Pain, Agitation/Sedation, Delirium, Immobility, Sleep Disruption, and Neuromuscular Blockade

Awareness: Recent case reports document patient awareness during paralysis in the ICU. These patients

report weird dreams, fear, resistance of restraints, thoughts of life and death, and pain. Patients must be

Resistance to paralysis and/or potentiation: Certain disease states may produce an up-regulation in

acetylcholine skeletal muscle receptors, leading to higher-than-normal doses of the NMBA (e.g., muscle

trauma, muscle atrophy, burns). Acid-base disorders, electrolyte imbalances, and adrenal insufficiency

may also cause unpredictable alterations in dosing requirements.

Anaphylaxis: Allergic reactions can occur after the first dose of an NMBA because the ammonium ions

in NMBAs are commonly found in the household environment and in household products. If an allergic

reaction is suspected, skin prick testing for the NMBA against a control can be done within 6 weeks of

the reaction.

Patient Cases

A 55-year-old man intubated for severe ARDS (Pao2/Fio2 ratio less than 100 mm Hg) is receiving fentanyl

200 mcg/hour, midazolam 8 mg/hour, and propofol 40 mcg/kg/minute. He is deeply sedated but remains

hypoxic and dyssynchronous with the ventilator after several changes in mechanical ventilation settings.

Which is the most appropriate consideration at this time?

A 70-year-old woman who is day 2 in the ICU is receiving a neuromuscular blocking agent (NMBA) and

is sedated for severe ARDS. The TOF over 24 hours is 2 of 4 twitches at an amplitude of 10 mA. Arterial

blood gas is pH 7.38, Pco2 40 mm Hg, Po2 91 mm Hg, and bicarbonate 24 mEq/L on 50% inspired oxygen

and 10 cm H2O PEEP; the patient is synchronous with the ventilator, and other clinical markers are stable.

Which changes in management would be best to recommend?