Neuromuscular blocking agents
Background
| Overview: Neuromuscular blocking agents are used in the ICU setting for 3 reasons: (1) to eliminate spontaneous breathing and promote mechanical ventilation (eg eliminate urge to fight the vent. (2) Cause a pharmacologic restraint so patients do not harm themselves. (3) To decrease oxygen consumption. |
Train of four
| Whenever a paralytic agent is used, the Train of Four is the test used to measure the degree of neuromuscular blockade. A peripheral nerve stimulator is used. Do a baseline measurement before paralytic agent is started to determine current necessary to obtain twitch. 20 mA may be enough for the patient. Complete and document until TOF to 2/4.
Instructions 1. Attach 2 electrodes along the course of the ulnar nerve. (Temporal may be used.) |
Atracurium (tracrium ® )
| May be given undiluted by IV bolus. Dosing (Adults): initially 0.4 to 0.5 mg/kg IV bolus, followed by 0.08 to 0.1 mg/kg every 20 to 45 minutes after initial dose. Continuous infusion: initially 0.4 to 0.5 mg IV bolus, followed by 9 to 10 mcg/kg/min. Maintenance infusion rates of 5 to 9 mcg/kg/min are usually adequate. (Range: 2 to 15 mcg/kg/min). Toxic metabolite (laudanosine) may accumulate in renal failure. [Supplied: 50 mg/5 ml ; 100 mg/10ml vial] |
Cisatracurium (nimbex ® )
| Dosing (Adults): Intermittent: initial dose: 0.15 to 0.2 mg/kg IV bolus followed by 0.03 mg/kg IV every 40 to 60 minutes. Continuous infusion: 0.15 to 0.2 mg/kg IV bolus followed by 1 to 3 mcg/kg/min. The average infusion rate for long term use in the ICU is @ 3 mcg/kg/min (range: 0.5 to 10.2 mcg/kg/min). In some cases, re-administration of the bolus dose may be req'd while titrating. Dosage reductions are not required in renal or hepatic failure. Drug of choice in the following cases: (1) hemodynamically significant increases in HR (eg >20%) while paralyzed with pancuronium or MAP>110. (2) Concurrent corticosteroid administration (>72hrs) (3) Significant renal dysfunction (CRCL < 30 ml/min) (4)History of asthma or bronchospasm. |
Doxacurium (nuromax ® )
| Dosing (Adults): (usual) Anesthesia adjunct: initial, 0.05 mg/kg and 0.08 mg/kg IV to provide neuromuscular block for an average 100 min and 160 min, respectively. Maintenance, 0.005 mg/kg and 0.01 mg/kg IV to provide neuromuscular blockage for an average of 30 min and 45 min, respectively. Endotracheal intubation: 0.05 mg/kg IV. Endotracheal intubation: (with succinylcholine) initial, 0.025 mg/kg IV. [ Supplied: 1 mg/ml Solution] |
Mivacurium (mivacron ® )
| Short-acting arizing neuromuscular blocking agent. Dosing (Adults) Endotracheal intubation: 0.15 mg/kg IV bolus. For extended neuromuscular block, IV average infusion rates of 6 to 7 mcg/kg/min are used. Recovery from muscular paralysis occurs within 15 to 30 minutes. |
Pancuronium (pavulon ® )
| Non-depolarizing skeletal muscle blocker--competes with acetylcholine at the neuromuscular junction. Dosing (Adults) Intermittent dosing: 0.1 to 0.2 mg/kg (usually 0.1) every 1 to 3 hours (range: 0.04 to 0.2 mg/kg). Continuous infusion: Loading dose: 0.04 to 0.10 mg/kg , followed by 1 to 1.7 mcg/kg/min or 0.06 to 0.1 mg/kg/hr |
Rocuronium (zemuron ® )
| Dosing (Adults) (usual): Intubation(rapid sequence intubation): initial, 0.6-1.2 mg/kg IV. tracheal intubation: initial, 0.6 mg/kg IV. Maintenance, 0.1-0.2 mg/kg IV repeated as needed. Maintenance (continuous IV infusion): 0.01-0.012 mg/kg/minute. Skeletal muscle relaxation: initial, 0.6 mg/kg IV. Maintenance: 0.1-0.2 mg/kg IV repeated as needed. Alternatively: maintenance (continuous IV infusion): 0.01-0.012 mg/kg/minute |
Succinylcholine
| Depolarizing skeletal muscle blocker. Indications: procedures of short duration such as endotracheal intubation. Dosing (Adults): Intermittent: 0.6 mg/kg (0.3 to 1.1) over 10-30 seconds, up to 150mg total dose. Maintenance: 0.04 to 0.07 mg/kg every 5-10 minutes as needed. Continuous infusion: 2.5 mg/min (0.5 to 10 mg/min). D Dilute to 1-2 mg/ml. |
Vecuronium (norcuron ® )
| Dosing (Adults) Intermittent dosing: initially 0.08 to 0.1 mg/kg IBW IV bolus. (Higher initial doses-up to 0.3 mg/kg-may be used for rapid onset. Maintenance: 0.01 to 0.015 mg/kg every 25 to 45 minutes as needed. Continuous infusion: initial IV bolus (0.08 to 0.3 mg/kg), followed by (after 20-40min), 1 mcg/kg/min infusion (usual range: 0.8 to 1.2 mcg/kg/min). Dosage reductions are not req'd in renal failure. |
Pharmacokinetic profiles
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ED90-95 = Dose required to produce 90-95% suppression of muscle response
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Bridion®- sugammadex sodium injection
| Drug UPDATES: BRIDION®- sugammadex sodium injection [Dosing information / PDF]  Click link for the latest monographDosing: Click (+) next to Dosage and Administration section Initial U.S. Approval: 2015 INDICATIONS AND USAGE: BRIDION is indicated for the reversal of neuromuscular blockade induced by rocuronium bromide and vecuronium bromide in adults undergoing surgery. HOW SUPPLIED/STORAGE AND HANDLING: BRIDION 2-mL single-dose vials containing 200 mg sugammadex (100 mg/mL) The packaging of this product is not made with natural rubber latex. |
Reference(s)
National Institutes of Health, U.S. National Library of Medicine, DailyMed Database.
Provides access to the latest drug monographs submitted to the Food and Drug Administration (FDA). Please review the latest applicable package insert for additional information and possible updates. A local search option of this data can be found here.
