ABSTRACT
Neuromuscular blocking agents (NMBAs) are an important armamentarium of intensive care units (ICU); however, lately, their indications are limited due to potential complications associated with their use. Some important indications include facilitation of tracheal intubation, improving patient ventilator synchrony, improving oxygenation in refractory hypoxemia, and control of the increase in intracranial pressure by preventing bucking and coughing in the endotracheal tube and decreasing oxygen consumption and cerebral metabolism. In neurointensive care units, the choice of NMBA is influenced by its effect on intracranial pressure, cerebral blood flow, and cerebral metabolism. Critically ill patients with multiple organ involvement and polypharmacotherapy often show an unpredictable response to NMBAs. The pharmacokinetic and pharmacodynamic properties of NMBAs in this population are poorly understood. As such, use of NMBAs should be considered only in absolutely essential indications for the shortest duration possible. Careful administration and monitoring is warranted whenever NMBAs are used. The clinical practice guidelines for sustained NM blockade in the critically ill adult patient suggested that training of four (TOF) monitoring alone is not beneficial in patients receiving continuous infusion of NMBAs and should be incorporated into a more inclusive assessment of the patient, which includes clinical assessment.
