Clinical use of neuromuscular blocking agents in critically ill patients
- Edward A Bittner, MD, PhD, MSEd, FCCM
Edward A Bittner, MD, PhD, MSEd, FCCM
- Associate Professor of Anaesthesia
- Harvard Medical School
- Section Editor
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Deputy Editors
- Geraldine Finlay, MD
Geraldine Finlay, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor
- Tufts University School of Medicine
- Marianna Crowley, MD
Marianna Crowley, MD
- Deputy Editor — Anesthesiology
- Assistant Professor of Anesthesiology
- Harvard Medical School
Neuromuscular blocking agents (NMBAs) paralyze skeletal muscles by blocking the transmission of nerve impulses at the myoneural junction. NMBAs may be useful in the intensive care unit (ICU) for several indications.
The clinical use, administration, and potential adverse effects of NMBAs in critically ill patients will be discussed here. The pharmacology of NMBAs and use in patients undergoing anesthesia, and intubation in the emergency department, are discussed separately. (See "Clinical use of neuromuscular blocking agents in anesthesia" and "Neuromuscular blocking agents (NMBAs) for rapid sequence intubation in adults outside of the operating room".)
CLASSIFICATION AND MECHANISM OF ACTION
Neuromuscular blocking agents (NMBAs) (table 1) block the binding of acetylcholine (ACh) to the motor endplate. They are divided into depolarizing or nondepolarizing agents based upon their mechanism of action [1-4].
●Depolarizing NMBAs bind to cholinergic receptors on the motor endplate, causing initial depolarization on the endplate membrane followed by blockade of neuromuscular transmission. Succinylcholine is the only depolarizing agent available in the United States and is utilized almost exclusively to facilitate intubation or treat laryngospasm [3,5].
●Nondepolarizing NMBAs competitively inhibit the ACh receptor on the motor endplate. Drug binding to the ACh receptor either prevents the conformational change in the receptor or physically obstructs the ion channels so that an endplate potential is not generated [6,7]. Nondepolarizing NMBAs are divided into aminosteroid compounds (eg, pancuronium, vecuronium, rocuronium) and benzylisoquinolinium compounds (eg, atracurium, cisatracurium, mivacurium).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CLASSIFICATION AND MECHANISM OF ACTION
- CLINICAL USE
- SELECTING AN AGENT
- Hepatic insufficiency
- Renal insufficiency
- Older adult patients
- Sepsis and septic shock
- Acute respiratory distress syndrome
- Electrolyte abnormalities
- Bolus versus infusion
- Target level of paralysis
- Duration of infusions
- SUPPORTIVE CARE
- ADVERSE EFFECTS
- Allergic reactions
- Cardiovascular effects
- Prolonged paralysis and ICU-acquired skeletal muscle weakness
- SUMMARY AND RECOMMENDATIONS