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Updated 2016 Guidelines For Neuromuscular Blockade In The ICU Category: Pharmacotherapy by - November 11, 2016 | Views: 10673 | Likes: 1 | Comment: 1  

    10.    Monitoring degree of blockade: Suggest against the use of PNS with train of four (TOF) alone for monitoring the depth of neuromuscular blockade in patients on continuous infusion of NMBAs (weak recommendation, very low quality of evidence). Suggest PNS with TOF monitoring may be beneficial if used patient clinical assessment (weak recommendation, very low quality of evidence)

    11.    Physiotherapy: Suggest that in patients receiving continuous NMBA infusion receive structured regimen of physiotherapy to improve mortality, quality of life, and exercise capacity (weak recommendation, very low quality of evidence)

    12 .   Eye lubrication: Recommend scheduled eye care that includes drops or gel and eyelid closure for patients receiving continuous NMBA infusion (strong recommendation, low quality of evidence)

    13.    Nutrition: No recommendation regarding nutritional requirements specific to patients receiving infusions of NMBAs (insufficient evidence)

    14.    Safeguards: Recommend implementing measures (physical restraints, staffing ratios, etc.) to attenuate risk of unplanned extubation (good practice statement)

    15.    Blood glucose target: Suggest in critically ill patients receiving NMBAs, clinicians target a blood glucose level of less than 180 mg/dL (weak recommendation, low quality of evidence)

    16.    Myasthenic syndromes: Recommend a reduced NMBA dose be used in patients with myasthenia gravis and dose should be based on PNS with TOF monitoring (good practice statement)

    17.    Myasthenia gravis muscle group to use for monitoring: No recommendation on which muscle group to use for monitoring in patients with myasthenia gravis receiving NMBAs (insufficient evidence)

    18.    Obese patients: Suggest clinicians NOT use actual body weight and instead use ideal or adjusted body weight when calculating NMBA doses for obese patients (body mass index greater than or equal 30 mg/m2)

    19.    Pregnant patients: No recommendation on the use of NMBAs in pregnant patients (insufficient evidence)

    20.    Brain death: Recommend NMBAs be discontinued prior to brain death determination (good practice statement)

    21.   End of life: Suggest NMBAs be discontinued at end of life or when support is withdrawn (weak recommendation, very low quality of evidence)

Clinical Pearls

  • NMBAs do NOT have sedative, amnestic, or analgesic properties
  • In patients with renal and/or hepatic insufficiency, atracurium or cisatracurium are preferred. Both agents undergo Hoffman degradation and are less dependent on renal or hepatic function.
  • In patients with cardiovascular disease, vecuronium may be preferred due to it having the least adverse cardiovascular effects.
  • Succinylcholine is the only available depolarizing neuromuscular blocking agent with rapid onset and brief duration of action and is mostly used for facilitating intubation.
  • A potential side effect of succinylcholine is hyperkalemia (can raise serum potassium concentrations by 0.5 – 1 meq/L due to efflux of potassium from muscle cells).
  • Aminoglycoside antibiotics (gentamicin, tobramycin, amikacin, etc.) may enhance neuromuscular effects of NMBAs

References

Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med. 2016;44(11):2079-2103

Hanson CW 3rd. Pharmacology of neuromuscular blocking agents in the intensive care unit. Crit Care Clin 1994; 10:779.

Topulos GP. Neuromuscular blockade in adult intensive care. New Horiz 1993; 1:447.

Yentis SM. Suxamethonium and hyperkalemia. Anaesth Intensive Care 1990; 18:92.

 



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