Neuromuscular Blockade (Paralytics) and Monitoring



Neuromuscular blockade caring for patients with severe ARDS and may reduce mortality.

 • Improved ventilator synchrony / prevention of patient induced lung injury (e.g. double-stacking)

 • Decreased oxygen consumption

However, NMB can also be harmful:

 • Prolonged/excessive NMB is associated with neuromuscular weakness/muscle loss

 • Prolonged/deeper sedation is associated with increased risk of delirium, neurocognitive impairment

 • NMB is associated with increased risk of pressure injuries, corneal abrasions, & DVTs



Choice of Neuromuscular Blocker (NMB) - All NMBs are non-depolarizing and administered by continuous infusion:

 • Cisatrocurium — Metabolized by esterases/spontaneously in plasma (Hoffman elimination); not renally or hepatically cleared. More expensive.

 • Rocuronium - Mostly hepatic metabolism, though with renal/biliary excretion of metabolites. Avoid in renal failure.

 • Vecuronium - 40% renal, 60% biliary clearance. Avoid in liver/renal failure.



Monitoring:

 • EEG/Bispectral Index (BIS) Monitoring - Use EEG/BIS monitor to ensure sedation depth is adequate

 • Train of Four (TOF) Monitoring - Use TOF monitor to ensure NMB is at lowest dose possible



by Nick Mark MD @nickmmark



#Neuromuscular #Blockade #NMB #Paralytics #Monitoring #neurology #criticalcare #ARDS #management