Adverse Events

NMBAS and ICU-Acquired Weakness (ICUAW)

NMBAs have been dispraised due to a supposed association with ICUAW.

ICUAW is defined by a generalized muscle weakness that develops during the course of an ICU admission and for which no cause other than the acute illness or its treatment can be identified [32]. ICUAW is present among approximately 60% of ARDS patients at the time of awakening [33] and 36% at the time of hospital discharge [34]. ICUAW is associated with prolonged ICU and hospital stays, prolonged mechanical ventilation duration and increased ICU and hospital mortalities [35-38]. Risk factors have been discussed widely in the literature, and independent risk factors, such as female sex, multiple organ dysfunctions (>2), the duration of mechanical ventilation, hyperglycaemia [39] and the administration of corticosteroids [36], have been identified.

The prolonged use of neuromuscular blocking agents (more than 48 h) [40, 41], their simultaneous administration with corticosteroids [42] and steroid NMBAs may contribute to ICUAW [43, 44], but there is actually no evidence that non-steroid NMBAs increase the risk of ICUAW when used for short durations and without the simultaneous administration of corticosteroids [32]. In a meta-analysis [17] of RCTs evaluating the effects of the use of NMBAs during ARDS, the incidence of ICU-acquired paresis (assessed via clinical evaluations of quadriparesis or by the Medical Research Council (MRC) score at day 28 or at ICU discharge) was not higher among the treated patients than in the control group.

Insufficient Sedation and Memorizing

The continuous use of NMBA infusion highlights the problem of inadequate sedation. Hardin et al. [45] demonstrated that patients receiving NMBAs were awake for 22% of the sleep period over a time span of 24 h. Neuromonitoring via continuous electroencephalography or with a device such as the bispectral index (BIS, Aspect Medical Systems, Natick, MA, USA) can reduce the risk of consciousness in paralysed patients [46]. However, studies evaluating the reliabilities of such devices in the monitoring of the level of sedation of paralysed patients have found contradictory results [47, 48].

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