The American Society of Health System Pharmacists (ASHP) has developed a flow diagram for guiding use of neuromuscular blocking agents in the intensive care unit (ICU).


Indications for neuromuscular blocking agent:

(1) mechanical ventilation

(2) muscle spasms from tetanus, seizures or other cause

(3) increased intracranial pressure


Use of a blocking agent should be considered if optimizing sedatives and/or analgesics is insufficient to manage the patient.


Use cisatracurium or atracurium if either:

(1) there is a contraindication to a vagolytic drug (pancuronium is vagolytic, which results in an increase in the heart rate by >= 10 beats per minute)

(2) there is evidence of hepatic or renal dysfunction (renal failure, cirrhosis, etc. prolong the neuromuscular blocking effects of pancuronium).


Otherwise, use pancuronium.


While neuromuscular blockade is in use:

(1) monitor with the train-of-four (see above)

(2) protect the eyes

(3) use decubitus ulcer prevention such as positioning the patient to protect pressure points

(4) consider prophylaxis to prevent deep vein thrombosis

(5) reassess every 12-24 hours to determine if blocking agents are still indicated.


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