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PubMed1995

Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: an executive summary. Society of Critical Care Medicine.

OBJECTIVE: The development of practice parameters for achieving sustained neuromuscular blockade in the adult critically ill patient for the purpose of guiding clinical practice. PARTICIPANTS: A task force of more than 40 experts in disciplines related to the use of neuromuscular blocking agents in the intensive care unit was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM). EVIDENCE: The task force members provided the personal experience and determined the published literature (MEDLINE articles, textbooks, pharmacopeias, etc.) from which consensus would be sought. Published literature was reviewed and classified into one of four predetermined categories, according to study design and scientific value. CONSENSUS PROCESS: The task force met several times as a whole, and numerous times in smaller groups by teleconference, over a 1-yr period to identify the pertinent literature and arrive at consensus recommendations for the whole task force to discuss. Consideration was given to the relationship between the weight of scientific information and the experts' viewpoints. Over the next year, draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft was then reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. DATA SYNTHESIS: To facilitate rapid communication of the three recommendations contained within the complete and unabridged practice parameter document, an executive summary was prepared for publication by the ACCM Board of Regents, and this executive summary was approved by the task force steering committee and the SCCM Executive Council. CONCLUSIONS: A consensus of experts provided three recommendations with supporting data for achieving sustained neuromuscular blockade in critically ill patients: a) pancuronium is the preferred neuromuscular blocking agent for most critically ill patients; b) vecuronium is the preferred neuromuscular blocking agent for those patients with cardiac disease or hemodynamic instability in whom tachycardia may be deleterious; c) patients receiving neuromuscular blocking agents should be appropriately assessed for the degree of blockade that is being sustained. This executive summary selectively presents supporting information and is not intended as a substitute for the complete document.

Adult↗

PubMedDate not supplied

A prospective evaluation of the continuous infusion of cis-atracurium for neuromuscular blockade in the pediatric intensive care unit patient: efficacy and dosage requirements.

PURPOSE: To prospectively evaluate the efficacy and dosage requirements of cis-atracurium administered by continuous infusion for neuromuscular blockade in a pediatric intensive care unit population. METHODS: Neuromuscular function was monitored by a train-of-four (TOF) over the ulnar or peroneal nerve. cis-Atracurium was administered as a bolus dose (0.2 mg/kg) followed by a continuous infusion starting at 3 microg/kg/min. The infusion was increased or decreased by 1 mIcrog/kg/min to maintain one twitch of the TOF. All patients also received a benzodiazepine infusion. RESULTS: The study population included 15 children ranging in age from 10 months to 11 years and in weight from 4-28 kg. The duration of the infusion varied from 18-224 hours for a total of 1088 hours in the 15 patients. The cis-atracurium infusion requirements varied from 2.1 to 3.8 microg/kg/min (3.1 +/- 0.6) on day 1, to 1.4 to 6.4 microg/kg/min (3.4 +/- 1.4) on day 2, to 2.9 to 8.1 microg/kg/min (4. 5 +/- 1.6) on day 3. Overall, the infusion requirements varied from 1.4-22.7 microg/kg/min. The highest infusion requirements (22.7 and 10.2 microg/kg/min) were noted in patients who received cis-atracurium for prolonged periods of time (150 and 224 hours, respectively). The lowest infusion requirement occurred with the use of hypothermia to treat increased intracranial pressure. CONCLUSIONS: cis-Atracurium can be used by continuous infusion to provide neuromuscular blockade in the pediatric intensive care unit patient. Because of the variability in infusion requirements, monitoring of neuromuscular function is suggested.

Atracurium↗

PubMed2001

Inflammatory liver disease shortens atracurium-induced neuromuscular blockade in rats.

BACKGROUND: and objective Inflammatory liver dysfunction in rats leads to a prolonged vecuronium-induced neuromuscular blockade due to insufficient metabolism. A coexisting resistance against the drug partly counteracts this prolongation. The present study investigates the pharmacodynamics of atracurium whose metabolism does not depend on liver function. METHODS: Male Sprague-Dawley rats (n=14; 290 +/- 30 g) were randomly allocated to either a group in which liver inflammation was induced by intravenous injection of 60 mg kg(-1) heat-killed Corynebacterium parvum or to a control group. On day 5 after injection, liver function was assessed using the aminopyrine breath test. Under propofol anaesthesia, duration of action of atracurium (4.8 mg kg(-1)) was measured by evoked mechanomyography (stimulation of the sciatic nerve; contraction of the gastrocnemius muscle). Nitric oxide concentrations, as variables for the severity of the inflammation, were assessed by measurement of nitrite/nitrate plasma concentrations. RESULTS: In C. parvum-injected rats, nitrite/nitrate plasma concentrations were increased (972 +/- 597 vs. 25 +/- 7 micromol L(-1)), the aminopyrine turnover was depressed (1.7 +/- 0.4% vs. 3.5 +/- 0.5%), and the atracurium-induced neuromuscular blockade was shortened (372 +/- 128 s vs. 1081 +/- 234 s). CONCLUSIONS: A systemic inflammatory response syndrome with liver dysfunction results in decreased sensitivity to atracurium. Further investigations are needed regarding a possible up-regulation of acetylcholine receptors or an increased protein binding of atracurium during sepsis to clarify reasons behind this phenomenon.

Alanine Transaminase↗

PubMed2000

Cisatracurium-induced neuromuscular blockade in anticonvulsant treated neurosurgical patients.

Patients treated with the anticonvulsants phenytoin or carbamazepine are resistant to steroidal neuromuscular blocking agents. We studied the effect of cisatracurium on onset, duration, and speed of recovery from neuromuscular blockade (NMB) in acutely anticonvulsant treated patients ([< 2 weeks] [AA]), chronically anticonvulsant treated patients ([> 2 weeks] [CA]) and patients not on anticonvulsants ([controls] [C]). After Internal Review Board approval, 10 AA, 14 CA, and 14 C neurosurgical patients were studied. Anesthetic induction was midazolam, fentanyl, and thiopental, and maintenance was fentanyl and 0.5 MAC isoflurane in O2. The evoked compound electromyogram of the hypothenar eminence was monitored (TOF supramaximal stimulus at 2 Hz every 20 seconds). Baseline TOF was established, then cisatracurium (0.2 mg/kg) was administered IV. Onset (time to maximal paralysis), duration [time to recovery of first twitch (T1) to 25% of baseline] and speed of recovery (time of recovery from 10%-25% of baseline) were recorded. Data were analyzed using ANOVA. Onset (C = 4 +/- 2, AA = 3 +/- 1, CA = 3 +/- 1.5 minutes) and duration (C = 69 +/- 13, AA = 64 +/- 19, CA = 59 +/- 19 minutes) were not different among the groups (P > .7). Speed of recovery was significantly faster in both AA (6 +/- 2 minutes) and CA (6 +/- 3 minutes) than in C (12 +/- 9 minutes) patients (P < .05). (Data = mean +/- SD). Onset and duration of cisatracurium-induced neuromuscular relaxation was not affected by acute or chronic anticonvulsant treatment, but speed of recovery was significantly faster. Frequent NMB monitoring is necessary to detect the greater speed of recovery in anticonvulsant-treated patients during cisatracurium muscle relaxation.

Adult↗

PubMed2003

Accelerometry of adductor pollicis muscle predicts recovery of respiratory function from neuromuscular blockade.

BACKGROUND: Residual paralysis increases the risk of pulmonary complications but is difficult to detect. To test the hypothesis that accelerometry predicts effects of residual paralysis on pulmonary and upper airway function, the authors related tests of pulmonary and pharyngeal function to accelerometry of adductor pollicis muscle in 12 partially paralyzed volunteers. METHODS: Rocuronium (0.01 mg/kg + 2-10 microg x kg-1 x min-1) was administered to maintain train-of-four (TOF) ratios (assessed every 15 s) of approximately 0.5 and 0.8 over a period of more than 5 min. The authors evaluated pharyngeal and facial muscle functions during steady state relaxation and performed spirometric measurements every 5 min until recovery. Upper airway obstruction was defined as a mean ratio of expiratory and inspiratory flow at 50% of vital capacity of greater than 1. The TOF ratio associated with "acceptable" pulmonary recovery (forced vital capacity and forced inspiratory volume in 1 s of > or =90% of baseline) was calculated using a linear regression model. RESULTS: At peak blockade (TOF ratio 0.5 +/- 0.16), forced inspiratory flow was impaired (53 +/- 19%) to a greater degree than forced expiratory flow (75 +/- 20%) with a mean ratio of expiratory and inspiratory flow at 50% of vital capacity of 1.18 +/- 0.6. Upper airway obstruction, observed in 8 of 12 volunteers, paralleled an impaired ability to swallow reported by 10 of 12 volunteers. In contrast, all volunteers except one could sustain a head lift for more than 5 s. The authors calculated that a mean TOF ratio of 0.56 (95% confidence interval, 0.22-0.71) predicts "acceptable" recovery of forced vital capacity, whereas forced inspiratory volume in 1 s was impaired until a TOF ratio of 0.95 (0.82-1.18) was reached. A 100% recovery of TOF ratio predicts an acceptable recovery of forced vital capacity, forced inspiratory volume in 1 s, and mean ratio of expiratory and inspiratory flow at 50% of vital capacity in 93%, 73%, and 88% of measurements (calculated negative predictive values), respectively. CONCLUSION: Impaired inspiratory flow and upper airway obstruction frequently occur during minimal neuromuscular blockade (TOF ratio 0.8), and extubation may put the patient at risk. Although a TOF ratio of unity predicts a high probability of adequate recovery from neuromuscular blockade, respiratory function can still be impaired.

Adult↗

PubMed1989

The effect of acutely administered phenytoin on vecuronium-induced neuromuscular blockade.

Phenytoin was administered intravenously in a dose of 10 mg kg to a group of patients in whom steady state neuromuscular blockade had been established with an infusion of vecuronium. A control group of patients were given 0.9% saline instead of phenytoin. Administration of phenytoin produced significant augmentation of neuromuscular blockade (p less than 0.001). The possible mechanism of this effect is discussed.

Adult↗

PubMed1996

Electromyographic facial nerve monitoring during resection for acoustic neurinoma under moderate to profound levels of peripheral neuromuscular blockade.

The facial nerve is monitored intra-operatively using electromyography to identify and prevent damage during the excision of an acoustic neurinoma. In order to determine whether a profound level of peripheral neuromuscular blockade could be achieved without compromising facial electromyographic monitoring, 11 patients undergoing resection of acoustic neurinoma were studied. After induction of anaesthesia, an infusion of atracurium was administered to reduce the integrated electrically evoked muscle potential (EEMP) of the hypothenar eminence by 70-100%. The facial nerve was directly stimulated in the surgical field and the facial evoked muscle potentials (EMPs) were recorded. Even under complete peripheral neuromuscular blockade (i.e. no electrically evoked muscle potential measurable over the hypothenar eminence, no palpable hypothenar muscle response) it was possible to evoke facial muscle electromyographic responses by stimulation of the facial nerve.

Adult↗

PubMed1994

[Anesthesia for a patient with spinocerebellar degeneration--with special reference to neuromuscular blockade monitoring].

A 51 year-old female with spinocerebrellar degeneration was anesthetized with O2-N2O-isoflurane for abdominal total hysterectomy. After monitoring of both orbicularis oculi and adductor pollicis twitches in the response to train-of-four stimulation of the facial and ulnar nerves had been prepared, vecuronium was administered as a bolus. The time from vecuronium injection to forth twitch abolishment is known to be longer with the adductor pollicis than with the orbicularis oculi. In our case, however, neuromuscular blockade showed a faster onset with the adductor pollicis. The onset with the adductor pollicis did not indicate good intubating conditions. In patients with spinocerebrellar degeneration, the twitch response of the orbicularis oculi should be monitored to determine accurately the degree of neuromuscular blockade when neuromuscular blocking drugs are administered.

Anesthesia, General↗

PubMed2004

Sedation, analgesia, and neuromuscular blockade in the pediatric intensive care unit: survey of fellowship training programs.

OBJECTIVE: To survey current sedation, analgesia, and neuromuscular blockade practices in pediatric critical care fellowship training programs in the United States. DESIGN: Questionnaire survey sent by all program directors. The survey could be submitted either via a Web site, fax, or mail. SETTING: University school of medicine. SUBJECTS: Fifty-nine pediatric critical care fellowship training program directors in the United States, listed on the Accreditation Council for Graduate Medical Education Web site. INTERVENTIONS: Survey. MEASUREMENTS AND MAIN RESULTS: The response rate was 59.3% (35 questionnaires). Midazolam, lorazepam, morphine, and fentanyl are the most frequently used drugs in pediatric intensive care units for analgesia and sedation. Most pediatric intensive care units surveyed have a written sedation policy (66%). The majority of units responding to the survey (85.7%) routinely use a scoring system to assess agitation and pain in children, with the most common being the COMFORT score. All of the pediatric intensive care units surveyed reported weaning drugs slowly to try to prevent drug withdrawal. Movement disorders related to prolonged sedation and analgesia seem to be more common than is reported in the literature, with 65.7% of units reporting cases. There is good consensus on the indications for neuromuscular blockade, with vecuronium being the most popular drug. CONCLUSIONS: When compared with a similar survey from 1989, this survey suggests that pediatric critical care units with fellowship training programs have made some changes in their approach to sedation and analgesia over the past decade. More fellowship directors report the use of sedation protocols and better recognition, prevention, and management of drug withdrawal. Similar analgesic, sedative, and neuromuscular blocking drugs are being used but some more commonly than a decade ago.

Analgesics↗

PubMed2005

Novel pharmacological approaches for the antagonism of neuromuscular blockade.

Gamma cyclodextrin and purified plasma cholinesterase are 2 novel pharmacological agents being investigated as to their suitability for antagonism of neuromuscular blockade. Both of these agents are devoid of cholinergic stimulation and the accompanying side effects because their action is independent of acetylcholinesterase inhibition. Gamma cyclodextrin antagonizes the steroidal neuromuscular blocker rocuronium via the chemical encapsulation of the molecule forming a "host-guest" complex through van der Waals and hydrophobic interactions in the plasma. Encapsulation decreases plasma drug concentrations, shifting the neuromuscular blocking drug molecules from the neuromuscular junction back to the plasma compartment resulting in a rapid recovery of the neuromuscular function. Org 25969, a modified gamma cyclodextrin, will antagonize profound neuromuscular block induced by rocuronium in approximately 2 minutes. A commercial preparation of purified human plasma cholinesterase has been shown to be effective in reversing succinylcholine or mivacurium-induced block. Administration of exogenous plasma cholinesterase also has been shown to be effective in antagonizing mivacurium-induced neuromuscular block, cocaine toxicity, and organophosphate poisoning.

Androstanols↗

PubMed1981

Succinylcholine neuromuscular blockade in subjects heterozygous for abnormal plasma cholinesterase.

The relationship between plasma cholinesterase genotype and duration and type of succinylcholine neuromuscular blockade was studied in 43 anesthetized patients heterozygous for abnormal plasma cholinesterase using train-of-four nerve stimulation. Twenty-eight patients were heterozygous for the usual and the atypical gene (E1uE1a), eight were heterozygous for the usual and the silent gene (E1uE1s), three were heterozygous for the usual and the fluoride-resistant gene (E1uE1f), three were heterozygous for the fluoride-resistant and the atypical gene (E1fE1a), and one was heterozygous for the fluoride-resistant and the silent gene (E1fE1s). Mean time to 90 per cent recovery of twitch height in patients with genotypes E1uE1a, E1uE1s, and E1uE1f (14.6, 12.4, and 12.0 min, respectively) was significantly prolonged compared to patients with normal cholinesterase genotype (9.3 min). No significant difference was found between the three groups of patients with one abnormal gene (E1uE1a, E1uE1s, and E1uE1f). In 13 (46 per cent) of the 28 patients with genotype E1uE1a the twitch height did not return to control for more than 15 min after the administration of succinylcholine and in three patients (10.7 per cent) for more than 20 min after succinylcholine. The four patients with abnormal genes on both chromosomes (E1fE1a and E1fE1s) all showed significantly prolonged paralysis following the administration of succinylcholine (mean time to 90 per cent twitch recovery was 30 min). Patients heterozygous for the usual and one of the abnormal genes (E1uE1a, E1uE1s, and E1uE1f) had typically depolarizing blocks following the administration of succinylcholine, 1 mg/kg. Patients with abnormal genes on both chromosomes (E1fE1a and E1fE1s), however, all showed desensitization type of neuromuscular blockade (phase II block).

Adolescent↗

PubMed1978

Effectiveness of pyridostigmine in reversing neuromuscular blockade produced by soman.

The effects of pyridostigmine pretreatment on the neuromuscular blockade produced by soman in anaesthetized, atropinized animals have been studied on the soleus and anterior tibialis muscle (rhesus monkeys, cats and rabbits) and the gastrocnemius muscle (guinea-pigs and rats). Pyridostigmine pretreatment produced a complete recovery of neuromuscular function following blockade by soman; the rate of recovery was similar in all the species, suggesting a common mechanism of action. In the absence of pyridostigmine or if pyridostigmine was delayed until after blockade by soman, there was no recovery of neuromuscular function. Detailed studies in the guinea-pig showed that the recovery of neuromuscular function was related to the dose of soman and to the degree of carbamoylation of blood cholinesterase at the time of nerve agent challenge, i.e. to the dose of pyridostigmine and the time interval between the administration of pyridostigmine and soman. It is suggested that the effectiveness of pyridostigmine pretreatment is due to the carbamoylation of a portion of the tissue acetylcholinesterase, which protects it against irreversible inhibition by soman: after poisoning spontaneous decarbamoylation produces sufficient free acetylcholinesterase to restore normal function.

Animals↗

PubMed2005

An external monitoring site at the neck cannot be used to measure neuromuscular blockade of the larynx.

Using phonomyography, a new monitoring technique of neuromuscular blockade (NMB), we compared NMB after mivacurium 0.1 mg/kg at the lateral cricoarytenoid muscle (LCA) with a possible external monitoring site of the larynx. In 12 patients, data were obtained at both sites using phonomyography. Anesthesia was induced with remifentanil 0.25-0.5 microg . kg(-1) . min(-1) followed by propofol 2-3 mg/kg. A small piezo-electric microphone was positioned beside the vocal cords into the muscular process at the base of the arytenoid cartilage to record acoustic signals from the contraction of the LCA. A second microphone was positioned at an external site, lateral to the trachea, just below the thyroid notch. The recurrent laryngeal nerve was stimulated supramaximally using train-of-four (TOF) stimulation every 12 s. Onset, maximum effect, and offset of NMB were measured and compared. Peak effect, time to reach (T) 25%, 75%, and 90% of control twitch response, and TOF recovery to TOF ratios 0.5-0.8 were significantly longer at the external site. The onset time was not significantly different between the two sites. We used phonomyography with a microphone placed at the neck to evaluate the possibility to externally monitor NMB at the larynx. When compared with LCA, we found a more pronounced peak effect and longer offset of NMB. The acoustic signals recorded at this external site are unlikely to stem from laryngeal muscle contraction but are rather a result of contraction of the strap muscles of the neck.

Adult↗

PubMed1992

The influence of atropine dose on recovery from vecuronium-induced neuromuscular blockade.

To determine whether the dose of atropine affects the rate of neostigmine-induced recovery from vecuronium-induced neuromuscular blockade, the authors monitored isometric adductor pollicis mechanical activity in 36 anesthetized (thiopental, fentanyl, nitrous oxide) adult patients (ASA physical status 1 or 2). Once surgery was completed and twitch height had spontaneously regained 25% of its initial value, the patients were randomly allocated into three groups (A10, A15, A20; n = 12 in each group) according to the dose of atropine (10, 15, or 20 micrograms/kg) that was mixed with 40 micrograms/kg neostigmine. Twitch height, train-of-four, and 50- and 100-Hz tetanic fade were recorded for 15 min after the administration of the reversal agents. No significant differences were found among the three groups in the final twitch height (95% +/- 2%), train-of-four (87% +/- 1%, 88% +/- 2%, 89% +/- 1%), and 50-Hz tetanic fade (90% +/- 1%, 94% +/- 1%, 93% +/- 1%) (mean +/- SEM). Fifteen minutes after reversal, fade in response to 100-Hz tetanus was statistically greater in the A10 group than in the two other groups (70% +/- 3% of control versus 84% +/- 4% and 81% +/- 2%) (mean +/- SEM, P less than 0.05). The present results demonstrate that larger doses of atropine facilitate neostigmine's reversal of vecuronium neuromuscular blockade. The clinical implications of the differences observed in this study remain to be determined.

Adult↗

PubMed1986

Effects of pulse duration on neuromuscular blockade monitoring: implications for supramaximal stimulation.

Questions have been raised concerning the reliability of surface electrodes in achieving supramaximal stimulation during the monitoring of neuromuscular blockade; needle electrodes are considered reliable in this respect. This study compares interelectrode impedances of needle and surface electrodes during neuromuscular blockade monitoring and suggests those characteristics of the stimulation pulse that can ensure reliable supramaximal stimulation with either type of electrode. Interelectrode voltage and current for surface and needle electrodes were measured by using 1.0-ms pulses at low, medium, and high stimulation levels on 22 surgical patients during anesthesia. Data were collected immediately after electrode application, and again at 10 minutes after application. Stimulation with surface electrodes produced an initial, transient surge of current, followed by a lower steady-state value. At high stimulation levels, the peak transient current was 87% higher than the steady-state current. Needle electrodes produced a constant high-current response. At high stimulation levels the transient impedance of the surface electrode and the impedance of the needle electrode were essentially equal (0.7 k omega and 0.75 k omega, respectively). The transient impedance was significantly lower (P less than 0.001) and was associated with less interpatient variation (P less than 0.001) and less sensitivity to the duration of electrode application than was the steady-state impedance of the surface electrode. These data suggest that high-current pulses with widths of less than 0.2 ms could provide reliable supramaximal stimulation with either type of electrode.

Electric Conductivity↗

PubMed1977

Pancuronium-induced neuromuscular blockade, and its antagonism by neostigmine, at 29, 37, and 41 c.

To determine the effects of variations in temperature on the neuromuscular blockade produced by pancuronium, the drug was infused intravenously into 18 cats anesthetized with chloralose and urethane at a constant continuous rate to produce and maintain 90 per cent depression of twitch tension of the anterior tibial muscle following supramaximal stimulation of the peroneal nerve. The mean (+/-SE) infusion rates of pancuronium needed were 0.44 +/- 0.05, 0.99 +/- 0.11, and 1.05 +/- 0.09 microng/kg/min (r = 0.73) at 29, 37, and 41 C, respectively. In contrast, the doses of neostigmine necessary for 50 per cent antagonism of the pancuronium-induced depression of twitch tension were not significantly different at the three temperatures. The time required to achieve peak neostigmine effect was longer at the lowest temperature. The durations of neostigmine action were longer at 29 and 37 than at 41 C. It is concluded that hypothermia augments neuromuscular blockade produced by pancuronium and prolongs the time to peak effect, and possibly the duration of action, but not the dose of neostigmine needed to antagonize the blockade.

Anesthesia, Intravenous↗

PubMed1994

Prolonged muscle weakness after neuromuscular blockade in the intensive care unit.

As noted, quadriparesis with reduced reflexes and difficulty with ventilator weaning may be seen as a result of a number of neuromuscular disorders. The clinical approach relies on exclusion of a central cause first, followed by careful examination of peripheral nerve and muscle function. Persistent neuromuscular blockade should be excluded initially because it is a readily reversible condition. Use of a train of four stimulation with a peripheral twitch monitor can quickly establish integrity of conduction across the neuromuscular junction. If necessary, further electrophysiologic studies allow differentiation among the relevant diagnostic possibilities. CIP is characterized by nerve conduction and EMG findings consistent with axonal degeneration of sensory and motor fibers. GBS is distinguished by evidence of demyelination on nerve conduction studies, in addition to elevated spinal fluid protein. Persistent neuromuscular blockade is identified by a decremental response on repetitive stimulation studies of neuromuscular transmission. The acute myopathy following neuromuscular blockage does not involve sensory responses. Needle EMG examination reflects a myopathic pattern, rather than a neurogenic one as seen in CIP or GBS. In myopathic patients who are unable to move their limbs at all (precluding a full EMG examination), a muscle biopsy identifies muscle as the site of involvement.

Adult↗

PubMed1995

Monitoring the administration of neuromuscular blockade in critical care.

The future direction of neuromuscular blockade (NMB) in critical care will be characterized by prudent utilization and quality monitoring. With the potential for persistent paralysis and less than optimal outcomes, this direction makes sense. Prudent utilization can be further defined as exhausting other therapies prior to NMB utilization. When NMB is necessary, the agents should be titrated consistently according to a protocol, using the minimally effective dose to produce the least amount of NMB in order to facilitate patient management. Quality monitoring requires that peripheral nerve stimulator (PNS) monitoring become the standard for monitoring the administration of NMB agents and also that monitoring be accurate. Inherent to prudent utilization and quality monitoring is an adequate knowledge related to all aspects of NMB. The purpose of this article is to provide the necessary knowledge base for practitioners to understand normal and altered neuromuscular junction function, perform accurate PNS monitoring, and titrate NMB therapy according to the individual and desired response.

Critical Care↗