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Neuromuscular Blockade

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Pediatric Critical Care Medicine

Abstract

Since the introduction of the neuromuscular blocking agents (NMBAs) in anesthesia in 1942, a marked evolution has occurred in these drugs. Currently, there are many recognized indications to starting treatment with a NMBA in critically ill children. These may be categorized as short-term, to facilitate procedures, or long-term (sustained neuromuscular blockade), as therapeutic interventions. Atracurium or vecuronium administered by continuous infusion are the choice for the majority of PICU children requiring neuromuscular blockade, however, intermittent doses of pancuronium may be considered as well. Neuromuscular blockade complications can be classified as short-term (accidental extubation, disconnection of the mechanical ventilator), medium-term (edema, venous thrombosis) and long-term (prolonged paralysis, muscle atrophy). Monitoring the neuromuscular blockade level (clinical examination and peripheral nerve stimulation) is recommended and allows the use of lower doses of NMBAs, which may minimize these side effects. Train-of-four is the more commonly used method and involves electrical stimulation of a peripheral motor nerve with four sequential stimuli over a two second period and observation of the responses of a muscle innervated by the stimulated nerve. Adequate neuromuscular blockade reversal is essential for restoring and maintaining laryngeal reflexes, respiratory effort and motor function. Recovery may be obtained by using agents that reverse the action of NMBAs, such as anticholinesterase drugs (neostigmine, edrophonium and pyridostigmine) or cyclodextrins (sugammadex).

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References

  1. Changeux JP, Edelstein SJ. Allosteric receptors after 30 years. Neuron. 1998;21(5):959–80.

    Article  PubMed  CAS  Google Scholar 

  2. Karlin A. Emerging structure of the nicotinic acetylcholine receptors. Nat Rev Neurosci. 2002;3(2):102–14.

    Article  PubMed  CAS  Google Scholar 

  3. Martyn JA, Fagerlund MJ, Eriksson LI. Basic principles of neuromuscular transmission. Anaesthesia. 2009;64 Suppl 1:1–9.

    Article  PubMed  CAS  Google Scholar 

  4. Cohen-Cory S. The developing synapse: construction and modulation of synaptic structures and circuits. Science. 2002;298(5594):770–6.

    Article  PubMed  CAS  Google Scholar 

  5. Naguib M, Brull SJ. Update on neuromuscular pharmacology. Curr Opin Anaesthesiol. 2009;22(4):483–90.

    Article  PubMed  Google Scholar 

  6. Foldes FF, McNall PG, Borrego-Hinojosa JM. Succinylcholine: a new approach to muscular relaxation in anesthesiology. N Engl J Med. 1952;247(16):596–600.

    Article  PubMed  CAS  Google Scholar 

  7. Baird WL, Reid AM. The neuromuscular blocking properties of a new steroid compound, pancuronium bromide. A pilot study in man. Br J Anaesth. 1967;39(10):775–80.

    Article  PubMed  CAS  Google Scholar 

  8. Savage DS, Sleigh T, Carlyle I. The emergence of ORG NC 45, 1- [2 beta,3 alpha,5 alpha,16 beta,17 beta)-3, 17-bis(acetyloxy)-2-(1-piperidinyl)-androstan-16-yl]-1-methylpiperidinium bromide, from the pancuronium series. Br J Anaesth. 1980;52 Suppl 1:3S–9.

    Article  PubMed  CAS  Google Scholar 

  9. Stenlake JB, Waigh RD, Urwin J, Dewar GH, Coker GG. Atracurium: conception and inception. Br J Anaesth. 1983;55 Suppl 1:3S–10.

    PubMed  Google Scholar 

  10. Savarese JJ, Ali HH, Basta SJ, Embree PB, Scott RP, Sunder N, et al. The clinical neuromuscular pharmacology of mivacurium chloride (BW B1090U). A short-acting nondepolarizing ester neuromuscular blocking drug. Anesthesiology. 1988;68(5):723–32.

    Article  PubMed  CAS  Google Scholar 

  11. Bovet D. Some aspects of the relationship between chemical constitution and curare-like activity. Ann N Y Acad Sci. 1951;54(3):407–37.

    Article  PubMed  CAS  Google Scholar 

  12. Alcuronium (Alloferin) – a new neuromuscular blocking agent. Drug Ther Bull. 1967;5(17):67–8.

    Google Scholar 

  13. Hughes R, Payne JP, Sugai N. Studies on fazadinium bromide (ah 8165): a new non-depolarizing neuromuscular blocking agent. Can Anaesth Soc J. 1976;23(1):36–47.

    Article  PubMed  CAS  Google Scholar 

  14. Karpati E, Biro K. Pharmacological study of a new competitive neuromuscular blocking steroid, pipecurium bromide. Arzneimittelforschung. 1980;30(2a):346–57.

    PubMed  CAS  Google Scholar 

  15. Basta SJ, Savarese JJ, Ali HH, Embree PB, Schwartz AF, Rudd GD, et al. Clinical pharmacology of doxacurium chloride. A new long-acting nondepolarizing muscle relaxant. Anesthesiology. 1988;69(4):478–86.

    Article  PubMed  CAS  Google Scholar 

  16. Wastila WB, Maehr RB, Turner GL, Hill DA, Savarese JJ. Comparative pharmacology of cisatracurium (51 W89), atracurium, and five isomers in cats. Anesthesiology. 1996;85(1):169–77.

    Article  PubMed  CAS  Google Scholar 

  17. Wierda JM, van den Broek L, Proost JH, Verbaan BW, Hennis PJ. Time course of action and endotracheal intubating conditions of Org 9487, a new short-acting steroidal muscle relaxant; a comparison with succinylcholine. Anesth Analg. 1993;77(3):579–84.

    Article  PubMed  CAS  Google Scholar 

  18. Belmont MR, Lien CA, Tjan J, Bradley E, Stein B, Patel SS, et al. Clinical pharmacology of GW280430A in humans. Anesthesiology. 2004;100(4):768–73.

    Article  PubMed  CAS  Google Scholar 

  19. Elliot JM, Bion JF. The use of neuromuscular blocking drugs in intensive care practice. Acta Anaesthesiol Scand Suppl. 1995;106:70–82.

    Article  PubMed  CAS  Google Scholar 

  20. Meakin G, McKiernan EP, Morris P, Baker RD. Dose-response curves for suxamethonium in neonates, infants and children. Br J Anaesth. 1989;62(6):655–8.

    Article  PubMed  CAS  Google Scholar 

  21. Liu LM, DeCook TH, Goudsouzian NG, Ryan JF, Liu PL. Dose response to intramuscular succinylcholine in children. Anesthesiology. 1981;55(5):599–602.

    Article  PubMed  CAS  Google Scholar 

  22. Whittaker M. Plasma cholinesterase variants and the anaesthetist. Anaesthesia. 1980;35(2):174–97.

    Article  PubMed  CAS  Google Scholar 

  23. Slamon MB, Theroux MC, Jr AT. Neuromuscular blockade. In: Wheeler DS, Wong HR, Shanley TP, editors. Pediatric critical care medicine – basic science and clinical evidence. 1st ed. London: Springer; 2007. p. 1674–86.

    Google Scholar 

  24. Martyn JA, White DA, Gronert GA, Jaffe RS, Ward JM. Up-and-down regulation of skeletal muscle acetylcholine receptors. Effects on neuromuscular blockers. Anesthesiology. 1992;76(5):822–43.

    Article  PubMed  CAS  Google Scholar 

  25. MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology. 1998;89(3):749–70.

    Article  PubMed  CAS  Google Scholar 

  26. Tobias JD, Lynch A, McDuffee A, Garrett JS. Pancuronium infusion for neuromuscular block in children in the pediatric intensive care unit. Anesth Analg. 1995;81(1):13–6.

    PubMed  CAS  Google Scholar 

  27. Hodges UM. Vecuronium infusion requirements in paediatric patients in intensive care units: the use of acceleromyography. Br J Anaesth. 1996;76(1):2328.

    Article  Google Scholar 

  28. Burmester M, Mok Q. Randomised controlled trial comparing cisatracurium and vecuronium infusions in a paediatric intensive care unit. Intensive Care Med. 2005;31(5):686–92.

    Article  PubMed  Google Scholar 

  29. Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs. succinylcholine in the emergency department: a critical appraisal. J Emerg Med. 2009;37(2):183–8.

    Article  PubMed  Google Scholar 

  30. Tobias JD. Continuous infusion of rocuronium in a paediatric intensive care unit. Can J Anaesth. 1996;43(4):353–7.

    Article  PubMed  CAS  Google Scholar 

  31. Kushimo OT, Darowski MJ, Morris P, Hollis S, Meakin G. Dose requirements of atracurium in paediatric intensive care patients. Br J Anaesth. 1991;67(6):781–3.

    Article  PubMed  CAS  Google Scholar 

  32. Topulos GP. Neuromuscular blockade in adult intensive care. New Horiz. 1993;1(3):447–62.

    PubMed  CAS  Google Scholar 

  33. Tobias JD. Increased cis-atracurium requirements during prolonged administration to a child. Can J Anaesth. 1997;44(1):82–4.

    Article  PubMed  CAS  Google Scholar 

  34. Odetola FO, Bhatt-Mehta V, Zahraa J, Moler FW, Custer JR. Cisatracurium infusion for neuromuscular blockade in the pediatric intensive care unit: a dose-finding study. Pediatr Crit Care Med. 2002;3(3):250–4.

    Article  PubMed  Google Scholar 

  35. Twite MD, Rashid A, Zuk J, Friesen RH. Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs. Pediatr Crit Care Med. 2004;5(6):521–32.

    Article  PubMed  Google Scholar 

  36. Jenkins IA, Playfor SD, Bevan C, Davies G, Wolf AR. Current United Kingdom sedation practice in pediatric intensive care. Paediatr Anaesth. 2007;17(7):675–83.

    Article  PubMed  Google Scholar 

  37. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–16.

    Article  PubMed  CAS  Google Scholar 

  38. Shapiro BA, Warren J, Egol AB, Greenbaum DM, Jacobi J, Nasraway SA, et al. 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(9):1601–5.

    Article  PubMed  CAS  Google Scholar 

  39. Watling SM, Dasta JF. Prolonged paralysis in intensive care unit patients after the use of neuromuscular blocking agents: a review of the literature. Crit Care Med. 1994;22(5):884–93.

    Article  PubMed  CAS  Google Scholar 

  40. Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, et al. Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth. 2007;17(9):881–7.

    Article  PubMed  Google Scholar 

  41. Murray MJ, Cowen J, DeBlock H, Erstad B, Gray Jr AW, Tescher AN, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2002;30(1):142–56.

    Article  PubMed  CAS  Google Scholar 

  42. 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(6):503–6.

    PubMed  CAS  Google Scholar 

  43. Rudis MI, Sikora CA, Angus E, Peterson E, Popovich Jr J, Hyzy R, et al. 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(4):575–83.

    Article  PubMed  CAS  Google Scholar 

  44. Zarowitz BJ, Rudis MI, Lai K, Petitta A, Lulek M. Retrospective pharmacoeconomic evaluation of dosing vecuronium by peripheral nerve stimulation versus standard clinical assessment in critically ill patients. Pharmacotherapy. 1997;17(2):327–32.

    PubMed  CAS  Google Scholar 

  45. Farooq K, Hunter JM. Neuromuscular blocking agents and reversal agents. Anesth Intensive Care Med. 2011;12(6):266–70.

    Article  Google Scholar 

  46. Cronnelly R, Stanski DR, Miller RD, Sheiner LB, Sohn YJ. Renal function and the pharmacokinetics of neostigmine in anesthetized man. Anesthesiology. 1979;51(3):222–6.

    Article  PubMed  CAS  Google Scholar 

  47. de Boer HD, van Egmond J, van de Pol F, Bom A, Booij LH. Chemical encapsulation of rocuronium by synthetic cyclodextrin derivatives: reversal of neuromuscular block in anaesthetized Rhesus monkeys. Br J Anaesth. 2006;96(2):201–6.

    Article  PubMed  Google Scholar 

  48. Plaud B, Meretoja O, Hofmockel R, Raft J, Stoddart PA, van Kuijk JH, et al. Reversal of rocuronium-induced neuromuscular blockade with sugammadex in pediatric and adult surgical patients. Anesthesiology. 2009;110(2):284–94.

    PubMed  CAS  Google Scholar 

  49. Srivastava A, Hunter JM. Reversal of neuromuscular block. Br J Anaesth. 2009;103(1):115–29.

    Article  PubMed  CAS  Google Scholar 

  50. Biro K. Effects of respiratory and metabolic alkalosis and acidosis on pipecuronium neuromuscular block. Eur J Pharmacol. 1988;154(3):329–33.

    Article  PubMed  CAS  Google Scholar 

  51. Pogson D, Telfer J, Wimbush S. Prolonged vecuronium neuromuscular blockade associated with Charcot Marie Tooth neuropathy. Br J Anaesth. 2000;85(6):914–7.

    Article  PubMed  CAS  Google Scholar 

  52. Kronenfeld MA, Thomas SJ, Turndorf H. Recurrence of neuromuscular blockade after reversal of vecuronium in a patient receiving polymyxin/amikacin sternal irrigation. Anesthesiology. 1986;65(1):93–4.

    Article  PubMed  CAS  Google Scholar 

  53. Jones RM, Cashman JN, Casson WR, Broadbent MP. Verapamil potentiation of neuromuscular blockade: failure of reversal with neostigmine but prompt reversal with edrophonium. Anesth Analg. 1985;64(10):1021–5.

    Article  PubMed  CAS  Google Scholar 

  54. Triantafillou AN, Tsueda K, Berg J, Wieman TJ. Refractory bradycardia after reversal of muscle relaxant in a diabetic with vagal neuropathy. Anesth Analg. 1986;65(11):1237–41.

    Article  PubMed  CAS  Google Scholar 

  55. van Vlymen JM, Parlow JL. The effects of reversal of neuromuscular blockade on autonomic control in the perioperative period. Anesth Analg. 1997;84(1):148–54.

    PubMed  Google Scholar 

  56. Mirakhur RK, Dundee JW, Jones CJ, Coppel DL, Clarke RS. Reversal of neuromuscular blockade: dose determination studies with atropine and glycopyrrolate given before or in a mixture with neostigmine. Anesth Analg. 1981;60(8):557–62.

    Article  PubMed  CAS  Google Scholar 

  57. Latronico N, Guarneri B. Critical illness myopathy and neuropathy. Minerva Anestesiol. 2008;74(6):319–23.

    PubMed  CAS  Google Scholar 

  58. De Jonghe B, Sharshar T, Lefaucheur JP, Authier FJ, Durand-Zaleski I, Boussarsar M, et al. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA. 2002;288(22):2859–67.

    Article  PubMed  Google Scholar 

  59. Schweickert WD, Hall J. ICU-acquired weakness. Chest. 2007;131(5):1541–9.

    Article  PubMed  Google Scholar 

  60. Eikermann M, Vogt FM, Herbstreit F, Vahid-Dastgerdi M, Zenge MO, Ochterbeck C, et al. The predisposition to inspiratory upper airway collapse during partial neuromuscular blockade. Am J Respir Crit Care Med. 2007;175(1):9–15.

    Article  PubMed  Google Scholar 

  61. Testelmans D, Maes K, Wouters P, Gosselin N, Deruisseau K, Powers S, et al. Rocuronium exacerbates mechanical ventilation-induced diaphragm dysfunction in rats. Crit Care Med. 2006;34(12):3018–23.

    PubMed  CAS  Google Scholar 

  62. Ochala J, Renaud G, Llano Diez M, Banduseela VC, Aare S, Ahlbeck K, et al. Diaphragm muscle weakness in an experimental porcine intensive care unit model. PLoS One. 2011;6(6):e20558.

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  63. Vender JS, Szokol JW, Murphy GS, Nitsun M. Sedation, analgesia, and neuromuscular blockade in sepsis: an evidence-based review. Crit Care Med. 2004;32(11 Suppl):S554–61.

    Article  PubMed  Google Scholar 

  64. Grehn LS. Adverse responses to analgesia, sedation, and neuromuscular blocking agents in infants and children. AACN Clin Issues. 1998;9(1):36–48.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Pediatric Intensive Care Unit, Department of Pediatrics, Hospital do Servidor Publico Municipal, Rua Castro Alves 60, São Paulo, SP, 01532-000, Brazil

    Paulo Sérgio Lucas da Silva MD, MsC

  2. Emergency Department, Hospital Israelita Albert Einstein, Alameda Purus, 105, Alphaville, Barueri, SP, 06454-030, Brazil

    Henrique Monteiro Neto MD

  3. Pediatric Intensive Care Unit/Division of Neonatology, Department of Pediatrics, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Correia de Lemos, 153 – apto. 71 – Chácara Inglesa, São Paulo, SP, 04140-000, Brazil

    Werther Brunow de Carvalho PhD

Authors
  1. Paulo Sérgio Lucas da Silva MD, MsC
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  2. Henrique Monteiro Neto MD
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  3. Werther Brunow de Carvalho PhD
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Correspondence to Paulo Sérgio Lucas da Silva MD, MsC .

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Editors and Affiliations

  1. Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA

    Derek S. Wheeler

  2. Div. of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA

    Hector R. Wong

  3. University of Michigan Medical School, Ann Arbor, Michigan, USA

    Thomas P. Shanley

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da Silva, P.S.L., Neto, H.M., de Carvalho, W.B. (2014). Neuromuscular Blockade. In: Wheeler, D., Wong, H., Shanley, T. (eds) Pediatric Critical Care Medicine. Springer, London. https://doi.org/10.1007/978-1-4471-6359-6_5

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  • DOI: https://doi.org/10.1007/978-1-4471-6359-6_5

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