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Table 1 Clinical practice guidelines for the sustained neuromuscular blockade in the adult critically ill patient [3]

From: Neuromuscular blockade management in the critically Ill patient

Clinical practice(s)

Strength of Recommendation

• Scheduled eye care with lubrication and eyelid closure

Strong recommendation

• Continuous infusion of NMBA rather than intermittent boluses

• Avoid use in status asthmaticus

• Trial of NMBA in life-threatening situations with hypoxemia, respiratory acidosis, and hemodynamic compromise

• May be used to manage overt shivering in therapeutic hypothermia

• PNS with inclusive clinical assessment may be a useful tool for determining the depth of blockade

• PNS should not be used alone (without clinical assessments) in patients receiving a continuous infusion of NMBAs

• Implementation of a structured physiotherapy regimen

• Target blood glucose level < 180 mg/dL

• Dose NMBA based on ideal body weight or adjusted boy weight (rather than actual)

Weak recommendation

• PNS can be used with clinical assessment in patients undergoing therapeutic hypothermia

• Protocols should be utilized to guide NMBA administration in patients undergoing therapeutic hypothermia

• Analgesic and sedative drugs should be used before and during neuromuscular blockade

• Implement measures to reduce risk of unintended extubation in patients receiving NMBAs

• Reduce dosing in patients with myasthenia gravis based on PNS use

• Discontinue NMBAs prior to determining brain death

Good practice based on expert opinion with insufficient evidence

  1. NMBA neuromuscular blocking agents, PNS peripheral nerve stimulator