Continuous‐Infusion Neuromuscular Blocking Agents in Critically Ill Neonates and Children

Abstract

Neuromuscular blocking agents (NMBAs) are often administered as a prolonged (> 24 hrs) continuous infusion in infants and children in the intensive care unit for a variety of reasons including facilitation of oxygenation and ventilation. No guidelines on the use of NMBAs in pediatric patients are available yet in the United States; however, pediatric guidelines are available in the United Kingdom. Based on a 2007 U.S. survey, the most commonly used nondepolarizing NMBAs for sustained neuromuscular blockade in critically ill children are pancuronium and vecuronium. Recent national drug shortages involving NMBAs have been reported for atracurium, cisatracurium, pancuronium, rocuronium, and vecuronium. Therefore, to explore alternative options for neuromuscular blockade, we conducted a literature search to identify articles evaluating prolonged use (> 24 hrs) of NMBAs administered by continuous infusion. The search was limited to English-language articles in the MEDLINE (1950-August 2010), EMBASE (1988-August 2010), International Pharmaceutical Abstracts (1970-August 2010), and Cochrane Library (1996-August 2010) databases. Relevant abstracts, reference citations, and manufacturers' product information were also reviewed. A total of 13 reports representing 208 children were included in the analysis. Many of the reports described wide interpatient variability in dosing for the specific NMBAs evaluated. Selection of the most appropriate NMBA should be based on the patient's clinical status, potential adverse effects, and pharmacoeconomics. All patients receiving sustained neuromuscular blockade should be monitored routinely to ensure that dosing is appropriate in order to obtain the desired level of blockade. The goal is to use the lowest dose possible in an effort to limit adverse effects or prolonged blockade.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility

“…Rationale: The most commonly described method to assess the level of neuromuscular blockade in critically ill patients receiving NMBAs is by peripheral nerve stimulation or TOF monitoring. One to three twitches typically indicates adequate neuromuscular blockade (178). Surveys have reported that TOF monitoring along with clinical assessment is used in 63–84% of critically ill patients receiving NMBAs (179, 180), whereas a small percentage of patients are assessed using only TOF (181).…”

Physical compatibility of cisatracurium with selected drugs during simulated Y-site administration

“…Due to its metabolism via ester hydrolysis and Hoffman elimination, it may be a superior option for patients with renal or hepatic insufficiency requiring an NMBA, as the potential for drug accumulation is minimal in comparison with other agents. 11 Cisatracurium may be used more frequently during shortages of other NMBAs. Appropriate indications for NMBA infusions in an ICU setting include the management or facilitation of mechanical ventilation, treatment of muscle spasms, management of increases in intracranial pressure, and control of decreases in oxygen consumption when patients have failed other treatments.…”

Paediatric Acute Respiratory Distress Syndrome Neuromuscular Blockade study (PAN-study): a phase IV randomised controlled trial of early neuromuscular blockade in moderate-to-severe paediatric acute respiratory distress syndrome

“…It is one of the many non-depolarizing neuromuscular blockers used but has the distinct advantage of being fast-acting and reversible [ 21 ]. It is often used in critically ill, mechanically ventilated children when sedation alone is inadequate to achieve effective mechanical ventilation [ 22 ]. The occurrence of allergic or anaphylactic reactions is a known risk for rocuronium; its occurrence in children appears very rare as to date only three case reports have been published [ 23 ].…”