The use of neuromuscular blocking drugs in the intensive care unit: A US perspective

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Abstract
Surprisingly little is known about the use of neuromuscular blockers (NMBs) in intensive care units (ICUs) in the USA. Recently, Klessig et al. [1] surveyed anesthesiologists/intensivists in the USA and found that the 55% who responded used NMBs in the ICU in an average of 10 patients per ICU per month. Anxiolytics and analgesics were administered concomitantly with NMBs, but a majority of respondents did not use electrophysiologic measures of the degree of blockade. Another survey of predominantly medical ICUs also demonstrated widespread use of NMBs, but internists did not use sedation/analgesia as frequently as anesthesiologists for patients receiving NMBs, and infrequently monitored the degree of neuromuscular blockade [2]. Because these were retrospective surveys, we decided to monitor prospectively the use of NMBs in our ICUs. The use of NMBs was ascertained by daily review of pharmacy records and, when use was documented, the patients hospital records were reviewed. Where information was missing or not found, attending physicians were interviewed. On averages, one patient per month per ICU received NMBs. Approximately 5% of neonatal and pediatric, and 1% of adult, ICU patients received NMBs. Eighty-three percent of patients received NMBs to facilitate mechanical ventilation, and mortality was high (51%) in those critically ill patients. More than half the patients were treated for ≤24 h, the remainder for 2 days to >3 weeks. Twitch monitors were used for monitoring the degree of neuromuscular blockade in adult patients, and all patients received sedatives/analgesics. We estimated that the risk of clinically significant, prolonged neuromuscular blockade following the discontinuation of NMBs was 5% per year. Our data demonstrate that NMBs in our practice are used less frequently than previous surveys indicate, that it is possible to change behavior with respect to the use of monitors of neuromuscular treatment, and that clinically significant prolonged blockade was an infrequent but serious problem in this population of critically ill patients.