Use Of Neuromuscular Blocking Agents Research Articles

Prevalence and Risk Factors of Intensive Care Unit-acquired Weakness in Patients With COVID-19: A Systematic Review and Meta-analysis.

Intensive care unit acquired weakness (ICUAW) is a common neuromuscular complication of critical illness, impacting patients' recovery and long-term outcomes. However, limited evidence is available on pooled prevalence and risk factors of ICUAW specifically in the COVID-19-infected population. We searched on PubMed, Embase, Cochrane Library, Web of Science, PEDro, and EBSCOhost/CINAHL up to January 31, 2024. Data synthesis was conducted using the Freeman-Tukey double-arcsine transformation model for the pooled prevalence rate and odds ratios with corresponding 95% confidence intervals was used to identify risk factors. The pooled prevalence of ICUAW in COVID-19 patients was 55% in eight studies on 868 patients. Risk factors for developing ICUAW in these patients were: old age (WMD 4.78, 95% CI, 1.06-8.49), pre-existing hypertension (OR = 1.63, 95% CI, 1.02-2.61), medical intervention of prone position (OR = 5.21, 95% CI, 2.72-9.98), use of neuromuscular blocking agents (NMBA) (OR = 12.04, 95% CI, 6.20-23.39), needed tracheostomy (OR = 18.07, 95% CI, 5.64-57.92) and renal replacement therapy (RRT) (OR = 5.24, 95% CI = 2.36-11.63). The prevalence of ICUAW in patients with COVID-19 was considered relatively high. Older age, pre-existing hypertension, medical intervention of prone position, NMBA use, needed tracheostomy and RRT were likely risk factors. In the future, interdisciplinary medical team should pay attention to high-risk groups for ICUAW prevention and early treatments.

Neuromuscular Blockade in the Critically Ill

The management of sedation in intensive care medicine has changed substantially in the last few years. Neuromuscular blocking agents (NMBA) are only rarely indicated in modern intensive care medicine. In this review, the mechanism of action, potential side effects, and special considerations for the application of NMBA to critically ill patients will be discussed. We further present the rationale for the use of NMBA for the remaining indications, such as endotracheal intubation, selected cases of severe acute respiratory distress syndrome, and shivering during temperature control after cardiac arrest. The review will close with a description of potential side effects of NMBA use in the intensive care setting, such as awareness, acquired skeletal muscle weakness as well as corneal injuries, and how monitoring of sedation and peripheral muscle blockade may be handled.

Eliminating residual neuromuscular blockade: a literature review.

Although millions of patients receive neuromuscular blocking agents (NMBAs) each year as part of an anesthetic, residual neuromuscular blockade (NMB) remains a too-frequent occurrence and its adverse consequences continue to negatively impact patient outcomes. The goal of this manuscript is to provide clinicians with the information they need to decrease the incidence of residual NMB. Published literature was reviewed and incorporated into the narrative as appropriate. Search terms for articles included nondepolarizing NMBAs, residual NMB, monitoring depth of NMB, qualitative monitoring, quantitative monitoring, reversal agents, sugammadex, and anticholinesterases. This review will define what is currently considered adequate recovery of neuromuscular function, discuss and compare the different modalities to determine the depth of NMB, discuss the currently available NMBAs-including their durations of action and dosing, describe the incidence and complications associated with residual NMB, and discuss reversal of nondepolarizing NMB with neostigmine or sugammadex. Nondepolarizing NMBAs are commonly used as part of a general anesthetic. Understanding the pharmacology of the neuromuscular blocking and reversal agent, in combination with quantitative monitoring of depth of NMB is essential to avoid residual paralysis. Quantitative monitoring and dosing of either neostigmine or sugammadex based on the results of monitoring is essential to eliminate residual NMB associated with the use of nondepolarizing NMBAs.

Assessing pain in paralyzed critically ill patients receiving neuromuscular blocking agents: A monocenter prospective cohort

IntroductionGiven the absence of established recommendations for pain assessment in pharmacologically paralyzed Intensive-Care-Units (ICU) patients under Neuro-Muscular-Blocking Agents (NMBA), this study assessed the validity of various parameters for evaluating pain in this specific population. Patients and methodsFour electrophysiological parameters (instant-Analgesia-Nociception-Index (ANI), Bispectral index (BIS), Heart Rate (HR) and Mean Arterial Blood Pressure (ABP)) and one clinical parameter (Behavioural-Pain-Scale (BPS)) were recorded during tracheal-suctioning in all consecutive ICU patients who required a continuous infusion of cisatracurium, before and just after paralysis recovery measured by Train-of-Four ratio. The validity of the five pain-related parameters was assessed by comparing the values recorded during different situations (before/during/after the nociceptive procedure) (discriminant-validity, primary outcome), and the effect of paralysis was assessed by comparing values obtained during and after paralysis (reliability, secondary outcome). ResultsTwenty patients were analyzed. ANI, BIS, and HR significantly changed during the nociceptive procedure in both paralysis and recovery, while BPS changed only post-recovery. ANI and HR were unaffected by paralysis, unlike BIS and BPS (mixed-effect model). ANI exhibited the highest discriminant-validity, with values (min 0/max 100) decreasing from 71 [48–89] at rest to 41 [25–72] during tracheal suctioning in paralyzed patients, and from 71 [53–85] at rest to 40 [31–52] in non-paralyzed patients. ConclusionsANI proves the most discriminant parameter for pain detection in both paralyzed and non-paralyzed sedated ICU patients. Its significant and clinically relevant decrease during tracheal suctioning remains unaltered by NMBA use. Pending further studies on analgesia protocols based on ANI, it could be used to assess pain during nociceptive procedures in ICU patients receiving NMBA.

Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants: a protocol for a systematic review, meta-analysis and trial sequential analysis.

The European Society of Anesthesiology and Intensive Care recommends the use of neuromuscular blocking agents (NMBA) in adults, to facilitate tracheal intubation and reduce its associated complications. Children who undergo tracheal intubation may suffer some of the same complications, however, no consensus exists regarding the use of NMBA for tracheal intubation in the pediatric population. We will explore the existing evidence assessing the effects of avoidance versus the use of NMBA for the facilitation of tracheal intubation in children and infants. This protocol follows the preferred reporting items for systematic reviews and meta-analyses protocols recommendations. We will include all randomized controlled clinical trials assessing the effects of avoidance versus the use of NMBA for facilitation of tracheal intubation (oral or nasal) using direct laryngoscopy or video laryngoscopy in pediatric participants (<18 years). Our primary outcome is incidence of difficult tracheal intubation. Secondary outcomes include incidence of serious adverse events, failed intubation, events of upper airway discomfort or injury, and difficult laryngoscopy. We will conduct a thorough database search to identify relevant trials, including CENTRAL, MEDLINE, EMBASE, BIOSIS, Web of Science, CINAHL, and trial registries. Two review authors will independently handle the screening of literature and data extraction. Each trial will be evaluated for major sources of bias with the "classic risk of bias tool" used in the Cochrane Collaboration tool from 2011. We will use Review manager (RevMan) or R with the meta package to perform the meta-analysis. We will perform a trial sequential analysis on the meta-analysis of our primary outcome, providing an estimate of statistical reliability. Two review authors will independently assess the quality of the body of evidence using the grading of recommendations assessment, development, and evaluation (GRADE) approach. We will use GRADEpro software to conduct the GRADE assessments and to create "Summary of the findings" tables.

Effective bolus dose of remimazolam for i-gel® insertion in nonparalyzed patients: a dose-finding study

PurposeRemimazolam is a recently developed ultra-short-acting benzodiazepine used for anesthesia induction and maintenance. Nevertheless, the effective bolus dose of remimazolam for i-gel® (Intersurgical Ltd., Wokingham, Berkshire, UK) insertion without the use of neuromuscular blocking agents (NMBAs) has not been well established.MethodsThis study included 25 adult patients scheduled for surgery under general anesthesia who were eligible for i-gel use. Anesthesia was induced with predetermined bolus doses of remimazolam, starting at 0.3 mg·kg−1 for the first patient, without the use of NMBAs. All patients concurrently received remifentanil using target-controlled infusion (TCI) at a fixed effect-site concentration (Ce) of 3.0 ng·mL−1. Insertion of the i-gel was attempted 90 sec after remimazolam administration, and insertion conditions were assessed. Subsequent doses of remimazolam were decreased or increased by 0.05 mg·kg−1, depending on the success or failure of i-gel insertion.ResultsThe mean (standard deviation) 50% effective dose (ED50) of a remimazolam bolus for successful i-gel insertion as determined by the modified Dixon’s up-and-down method was 0.100 (0.027) mg·kg−1. The ED50 and ED95 estimated by isotonic regression were 0.111 (83% confidence interval [CI], 0.096 to 0.131) mg·kg−1 and 0.182 (95% CI, 0.144 to 0.195) mg·kg−1, respectively. None of the patients required treatment for hypotension or bradycardia during anesthesia induction.ConclusionBased on the ED95 of remimazolam bolus dose determined in our study, we recommend using 0.182 mg·kg−1 of remimazolam in combination with remifentanil TCI at a Ce of 3.0 ng·mL−1 for successful i-gel insertion without NMBAs in adult patients. This regimen seems effective with a low risk of hemodynamic instability during anesthesia induction.Study registrationClinicalTrials.gov (NCT05298228); first submitted 6 March 2022.

Neuromuscular Blocking Agent Use in Critical Care Transport Not Associated With Intubation

ObjectiveVariable indications exist for neuromuscular blocking agents (NMBAs) in the critical care transport setting beyond facilitation of intubation. MethodsThis retrospective cohort study included adult patients (≥ 18 years) who underwent critical care transport from July 1, 2020, to May 2, 2023, and received NMBAs during transport that was not associated with intubation. The primary outcome was the indication for NMBA administration. Secondary outcomes included the characterization of NMBA use, mean Richmond Agitation Sedation Scale score before NMBA administration, sedation strategy used, and continuation of NMBAs within 48 hours of hospital admission. ResultsOne hundred twenty-six patients met the inclusion criteria. The most common indication for NMBA administration was ventilator dyssynchrony (n = 71, 56.4%). The majority of patients received rocuronium during transport (n = 113, 89.7%). The mean pre-NMBA Richmond Agitation Sedation Scale score was −3.7 ± 2.4. The most common sedation strategy was a combination of continuous infusion and bolus sedatives (76.2%). One hundred (79.4%) patients had sedation changes in response to NMBA administration. Seventy-two (57.1%) received NMBAs during the first 48 hours of their intensive care unit admission. ConclusionNMBAs were frequently administered for ventilator dyssynchrony and continuation of prior therapy. Optimization opportunities exist to ensure adequate deep sedation and reassessment of NMBA indication.

Management of Neuromuscular Blocking Agents in Critically Ill Patients with Lung Diseases.

The use of neuromuscular blocking agents (NMBAs) is common in the intensive care unit (ICU). NMBAs have been used in critically ill patients with lung diseases to optimize mechanical ventilation, prevent spontaneous respiratory efforts, reduce the work of breathing and oxygen consumption, and avoid patient-ventilator asynchrony. In patients with acute respiratory distress syndrome (ARDS), NMBAs reduce the risk of barotrauma and improve oxygenation. Nevertheless, current guidelines and evidence are contrasting regarding the routine use of NMBAs. In status asthmaticus and acute exacerbation of chronic obstructive pulmonary disease, NMBAs are used in specific conditions to ameliorate patient-ventilator synchronism and oxygenation, although their routine use is controversial. Indeed, the use of NMBAs has decreased over the last decade due to potential adverse effects, such as immobilization, venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, ICU-acquired weakness, and residual paralysis after cessation of NMBAs use. The aim of this review is to highlight current knowledge and synthesize the evidence for the effects of NMBAs for critically ill patients with lung diseases, focusing on patient-ventilator asynchrony, ARDS, status asthmaticus, and chronic obstructive pulmonary disease.

Endotracheal Intubation without Neuromuscular Blocking Agent in Patient with Fracture Cervical Spine C1 and C4 Underwent Fusion C1–2 and C4–6

About 30% of cervical spine fractures involve injuries to the C1 and C2 vertebrae, which are considered unstable. Ensuring the stability of the injured cervical spine throughout perioperative period, including preoperative examinations, anesthesia induction, laryngoscopy, and intubation, is crucial for anesthesiologists. A 40-year-old woman suffered neck pain following a motorcycle accident, suffering a Spinal Cord Injury ASIA Impairment Scale (SCI AIS) E, a fracture of the C5 vertebral body (CV) classified as AO Spine Type A2, a Jefferson Type IV fracture, and mild head trauma. She underwent surgical fusion of the C1–C2 and C4–C6 vertebrae under general anesthesia, which included dexmedetomidine, propofol, sevoflurane, and fentanyl without any neuromuscular blocking agents (NMBA). The primary goal of perioperative airway management in cervical injury is a secured airway, while maintaining cervical stability without inflicting secondary injury. The cervical muscle group is essential for maintaining cervical stability, and the use of NMBA may jeopardize this stability, necessitating external cervical stabilization, especially during laryngoscopy and intubation. Induction agents in combination with opioid, widely used to facilitate laryngoscopy and intubation without using NMBA. Anesthesiologists must precisely arrange the management of cervical spine injuries patient to avoid secondary injury and improve surgical outcomes

Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation.

Mechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality. We conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed. A total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029-1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579). MPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.

A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes.

Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. Prospective, observational, and cohort study. Forty-three Spanish ICU. A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). None. At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.

Association between neuromuscular blocking agent use and outcomes among out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation and target temperature management: A secondary analysis of the SAVE-J II study

BackgroundNeuromuscular blocking agents are used to control shivering in cardiac arrest patients treated with target temperature management. However, their effect on outcomes in patients treated with extracorporeal cardiopulmonary resuscitation is unclear. MethodsThis study was a secondary analysis of the SAVE-J II study, a retrospective multicenter study of 2175 out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation in Japan. We classified patients into those who received neuromuscular blocking agents and those who did not and compared in-hospital mortality and incidence rates of favorable neurological outcome and in-hospital pneumonia between the groups using multivariable regression models and stabilized inverse probability weighting with propensity scores. ResultsSix hundred sixty patients from the SAVE-J II registry were analyzed. Neuromuscular blocking agents were used in 451 patients (68.3%). After adjusting for potential confounders, neuromuscular blocking agents use was not significantly associated with in-hospital mortality (aHR 0.88; 95% CI, 0.67–1.14), favorable neurological outcome (aOR 0.85; 95% CI, 0.60–1.11), or pneumonia (aOR 1.52; 95% CI, 0.85–2.71). The results for in-hospital mortality (aHR 0.89; 95% CI, 0.64–1.25), favorable neurological outcome (aOR 0.94; 95% CI, 0.59–1.48) and pneumonia (aOR 1.59; 95% CI, 0.74–3.41) were similar after weighting was performed. ConclusionsAlthough data on the rationale for using neuromuscular blocking agents were unavailable, their use was not significantly associated with outcomes in out-of-hospital cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation and targeted temperature management. Neuromuscular blocking agents should be used based on individual clinical indications.

Total Intravenous Anesthesia Protocol for Decreasing Unacceptable Movements during Cerebral Aneurysm Clipping with Motor-Evoked Potential Monitoring: A Historical Control Study and Meta-Analysis.

Injury can occur during intraoperative transcranial motor-evoked potential (MEP) monitoring caused by patient movement related to insufficient neuromuscular blocking agent use. Here, we evaluated the incidence of unacceptable movements in patients undergoing intraoperative MEP monitoring following our anesthetic protocol. We reviewed the anesthesia records of 419 patients who underwent unruptured cerebral aneurysm clipping with intraoperative MEP monitoring. The anesthetic protocol included target-controlled infusion with a fixed effect-site propofol concentration of 3 μg/mL and an adjustable effect-site remifentanil concentration of 10-12 ng/mL. We compared our findings of the intraoperative parameters and incidence of spontaneous movement and respiration with those of published meta-analysis studies. Spontaneous movement and respiration occurred in one (0.2%) patient each. The meta-analysis included six studies. The pooled proportions of spontaneous movement and respiration were 6.9% (95% confidence interval [CI], 1.3-16.5%) and 4.1% (95% CI, 0.5-14.1%), respectively. The proportion of spontaneous movement in our study was significantly lower than that in previous studies (p = 0.013), with no significant difference in spontaneous respiration (p = 0.097). Following our center's anesthesia protocol during cerebral aneurysm clipping resulted in a low incidence of spontaneous respiration and movement, indicating its safety for patients undergoing intraoperative MEP monitoring.

Use of NMBA and reversal agent during thyroid surgery with intraoperative neuromonitoring

Neuromuscular blocking agent (NMBA) provides adequate muscle relaxation for intubation and surgery, but their use can interfere with the interpretation of intraoperative neuromonitoring (IONM) signals. Various strategies for the use of NMBA during thyroid surgery with IONM have been proposed for both safe anesthesia and surgery, and adequate quality of IONM. Relaxant-free anesthesia or use of succinylcholine is not recommended as a routine use due to the potential of fatal complications such as laryngeal injury or malignant. Instead, the use of a single dose of rocuronium for intubation with or without a reversal agent has been widely adapted. Though spontaneous recovery of neuromuscular blockade can be achieved without a reversal agent, use of a reversal agent can shorten the time for adequate IONM. Both neostigmine and Sugammadex can be used to reverse the neuromuscular blockade. Neostigmine reverses all types of non-depolarizing NMBA, but can accompany systemic cholinergic effect, and is not effective to deep or higher level of blockade. Sugammadex only reverses the effect of aminosteroid NMBAs, but effective to all levels of blockade. Overall, appropriate strategies for the use of NMBAs and reversal agents are needed to ensure effective IONM without increasing the risk of nerve injury during surgery.

Time for change: improving neuromuscular blocking agent safety in Australia

AbstractIncidents involving mis‐selection and administration of neuromuscular blocking agents (NMBAs) leading to patient harm resulted in the initiation of activity in Victorian hospitals to review the management of this high‐risk group of medicines. Local risk mitigation strategies, such as in‐house labelling and restricting access, were considered partially effective, but it was recognised that a national approach was required. In 2015, hospital pharmacists — together with anaesthetist colleagues and peak patient safety organisations — made a submission to the Therapeutic Goods Administration (TGA) describing safety risks with NMBAs, with recommendations for improved NMBA labelling. This report describes the five‐year process which eventually led to the TGA mandating manufacturers to place alert labelling on NMBA products. As a result of this effort, a Victorian Therapeutics Advisory Group (VicTAG) grant enabled the development of a ‘NMBA Safer Practice Advisory Tool for Australian Hospitals’, providing a standard guide to monitor the safe use of NMBAs.

Adequacy of Reversal of Neuromuscular Blockade with or without Train-of-Four Monitoring: A Randomised Controlled Study

Introduction: Adequate reversal of Neuromuscular Blockade (NMB) is essential when using muscle relaxants to avoid residual paralysis postoperatively. Reversal can be achieved using clinical parameters or, alternatively, by Train-of-Four (TOF) monitoring. Aim: To evaluate the adequacy of successful NMB reversal using clinical parameters-based endpoints compared to using TOF monitoring. Materials and Methods: The hospital-based randomised controlled study conducted in the Department of Anaesthesiology, SDM Medical College, Dharwad, Karnataka, India for a peroid of two years from November 2019 to December 2021. Consisted of 120 subjects divided into two groups: Group-C (Clinical parameters) and group T (TOF monitoring), aged 18-60 years of either sex with American Soceity of Anaesthesiologists (ASA) physical status I and II, undergoing elective surgery under general anaesthesia requiring intubation. Extubation was achieved in group C using clinical parameters like return of spontaneous respiratory efforts, adequate Tidal Volume (TV) (≥5 mL/kg), obeying simple commands, absence of excessive secretions, and in group T using TOF monitoring. The t-test was used to compare the difference between the groups. The Chi-square test was done for contingency data. A p-value of less than or equal to 0.05 (p-value≤0.05) indicates statistical significance. Results: In the study, both group C and group T were comparable in terms of age {(41.15±10.23 years, 41.03±11.9 years) p-value=0.95}, sex (m/f) {(46.6%/53.3% and 63.3%/36.6%) p-value=0.06}, and Basal Metabolic Index (BMI) {≤25=59.1%, 25- 30=33.3%, ≥30=7.5%, p-value=0.57}, respectively. Five patients in group C had residual paralysis, whereas none in group T. Reversal-extubation time in minutes (min) in group C {5.9± 2.2, 5.4 (2-15.2)} and group T {6.6± 1.9, 6.24 (3.3-12.2)} (p-value=0.07), TOF value at the time of extubation in group C {72.1±11.6, 72 (41-91)}, group T {72.75±2.74, 72 (70-79)} (p-value=0.69). TOF value after 10 minutes of extubation in group C {92.5±7.1, 94 (66- 100)} and group T {95.6±2.7, 96 (90-100)} (p-value=0.006). Conclusion: The TOF monitoring is better compared to a clinical parameters-based reversal strategy in reducing the incidence of residual paralysis and resulting complications whenever Neuromuscular Blocking Agents (NMBAs) are used. Hence, it is desirable to use Neuromuscular Monitoring with the use of NMBAs.

Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients

Acute respiratory distress syndrome (ARDS) accounts for a quarter of mechanically ventilated patients, while during the pandemic, it overwhelmed the capacity of intensive care units (ICUs). Lung protective ventilation (low tidal volume, positive-end expiratory pressure titrated to lung mechanics and oxygenation, permissive hypercapnia) is a non-pharmacological approach that is the gold standard of management. Among the pharmacological treatments, the use of neuromuscular blocking agents (NMBAs), although extensively studied, has not yet been well clarified. The rationale is to minimize the risk for lung damage progression, in the already-injured pulmonary parenchyma. By abolishing rigorous spontaneous efforts, NMBAs may decrease the generation of high transpulmonary pressures that could aggravate patients’ self-inflicted lung injury. Moreover, NMBAs can harmonize the patient–ventilator interaction. Recent randomized controlled trials reported contradictory results and changed the clinical practice in a bidirectional way. NMBAs have not been documented to improve long-term survival; thus, the current guidance suggests their use only in patients in whom a lung protective ventilation protocol cannot be applied, due to asynchrony or increased respiratory efforts. In the present review, we discuss the published data and additionally the clinical practice in the “war” conditions of the COVID-19 pandemic, concerning NMBA use in the management of patients with ARDS.

Neuromuscular blocking agents in the intensive care unit.

Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.

Evolution of Respiratory Muscles Thickness in Mechanically Ventilated Patients With COVID-19.

Given the long ventilation times of patients with COVID-19 that can cause atrophy and contractile weakness of respiratory muscle fibers, assessment of changes at the bedside would be interesting. As such, the aim of this study was to determine the evolution of respiratory muscle thickness assessed by ultrasound. Adult (> 18 y old) patients admitted to the ICU who tested positive for SARS-CoV-2 and were ventilated for < 24 h were consecutively included. The first ultrasound examination (diaphragm, rectus abdominis, and lateral abdominal wall muscles) was performed within 24 h of intubation and regarded as baseline measurement. After that, each following day an additional examination was performed, for a maximum of 8 examinations per subject. In total, 30 subjects were included, of which 11 showed ≥ 10% decrease in diaphragm thickness from baseline; 10 showed < 10% change, and 9 showed ≥ 10% increase from baseline. Symptom duration before intubation was highest in the decrease group (12 [11-14] d, P = .03). Total time ventilated within the first week was lowest in the increase group (156 [129-172] h, P = .03). Average initial diaphragm thickness was 1.4 (1.1-1.6) mm and did not differ from final average thickness (1.3 [1.1-1.5] mm, P = .54). The rectus abdominis did not show statistically significant changes, whereas lateral abdominal wall thickness decreased from 14 [10-16] mm at baseline to 11 [9-13] mm on the last day of mechanical ventilation (P = .08). Mixed-effect linear regression demonstrated an association of atrophy and neuromuscular-blocking agent (NMBA) use (P = .01). In ventilated subjects with COVID-19, overall no change in diaphragm thickness was observed. Subjects with decreased or unchanged thickness had a longer ventilation time than those with increased thickness. NMBA use was associated with decreased thickness. Rectus muscle thickness did not change over time, whereas lateral abdominal muscle thickness decreased but this change was not statistically significant.

Updates in diagnosis, treatment, and prevention of anaphylaxis to neuromuscular blocking agents and their antagonists

Anaphylaxis to perioperative drugs has an insidious and rapid onset, can be life-threatening, and often results in the suspension of surgery. Neuromuscular blocking agents (NMBAs) are currently considered to be the most common cause of anaphylactic reactions among anesthetic drugs. With the increasing amount of anesthesia and surgery in the world, there are more and more NMBAs use, and the corresponding allergic risk is also increasing. With the use of NMBAs, their antagonists, such as neostigmine and sugammadex, are often used too, which have more and more allergy reports in clinical practice. Due to the complex mechanism of allergy caused by NMBAs and their antagonists, it is difficult to find out the culprit drug. The cross-reactivity between NMBAs is common, so it is often difficult to choose alternative drugs. This article summarized the epidemiology, pathological mechanisms, diagnostic methods and procedures, immediate treatment, and prevention strategies of anaphylaxis caused by these drugs.