Do patients with respiratory failure or at risk of abdominal compartment syndrome require paralysis?

Neuromuscular Blockade in Abdominal Compartment Syndrome and Respiratory Failure

Paralysis (neuromuscular blockade) should be considered as a specific intervention to reduce intra-abdominal pressure in patients with intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS), particularly when other medical management strategies have failed. 1

When Paralysis is Indicated

For Abdominal Compartment Syndrome

• Neuromuscular blockade is recommended as part of the stepwise medical management algorithm for IAH/ACS when intra-abdominal pressure (IAP) remains ≥12 mmHg despite initial interventions. 1
• Through reduction in abdominal muscular tone and increase in abdominal wall compliance, neuromuscular blockade can effectively reduce IAP among patients with IAH and/or ACS. 1
• Deep sedation and paralysis become necessary to limit intra-abdominal hypertension when other non-operative treatments (such as sedation alone, fluid optimization, and enteral decompression) are insufficient. 2

Specific Clinical Context

• In pancreatitis with respiratory failure, limitation of sedation, fluids, and vasoactive drugs should be attempted first, but deep sedation and paralysis are necessary if other non-operative treatments fail to control IAH. 2
• A case report demonstrated that chemical paralysis rapidly resolved excessive auto-PEEP in a mechanically ventilated patient, leading to immediate improvement in intra-abdominal hypertension and recovery of kidney function. 3

Algorithmic Approach to Paralysis Decision

Step 1: Identify Risk and Measure IAP

• Measure IAP at least every 4-6 hours (or continuously) in all critically ill patients at risk for IAH/ACS. 1
• Begin medical management when IAP ≥12 mmHg. 1

Step 2: Implement Initial Medical Interventions First

Before considering paralysis, ensure the following have been attempted: 1

• Adequate sedation and analgesia to optimize abdominal wall compliance
• Nasogastric and rectal tube decompression for intraluminal contents
• Gastro-colonic prokinetic agents (neostigmine for colonic ileus)
• Fluid balance optimization targeting zero to negative balance after initial resuscitation
• Percutaneous catheter drainage if fluid collections are present

Step 3: Consider Neuromuscular Blockade

• If IAP remains elevated despite the above interventions, neuromuscular blockade should be considered. 1
• This is particularly important when IAP ≥20 mmHg with new organ dysfunction is present, as this indicates refractory IAH/ACS. 1

Step 4: Surgical Decompression if Medical Management Fails

• If IAP ≥20 mmHg with organ failure persists despite all medical management including paralysis, strongly consider surgical abdominal decompression. 1

Important Caveats and Pitfalls

Monitoring Requirements

• Neuromuscular blockade should only be administered where facilities for intubation, mechanical ventilation, oxygen therapy, and reversal agents are immediately available. 4
• A peripheral nerve stimulator should be employed to monitor drug effect, need for additional doses, and adequacy of recovery. 4

Long-Term ICU Use Concerns

• Rocuronium and other neuromuscular blocking agents have not been adequately studied for long-term use in the ICU setting. 4
• Prolonged paralysis and skeletal muscle weakness may occur during ventilator weaning in patients who have chronically received neuromuscular blocking agents. 4
• Myopathy has been reported after long-term administration, particularly when combined with corticosteroid therapy. 4
• The period of neuromuscular blockade should be limited as much as possible. 4

Specific to Respiratory Failure

• In patients with severe obstructive lung disease and auto-PEEP, paralysis can rapidly resolve air-trapping and reduce transmitted intra-abdominal pressure. 3
• Protective mechanical ventilation strategies should be adopted during paralysis. 1

Not a Standalone Treatment

• Neuromuscular blockade has no effect on consciousness, pain threshold, or cerebration, so it must be accompanied by adequate anesthesia or sedation. 4
• It is one component of a multidisciplinary ICU management approach that includes damage control resuscitation, physiologic optimization, and careful fluid balance. 1

Strength of Evidence

The recommendation for neuromuscular blockade in IAH/ACS comes from the World Society of the Abdominal Compartment Syndrome (WSACS) 2013 guidelines, which suggest its use with GRADE 1D evidence. 1 While this represents lower quality evidence, the intervention is included in the formal stepwise medical management algorithm and has physiologic rationale through reduction of abdominal wall muscular tone. The clinical context matters significantly—paralysis is not a first-line intervention but rather a specific tool when initial medical management fails to control elevated IAP.