The use of depolarizing neuromuscular blocking agents (NMB) in the Intensive Care Unit (ICU) is still prevalent1Ford E.V. Monitoring neuromuscular blockade in the ICU.Am J Crit Care. 1995; 4: 122-130PubMed Google Scholar and, with the introduction of more sophisticated modes of mechanical ventilation (pressure-control, inverse ratio, permissive hypercapnia), it may actually be increasing 2Shapiro B.A. Warren J. Egol A.B. et al.Practice parameters for sustained neuromuscular blockade in the adult critically ill patient an executive summary.Crit Care Med. 1995; 23: 1601-1605Crossref PubMed Scopus (104) Google Scholar. Inability to adequately ventilate a restless patient, despite analgesia and sedation, represents the main indication for muscle paralysis.3Meistelman C. Plaud B. Neuromuscular blockade is it still useful in the ICU?.Eur J Anaesth. 1997; 14: 53-56Crossref Google Scholar NMB cause known risks such as muscle atrophy, venous thromboembolism and nerve compression syndromes. By leaving an intact sensorium, the use of NMB also renders physicians and nurses unable to adequately assess ongoing needs for analgesia and sedation. The Practice Parameters for NMB by the American College of Critical Care Medicine clearly state that: “Since these agents are devoid of amnestic, analgesic and sedative properties, they must always be used in conjunction with appropriate sedative and/or analgesic agents. Unrecognized wakefulness is known to occur in paralyzed patients and the simple act of administering sedatives does not guarantee the absence of patient awareness”.2Shapiro B.A. Warren J. Egol A.B. et al.Practice parameters for sustained neuromuscular blockade in the adult critically ill patient an executive summary.Crit Care Med. 1995; 23: 1601-1605Crossref PubMed Scopus (104) Google Scholar Intubated patients often can express unrelieved pain or discomfort only as agitation. Unfortunately, there is not a standard “appropriate” dose of sedatives and analgesics that will provide adequate comfort for all patients. Paradoxically, intractable agitation, which is the actual indication for the use of NMB, is in itself an implication that the sedation and analgesia are inadequate. Patients on chronic opioid therapy are known to require very high doses of opioids when their pain worsens or a new pain supervenes.4Kanner R.M. Foley K.M. Patterns of narcotic drug use in a cancer pain clinic.Ann NY Acad Sci. 1981; 362: 161-172Crossref PubMed Scopus (173) Google Scholar In these patients, when a given opioid dose is not effective in controlling pain, the opioid is titrated upward until pain is relieved. Switching to a different opioid might be indicated when adequate analgesia is not achieved with the first opioid.5Levy M.H. Pharmacologic treatment of cancer pain.N Engl J Med. 1996; 335: 1125-1130Crossref Scopus (40) Google Scholar, 6Jacox A, Carr DB, Payne R, et al. Management of cancer pain. AHCPR Publication No. 94-O592: Clinical Practice Guideline No. 9 Rockville, MD, U.S. Department of Health and Human Services, Public Health Service; March 1994.Google Scholar In a patient with worsening pain preceding intubation, persistent agitation calls for upward titration or a switch in analgesics rather than NMB and paralysis. NMB provide only an illusory appearance of comfort that impedes proper titration of sedatives and analgesics and offers a false sense of reassurance to physicians, nurses, and families. This illusion of comfort may be so deceiving that analgesics may actually be reduced after the onset of paralysis. Pain and discomfort are subjective feelings that can be measured accurately only from the patient's self-report. Behavioral cues are used when patients are unable to communicate (infants, demented and delirious patients) and an attempt is made to match the behavioral cues to the clinical setting. Once the patient is paralyzed, the presence or absence of pain and hence the response to treatment are unknown. Changes in blood pressure and pulse rate are not adequate parameters for assessment of discomfort, especially in the critically ill patient. NMB can be essential for expedient intubation but should have a very limited role in the symptomatic management of ongoing agitation in the intubated patient, regardless of the cause for the agitation. More appropriate drugs in this setting are opioids, benzodiazepines, barbiturates and neuroleptics. In refractory cases, propofol infusions will succeed in sedating even extremely agitated patients. Careful titration of analgesia and sedation should eliminate the need for ongoing NMB of critically ill, intubated patients. Particular attention should be given to patients with a known painful condition; these patients may need extremely high doses of analgesics and/or switches to multiple opioids for control of worsening pain and agitation. Finally, it cannot be overemphasized that the families of critically ill patients are very much concerned with the level of comfort of their loved ones. This concern often becomes primary as the prognosis worsens. We cannot assure family members that adequate comfort is provided to the patient if we render assessment impossible by the use of NMB.