Neuromuscular blockade in Critical Care

Michael J. Murray  Heidi DeBlock et al published revised guidelines for use of sustained neuromuscular blocking agents in critical care in November issue of critical care medicine.  It is an extensive review of current evidence.

Here is a summary of recommendations




For recommendation


Acute ARDS

Continuous IV infusion early in the course of ARDS for patients with a Pao2/Fio2 less than 150, for 48 hrs. Shown to reduce mortality. Identical risks of ICU-acquired weakness at day 28 and at ICU discharge whether or not patients received NMBAs. All trials used cisatracurium


Against recommendation

Status asthmaticus

Against the routine use in status but suggest a trial of an NMBA in life-threatening situations

associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise when other measures such as deep sedation fails.


No recommendations

  1. Adult patients with acute brain injury and elevated intracranial pressure (ICP)
  2. Routine use of NMBAs for patients undergoing therapeutic hypothermia following cardiac arrest (insufficient evidence). But NMBAs can be used to manage overt shivering in therapeutic hypothermia. If used, should be used with a protocol.
  3. No recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients



Monitoring and administration


For recommendations

  1. Administering analgesic and sedative drugs prior to and during neuromuscular blockade, with the goal of achieving deep sedation
  2. PNS (Peripheral nerve stimulation)with TOF (train of four) monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment
  3. Patients receiving a continuous infusion of NMBA receive a structured regimen of physiotherapy
  1. Scheduled eye care that includes lubricating drops or gel and eyelid closure for patients
  2. Clinicians should target a blood glucose level of less than 180 mg/dL in patients receiving NMBAs
  1. NMBAs be discontinued prior to the clinical determination of brain death, unless the patient has a TOF of 4/4 as measured using PNS at the maximum current.
  2. NMBAs be discontinued at the end of life or when life support is withdrawn
  3. Clinicians at the bedside implement measures to attenuate the risk of Unplanned Extubation in patients receiving NMBAs (risk factors are male sex, younger patient age, sepsis, agitation, benzodiazepine use, physical restraint use, and staffing ratios and experience)


No recommendations

  1. No recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of NMBAs
  2. No recommendation regarding nutritional requirements specific to patients receiving infusions of NMBAs


Special populations

  1. No recommendation on the use of NMBAs in pregnant patients, but Cisatracurium and rocuronium are the only NMBAs that are listed as pregnancy category B drugs. All NMBAs or their metabolites, with the exception of cisatracurium, cross the placental barrier
  2. A reduced dose of an NMBA be used for patients with myasthenia gravis and that the dose should be based on PNS with TOF monitoring
  3. Use a consistent weight (ideal body weight or adjusted body weight) when calculating NMBA doses for obese patients



Pantoprazole reduces GI bleeding in intubated patients without improving mortality.Read more