UMEM Educational Pearls

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Title: NMBA Pearls

Category: Critical Care

Posted: 4/30/2013 by Mike Winters, MBA, MD

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%

Greenberg SB, et al. The use of neuromuscular blocking agents in the ICU: Where are we know? Crit Care Med 2013; 41:1332-1344.