and pancuronium: comparison of pharmacokinetics and duration of action.  Br J Anaesth . 1988;  61 693
    PubMedGoogle Scholar
  • 31 Atherton D P, Hunter J M. Clinical pharmacokinetics of the newer neuromuscular blocking drugs.  Clin Pharmacokinet . 1999;  36 169-189
    PubMedGoogle Scholar
  • 32 Cook D R, Freeman J A, Lai A A. Pharmacokinetics and pharmacodynamics of doxacurium in normal patients and in those with hepatic or renal failure.  Anesth Analg . 1991;  72 145-150
    PubMedGoogle Scholar
  • 33 Doenicke A W, Czeslick E, Moss J, Hoernecke R. Onset time, endotracheal intubating conditions, and plasma histamine after cisatracurium and vecuronium administration.  Anesth Analg . 1998;  87 434-438
    PubMedGoogle Scholar
  • 34 Schramm W M, Papousek A, Michalek-Sauberer A, Czech T, Illievich U. The cerebral and cardiovascular effects of cisatracurium and atracurium in neurosurgical patients.  Anesth Analg . 1998;  86 123-127
    PubMedGoogle Scholar
  • 35 Kisor D F, Schmith V D, Wargin W A, Lien C A, Ornstein E, Cook D R. Importance of the organ-independent elimination of cisatracurium.  Anesth Analg . 1996;  83 1065-1071
    CrossrefPubMedGoogle Scholar
  • 36 Smith C E, van Miert M M, Parker C J, Hunter J M. A comparison of the infusion pharmacokinetics and pharmacodynamics of cisatracurium, the 1R-cis 1'R-cis isomer of atracurium, with atracurium besylate in healthy patients.  Anaesthesia . 1997;  52 833-841
    CrossrefPubMedGoogle Scholar
  • 37 Prielipp R C, Coursin D B, Scuderi P E. Comparison of the infusion requirements and recovery profiles of vecuronium and cisatracurium 51W89 in intensive care unit patients.  Anesth Analg . 1995;  81 3-12
    PubMedGoogle Scholar
  • 38 Bryson H M, Faulds D. Cisatracurium besilate: a review of its pharmacology and clinical potential in anaesthetic practice.  Drugs . 1997;  53 848-866
    PubMedGoogle Scholar
  • 39 Pearson A J, Harper N J, Pollard B J. The infusion requirements and recovery characteristics of cisatracurium or atracurium in intensive care patients.  Intensive Care Med . 1996;  22 694-698
    PubMedGoogle Scholar
  • 40 Davidson J E. Neuromuscular blockade: indications, peripheral nerve stimulation, and other concurrent interventions.  New Horiz . 1994;  2 75-84
    PubMedGoogle Scholar
  • 41 Blacher R S. On awakening paralyzed during surgery: a syndrome of traumatic neurosis.  JAMA . 1975;  234 67-68
    CrossrefPubMedGoogle Scholar
  • 42 Nielsen C H, Johnson G A. The experience of complete neuromuscular blockade in awake patients.  J Clin Anesth . 1994;  6 450
    PubMedGoogle Scholar
  • 43 Wagner B K, Zavotsky K E, Sweeney J B, Palmeri B A, Hammond J S. Patient recall of therapeutic paralysis in a surgical critical care unit.  Pharmacotherapy . 1998;  18 358-363
    PubMedGoogle Scholar
  • 44 Simmons L E, Riker R R, Prato B S, Fraser G L. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation-Agitation Scale.  Crit Care Med . 1999;  27 1499-1504
    CrossrefPubMedGoogle Scholar
  • 45 Segredo V, Matthay M A, Sharma M L, Gruenke L D, Caldwell J E, Miller R D. Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients.  Anesthesiology . 1990;  72 566-570
    CrossrefPubMedGoogle Scholar
  • 46 Engbaek J, Ostergaard D, Viby-Mogensen J, Skovgaard L T. Clinical recovery and train-of-four ratio measured mechanically and electromyographically following atracurium.  Anesthesiology . 1989;  71 391-395
    PubMedGoogle Scholar
  • 47 Orko R, Heino A, Rosenberg P H. Vecuronium in patients with and without renal failure.  Acta Anaesthesiol Scand . 1985;  29 326-329
    PubMedGoogle Scholar
  • 48 Miller L R, Benumof J L, Alexander L, Miller C A, Stein D. Completely absent response to peripheral nerve stimulation in an acutely hypothyroid patient.  Anesthesiology . 1989;  71 779-781
    PubMedGoogle Scholar
  • 49 Sgalio T. Monitoring the administration of neuromuscular blockade in critical care.  Crit Care Nurs Q . 1995;  18 41-59
    PubMedGoogle Scholar
  • 50 Brull S J, Silverman D G. Real time versus slow-motion train-of-four monitoring: a theory to explain the inaccuracy of visual assessment.  Anesth Analg. 1995;  80 548-551
    PubMedGoogle Scholar
  • 51 Wymore M L, Eisele J H. Differential effects of d-tubocurarine on inspiratory muscles and two peripheral muscle groups in anesthetized man.  Anesthesiology . 1978;  48 360-362
    PubMedGoogle Scholar
  • 52 Murray M J. Monitoring of peripheral nerve stimulation versus standard clinical assessment for dosing of neuromuscular blocking agents.  Crit Care Med . 1997;  25 561-562
    PubMedGoogle Scholar
  • 53 Fernando P U, Viby-Mogensen J, Bonsu A K, Tamilarasan A, Muchhal K K, Lambourne A. Relationship between post-tetanic count and response to carinal stimulation during vecuronium-induced neuromuscular blockade.  Acta Anaesthesiol Scand . 1987;  31 593-596
    PubMedGoogle Scholar
  • 54 Harper N J. Neuromuscular blocking drugs: practical aspects of research in the intensive care unit.  Intensive Care Med . 1993;  19 S80-S85
    CrossrefPubMedGoogle Scholar
  • 55 Bragg P, Fisher D M, Shi J. Comparison of twitch depression of the adductor pollicis and the respiratory muscles: pharmacodynamic modeling without plasma concentrations.  Anesthesiology . 1994;  80 310-319
    PubMedGoogle Scholar
  • 56 Frankel H, Jeng J, Tilly E, St Andre A, Champion H. The impact of implementation of neuromuscular blockade monitoring standards in a surgical intensive care unit.  Am Surg . 1996;  62 503-506
    PubMedGoogle Scholar
  • 57 Bencini A F, Houwertjes M C, Agoston S. Effects of hepatic uptake of vecuronium bromide and its putative metabolites on their neuromuscular blocking actions in the cat.  Br J Anaesth . 1985;  57 789-795
    PubMedGoogle Scholar
  • 58 Marshall I G, Gibb A J, Durant N N. Neuromuscular and vagal blocking actions of pancuronium bromide, its metabolites, and vecuronium bromide (Org NC45) and its potential metabolites in the anaesthetized cat.  Br J Anaesth . 1983;  55 703-714
    PubMedGoogle Scholar
  • 59 Marik P E. Doxacurium-corticosteroid acute myopathy: another piece to the puzzle.  Crit Care Med . 1996;  24 1266-1267
    PubMedGoogle Scholar
  • 60 Davis N A, Rodgers J E, Gonzalez E R, Fowler III A A. Prolonged weakness after cisatracurium infusion: a case report.  Crit Care Med . 1998;  26 1290-1292
    PubMedGoogle Scholar
  • 61 Segredo V, Caldwell J E, Matthay M A, Sharma M L, Gruenke L D, Miller R D. Persistent paralysis in critically ill patients after long-term administration of vecuronium.  N Engl J Med . 1992;  327 524-528
    CrossrefPubMedGoogle Scholar
  • 62 Fischer J R, Baer R K. Acute myopathy associated with combined use of corticosteroids and neuromuscular blocking agents.  Ann Pharmacother . 1996;  30 1437-1445
    PubMedGoogle Scholar
  • 63 Leatherman J W, Fluegel W L, David W S, Davies S F, Iber C. Muscle weakness in mechanically ventilated patients with severe asthma.  Am J Respir Crit Care Med . 1996;  153 1686-1690
    CrossrefPubMedGoogle Scholar
  • 64 Giostra E, Magistris M R, Pizzolato G, Cox J, Chevrolet J C. Neuromuscular disorder in intensive care unit patients treated with pancuronium bromide: occurrence in a cluster group of seven patients and two sporadic cases, with electrophysiologic and histologic examination.  Chest . 1994;  106 210-220
    PubMedGoogle Scholar
  • 65 Douglass J A, Tuxen D V, Horne M. Myopathy in severe asthma.  Am Rev Respir Dis . 1992;  146 517-519
    PubMedGoogle Scholar
  • 66 Hansen-Flaschen J, Cowen J, Raps E C. Neuromuscular blockade in the intensive care unit: more than we bargained for.  Am Rev Respir Dis . 1993;  147 234-236
    PubMedGoogle Scholar
  • 67 Zochodne D W, Bolton C F, Wells G A. Critical illness polyneuropathy: a complication of sepsis and multiple organ failure.  Brain . 1987;  110 819-841
    CrossrefPubMedGoogle Scholar
  • 68 Leijten F S, de Weerd W A. Critical illness polyneuropathy, facts and controversies.  J Peripher Nerv Syst . 1996;  1 28-33
    PubMedGoogle Scholar
  • 69 Kupfer Y, Okrent D G, Twersky R A, Tessler S. Disuse atrophy in a ventilated patient with status asthmaticus receiving neuromuscular blockade.  Crit Care Med . 1987;  15 795-796
    PubMedGoogle Scholar
  • 70 Watling S M, Dasta J F. Prolonged paralysis in intensive care unit patients after the use of neuromuscular blocking agents: a review of the literature.  Crit Care Med . 1994;  22 884-893
    CrossrefPubMedGoogle Scholar
  • 71 Newman P J, Quinn A C, Grounds R M. A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients.  Crit Care Med . 1997;  25 1139-1142
    PubMedGoogle Scholar
  • 72 Prielipp R C, Robinson J C, Wilson J A, MacGregor D A, Scuderi P E. Dose response, recovery, and cost of doxacurium as a continuous infusion in neurosurgical intensive care unit patients.  Crit Care Med . 1997;  25 1236-1241
    PubMedGoogle Scholar
  • 73 de Lemos M J, Carr R R, Shalansky K F, Bevan D R, Ronco J J. Paralysis in the critically ill: intermittent bolus pancuronium compared with continuous infusion.  Crit Care Med . 1999;  27 2648-2655
    PubMedGoogle Scholar
  • 74 MacFarlane I A, Rosenthal F D. Severe myopathy after status asthmaticus.  Lancet . 1977;  2 615
    PubMedGoogle Scholar
  • 75 Ramsay D A, Zochodne D W, Robertson D M, Nag S, Ludwin S K. A syndrome of acute severe muscle necrosis in intensive care unit patients.  J Neuropathol Exp Neurol . 1993;  52 387-398
    PubMedGoogle Scholar
  • 76 Sladen R N. Neuromuscular blocking agents in the intensive care unit: a two-edged sword.  Crit Care Med . 1995;  23 423-428
    PubMedGoogle Scholar
  • 77 Op de Coul A A, Lambregts P C, Koeman J, van Puyenbroek J M, Ter Laak J H, Gabreels-Festen A A. Neuromuscular complications in patients given Pavulon (pancuronium bromide) during artificial ventilation.  Clin Neurol Neurosurg . 1985;  87 17-22
    CrossrefPubMedGoogle Scholar
  • 78 Gooch J L, Suchyta M R, Balbierz J M, Petajan J H, Clemmer T P. Prolonged paralysis after treatment with neuromuscular junction blocking agents.  Crit Care Med . 1991;  19 1125-1131
    PubMedGoogle Scholar
  • 79 Branney S W, Haenel J B, Moore F A, Tarbox B B, Schreiber R H, Moore E E. Prolonged paralysis with atracurium infusion: a case report.  Crit Care Med . 1994;  22 1699-1701
    PubMedGoogle Scholar
  • 80 Behbehani N A, Al-Mane F, D'Yachkova Y, Pare P, FitzGerald J M. Myopathy following mechanical ventilation for acute severe asthma: the role of muscle relaxants and corticosteroids.  Chest . 1999;  115 1627-1631
    CrossrefPubMedGoogle Scholar
  • 81 Larsson L, Li X, Edstrom L. Acute quadriplegia and loss of muscle myosin in patients treated with nondepolarizing neuromuscular blocking agents and corticosteroids: mechanisms at the cellular and molecular levels.  Crit Care Med . 2000;  28 34-45
    PubMedGoogle Scholar
  • 82 Rudis M I, Guslits B J, Peterson E L. Economic impact of prolonged motor weakness complicating neuromuscular blockade in the intensive care unit.  Crit Care Med . 1996;  24 1749-1756
    PubMedGoogle Scholar
  • 83 Barohn R J, Jackson C E, Rogers S J, Ridings L W, McVey A L. Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids.  Muscle Nerve . 1994;  17 647-654
    PubMedGoogle Scholar
  • 84 Meyer K C, Prielipp R C, Grossman J E, Coursin D B. Prolonged weakness after infusion of atracurium in two intensive care unit patients.  Anesth Analg . 1994;  78 772-774
    PubMedGoogle Scholar
  • 85 Faragher M W, Day B J, Dennett X. Critical care myopathy: an electrophysiological and histological study.  Muscle Nerve . 1996;  19 516-518
    PubMedGoogle Scholar
  • 86 Massa R, Carpenter S, Holland P, Karpati G. Loss and renewal of thick myofilaments in glucocorticoid-treated rat soleus after denervation and reinnervation.  Muscle Nerve . 1992;  15 1290-1298
    CrossrefPubMedGoogle Scholar
  • 87 DuBois D C, Almon R R. A possible role for glucocorticoids in denervation atrophy.  Muscle Nerve . 1981;  4 370-373
    PubMedGoogle Scholar
  • 88 Panegyres P K, Squier M, Mills K R, Newsom-Davis J. Acute myopathy associated with large parenteral dose of corticosteroid in myasthenia gravis.  J Neurol Neurosurg Psychiatry . 1993;  56 702-704
    CrossrefPubMedGoogle Scholar
  • 89 Bolton C F. Neuromuscular conditions in the intensive care unit.  Intensive Care Med . 1996;  22 841-843
    CrossrefPubMedGoogle Scholar