A fresh look at paralytics in the critically ill: real promise and real concern

Abstract

Neuromuscular blocking agents (NMBAs), or “paralytics,” often are deployed in the sickest patients in the intensive care unit (ICU) when usual care fails. Despite the publication of guidelines on the use of NMBAs in the ICU in 2002, clinicians have needed more direction to determine which patients would benefit from NMBAs and which patients would be harmed. Recently, new evidence has shown that paralytics hold more promise when used in carefully selected lung injury patients for brief periods of time. When used in early acute respiratory distress syndrome (ARDS), NMBAs assist to establish a lung protective strategy, which leads to improved oxygenation, decreased pulmonary and systemic inflammation, and potentially improved mortality. It also is increasingly recognized that NMBAs can cause harm, particularly critical illness polyneuromyopathy (CIPM), when used for prolonged periods or in septic shock. In this review, we address several practical considerations for clinicians who use NMBAs in their practice. Ultimately, we conclude that NMBAs should be considered a lung protective adjuvant in early ARDS and that clinicians should consider using an alternative NMBA to the aminosteroids in septic shock with less severe lung injury pending further studies.

The Current State of Pediatric Acute Respiratory Distress Syndrome

“…[57][58][59][60] Of note, these studies have evaluated cisatricurium, while aminosteroids (ie, rocuronium, vecuronium) have been found to have a higher risk of myopathy and neuropathy and potentially deserve separate investigation. 61 To date, no RCTs have evaluated the utility of NMB in children with PARDS. A prospective physiologic study by Wilsterman et al showed improved OI in pediatric patients with acute hypoxemic respiratory failure who received continuous NMB during mechanical ventilation.…”

An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome

“…In addition, cisatracurium metabolism does not depend on renal or hepatic functionwhich may increase its use in patients with multiorgan dysfunction and an increased risk of death. In addition, the chemical structure of cisatracurium may reduce the risk of ICU-associated weakness when compared with other neuromuscular blockade agents (10). Consequently, other neuromuscular blockade agents may not have the same potential beneficial effects on patient outcomes.…”

Neuromuscular blocking agents for acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials

“…The most used NMBAs in patients with ARDS is cisatracurium. Comparison with cisatracurium, vecuronium has different pharmacological properties [24]. Lyu [20] evaluated the effects of vecuronium in patients with moderate or severe ARDS and they found vecuronium is associated with better prognosis.…”