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Current Anesthesiology Reports
Published in: Current Anesthesiology Reports 4/2023

01-09-2023 | ICU-Acquired Weakness | Neuromuscular Blockade (CA Lien, Section Editor)

Neuromuscular Blocking Agents in the Intensive Care Unit

Authors: Harold E. Chaves-Cardona, J. Ross Renew

Published in: Current Anesthesiology Reports | Issue 4/2023

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Abstract

Purpose of Review

The purpose of this review is to recognize common complications associated with the use of neuromuscular blocking agents in critically ill patients.

Recent Findings

Neuromuscular blocking agents have been commonly used in the operating room to facilitate endotracheal intubation and improve surgical outcomes. Similarly, neuromuscular blocking agents in the intensive care unit have been frequently used in critically ill patients who require advanced ventilatory and respiratory support. Intensive care unit-acquired weakness, hypoxia, and respiratory adverse events associated with residual neuromuscular blockade are common complications seen with the use of neuromuscular blocking agents in the intensive care unit.

Summary

Neuromuscular blockade is a common practice in the intensive care unit, especially, in patients who require endotracheal intubation and mechanical ventilation. However, complications have been documented in critically ill patients while receiving neuromuscular blocking agents and this patient population warrants special considerations.
Literature
1.••
Fuchs-Buder T, Romero CS, Lewald H, Lamperti M, Afshari A, Hristovska AM, et al. Peri-operative management of neuromuscular blockade: a guideline from the European Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2023;40(2):82–94. The first guidelines for the safe use of neuromusuclar blocking agents from the ESAICCrossRefPubMed
2.
Groth CM, Acquisto NM, Khadem T. Current practices and safety of medication use during rapid sequence intubation. J Crit Care. 2018;45:65–70.CrossRefPubMed
3.
De Jong A, Myatra SN, Roca O, Jaber S. How to improve intubation in the intensive care unit. Update on knowledge and devices. Intensive Care Med. 2022;48(10):1287–98.CrossRefPubMedPubMedCentral
4.
Torbic H, Krishnan S, Harnegie MP, Duggal A. Neuromuscular blocking agents for ARDS: a systematic review and meta-analysis. Respir Care. 2021;66(1):120–8.CrossRefPubMed
5.••
Murray MJ, DeBlock H, Erstad B, Gray A, Jacobi J, Jordan C, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079–103. The SCCM guidelines for the safe use of neuromusuclar blocking agents in the ICUCrossRefPubMed
6.
Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically ill patient. J Intensive Care. 2020;8:37.CrossRefPubMedPubMedCentral
7.
Laurin EG, Sakles JC, Panacek EA, Rantapaa AA, Redd J. A comparison of succinylcholine and rocuronium for rapid-sequence intubation of emergency department patients. Acad Emerg Med. 2000;7(12):1362–9.CrossRefPubMed
8.
Levy JH, Davis GK, Duggan J, Szlam F. Determination of the hemodynamics and histamine release of rocuronium (Org 9426) when administered in increased doses under N2O/O2-sufentanil anesthesia. Anesth Analg. 1994;78(2):318–21.CrossRefPubMed
9.
Luxen J, Trentzsch H, Urban B. Rocuronium and sugammadex in emergency medicine: requirements of a muscle relaxant for rapid sequence induction. Anaesthesist. 2014;63(4):331–7.CrossRefPubMed
10.
Taboada M, Doldan P, Calvo A, Almeida X, Ferreiroa E, Baluja A, et al. Comparison of tracheal intubation conditions in operating room and intensive care unit: a prospective, observational study. Anesthesiology. 2018;129(2):321–8.CrossRefPubMed
11.
Serpa Neto A, Simonis FD, Barbas CS, Biehl M, Determann RM, Elmer J, et al. Association between tidal volume size, duration of ventilation, and sedation needs in patients without acute respiratory distress syndrome: an individual patient data meta-analysis. Intensive Care Med. 2014;40(7):950–7.CrossRefPubMed
12.
Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRefPubMed
13.
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.CrossRefPubMed
14.
Gallo de Moraes A, El-Yafawi R, Oeckler RA. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;381(8):787.PubMed
15.
Prielipp RC, Coursin DB, Scuderi PE, Bowton DL, Ford SR, Cardenas VJ Jr, et al. Comparison of the infusion requirements and recovery profiles of vecuronium and cisatracurium 51W89 in intensive care unit patients. Anesth Analg. 1995;81(1):3–12.PubMed
16.
Newman PJ, Quinn AC, Grounds RM, Hunter JM, Boyd AH, Eastwood NB, et al. A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients. Crit Care Med. 1997;25(7):1139–42.CrossRefPubMed
17.
Prielipp RC, Robinson JC, Wilson JA, MacGregor DA, Scuderi PE. Dose response, recovery, and cost of doxacurium as a continuous infusion in neurosurgical intensive care unit patients. Crit Care Med. 1997;25(7):1236–41.CrossRefPubMed
18.
de Lemos JM, Carr RR, Shalansky KF, Bevan DR, Ronco JJ. Paralysis in the critically ill: intermittent bolus pancuronium compared with continuous infusion. Crit Care Med. 1999;27(12):2648–55.CrossRefPubMed
19.
Segredo V, Caldwell JE, Matthay MA, Sharma ML, Gruenke LD, Miller RD. Persistent paralysis in critically ill patients after long-term administration of vecuronium. N Engl J Med. 1992;327(8):524–8.CrossRefPubMed
20.••
Thilen SR, Weigel WA, Todd MM, Dutton RP, Lien CA, Grant SA, et al. 2023 American Society of Anesthesiologists Practice Guidelines for monitoring and antagonism of neuromuscular blockade: a report by the American Society of Anesthesiologists Task Force on neuromuscular blockade. Anesthesiology. 2023;138(1):13–41. The first guidelines for the safe use of neuromusuclar blocking agents from the ASACrossRefPubMed
21.
Chaves-Cardona H, Hernandez-Torres V, Kiley S, Renew J. Neuromuscular blockade management in patients with COVID-19. Korean J Anesthesiol. 2021;74(4):285–92.CrossRefPubMedPubMedCentral
22.
Naguib M, Brull SJ, Johnson KB. Conceptual and technical insights into the basis of neuromuscular monitoring. Anaesthesia. 2017;72(Suppl 1):16–37.CrossRefPubMed
23.
Brull SJ, Kopman AF. Clarifications on technologies to optimize care of severe COVID-19 patients. Anesth Analg. 2020;131(4):e192–e3.CrossRefPubMed
24.
Panahi A, Malekmohammad M, Soleymani F, Hashemian SM. The prevalence and outcome of intensive care unit acquired weakness (ICUAW). Tanaffos. 2020;19(3):250–5.PubMedPubMedCentral
25.
26.
de Letter MA, Schmitz PI, Visser LH, Verheul FA, Schellens RL, Op de Coul DA, et al. Risk factors for the development of polyneuropathy and myopathy in critically ill patients. Crit Care Med. 2001;29(12):2281–6.CrossRefPubMed
27.
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.CrossRefPubMed
28.
Leijten FS, Harinck-de Weerd JE, Poortvliet DC, de Weerd AW. The role of polyneuropathy in motor convalescence after prolonged mechanical ventilation. Jama. 1995;274(15):1221–5.CrossRefPubMed
29.
Tennilä A, Salmi T, Pettilä V, Roine RO, Varpula T, Takkunen O. Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis. Intensive Care Med. 2000;26(9):1360–3.CrossRefPubMed
30.
Tepper M, Rakic S, Haas JA, Woittiez AJ. Incidence and onset of critical illness polyneuropathy in patients with septic shock. Neth J Med. 2000;56(6):211–4.CrossRefPubMed
31.
Helliwell TR, Coakley JH, Wagenmakers AJ, Griffiths RD, Campbell IT, Green CJ, et al. Necrotizing myopathy in critically-ill patients. J Pathol. 1991;164(4):307–14.CrossRefPubMed
32.
Wijdicks EF, Litchy WJ, Harrison BA, Gracey DR. The clinical spectrum of critical illness polyneuropathy. Mayo Clin Proc. 1994;69(10):955–9.CrossRefPubMed
33.
Zochodne DW, Bolton CF, Wells GA, Gilbert JJ, Hahn AF, Brown JD, et al. Critical illness polyneuropathy. A complication of sepsis and multiple organ failure. Brain. 1987;110(Pt 4):819–41.CrossRefPubMed
34.
Van den Berghe G, Wouters PJ, Bouillon R, Weekers F, Verwaest C, Schetz M, et al. Outcome benefit of intensive insulin therapy in the critically ill: insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359–66.CrossRefPubMed
35.
Aljada A, Ghanim H, Mohanty P, Kapur N, Dandona P. Insulin inhibits the pro-inflammatory transcription factor early growth response gene-1 (Egr)-1 expression in mononuclear cells (MNC) and reduces plasma tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1) concentrations. J Clin Endocrinol Metab. 2002;87(3):1419–22.CrossRefPubMed
36.
Ishii DN, Lupien SB. Insulin-like growth factors protect against diabetic neuropathy: effects on sensory nerve regeneration in rats. J Neurosci Res. 1995;40(1):138–44.CrossRefPubMed
37.
Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.CrossRefPubMed
38.
Van den Berghe G, Wilmer A, Milants I, Wouters PJ, Bouckaert B, Bruyninckx F, et al. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes. 2006;55(11):3151–9.CrossRefPubMed
39.
Garnacho-Montero J, Madrazo-Osuna J, García-Garmendia JL, Ortiz-Leyba C, Jiménez-Jiménez FJ, Barrero-Almodóvar A, et al. Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients. Intensive Care Med. 2001;27(8):1288–96.CrossRefPubMed
40.
Thiele RI, Jakob H, Hund E, Tantzky S, Keller S, Kamler M, et al. Sepsis and catecholamine support are the major risk factors for critical illness polyneuropathy after open heart surgery. Thorac Cardiovasc Surg. 2000;48(3):145–50.CrossRefPubMed
41.
Danon MJ, Carpenter S. Myopathy with thick filament (myosin) loss following prolonged paralysis with vecuronium during steroid treatment. Muscle Nerve. 1991;14(11):1131–9.CrossRefPubMed
42.
Hirano M, Ott BR, Raps EC, Minetti C, Lennihan L, Libbey NP, et al. Acute quadriplegic myopathy: a complication of treatment with steroids, nondepolarizing blocking agents, or both. Neurology. 1992;42(11):2082–7.CrossRefPubMed
43.
Hirano M, Raps EC, Cowen J. Prolonged weakness and vecuronium. Annals of Internal Med. 1993;118(7):569–71.CrossRef
44.
Douglass JA, Tuxen DV, Horne M, Scheinkestel CD, Weinmann M, Czarny D, et al. Myopathy in severe asthma. Am Rev Respir Dis. 1992;146(2):517–9.CrossRefPubMed
45.
Leatherman JW, Fluegel WL, David WS, Davies SF, Iber C. Muscle weakness in mechanically ventilated patients with severe asthma. Am J Respir Crit Care Med. 1996;153(5):1686–90.CrossRefPubMed
46.
Marik PE. Doxacurium-corticosteroid acute myopathy: another piece to the puzzle. Crit Care Med. 1996;24(7):1266–7.CrossRefPubMed
47.
Murphy GS, Szokol JW, Marymont JH, Franklin M, Avram MJ, Vender JS. Residual paralysis at the time of tracheal extubation. Anesth Analg. 2005;100(6):1840–5.CrossRefPubMed
48.
Stewart PA, Liang SS, Li QS, Huang ML, Bilgin AB, Kim D, et al. The impact of residual neuromuscular blockade, oversedation, and hypothermia on adverse respiratory events in a postanesthetic care unit: a prospective study of prevalence, predictors, and outcomes. Anesth Analg. 2016;123(4):859–68.CrossRefPubMed
49.
Prielipp RC, Coursin DB, Wood KE, Murray MJ. Complications associated with sedative and neuromuscular blocking drugs in critically ill patients. Crit Care Clin. 1995;11(4):983–1003.CrossRefPubMed
50.
Colin JN, Singlas E. Metabolism and pharmacokinetics of atracurium. Ann Fr Anesth Reanim. 1985;4(6):465–70.CrossRefPubMed
51.
Kisor DF, Schmith VD. Clinical pharmacokinetics of cisatracurium besilate. Clin Pharmacokinet. 1999;36(1):27–40.CrossRefPubMed
52.
Boddi M, Barbani F, Abbate R, Bonizzoli M, Batacchi S, Lucente E, et al. Reduction in deep vein thrombosis incidence in intensive care after a clinician education program. J Thromb Haemost. 2010;8(1):121–8.CrossRefPubMed
53.
Lenart SB, Garrity JA. Eye care for patients receiving neuromuscular blocking agents or propofol during mechanical ventilation. Am J Crit Care. 2000;9(3):188–91.CrossRefPubMed
54.
Kuruvilla S, Peter J, David S, Premkumar PS, Ramakrishna K, Thomas L, et al. Incidence and risk factor evaluation of exposure keratopathy in critically ill patients: a cohort study. J Crit Care. 2015;30(2):400–4.CrossRefPubMed
55.
Warr J, Thiboutot Z, Rose L, Mehta S, Burry LD. Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults. Ann Pharmacother. 2011;45(9):1116–26.CrossRefPubMed
56.
LeBlanc JM, Dasta JF, Pruchnicki MC, Gerlach A, Cook C. Bispectral index values, sedation-agitation scores, and plasma Lorazepam concentrations in critically ill surgical patients. Am J Crit Care. 2012;21(2):99–105.CrossRefPubMed
57.
Ballard N, Robley L, Barrett D, Fraser D, Mendoza I. Patients’ recollections of therapeutic paralysis in the intensive care unit. Am J Crit Care. 2006;15(1):86–94. quiz 5CrossRefPubMed
58.
Shapiro JM. Management of respiratory failure in status asthmaticus. Am J Respir Med. 2002;1(6):409–16.CrossRefPubMed
59.
Shapiro JM, Condos R, Cole RP. Myopathy in status asthmaticus: relation to neuromuscular blockade and corticosteroid administration. J Intensive Care Med. 1993;8(3):144–52.CrossRef
60.
Hafeez KR, Tuteja A, Singh M, Wong DT, Nagappa M, Chung F, et al. Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnea patients: a systematic review. BMC Anesthesiol. 2018;18(1):91.CrossRefPubMedPubMedCentral
Metadata
Title
Neuromuscular Blocking Agents in the Intensive Care Unit
Authors
Harold E. Chaves-Cardona
J. Ross Renew
Publication date
01-09-2023
Publisher
Springer US
Published in
Current Anesthesiology Reports / Issue 4/2023
Electronic ISSN: 2167-6275
DOI
https://doi.org/10.1007/s40140-023-00577-x

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