Considerations of Neuromuscular Blocking Agents for Critically Ill

Neuromuscular blocking agents(NMBAs) have been used in critical care medicine for decades. An internation-al observational study of intensive care units (ICUs) in 20 countries published in 2005 found that 13 % of mechanically ventilated patients received NMBAs.1 Be-cause of the well-recognized risk of ad-verse effects, sustained use of these high-alert medications remains controversial. Clinical practice guidelines published by the Society of Critical Care Medicine2 (SCCM) in 2002 and a subsequent review3 emphasize that all other treatment modalities to improve a clinical situation should be tried before NMBAs are admin-istered, with use guided by practitioner preference. NMBAs may be used on a short-term basis, such as for immobilization during procedures (eg, rapid sequence intubation [RSI], tracheotomy), or on a more pro-longed basis of hours to days to reduce oxygen consumption in severe hypox-emia, facilitate mechanical ventilation, reduce intracranial pressure (ICP), pre-vent shivering, and manage tetanus.2,4,5 NMBAs are most commonly used in the ICU to facilitate mechanical ventilation for patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Recent observational studies es-timate that 25-50 % of patients with ARD