Neuromuscular Blocking Agents in the Critically Ill
NMBAs are used in critically ill patients for RSI, patient-ventilator asynchrony, reducing intra-abdominal pressure, reducing intracranial pressure, and preventing shivering during therapeutic hypothermia.
There are a number of alterations in critical illness that affect the action of NMBAs
Electrolyte abnormalities
Hypercalcemia: decreases duration of blockade
Hypermagnesemia: prolongs duration of blockade
Acidosis: can enhance effect of nondepolarizing agents
Hepatic dysfunction: prolongs effects of vecuronium and rocuronium
In addition, there are a number of medications that may interact with NMBAs
Increased resistance: phenytoin and carbamazepine
Prolongs effect: clindamycin and vancomycin
Key complications of NMBAs in the critically ill include:
ICU-aquired weakness (controversial)
DVT: NMBAs are one of the strongest predictors for ICU-related DVT
Corneal abrasions: prevalence up to 60%
References
Greenberg SB, et al. The use of neuromuscular blocking agents in the ICU: Where are we know? Crit Care Med 2013; 41:1332-1344.
