title: Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults.
abstract: OBJECTIVE
  To summarize literature describing use of neuromuscular blocking agents (NMBAs) for common critical care indications and provide a review of NMBA pharmacology, pharmacokinetics, dosing, drug interactions, monitoring, complications, and reversal.
  
  
  METHODS
  Searches of MEDLINE (1975-May 2011), EMBASE (1980-May 2011), and Cumulative Index to Nursing and Allied Health Literature (1981-May 2011) were conducted to identify observational and interventional studies evaluating the efficacy or safety of NMBAs for management of acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), status asthmaticus, elevated intracranial pressure (ICP), and therapeutic hypothermia.
  
  
  METHODS
  We excluded case reports, animal- or laboratory-based studies, trials describing NMBA use during rapid sequence intubation or in the operating room, and studies published in languages other than English or French.
  
  
  RESULTS
  Clinical applications of NMBAs in intensive care include, but are not limited to, immobilizing patients for procedural interventions, decreasing oxygen consumption, facilitating mechanical ventilation, reducing intracranial pressure, preventing shivering, and management of tetanus. Recent data on ARDS demonstrated that early application of NMBAs improved adjusted 90-day survival for patients with severe lung injury. These results may lead to increased use of these drugs. While emerging data support the use of cisatracurium in select patients with ALI/ARDS, current literature does not support the use of one NMBA over another for other critical care indications. Cisatracurium may be kinetically preferred for patients with organ dysfunction. Close monitoring with peripheral nerve stimulation is recommended with sustained use of NMBAs to avoid drug accumulation and minimize the risk for adverse drug events. Reversal of paralysis is achieved by discontinuing therapy or, rarely, the use of anticholinesterases.
  
  
  CONCLUSIONS
  NMBAs are high-alert medications used to manage critically ill patients. New data are available regarding the use of these agents for treatment of ALI/ARDS and status asthmaticus, management of elevated ICP, and provision of therapeutic hypothermia after cardiac arrest. To improve outcomes and promote patient safety, intensive care unit team members should have a thorough knowledge of this class of medications.
authors.affiliation: University of Waterloo, Waterloo, Ontario, Canada.
authors.forename: Julia
authors.initials: J
authors.lastname: Warr
authors.forename: Zoé
authors.initials: Z
authors.lastname: Thiboutot
authors.forename: Louise
authors.initials: L
authors.lastname: Rose
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Burry
mesh_terms: D000328:Adult; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D004347:Drug Interactions; D016903:Drug Monitoring / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units; D009466:Neuromuscular Blocking Agents / Q000009:adverse effects / Q000494:pharmacology / Q000627:therapeutic use*; D012121:Respiration, Artificial / Q000379:methods
chemical_list: D009466:Neuromuscular Blocking Agents