Sustained Neuromuscular Blockade In The Adult Critically Ill Patient
Publication Date: January 15, 2017
Recommendations
We recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of NMBAs. (S)
624
We suggest that an NMBA be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FiO2 ratio less than 150. (W)
624
We suggest against the routine administration of an NMBA to mechanically ventilated patients with status asthmaticus. (W)
624
We suggest a trial of an NMBA in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. (W)
624
We suggest that NMBAs may be used to manage overt shivering in therapeutic hypothermia. (W)
624
We suggest that peripheral nerve stimulation (PNS) with train-of-four (TOF) monitoring may be a useful tool for monitori depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. (W)
624
We suggest against the use of PNS with TOF alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of NMBAs. (W)
624
We suggest that patients receiving a continuous infusion of an NMBA receive a structured physiotherapy regimen. (W)
624
We suggest that clinicians target a blood glucose level of <180 mg/dL in patients receiving NMBAs. (W)
624
We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating NMBA doses for obese patients. (W)
624
We suggest that NMBAs be discontinued at the end of life or when life support is withdrawn. (W)
624
We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. (I)
624
We make no recommendation on the routine use of NMBAs for patients undergoing therapeutic hypothermia following cardiac arrest. (I)
624
We make no recommendation on the use of PNS to monitor degree of block in patients undergoing therapeutic hypothermia. (I)
624
We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular volume assessment in mechanically ventilated patients. (I)
624
We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of NMBAs. (I)
624
We make no recommendation regarding nutritional requirements specific to patients receiving infusions of NMBAs. (I)
624
We make no recommendation concerning the use of one measure of consistent weight over another when calculating NMBA doses in obese patients. (I)
624
We make no recommendation on the use of NMBAs in pregnant patients. (I)
624
We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving NMBAs. (I)
624
If PNS is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator, degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. ()
(good practice statements)
624
Optimal clinical practice suggests that a protocol should include guidance on NMBA administration in patients undergoing therapeutic hypothermia. ()
(good practice statements)
624
Optimal clinical practice suggests that analgesic and sedative drugs should be used before and during neuromuscular blockade, with the goal of achieving deep sedation. ()
(good practice statements)
624
Optimal clinical practice suggests that clinicians at the bedside implement measures to attenuate the risk of unintended extubation in patients receiving NMBAs. ()
(good practice statements)
624
Optimal clinical practice suggests that a reduced NMBA dose be used for patients with myasthenia gravis and that the dose should be based on PNS with TOF monitoring. ()
(good practice statements)
624
Optimal clinical practice suggests that NMBAs be discontinued before the clinical determination of brain death. ()
(good practice statements)
624
Recommendation Grading
Disclaimer
Overview
Title
Sustained Neuromuscular Blockade In The Adult Critically Ill Patient
Authoring Organization
American Society of Health-System Pharmacists
Publication Month/Year
January 15, 2017
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Intended Users
Pharmacist, nurse, nurse practitioner, physician, physician assistant
Source Citation
American Journal of Health-System Pharmacy, Volume 74, Issue 2, 15 January 2017, Pages 76–78, https://doi.org/10.2146/ajhp160803
Supplemental Methodology Resources
Methodology
Number of Source Documents
230
Literature Search Start Date
November 1, 2001
Literature Search End Date
November 22, 2012