SCCM Resource Library-Neuromuscular Blocking Agents in the ICU: Shortages, Pitfalls, and Strategies Moving Forward

Pdf Summary

In the Fall 2020 issue of "Critical Connections," the article discusses the critical role and challenges of using neuromuscular blocking agents (NMBAs) in intensive care units (ICU), particularly during the COVID-19 pandemic. NMBAs are primarily employed for acute respiratory distress syndrome (ARDS), status asthmaticus, rapid sequence intubation (RSI), and therapeutic hyperthermia. However, the surge in critically ill COVID-19 patients has exacerbated shortages of these drugs, especially cisatracurium.<br /><br />NMBAs function either as depolarizing or nondepolarizing agents. The depolarizing NMBA, succinylcholine, is limited to RSI, while nondepolarizing agents like cisatracurium are favored in ICUs for their pharmacokinetic properties beneficial in ARDS. Despite guidelines recommending NMBA use in COVID-19-associated ARDS, no specific NMBA is singled out due to shortages. Delving into potential strategies, intermittent bolus dosing is advised over continuous infusions to conserve resources, albeit with challenges such as increased nursing workloads and the necessity for personal protective equipment.<br /><br />The NMBA shortage is compounded by the concomitant scarcity of required adjunctive sedatives and analgesics, potentially forcing institutions to rely on less familiar alternatives, raising safety concerns.<br /><br />Continuous NMBA infusions, per NIH and SCCM guidelines, may be necessary in certain situations with ventilator dyssynchrony or deep sedation, but caution is advised given risks like critical illness polyneuromyopathy. To mitigate such issues, daily pauses in infusions ("paralytic holidays") and reduced dosage strategies via train-of-four monitoring are recommended to balance efficacy with minimizing drug use and associated complications. Overall, a strategic and informed use of NMBAs is critical to optimizing patient outcomes amidst growing demand in global ICUs.

Asset Subtitle

Pharmacology, 2020, 00:04:29

Asset Caption

This article was first published in the Fall 2020 issue of Critical Connections. The most common uses for neuromuscular blocking agents (NMBAs) in the intensive care unit (ICU) are in the treatment of acute respiratory distress syndrome (ARDS), status asthmaticus, rapid sequence intubation (RSI), and therapeutic hyperthermia. As institutions continue to care for surges of critically ill patients with COVID-19, demand for medications to support these patients has increased. This has led to a worsening drug shortage of NMBAs, particularly cisatracurium. Critical Connections is the critical care industry’s only newsmagazine, provides information on cutting-edge topics in critical care useful to the entire multiprofessional team. Authors: Joanna L. Stollings, PharmD, FCCP, FCCM Darlene Chaykosky, PharmD, BCPS, BCCCP Ryan Hakimi, DO, MS, FNCS, NVSJoanna L.Stollings, PharmD, FCCP, FCCM; Darlene Chaykesky, PharmD, BCPS, BCCCP; Ryan Hakimi, DO, MS, FNCS, NVS

Meta Tag

Content Type Article

Knowledge Area Pharmacology

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Analgesia and Sedation

Tag Economics

Year 2020

Keywords

neuromuscular blocking agents

intensive care units

COVID-19 pandemic

acute respiratory distress syndrome

drug shortages

cisatracurium

rapid sequence intubation

therapeutic hyperthermia

sedatives and analgesics

train-of-four monitoring

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