Neuromuscular blocking agents in the management of respiratory failure. Indications and treatment guidelines

Local custom continues to dictate the clinical use of NMBDs in critically ill patients with respiratory failure. The safety of long-term administration of NMBDs to critically ill patients remains of great concern. Studies that clearly delineate the cause of severe myopathies and neuropathies in critically ill paralyzed patients remain to be performed. Because it appears these disorders may be related to the administration of drugs with steroidal structure, we believe it is prudent to avoid such drugs, if possible, in critically ill patients. We therefore continue to use curare, a nonsteroidal drug with a long history of safety, for long-term paralysis in these patients. Similarly, we believe that it is prudent to monitor the efficacy of NMBDs via the routine use of ulnar nerve stimulation. Patient movement in the face of adequate neuromuscular blockade as assessed by ulnar nerve stimulation then can be treated by deepening the level of sedation rather than by continually increasing the dose of the NMBD.