What is an appropriate neuromuscular blockade and sedation regimen?

From the Guidelines

Neuromuscular blockade and sedation should be administered together, with the goal of achieving deep sedation, as patients receiving neuromuscular-blocking agents (NMBAs) have no analgesic or sedating properties and require optimal clinical practice to administer analgesic and sedative drugs prior to and during neuromuscular blockade 1.

Key Considerations

• Sedation and analgesia are essential for patients receiving NMBAs, as they have no analgesic or sedating properties, and assessing pain and anxiety in these patients is difficult 1.
• Deep sedation should be the goal, as it is associated with improved clinical outcomes, and lighter levels of sedation should be maintained in ICU patients 1.
• Analgesia-first sedation is suggested, and non-benzodiazepines rather than benzodiazepine infusions should be used for sedation 1.
• Neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia, and peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade 1.
• Continuous deep sedation and NMBA may be required to achieve lung protective ventilation in patients with moderate or severe ARDS, and NMBA infusion up to 48 hours is suggested in these cases 1.

Medications and Monitoring

• Intravenous opioids should be used as first-line analgesic therapy for non-neuropathic pain, and non-opioid analgesics should be used to reduce opioid side effects 1.
• Brain function monitors should be used to primarily monitor depth of sedation in patients receiving NMBAs, and EEG monitoring should be used to monitor non-convulsive seizure activity in ICU patients at risk for seizures 1.
• The RASS and SAS scales are the most valid and reliable instruments for assessing adequacy and depth of sedation, and brain function monitors should be used as adjuncts to subjective sedation scales in unparalyzed patients 1.

From the Research

Appropriate Neuromuscular Blockade and Sedation Regimen

• The goal of sedation and neuromuscular blockade is to achieve a calm, comfortable patient who can easily be aroused and tolerate mechanical ventilation and procedures required for their care 2.
• Sedatives, opioids, and neuromuscular blocking agents are commonly used in the intensive care unit, and the goal of therapy should be directed toward a specific indication, not simply to provide restraint 2.
• Standard rating scales and unit-based guidelines facilitate the proper use of sedation and neuromuscular blocking agents 2.

Sedation Strategies

• Sedation is used almost universally in the care of critically ill patients, especially in those who require mechanical ventilatory support or other life-saving invasive procedures 3.
• The role of neuromuscular blocking agents in the ICU will be examined, and the pharmacology of commonly used agents is reviewed 3.
• A strategy for rational use of these sedative and neuromuscular blocking agents in critically ill patients can be proposed 3.

Use of Neuromuscular Blocking Agents

• Neuromuscular blocking agents are used in 1% to 10% or more of critically ill patients, and their use as adjunctive therapy to control intracranial hypertension is a concern 4.
• The incidence of prolonged weakness or myopathy, the potential for direct neurologic toxicity, and their effect on outcome are also concerns 4.
• Education and implementation of standardized protocol can improve the process of care by provider education of neuromuscular blocking agent titration and monitoring 5.

Patient Experiences

• Patients can remember having both negative and positive experiences during neuromuscular blockade, including feelings of loss of control, fear, and being scared 6.
• Improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs can improve the experiences of patients receiving neuromuscular blockers 6.
• Ways to decrease the use of neuromuscular blockers would also be useful, such as implementing comprehensive education, standardization of sedation prior to neuromuscular blocking agent initiation, and integration of clinical variables in determining paralysis achievement 5.