National Survey of the Use of Sedating Drugs, Neuromuscular Blocking Agents, and Reversal Agents in the Intensive Care Unit

Abstract

The objectives of this study were to describe the sedative, neuromuscular blocking agents (NMBA) and reversal agents utilized in adult intensive care units across the United States and determine the adherence to American College of Critical Care Medicine and Society of Critical Care Medicine (SCCM) guidelines. In addition, the authors assessed the use of written protocols, criteria used for selecting these agents, and monitoring practices. Questionnaires were mailed to attending physician members of SCCM in the spring of 1998. A cover letter was enclosed that explained the purpose of the survey asking the respondent to forward the questionnaire to a colleague if unable to complete. Four-hundred fifty-seven questionnaires were returned representing 393 different institutions for a response rate of 50.4% (393/780). Respondents were physicians (91.2%) practicing in a community (49.7%) or university teaching hospital (38.3%). The sedative agents used most often were opioids and benzodiazepines for >72 hours, and NMBA utilized were vecuronium and pancuronium for >24 hours. The most often cited indications for sedatives were agitation, anxiety/fear, and facilitation of intubation and maintenance of mechanical ventilation for NMBA. Only 32.6% used written protocols for sedatives and 46.8% for NMBA. Decisions regarding agent selection were based on clinician preference and experience and agent duration of action. Seventy-eight percent monitored sedative use primarily with the Glasgow Coma Scale and the modified Ramsay score. Monitoring of NMBA was used more frequently (91.3%) with peripheral nerve stimulation. The most common reversal agents used were naloxone and flumazenil for adverse drug effects. While many of the respondents indicated they used morphine and lorazepam for long-term sedation, the majority utilized midazolam and propofol for >24 hours despite the recommendation of SCCM. Vecuronium was prescribed more routinely than pancuronium. The number of institutions utilizing protocols for any of these agents was low; instead, decisions were based on clinician preference.

Use of Sedatives and Neuromuscular Blockers in a Cohort of Patients Receiving Mechanical Ventilation

“…There are data in the literature that suggest that sedation protocols can have a significant impact on outcome. 20 However, in a survey by Rhoney and Murry,26 only 33% of the 474 respondent reported the use of protocols for sedation in their ICUs, and 47% reported the use of protocols for NMBs.…”

Intensive Care Nurses' Knowledge About Use of Neuromuscular Blocking Agents in Patients With Respiratory Failure

“…3,19 Agents that affect the central nervous system (CNS-active agents) but are not NMBAs (eg, fentanyl, hydromorphone, lorazepam, propofol) were included in survey questions to provide a reference agent for descriptive comparisons to NMBAs. 14 Similar to the method of Rhoney and Murry, 20 after development, 20 ICU providers (including physicians, nurses, and pharmacists from a nonincluded surgical ICU at the primary site) reviewed and pretested the questionnaire. A structured critique form was given to each of these individuals upon survey completion, with specific probes designed to examine question clarity, response options, missing or superfluous survey items, and overall length.…”

A polynomial model of patient-specific breathing effort during controlled mechanical ventilation

“…Monitoring changes in patients breathing efforts during controlled ventilation modes can indicate to clinicians that a mode of ventilation that allows spontaneous breathing may be appropriate. Conversely, the patient efforts may be harmful for other clinical reasons, and increased sedation and muscle relaxants may be appropriate [13]. This model of patient effort allows the changes in patient effort to be monitored over time, different PEEP levels and different ventilator settings.…”