Comprehensive review: neuromuscular blocking agents in critical care

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. Areas of controversy include mounting adverse effects (especially prolonged paralysis and weakness from long-term overdosing), an inconsistent and deficient knowledge base among all levels of health care professionals, inadequate concurrent sedation and analgesia, and a lack of effective monitoring to ensure the lowest possible doses. There is a great need for research to define the practice and protocols that would optimize safe and efficacious use. 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.