Skip to main content

Use of Neuromuscular Blocking Agents in the Intensive Care Unit

  • Chapter
  • First Online:
Critical Care Study Guide

Abstract

Understand the pharmacokinetics and pharmacodynamics of various neuromuscular blocking (NMB) agents. Understand the complications associated with the prolonged use of NMB agents in the critically ill patient and how to minimize them. Recognize the potential for interaction among commonly used drugs and NMB agents. Make recommendations regarding the use and dose of NMB agents in the critically ill. Understand the need for routine and effective sedation and analgesia in the critically ill patient receiving NMB agents in order to prevent awareness and pain. Understand the need for evaluation and monitoring of neuromuscular function in the critically ill patient receiving NMB agents.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Hansen-Flaschen JH, Brazinsky S, Basile C et al (2870) Use of sedating and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure: a national survey. JAMA 1991:266.

    Google Scholar 

  2. Smith SM, Brown HO, Toman JEP, Goodman LS (1947) The lack of cerebral effects of d-Tubocurarine. Anesthesiology 1:1.

    Article  Google Scholar 

  3. Wagner BKJ, Zavotsky KE, Sweeney JB, Palmeri BA, Hammond JS (1998) Patient recall of therapeutic paralysis in a surgical critical care unit. Pharmacotherapy 18:358–363.

    PubMed  CAS  Google Scholar 

  4. Standaert FG (1994) Doughnuts and holes: molecules and muscle relaxants. Semin Anesth 13:286–96.

    Google Scholar 

  5. Naguib M, Lien C. Pharmacology of muscle relaxants and their antagonists. In: Miller RD, ed. Miller’s Anesthesia. 6th ed. Philadelphia: Elsevier/Churchill Livingstone. 2005;486-492.

    Google Scholar 

  6. Martyn JAJ, White DA, Gronert GA, Jaffe RS, Ward JM (1992) Up-and-down regulation of skeletal muscle acetylcholine receptors. Anesthesiology 76:822–843.

    Article  PubMed  CAS  Google Scholar 

  7. Lee C (1995) Intensive care unit neuromuscular syndrome? Anesthesiology 83:237–240.

    Article  PubMed  CAS  Google Scholar 

  8. Hunter JM (1995) New neuromuscular blocking drugs. N Engl J Med 332:1691–1699.

    Article  PubMed  CAS  Google Scholar 

  9. Kirkegaard-Nielsen H, Caldwell JE, Berry PD (1999) Rapid tracheal intubation with rocuronium: a probability approach to determining dose. Anesthesiology 91(1):131–136.

    Article  PubMed  CAS  Google Scholar 

  10. Sparr HJ, Wierda JH, Proost C, Keller C, Khuenl-Brady KS (1997) Pharmacodynamics and pharmacokinetics of rocuronium in intensive care patients. Br J Anaesth 78:267–273.

    Article  PubMed  CAS  Google Scholar 

  11. Hunter JM (1987) Infusions of atracurium and vecuronium in patients with multisystem organ failure in the intensive therapy unit. Insights into. Anaesthesiology 1:23.

    Google Scholar 

  12. Manthous CA, Chatila W (1995) Atracurium and status epilepticus? Crit Care Med 23:1440–1442.

    Article  PubMed  CAS  Google Scholar 

  13. Gwinnutt CL, Eddleston D, Edwards D, Pollard BJ (1990) Concentrations of atracurium and laudanosine in cerebrospinal fluid and plasma in three intensive care patients. Br J Anaesth 65:829–832.

    Article  PubMed  CAS  Google Scholar 

  14. Schmith VD, Phillips L, Kisor DF, Fiedler-Kelly J, Weatherley BC (1996) Pharmacokinetics/pharmacodynamics of cisatracurium in healthy adult patients. Curr Opin Anaesthesiol 9(suppl 1):S9–S15.

    Google Scholar 

  15. Pearson AJ, Harper NJ, Pollard BJ (1996) The infusion requirements and recovery characteristics of cisatracurium or atracurium in intensive care patients. Intensive Care Med 22:694–698.

    Article  PubMed  CAS  Google Scholar 

  16. Bion J, Prielipp RC, Bihari D, Grounds M, Harper N, Hunter JM, Pollard B, Pearson J, Coursin DB, Murray MJ, Prough DS, Scuderi P, Vender JS (1996) Cisatracurium in intensive care. Curr Opin Anaesthesiol 9(suppl 1):S45–S49.

    Google Scholar 

  17. Appadu BL, Greiff JMC, Thompson JP (1996) Postal survey on the long-term use of neuromuscular block in the intensive care. Intensive Care Med 22:862–866.

    Article  PubMed  CAS  Google Scholar 

  18. Murphy G, Szokol J (2004) Monitoring neuromuscular blockade. Int Anesthesiol Clin 42(2):25–40.

    Article  PubMed  Google Scholar 

  19. Nicholson WT, Sprung J, Jankowski CJ (2007) Sugammadex: a novel agent for the reversal of neuromuscular blockade. Pharmaco­therapy 27(8):1181–1188.

    Article  PubMed  CAS  Google Scholar 

  20. Sessler CN (2005) Sedation, analgesia and neuromuscular blockade for high-frequency oscillatory ventilation. Crit Care Med 33(suppl 3):S209–16.

    Article  PubMed  CAS  Google Scholar 

  21. Arroliga A et al (2005) Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest 128:496–506.

    Article  PubMed  Google Scholar 

  22. Murray M, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Critical Care Med. 2002;30(1):142-156.

    Article  CAS  Google Scholar 

  23. Vender JS. et al. Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review. Critical Care Med. 2004;32(suppl 11):S554-S561.

    Article  Google Scholar 

  24. Vinik HR, Bradley EL, Kissin I (1994) Triple anesthetic combination: propofol-midazolam-alfentanil. Anesth Analg 78:354–358.

    Article  PubMed  CAS  Google Scholar 

  25. Cohen AT, Kelly DR (1987) Assessment of alfentanyl by intravenous infusion as long-term sedation in intensive care. Anesthe­siology 42:545–548.

    CAS  Google Scholar 

  26. Sessler CN (2004) Train-of-four to monitor neuromuscular blockade? Chest 126:1018–1022.

    Article  PubMed  Google Scholar 

  27. Watling SM, Dasta JF (1994) Prolonged paralysis in intensive care unit patients after the use of neuromuscular blocking agents: a review of the literature. Crit Care Med 22:884–893.

    Article  PubMed  CAS  Google Scholar 

  28. Deem S, Lee C, Curtis R (2003) Acquired neuromuscular disorders in the intensive care unit. Am J Respir Crit Care Med 168:735–739.

    Article  PubMed  Google Scholar 

  29. Ely EW, Baker AM, Dunagan DP et al (1996) Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 335:1864–69.

    Article  PubMed  CAS  Google Scholar 

  30. Earl G, McMahon MB, Bartley M, Mancini W, Becker S (1997) Development of a policy for patients receiving neuromuscular blocking agents. J Trauma Nurs 4:76–81.

    PubMed  CAS  Google Scholar 

  31. Jones S (2003) An algorithm for train-of-four monitoring in patients receiving continuous neuromuscular blocking agents. Dimens Crit Care Nurs 22(2):50–7.

    Article  PubMed  Google Scholar 

  32. Lee CM (1975) Train of four quantitation of competitive neuromuscular blockade. Anesth Analg 54:649–53.

    PubMed  CAS  Google Scholar 

  33. Viby-Mogensen, J. Neuromuscular monitoring. In: Miller RD, ed. Anesthesia. 6th ed. Philadelphia: Elsevier/Churchill Livingstone. 2005;1557.

    Google Scholar 

  34. Donati F, Meistelman C, Plaud B (1990) Vecuronium neuromuscular blockade at the diaphragm, the orbicularis oculi, and adductor pollicis muscles. Anesthesiology 73:870–875.

    Article  PubMed  CAS  Google Scholar 

  35. Fiamengo SA, Savarese JJ (1991) Use of muscle relaxants in intensive care units. Crit Care Med 19:1457–58.

    Article  PubMed  CAS  Google Scholar 

  36. Eriksson LI, Lennmarken C, Staun P et al (1990) Use of post-tetanic count in assessment of a repetitive vecuronium-induced neuromuscular block. Br J Anaesth 65:487–493.

    Article  PubMed  CAS  Google Scholar 

  37. Bauman MH (2004) A prospective randomized comparison of train-of-four monitoring and clinical assessment during continuous ICU cisatracurium paralysis. Chest 126(4):1018–22.

    Article  Google Scholar 

  38. Schweickert WD, Hall J. ICU-acquired weakness. Chest. 2007;131(5)1541-1549.

    Article  PubMed  Google Scholar 

  39. Lopez DM, Singer LP, Weingarten-Arams JS, Rubin DH, Conway EE (1999) Use of neuromuscular blocking agents and sedation in pediatric patients and associated prolonged neuromuscular weakness. Pharm Ther 24:290–296.

    Google Scholar 

  40. Kupfer Y, Namba T, Kaldawi E, Tessler S (1992) Prolonged weakness after long-term infusion of vecuronium bromide. Ann Intern Med 117:484–6.

    PubMed  CAS  Google Scholar 

  41. Khuenl-Brady KS, Reitstatter B, Schlager A, Schreithofer D, Luger T, Seyr M, Mutz N, Agoston S (1994) Long-term administration of pancuronium and pipecuronium in the intensive care unit. Anesth Analg 78:1082–6.

    Article  PubMed  CAS  Google Scholar 

  42. Segredo V, Matthay MA, Sharma ML et al (1990) Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients. Anesthesiology 72:566.

    Article  PubMed  CAS  Google Scholar 

  43. Segredo V, Caldwell JE, Matthay MA et al (1992) Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med 327:524.

    Article  PubMed  CAS  Google Scholar 

  44. Caldwell JE, Szenohradszky J, Segredo V et al (1994) The pharmacodynamics and pharmacokinetics of the metabolite 3-desacetylvecuronium (ORG 7268) and its parent compound, vecuronium, in human volunteers. JPET 270:1216–1222.

    CAS  Google Scholar 

  45. Wright PMC, Hart P, Lau M et al (1994) Cumulative characteristics of atracurium and vecuronium. Anesthesiology 81:59–68.

    Article  PubMed  CAS  Google Scholar 

  46. Hansen-Flaschen J, Cowen J, Raps EC (1993) Neuromuscular blockade in the intensive care unit: more than we bargained for. Am Rev Respir Dis 147:234–236.

    Article  PubMed  CAS  Google Scholar 

  47. Lacomis D, Smith TW, Chad DA (1993) Acute myopathy and neuropathy in status asthmaticus: case report and literature review. Muscle Nerve 16:84–90.

    Article  PubMed  CAS  Google Scholar 

  48. Zochodne DW, Ramsay DA, Saly V et al (1994) Acute necrotizing myopathy of intensive care: electrophysiological studies. Muscle Nerve 17:285–292.

    Article  PubMed  CAS  Google Scholar 

  49. Leatherman, JW, Fluegel, WL, David WS, Davies SF, Iber C. Muscle weakness in mechanically ventilated patients with severe asthma. Am J Respir Crit Care Med. 1996;153:1686-1690.

    CAS  Google Scholar 

  50. Griffin D, Fairman N, Coursin D, Rawsthorne L, Grossman JE (1992) Acute myopathy during treatment of status asthmaticus with corticosteroids and steroidal muscle relaxants. Chest 102:510–14.

    Article  PubMed  CAS  Google Scholar 

  51. Douglass JA, Tuxen DV, Horne M, Scheinkestel CD, Weinmann M, Czarny D, Bowes G (1992) Myopathy in severe asthma. Am Rev Respir Dis 146:517–519.

    PubMed  CAS  Google Scholar 

  52. Meyer KC, Prielipp RC, Grossman JE et al (1994) Prolonged weakness after infusion of atracurium in intensive care unit patients. Anesth Analg 78:772–4.

    Article  PubMed  CAS  Google Scholar 

  53. Davis NA, Rodgers JOE, Gonzalez ER, Fowler AA (1998) Prolonged weakness after cisatracurium infusion: a case report. Crit Care Med 26:1290–1292.

    Article  PubMed  CAS  Google Scholar 

  54. Marik PE (1996) Doxacurium-corticosteroid acute myopathy: another piece of the puzzle. Crit Care Med 24:1266–1267.

    Article  PubMed  CAS  Google Scholar 

  55. Barohn RJ, Jackson CE, Rogers SJ, Ridings LW, McVey AL (1994) Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids. Muscle Nerve 17:647–654.

    Article  PubMed  CAS  Google Scholar 

  56. Dodson BA, Kelly BJ, Braswell LM, Cohen NH (1993) Long-term, high dose muscle relaxation causes up-regulation of acetylcholine receptors in critically ill adults. Anesthesiology 79:A292.

    Google Scholar 

  57. Rich MM, Teener JW, Schotland REC, DL BSJ (1996) Muscle is electrically inexcitable in acute quadriplegic myopathy. Neurology 46:731–736.

    Article  PubMed  CAS  Google Scholar 

  58. Tsukagoshi H, Morita T, Takahashi K, Kunimoto F, Goto F (1999) Cecal ligation and puncture peritonitis model shows decreased nicotinic acetylcholine receptor numbers in rat muscle. Anesthesiology 91:448–460.

    Article  PubMed  CAS  Google Scholar 

Additional Reading

  • Murray M, Cowen J, DeBlock H et al (2002) Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 30:142–156

    Article  PubMed  CAS  Google Scholar 

  • Arroliga A, Frutos-Vivar F et al (2005) Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation. Chest 128:496–506

    Article  PubMed  Google Scholar 

  • Murray M, Brull S, Bolton C (2006) Brief review: nondepolarizing neuromuscular blocking drugs and critical illness myopathy. Can J of Anesth 53(11):1148–1156

    Article  Google Scholar 

  • Fields A, Valdivelu N (2007) Sugammadex: a novel neuromuscular blocker binding agent. Curr Opin Anesth 20:307–310

    Article  Google Scholar 

  • Ballard N, Robley L et al (2006) Patient’s recollection of therapeutic paralysis in the intensive care unit. Am J Crit Care 16:86–95

    Google Scholar 

  • Barohn RJ, Jackson CE, Rogers SJ et al (1994) Prolonged paralysis due to nondepolarizing neuromuscular blocking agents and corticosteroids. Muscle Nerve 17:647–654

    Article  PubMed  CAS  Google Scholar 

  • Caldwell JE, Szenohradszky J, Segredo V et al (1994) The pharmacodynamics and pharmacokinetics of the metabolite 3-desacetylvecuronium (ORG 7268) and its parent compound, vecuronium, in human volunteers. JPET 270:1216–1222

    CAS  Google Scholar 

  • Gooch JL (1995) AAEM case report #29: prolonged paralysis after neuromuscular blockade. Muscle Nerve 18:937–942

    Article  PubMed  CAS  Google Scholar 

  • Hoyt JW (1994) Persistent paralysis in critically ill patients after the use of neuromuscular blocking agents. New Horiz 2:48–55

    PubMed  CAS  Google Scholar 

  • Lee C (1995) Intensive care unit neuromuscular syndrome? Anes­thesiology 83:237–240

    Article  PubMed  CAS  Google Scholar 

  • Lopez DM, Singer LP, Weingarten-Arams JS et al (1999) Use of neuromuscular blocking agents and sedation in pediatric patients and associated prolonged neuromuscular weakness. Pharm Ther 24: 290–296

    Google Scholar 

  • Martyn JAJ, White DA, Gronert GA et al (1992) Up-and-down regulation of skeletal muscle acetylcholine receptors. Anesthesiology 76:822–843

    Article  PubMed  CAS  Google Scholar 

  • Rich MM, Teener JW, Raps EC et al (1996) Muscle is electrically inexcitable in acute quadriplegic myopathy. Neurology 46: 731–736

    Article  PubMed  CAS  Google Scholar 

  • Standaert FG (1994) Doughnuts and holes: molecules and muscle relaxants. Semin Anesth 13:286–96

    Google Scholar 

  • Tsukagoshi H, Morita T, Takahashi K et al (1999) Cecal ligation and puncture peritonitis model shows decreased nicotinic acetyl­choline receptor numbers in rat muscle. Anesthesiology 91:448–460

    Article  PubMed  CAS  Google Scholar 

  • Wagner BKJ, Zavotsky KE, Sweeney JB et al (1998) Patient recall of therapeutic paralysis in a surgical critical care unit. Pharma­cotherapy 18:358–363

    PubMed  CAS  Google Scholar 

  • Watling SM, Dasta JF (1994) Prolonged paralysis in intensive care unit patients after the use of neuromuscular blocking agents: a review of the literature. Crit Care Med 22:884–893

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2010 Springer Science+Business Media, LLC

About this chapter

Cite this chapter

Barnette, R.E., Kamel, I.R., Fermin, L., Criner, G.J. (2010). Use of Neuromuscular Blocking Agents in the Intensive Care Unit. In: Criner, G., Barnette, R., D'Alonzo, G. (eds) Critical Care Study Guide. Springer, New York, NY. https://doi.org/10.1007/978-0-387-77452-7_58

Download citation

  • DOI: https://doi.org/10.1007/978-0-387-77452-7_58

  • Published:

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-0-387-77327-8

  • Online ISBN: 978-0-387-77452-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics