The use of muscle relaxants in the intensive care unit

Sharpe, Michael D.

doi:10.1007/bf03008345

Cited by 38 publications

(13 citation statements)

References 135 publications

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“…Paralysis suppresses the cough reflex, resulting in retention of secretions and atelectasis, both of which increase the risk of pulmonary infections. Prolonged immobility may also increase the risk of venous thromboembolic events, peripheral nerve injuries, skin breakdown, stasis ulcers, and slowed gastric motility [48]. Neuromuscular blockade has also been shown to be a risk factor for critical illness myopathy and neuropathy [49].…”

Section: Con: Tight Control Of Paco2 Is Not Indicated In This Patientmentioning

confidence: 99%

Pro/con debate: Should PaCO2 be tightly controlled in all patients with acute brain injuries?

Singh

2012

Critical Care

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You are the attending intensivist in a neurointensive care unit caring for a woman five days post-rupture of a cerebral aneurysm (World Federation of Neurological Surgeons Grade 4 and Fisher Grade 3). She is intubated for airway protection and mild hypoxemia related to an aspiration event at the time of aneurysm rupture, but is breathing spontaneously on the ventilator. Your patient is spontaneously hyperventilating with high tidal volumes despite minimal support and has developed significant hypocapnia. She has not yet developed the acute respiratory distress syndrome. You debate whether to tightly control her partial pressure of arterial carbon dioxide, weighing the known risks of acute hypocapnia in other forms of brain injury against the potential loss of clinical neuromonitoring associated with deep sedation and neuromuscular blockade in this patient who is at high risk of delayed ischemia from vasospasm. You are also aware of the potential implications of tidal volume control if this patient were to develop the acute respiratory distress syndrome and the effect of permissive hypercapnia on her intracranial pressure. In this paper we provide a detailed and balanced examination of the issues pertaining to this clinical scenario, including suggestions for clinical management of ventilation, sedation and neuromonitoring. Until more definitive clinical trial evidence is available to guide practice, clinicians are forced to carefully weigh the potential benefits of tight carbon dioxide control against the potential risks in each individual patient based on the clinical issues at hand.

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Section: Con: Tight Control Of Paco2 Is Not Indicated In This Patientmentioning

confidence: 99%

Pro/con debate: Should PaCO2 be tightly controlled in all patients with acute brain injuries?

Singh

2012

Critical Care

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“…Pancuronium has been associated with transient increases in heart rate and blood pressure thought to be mediated through a vagolytic and sympathomimetic 40 Studies of patients under anesthesia receiving pancuronium reported increased heart rates of 11.5-24% and increases in mean arterial presswe of 0 -2 2 % .~O~~ Patients with coronary artery disease or arrhythmogenic potential may be at risk for exacerbation of underlying cardiovascular disease. Our guidelines conservatively reflect this risk and suggest that these patients not receive pancuronium.…”

Section: Pancuroniummentioning

confidence: 99%

“…Only a small amount is metabolized hepatically to 3hydroxyvecuronium and 3-desacetylvecuronium. Both metabolites are thought to possess little neuromuscular blocking activity and are believed to be clinically insignificant in patients with normal hepatic and kidney function.I2, 13, 40,42 In patients undergoing surgery who receive a single dose or short-term infusions, renal dysfunction is not associated with significantly prolonging the drug's duration of e f f e c F 8 ; however, a longer duration of action and a 23.2% decrease in dosage requirements were reported with repeated Several investigators described the potential for prolonged duration of effect in patients with decreased renal function. Neuromuscular blockade lasted for up to 37 hours in seven patients with renal and respiratory failure receiving vecuronium; however, 71 o/o of these patients had hepatobiliary dysfunction as Prolonged recovery in seven ICU patients receiving long-term infusions may have been attributed to renal dysfunction and accumulation of 3-desacetyl-vec~ronium.~ Again, 57% of these patients had hepatic as well as renal impairment.…”

Section: Vecuroniummentioning

confidence: 99%

“…Atracurium has minimal cardiovascular adverse effects and is primarily metabolized by Hofmann elimination and ester hydrolysis. ", 40 It has non-organ-dependent metabolism. Single-dose studies in ICU patients undergoing surgery and long-term infusions demonstrated no clearance changes or cumulative effects associated with repeated dosing, renal dysfunction, or hepatic dysfun~tion.~~ 9.…”

Section: Atracu Ri U Mmentioning

confidence: 99%

“…Atracurium has been associated with histamine release, especially in bolus doses greater than 0.5 mg/kg,15 and with increased heart rates in patients undergoing su~gery.~' The cardiovascular effects tend to be transient and are considered clinically insignificant if the loading dose is given over 1 40 Our guidelines reserve the agent for patients who would be the best candidates to take advantage of its non-organ-dependent elimination, namely, those with multiple organ dysfunction.…”

Section: Atracu Ri U Mmentioning

confidence: 99%

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A Retrospective Analysis of Long‐Term Use of Nondepolarizing Neuromuscular Blocking Agents in the Intensive Care Unit, and Guidelines for Drug Selection

Ciarens,

Kelly,

Gilliland

et al. 1993

Pharmacotherapy

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Nondepolarizing neuromuscular blocking agents (NNMBAs) are frequently administered to patients in the intensive care unit (ICU). We conducted a retrospective study of patients in intensive care who received infusions (>48 hrs) of commonly used NNMBAs. The goals were to describe NNMBA use in our ICUs, determine patient characteristics, and assess the cost of the individual drugs. We found that atracurium was prescribed for 68% of study patients; 68% of the patients did not have renal, hepatic, or cardiovascular disease; dosages of NNMBAs varied; a statistically significant increase in dosage requirements over time occurred with atracurium; assessment of neuromuscular blockade was 100% subjective; and 41% and 17% of patients receiving atracurium and vecuronium, respectively, experienced prolonged neuromuscular weakness documented subjectively. As a result of this study, guidelines for agent selection were developed to facilitate cost effective use of NNMBA in our ICUs. Using these guidelines would potentially significantly decrease drug expenditures in this setting.

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Prolonged Neuromuscular Blockade in Two Critically Ill Patients Treated With Atracurium

Hoey,

Joslin,

Nahum

et al. 1995

Pharmacotherapy

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Recent literature suggests that the risk of prolonged neuromuscular blockade associated with atracurium compared with other nondepolarizing neuromuscular blocking agents may be minimal. Two patients experienced prolonged weakness associated with the administration of atracurium. Both received atracurium 0.5–0.7 mg/kg/hour in combination with methylprednisolone 500–600 mg/day. Electromyographic results and creatine kinase levels were suggestive of muscular weakness in both patients. Despite high‐dose corticosteroid therapy, the electromyographic evidence supporting prolonged weakness did not suggest typical corticosteroid myopathy. Although some clinicians advocate routine administration of atracurium in critically ill patients due to the relative lack of reports of prolonged weakness, this may be premature. Although there are fewer reports of atracurium‐associated prolonged weakness compared with pancuronium and vecuronium, the patients we describe suggest that it may occur.

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The use of muscle relaxants in the intensive care unit

Cited by 38 publications

References 135 publications

Pro/con debate: Should PaCO2 be tightly controlled in all patients with acute brain injuries?

Pro/con debate: Should PaCO2 be tightly controlled in all patients with acute brain injuries?

A Retrospective Analysis of Long‐Term Use of Nondepolarizing Neuromuscular Blocking Agents in the Intensive Care Unit, and Guidelines for Drug Selection

Prolonged Neuromuscular Blockade in Two Critically Ill Patients Treated With Atracurium

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