What is the recommended approach to neuromuscular (NM) monitoring in the Intensive Care Unit (ICU) for patients receiving neuromuscular blocking agents (NMBAs)?

From the Guidelines

The recommended approach to neuromuscular monitoring in ICU patients receiving neuromuscular blocking agents (NMBAs) is to use peripheral nerve stimulation with train-of-four monitoring as part of a comprehensive assessment, but not as the sole method for monitoring the depth of neuromuscular blockade. This approach is based on the guidelines developed by Murray et al 1, which suggest that peripheral nerve stimulation with 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. The guidelines also suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents 1. Some key points to consider when implementing neuromuscular monitoring in the ICU include:

• Using a comprehensive assessment that includes clinical evaluation and other monitoring parameters
• Avoiding the sole reliance on peripheral nerve stimulation with train-of-four monitoring
• Considering the use of structured physiotherapy regimens for patients receiving continuous infusions of neuromuscular-blocking agents 1
• Targeting a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents 1
• Using a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients 1. By following these guidelines and using a comprehensive approach to neuromuscular monitoring, clinicians can help minimize the risks associated with neuromuscular blocking agents and improve patient outcomes in the ICU.

From the FDA Drug Label

WHENEVER THE USE OF CISATRACURIUM OR ANY OTHER NEUROMUSCULAR BLOCKING AGENT IN THE ICU IS CONTEMPLATED, IT IS RECOMMENDED THAT NEUROMUSCULAR FUNCTION BE MONITORED DURING ADMINISTRATION WITH A NERVE STIMULATOR. The recommended approach to neuromuscular (NM) monitoring in the Intensive Care Unit (ICU) for patients receiving neuromuscular blocking agents (NMBAs) is to monitor neuromuscular function with a nerve stimulator during administration.

• Key points:
  • Monitor neuromuscular function with a nerve stimulator
  • Adjust infusion rates based on patient response to nerve stimulation
  • Discontinue infusion if no response is elicited until a response returns 2 2

From the Research

Recommended Approach to Neuromuscular Monitoring in ICU

The recommended approach to neuromuscular (NM) monitoring in the Intensive Care Unit (ICU) for patients receiving neuromuscular blocking agents (NMBAs) involves several key considerations:

• Monitoring the depth of neuromuscular blockade using peripheral nerve stimulators and train-of-four stimuli 3
• Using the smallest doses of NMB agents that will accomplish clinical goals, determined through clinical evaluations and peripheral nerve monitoring 4
• Ensuring appropriate sedation and analgesia for patients treated with NMB drugs 4, 5
• Being aware of risk factors that may predispose certain patients to neuromuscular complications, such as sepsis and the use of high-dose steroids 4

Indications for Neuromuscular Blockade

The indications for neuromuscular blockade in the ICU include:

• Facilitating intubation and ventilatory support 5
• Decreasing oxygen demand and consumption 5
• Facilitating bedside procedures and diagnostics 5
• Potentially decreasing intracranial pressure 5
• Treating agitation 3
• Assisting in mechanical ventilation 3
• Reducing oxygen consumption 3

Monitoring Practices

Variations exist in monitoring practices, including:

• Frequency of monitoring 3
• Use of baseline milliamperage 3
• Clinical assessment (31%) 3
• Peripheral nerve stimulator (16%) 3
• Both clinical assessment and peripheral nerve stimulator (52%) 3

Specific Recommendations

Specific recommendations for the use of neuromuscular blocking agents in the ICU include:

• Using a transient curarization during brief diagnostic or therapeutic procedures to avoid haemodynamic consequences of deep sedation 6
• Using a volume-controlled ventilation during the procedure 6
• Using a prolonged curarization of 48 hours or more in ARDS patients to improve systemic oxygenation 6
• Checking the depth of curarization using a train of four stimulation at the corugator supercilii with an endpoint of 2/4 responses 6
• Considering recovery from curarization daily if possible to check the depth of the underlying sedation 6