5/3/2023 0 Comments Icu copyclip reviewWhile guidelines can help clinicians navigate many clinical scenarios, these recommendations are often limited by the lack of well-designed prospective trials. The Society of Critical Care Medicine (SCCM) developed guidelines addressing optimal practice based on the available evidence to address these concerns. The impact of such “off-label” use of NMBAs in the ICU is still being investigated. Complications associated with the NMBA use can be particularly concerning in the critical care setting, as intensivists typically administer NMBAs to critically ill patients with multi-organ system derangements for long periods of time resulting in greater accumulation of NMB drug and drug metabolites. Optimal neuromuscular blockade management has challenged clinicians for decades, despite the frequent use of NMBAs in clinical practice. As with any therapy, however, the use of NMBAs has inherent risks, particularly when providers are unfamiliar with the nuances of selecting the appropriate agent, monitoring the depth of neuromuscular blockade, and ensuring adequate skeletal muscle recovery once NMBA therapy has ceased. The introduction of neuromuscular blocking agents to the ICU provides intensivists a unique capability in the management of critically ill patients. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU).
0 Comments
Leave a Reply. |