Monitoring neuromuscular blockade in the intensive care unit: The peripheral nerve stimulator

Heart & Lung ◽  
1999 ◽  
Vol 28 (5) ◽  
pp. 352-364 ◽  
Author(s):  
Sandra C. Rowlee
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator

Neuromuscular Blockade in the Pediatric Intensive Care Unit: Pancuronium, Vecuronium, Rocuronium, or Atracurium

1997 ◽  
Vol 12 (4) ◽  
pp. 213-217 ◽  
Author(s):  
Joseph D. Tobias
Keyword(s):  
Intensive Care Unit ◽  
Renal Function ◽  
Intensive Care ◽  
Peripheral Nerve ◽  
Continuous Infusion ◽  
Neuromuscular Blockade ◽  
Pediatric Intensive Care Unit ◽  
Pediatric Intensive Care ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator

Certain conditions may necessitate use of neuromuscular blocking agents (NMBAs) in children in the pediatric intensive care unit (PICU). Despite information concerning individual agents, there are limited studies comparing agents. I compare 4 of the more commonly used NMBAs: pancuronium, vecuronium, rocuronium, and atracurium. All agents were administered by bolus followed by a continuous infusion with the rate adjusted by use of a peripheral nerve stimulator to maintain one twitch of the train-of-four. Ten patients with normal hepatic and renal function were included in each group. The study period included the first 72 hours of neuromuscular blockade. All 4 agents were easily titrated by continuous infusion to maintain the desired level of blockade. Pancuronium infusion requirements varied from 0.03 to 0.12 mg/kg/hr, vecuronium requirements from 0.05 to 0.2 mg/kg/hr, rocuronium requirements from 0.5 to 1.9 mg/kg/hr, and atracurium requirements from 0.8 to 2.2 mg/kg/hr. No significant advantage of one agent over another was noted. The wide range of infusion requirements further stresses the need for close monitoring of the degree of neuromuscular blockade with a peripheral nerve stimulator. An additional 10 patients with abnormal hepatic/renal function received atracurium. The dose requirements were the same as in patients with normal end-organ function, ranging from 0.6 to 2.0 mg/kg/hr. In patients with abnormal hepatic or renal function, atracurium may be used without the need to alter the dose.

Technical and Interpretive Problems of Peripheral Nerve Stimulation in Monitoring Neuromuscular Blockade in the Intensive Care Unit

1996 ◽  
Vol 30 (2) ◽  
pp. 165-172 ◽  
Author(s):  
Maria I Rudis ◽  
Benjamin G Guslits ◽  
Barbara J Zarowitz
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
Critically Ill ◽  
Nerve Stimulation ◽  
Peripheral Nerve Stimulation ◽  
Motor Neuropathy ◽  
Operator Technique ◽  
Peripheral Nerve Stimulator

OBJECTIVE: To review the literature and provide an overview of the technical and interpretive problems associated with peripheral nerve stimulation in monitoring neuromuscular blockade in the intensive care unit. DATA SOURCES: A computerized search on MEDLINE from 1985 through 1994 was performed to identify English-language comparative studies, abstracts, and review articles pertaining to peripheral nerve stimulation, train-of-four monitoring, and neuromuscular blockade in the critical care setting. STUDY SELECTION AND DATA EXTRACTION: Relevant studies in humans were selected and information was extracted on the use of peripheral nerve monitoring in the critically ill. DATA SYNTHESIS: Use of peripheral nerve stimulation is complicated in the intensive care unit. Problems may occur with the patient, the device, as well as operator technique, all of which may lead to errors in interpretation of the depth of paralysis. The critically ill patient has changing comorbid disease states and total body water composition, which may impair the accuracy or reproducibility of measurements. Technical problems relate to the operation of the device, electrode placement, and suboptimal delivery of the desired current. Difficulties in performing peripheral nerve stimulation and interassessor variability contribute to errors of interpretation. CONCLUSIONS: These difficulties compromise the precision, accuracy, and reliability of the peripheral nerve stimulator as a tool for monitoring neuromuscular blockade in the critically ill. Peripheral nerve stimulation should be used in conjunction with clinical parameters to make decisions regarding dose adjustments. Doses should be reduced as much as possible to provide the minimum depth of paralysis that is clinically appropriate. Technical directions and training programs for peripheral nerve stimulation should be developed, and designated individuals should be trained in its application. Large, prospective, controlled studies are necessary to evaluate the incidence of prolonged paralysis or motor neuropathy with administration of neuromuscular blocking agents in patients whose dose is adjusted on the basis of peripheral nerve stimulation.

Use of peripheral nerve stimulators to monitor patients with neuromuscular blockade in the ICU

1996 ◽  
Vol 5 (6) ◽  
pp. 449-454 ◽  
Author(s):  
R Kleinpell ◽  
C Bedrosian ◽  
L McCormick ◽  
M Kremer ◽  
L Bujalski ◽  
...  
Keyword(s):  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
National Sample ◽  
Neuromuscular Blocking ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Number Of Patients ◽  
Train Of Four ◽  
Current Monitoring ◽  
Prolonged Neuromuscular Blockade

BACKGROUND: Neuromuscular blockade is a frequently used therapy in the ICU. However, recent reports of prolonged paralysis and general muscular weakness in patients treated with this procedure have raised concerns about its use in intensive care. OBJECTIVE: The purpose of this study was to assess current monitoring practices of nurses who care for patients treated with neuromuscular blockade. METHODS: In January 1995, questionnaires were mailed to a random national sample of 2000 critical care nurses. Of the 2000 questionnaires mailed, 744 were returned. RESULTS: The number of patients per month who were treated with neuromuscular blockade in ICU settings ranged from 0 to 75 (mean = 6.82, SD = 9.15). For each patient, the average number of days of blockade ranged from less than 1 to 63 (mean = 4.12, SD = 3.36). The most common indications for neuromuscular blockade were to assist in mechanical ventilation, reduce oxygen consumption, and treat agitation. Only 41% of respondents (n = 306) reported using train-of-four stimuli and a peripheral nerve stimulator to monitor patients. Depth of neuromuscular blockade was routinely monitored by using clinical assessment (31%), a peripheral nerve stimulator (16%), or both (52%). CONCLUSIONS: Among the respondents, variations existed in monitoring practices and in the use of peripheral nerve stimulators, including the frequency of monitoring and use of the baseline milliamperage. Appropriate monitoring and titration of neuromuscular blocking agents by ICU nurses may aid in preventing adverse effects, including the potential for prolonged neuromuscular blockade. The existing variations in practice may affect patients' outcomes.

Failure to Reverse Prolonged Vecuronium-Induced Neuromuscular Blockade with Edrophonium in an Anesthetized Dog

2011 ◽  
Vol 47 (4) ◽  
pp. 294-298 ◽  
Author(s):  
Manuel Martin-Flores ◽  
Jordyn Boesch ◽  
Luis Campoy ◽  
Robin D. Gleed
Keyword(s):  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
Neuromuscular Transmission ◽  
Muscle Relaxation ◽  
Complete Recovery ◽  
Neuromuscular Function ◽  
Partial Recovery ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Factors Affecting

A case of prolonged muscle relaxation after vecuronium in an anesthetized dog is presented. After using peripheral nerve stimulation to confirm partial recovery of neuromuscular transmission, administration of 0.5 mg/kg IV of intravenous edrophonium failed to complete the reversal process. Subsequent administration of neostigmine resulted in complete recovery from blockade. Without monitoring neuromuscular function with a peripheral nerve stimulator until reversal was complete, it was very likely this patient would have been extubated with incomplete neuromuscular transmission. Several factors affecting the duration of neuromuscular blockade and its reversal are addressed.

Monitoring neuromuscular blockade in the adult ICU

1995 ◽  
Vol 4 (2) ◽  
pp. 122-130 ◽  
Author(s):  
EV Ford
Keyword(s):  
Side Effects ◽  
Peripheral Nerve ◽  
Neuromuscular Blockade ◽  
Clinical Signs ◽  
Neuromuscular Blocking ◽  
Neuromuscular Blocking Agents ◽  
Individual Response ◽  
Nerve Stimulator ◽  
Peripheral Nerve Stimulator ◽  
Proper Operation

Although neuromuscular blocking agents are now administered in intensive care units for extended periods, no standard has been established for their use in critically ill patients. Also, despite wide variations in individual response to neuromuscular blockade, the level of paralysis is not monitored consistently. Paralytic agents are associated with numerous side effects such as prolonged weakness, which is gaining widespread attention. Side effects may be minimized or prevented by consistent and precise monitoring of the degree of blockade. Monitoring is best accomplished by the expert use of the peripheral nerve stimulator. The evoked responses must be correlated with clinical signs of muscle movement. Furthermore, staff education regarding the pharmacology of these agents and the proper operation of the peripheral nerve stimulator must be ongoing.

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