Neuromuscular blocking agents
|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.
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.
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.
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
| Depolarizing skeletal muscle blocker. Indications: procedures of short duration such as endotracheal intubation.
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.
ED90-95 = Dose required to produce 90-95% suppression of muscle response
Bridion®- sugammadex sodium injection
|Drug UPDATES: BRIDION®- sugammadex sodium injection
[Dosing information / PDF] Click link for the latest monograph
Dosing: 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.
National Institutes of Health, U.S. National Library of Medicine, DailyMed Database.
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