Abstract
Surprisingly little is known about the use of neuromuscular blockers (NMBs) in intensive care units (ICUs) in the USA. Recently, Klessig et al. [1] surveyed anesthesiologists/intensivists in the USA and found that the 55% who responded used NMBs in the ICU in an average of 10 patients per ICU per month. Anxiolytics and analgesics were administered concomitantly with NMBs, but a majority of respondents did not use electrophysiologic measures of the degree of blockade. Another survey of predominantly medical ICUs also demonstrated widespread use of NMBs, but internists did not use sedation/analgesia as frequently as anesthesiologists for patients receiving NMBs, and infrequently monitored the degree of neuromuscular blockade [2]. Because these were retrospective surveys, we decided to monitor prospectively the use of NMBs in our ICUs. The use of NMBs was ascertained by daily review of pharmacy records and, when use was documented, the patients hospital records were reviewed. Where information was missing or not found, attending physicians were interviewed. On averages, one patient per month per ICU received NMBs. Approximately 5% of neonatal and pediatric, and 1% of adult, ICU patients received NMBs. Eighty-three percent of patients received NMBs to facilitate mechanical ventilation, and mortality was high (51%) in those critically ill patients. More than half the patients were treated for ≤24 h, the remainder for 2 days to >3 weeks. Twitch monitors were used for monitoring the degree of neuromuscular blockade in adult patients, and all patients received sedatives/analgesics. We estimated that the risk of clinically significant, prolonged neuromuscular blockade following the discontinuation of NMBs was 5% per year. Our data demonstrate that NMBs in our practice are used less frequently than previous surveys indicate, that it is possible to change behavior with respect to the use of monitors of neuromuscular treatment, and that clinically significant prolonged blockade was an infrequent but serious problem in this population of critically ill patients.
Article PDF
Similar content being viewed by others
References
Klessig HT, Geiger HJ, Murray MJ, Coursin DB (1992) A national survey on the practice patterns of anesthesiologist intensivists in the use of muscle relaxants. Crit Care Med 20:1341–1345
Hansen-Flaschen JH, Brazinsky S, Basile C, Lanken PN (1991) Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure. A national survey. JAMA 226:2870–2875
Partridge BL, Abrams JH, Bazemore C, Rubin R (1990) Prolonged neuromuscular blockade after long-term inlusion of vecuronium bromide in the intensive care unit. Crit Care Med 18:1177–1179
Gooch JL, Suchyta MR, Balbierz JM, Penjan JH, Clemmer TP (1991) Prolonged paralysis after treatment with neuromuscular junction blocking agents. Crit Care Med 19:1125–1131
Griffin D, Fairman N, Coursin D, Rawsthorne L, Grossman JE (1992) Acute myopathy during treatment of status arthmaticus with corticosteroids and steroidal muscle relaxants. Chest 102:510–514
Miller-Jones CMH (1980) Paralysis or sedation for controlled ventilation? Lancet i:312
Coursin DB (1992) Neuromuscular blockade. Should patients be relaxed in the ICU? Chest 102:988–989
Sharpe MD (1992) The use of muscle relaxants in the intensive care unit. Can J Anaesth 39:949–962
Isenstein DA, Venner DS, Duggan J (1992) Neuromuscular blockade in the intensive care unit. Chest 102:1258–1266
Verbal evidence presented at Anesthetics and Life Support Drugs Advisory Committee (1992) Report, November 23 US FDA Center for Drug Evaluation and Research, Rockville, Maryland
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
Ashbaugh DG Bigelow DB, Petty TL, Levine BE (1967) Acute respiratory distress in adults. Lancet ii:319–323
Miller-Jones CMH, Williams JH (1980) Sedation for ventilation. A retrospective study of fifty patients. Anaesthesia 35:1104–1107
Anderson EF, Rosenthal MH (1975) Pancuronium bromide and tachyarrhythmias. Crit Care Med 3:13–15
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
Siler JN, Mager JG Jr, Wyche MQ Jr (1985) Atracurium: hypotension, tachycardia and bronchospasm. Anesthesiology 62:645–646
Yate PM, Flynn PJ, Arnold RW, Weatherly BC, Simmonds RJ, Dopson T (1987) Clinical experience and plasma laudanosine concentrations during the infusion of atracurium in the intensive therapy unit. Br J Anaesth 59:211–217
Robertson CS, Clifton GL, Taylor AA, Crossman RG (1983) Treatment of hypertension associated with head injury. J Neurosurg 59:455–460
Duncan SR, Rizk NW, Raffin TA (1987) Inverse ratio ventilation. PEEP in disguise? Chest 92:390–391
Sassoon CSH, Mahutte CK, Light RW (1990) Ventilator modes: old and new. Crit Care Clinic 6:605–634
Light RW, Bengfort JL, George RB (1975) The adult respiratory distress syndrome and pancuronium bromide. Anesth Analg 54:219–223
Bishop MJ (1984) Hemodynamic and gas exchange effects of pancuronium bromide in sedated patients with respiratory failure. Anesthesiology 60:369–371
Coggeshall JW, Marini JJ, Newman JH (1985) Improved oxygenation after muscle relaxation in adult respiratory distress syndrome. Arch Inern Med 145:1718–1720
Eddy D (1990) Practice policies: where do they come from? JAMA 263:1265–1275
Arduino MJ, Bland LA, McAllister SK et al (1991) Microbial growth and endotoxin production in the intravenous anesthetic propofol. Infect Control Hosp Epidemiol 12:535–539
Sebel PS, Lowdon JD (1989) Propofol: a new intravenous anesthetic. Anesthesiology 71:260–277
Marshall C, Lindgren L, Marshall BE (1984) Effects of halothane, enflurane, and isoflurane on hypoxic pulmonary vasoconstriction in rat lungs in vitro. Anesthesiology 60:304–308
Anand KJS, Hickey PR (1992) Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med 326:1–9
Coursin D, Murray M, Scuderi P, Prough D, Abou-Donia M, Miller D (1993) An evaluation of doxacurium and pancuronium in a multicenter, randomized, double-blind study in the critically ill. Crit Care Med 21:S263
Scott RPF, Savarese JJ, Basta SJ, Embree P, Ali HH, Sunder N, Hoaglin DC (1986) Clinical pharmacology of atracurium given in high dose. Br J Anaesth 58:834–838
Segredo V, Caldwell JE, Matthay MA, Sharma ML, Greunke LD, Miller RD (1992) Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med 327:524–528
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Murray, M.J., Strickland, R.A. & Weiler, C. The use of neuromuscular blocking drugs in the intensive care unit: A US perspective. Intensive Care Med 19 (Suppl 2), S40–S44 (1993). https://doi.org/10.1007/BF01708799
Issue Date:
DOI: https://doi.org/10.1007/BF01708799