Advertisement

Intensive Care Medicine

, Volume 44, Issue 12, pp 2305–2306 | Cite as

Monitoring of neuromuscular blockade: a comparison of train-of-four and the Campbell diagram

  • Elias Baedorf Kassis
  • Sarah Train
  • Bruce MacNeil
  • Stephen H. Loring
  • Daniel Talmor
Letter

Dear Editor,

Neuromuscular blockers (NMB) are frequently used in acute respiratory distress syndrome (ARDS) for severe hypoxemia and ventilator dyssynchrony and have been shown to improve mortality [1]. The benefit may be secondary to removal of spontaneous breathing, dyssynchrony and expiratory efforts [2] thereby decreasing inflammation [3]. NMB dosing protocols, however, do not utilize monitoring of spontaneous breathing activity when determining efficacy [4]. Prior studies used standardized dosing [1] regardless of weight which may under- or overdose patients. Additionally current guidelines recommend using train-of-four (TOF) monitoring, a type of peripheral nerve stimulation as a surrogate marker [4], despite the fact that NMB has variable effects on different muscles and the degree of peripheral paralysis may not reflect diaphragmatic and respiratory muscle paralysis [5]. Furthermore, TOF response and interpretation vary as a result of patient factors (edema, temperature,...

Notes

Funding

There was no funding for this letter.

Compliance with ethical standards

Conflicts of interest

The authors declare no conflicts of interest.

Ethical standards

All ethical standards were met in writing and submitting this correspondence.

Supplementary material

134_2018_5420_MOESM1_ESM.png (262 kb)
Supplementary material 1 (PNG 262 kb)
134_2018_5420_MOESM2_ESM.png (343 kb)
Supplementary material 2 (PNG 342 kb)
134_2018_5420_MOESM3_ESM.png (257 kb)
Supplementary material 3 (PNG 257 kb)
134_2018_5420_MOESM4_ESM.png (191 kb)
Supplementary material 4 (PNG 190 kb)

References

  1. 1.
    Papazian L, Forel JM, Gacouin A et al (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107–1116.  https://doi.org/10.1056/nejmoa1005372 CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Baedorf Kassis E, Loring SH, Talmor D (2018) Lung volumes and transpulmonary pressure are decreased with expiratory effort and restored with passive breathing in ARDS: a reapplication of the traditional Campbell diagram. Intensive Care Med 21:21.  https://doi.org/10.1007/s00134-018-5105-0 CrossRefGoogle Scholar
  3. 3.
    Sottile PD, Albers D, Moss MM (2018) Neuromuscular blockade is associated with the attenuation of biomarkers of epithelial and endothelial injury in patients with moderate-to-severe acute respiratory distress syndrome. Crit Care 22:63-018-1974-4.  https://doi.org/10.1186/s13054-018-1974-4 CrossRefGoogle Scholar
  4. 4.
    Murray MJ, DeBlock H, Erstad B et al (2016) Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 44:2079–2103.  https://doi.org/10.1097/ccm.0000000000002027 CrossRefPubMedGoogle Scholar
  5. 5.
    Moerer O, Baller C, Hinz J, Buscher H, Crozier TA (2002) Neuromuscular effects of rapacuronium on the diaphragm and skeletal muscles in anaesthetized patients using cervical magnetic stimulation for stimulating the phrenic nerves. Eur J Anaesthesiol 19:883–887CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Division of Pulmonary and Critical CareBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  2. 2.Department of MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  3. 3.Department of Respiratory CareBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA
  4. 4.Department of Anesthesia, Critical Care and Pain MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA

Personalised recommendations