Neuromuscular blocking drugs in the intensive care unit: Indications, protocols, and complications

Neuromuscular blocking drugs have clearly established themselves as a critical component of ICU care. With this increased use, a number of associated problems have become apparent. Substantial progress has been made in understanding the etiology and minimizing the risks of these side effects. However, there is clearly a need for additional information to guide rational decisions. A variety of recommendations are currently being made without firm scientific support. Some have recommended switching relaxants to a different structural class when tolerance develops, an interesting but entirely unsubstantiated suggestion. Monitoring of neuromuscular blockade is strongly recommended but is clearly not a panacea. Minimizing the dose and duration of drug administration may be helpful but other selective interventions may be equally efficacious, limiting morbidity and mortality while allowing maximal beneficial effects of the relaxant drugs. Although the ICU is the antithesis of the ideal setting for the definitive, prospective, randomized, placebo- controlled, double-blind scientific study, there is a clear need for relevant, scientifically rigorous information to guide the rational use of drugs in this complex clinical setting. A more extensive evaluation of the role of neuromuscular blockade in the ICU may require reassessment and revision of human subjects committee overview of critical care studies. This was suggested by Yarborough, who recently recommended an effort by clinical researchers to overcome ethical challenges of performing clinical studies involving patients in the ICU, so as to promote interdisciplinary critical care research. Perhaps the local philosopher and bluesman, Guitar Mack, summarizes it most succinctly when he says, 'we aren't where we want to be, and we aren't where we need to be, but thank goodness we aren't where we have been.