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Avoiding the pitfalls and ensuring the safety of sustained neuromuscular blockade.

N blockade in the intensive care unit (ICU) has traditionally been used to facilitate mechanical ventilation, improve oxygenation, decrease oxygen consumption, decrease intracranial pressure, manage extreme agitation, relieve tetanus or muscle contracture, and/or treat refractory status epilepticus. The decision to neuromuscular block or “paralyze” a patient is a difficult and multifaceted one, despite these very compelling indications for neuromuscular blockade. The concerns are based on the fact that drug-induced paralysis is not without potential harm to patients if certain safeguards aren’t employed. Subsequent to mounting evidence of preventable adverse events (eg, prolonged paralysis) associated with the use of neuromuscular blockers, the Society of Critical Care Medicine (SCCM) published a consensus statement designed to assist the bedside nurse and other ICU practitioners in identifying the potential pitfalls of neuromuscular blockade. Additionally, best practice strategies are outlined therein. Neuromuscular blockade may be accomplished through either continuous infusion or intermittent bolus infusions. Bolus infusions of neuromuscular blockers are theorized as having the advantage of decreased likelihood of tachyphylaxis (rapidly developing tolerance), along with facilitating the monitoring of concomitant sedation and analgesia. It is also postulated that this bolus strategy may then lead to a decreased potential for excessive neuromuscular blockade, lowered potential drug cost, and shortened duration of mechanical ventilation compared to continuous neuromuscular blockade. Despite these potential advantages of bolus administration, continuous infusions are by far the more common method of neuromuscular blocker administration in most ICUs. Neuromuscular blockers are primarily divided into 2 categories: depolarizing and nondepolarizing. Succinylcholine is the only depolarizing agent that is approved by the FDA. Because of the fast onset of action and short duration of action, usage of this agent is limited to bolus administration during intubation. Conversely, the more important neuromuscular blockers for critical care practitioners to know and understand are the nondepolarizing agents because they are the only agents used for prolonged paralysis. These nondepolarizing agents are further classified into two groups: steroid based and nonsteroid based. The steroid-based agents all commonly end in the suffix “onium” (ie, pancuronium AACN Advanced Critical Care