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

independently associated with the transition to delir-

ium from a non-delirious state (Answer B is correct).

Benzodiazepines have a sedating effect and may calm

an acutely agitated patient; however, they would not be

recommended in this patient because they could worsen

her confusion or delirium (Answer A is incorrect). The

PADIS guidelines state that no evidence supports the

use of haloperidol to reduce the duration of delirium

(Answer C is incorrect). Vancomycin is not currently

recognized as a cause of delirium; therefore, changing

to linezolid is not indicated (Answer D is incorrect).

Answer: D

The midazolam dose is high, and the patient is “deeply

sedated”; therefore, adding another benzodiazepine will

likely not improve this patient’s clinical status. Quetiapine

has no indication for general sedation in a critically ill

patient, and it should not be a consideration for sedation

in this patient with severe ARDS. Dexmedetomidine is

considered a weak sedative with no effect on respiratory

drive; therefore, it would likely not improve this patient’s

ventilator dyssynchrony and hypoxia (Answers A–C are

incorrect). At this stage in the patient’s clinical course,

it is reasonable to consider an NMDA. In a 2010 study

of cisatracurium versus placebo for 48 hours in early

ARDS, the cisatracurium group had more days free of

mechanical ventilation and decreased mortality (30%

vs. 44%) at 90 days for the subgroup of patients with

severe ARDS (Pao2/Fio2 ratio less than 120 mm Hg).

The incidence of pneumothorax was lower in the cisa-

tracurium group than in the placebo group (4% vs. 11%).

There were more days free of organ failure (non-lung)

in the cisatracurium group than in the placebo group

(15.8 vs. 12.2 days) in the first 28 days. A recent meta-

analysis concluded that using short-term cisatracurium

in patients with severe ARDS decreases mortality and

time on mechanical ventilation compared with placebo.

The risk of prolonged neuromuscular weakness was not

found in these studies; however, use beyond 48 hours

may increase this risk (Answer D is correct).

Answer: C

The TOF method of assessment is primarily used to help

determine the degree of neuromuscular blockade and

should not be used to titrate the dose of the NMBA. The

patient’s clinical status and laboratory values are the

true determinants for dose adjustment of the NMBA.

Patients may be at their clinical goal with a TOF of 2

or 3 twitches of 4. This is the ideal scenario, and it will

predict a faster reversal of neuromuscular blockade

(Answer C is correct). A TOF of 0 or 1 of 4 twitches

predicts a significantly slower neuromuscular recovery

time, and clinicians should try to decrease the NMBA as

soon as the patient is clinically stable by laboratory val-

ues and ventilator management (Answer D is incorrect).

A baseline electrical current intensity (amperage) should

be established before the onset of neuromuscular block-

ade and should not be changed during paralysis unless

a new baseline is indicated (Answer A is incorrect). As

the electrical intensity (amperage) is established, an

increase in the amperage is not indicated during infu-

sion of the NMBA in order to increase the number of

twitches. A decrease in the dose of NMBA would be

indicated if an increase in the number of twitches were

the clinical goal (Answer B is incorrect).