Critical care nursing quarterly
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Administration of neuromuscular blocking agents (NMBAs) in critical care units has become tremendously controversial. The increased use of these agents without a defined indication or research base has resulted in dangerous and costly complications and serious concerns. ⋯ Pharmacologic paralysis should be restricted to a very specific patient population after careful evaluation, and therapy should be discontinued at the earliest possible time. Chemical paralysis can be a safe and effective therapy for a select few patients when judicious care, multidisciplinary efforts, and prevention of adverse effects minimize the complications, growing costs, and unintended suffering.
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Pharmacology of neuromuscular blockade: interactions and implications for concurrent drug therapies.
Neuromuscular blocking agents (NMBAs) have historically been utilized in the operating room as an adjunct to general anesthesia to induce skeletal muscle relaxation. Within the past decade, their use has been extended to the intensive care setting to facilitate tracheal intubation, provide paralysis in patients unable to tolerate mechanical ventilation, or aid in the management of ventilatory failure. Numerous factors must be considered when selecting a potential NMBA for use: speed of onset, route of elimination, potential for adverse effects (cardiovascular or histamine release), potential for "cumulative" effect, intermittent or continuous infusion administration capability, and potential for drug-drug interactions. This article is concerned with the pharmacology, pharmacokinetics, and physiology of those NMBAs that are commonly prescribed and their therapeutic usefulness in the treatment of the critically ill.
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The future direction of neuromuscular blockade (NMB) in critical care will be characterized by prudent utilization and quality monitoring. With the potential for persistent paralysis and less than optimal outcomes, this direction makes sense. Prudent utilization can be further defined as exhausting other therapies prior to NMB utilization. ⋯ Quality monitoring requires that peripheral nerve stimulator (PNS) monitoring become the standard for monitoring the administration of NMB agents and also that monitoring be accurate. Inherent to prudent utilization and quality monitoring is an adequate knowledge related to all aspects of NMB. The purpose of this article is to provide the necessary knowledge base for practitioners to understand normal and altered neuromuscular junction function, perform accurate PNS monitoring, and titrate NMB therapy according to the individual and desired response.
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Neuromuscular blocking agents (NMBAs) are used to facilitate mechanical ventilation in critically ill patients. Individual NMBAs differ in their metabolism and elimination, side effects, and duration of action. These differences help designate which NMBA has the greatest efficacy, given different scenarios. A common theme with all NMBAs is their ability to ablate spontaneous breathing; hence, vigilant cardiopulmonary monitoring is warranted when NMBAs are used.
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Anxiety and pain pose a challenge in the management of the critically ill patient on continuous neuromuscular blockade. Without adequate treatment, anxiety can further complicate a patient's already compromised state. ⋯ Despite the fact that the physiologic consequences of pain can be devastating, the undertreatment of pain remains an issue. The opioid agonists constitute the agents of choice for parenteral analgesia in the critically ill.