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Informatics in Pharmacy

Neuromuscular Blockade and Sedation

August 12, 2018 By Dr. G, PharmD

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Assessment Tools:

  • Critical Care Pain Observation Tool (CPOT) (0-8)
  • Behaviour Pain Scale (BPS)
  • Sedation is Richmond Agitation Sedation Scale (RASS) or Sedation-Agitation Scale (SAS)

Sedation Agents:

  • Propofol:
    • Rapid onset (1-2 minutes)
    • Short duration (3-5 minutes).
    • Avoid prolonged infusions greater than 50 mcg/kg/min.
    • Monitor BP, triglycerides, adjust lipid calories
    • Monitor for propofol infusion syndrome: metabolic acidosis, hemodynamic instability, cardiac failure, arrhythmias, cardiac arrest, rhabdomyolysis, hypertriglyceridemia, kidney failure, and hyperkalemia
      • Usually for infusion rates higher than 75-83 mg/kg/min for more than 48 hours.
    • Causes respiratory depression, must be intubated.
  • Dexmedetomidine: Dexmedetomidine is a highly selective α2-adrenergic receptor agonist. It has effects similar to other α2-adrenergic receptor agonists (think clonidine) and is used as a sedative
    • Rapid onset (5-15 minutes)
    • Short duration (2-hour half-life)
    • Can cause bradycardia and hypotension (again think clonidine). However, initial titrations can cause a vasoconstrictive rise in BP (temporary and usually not clinically significant). It can also have EKG effects.
    • Can affect blood sugar.
    • Can be used to decrease intracranial pressure.
    • Low incidence of delirium.
    • Does not cause respiratory depression.
    • Dexmedetomidine can have withdrawal symptoms if used long term (1-2 days). Rebound increase in heart rate and blood pressure and increased anxiety unless titrated.
    • Adverse effects are mostly additive effects with other sedatives or medications that lower heart rate and blood pressure.
  • Ketamine –
    • Analgesic and sedative properties.
    • Risk of delirium.
    • Adverse effects: hypertension, tachycardia, and delirium.
    • No respiratory depression
  • Delirium
    • CAM-ICU Scale – Confusion Assessment Scale for ICU
    • ICDSC: Intensive Care Delirium Screening Checklist
    • Best course is prevention, including minimizing BZD doses, opioids, and anticholenergic medications.
    • Can treat with: haloperidol, quetiapine, olanzapine, risperidone, ziprasidone.  Olanzapine and risperidone have the lowest risk of QTc prolongation.

Neuromuscular Blockade

  • Never use a neuromuscular blocker on someone who is not sedated and doesn’t have analgesia.
  • Drugs/Electrolytes that potentiate block: corticosteroids, aminoglycosides, clindamycin, tetracyclines, polymixin, calcium channel blockers, Type 1a antiarrhythmics, furosemide, lithium, hypocalcemia, hypermagnesemia, hypokalemia
  • Drugs/Electrolytes that antagonize block: aminophylline, theophylline, carbamazepine, phenytoin, hyperkalemia, hypercalcemia
  • Succinylcholine and atracurium cause direct mast cell release.  Pancuronium, rocuronium, and vecuronium cause the least.  This is not anaphylaxis.
  • When neuromuscular blockers are used in combination with steroids, it increases the risk of acute quadriplegic myopathy syndrome.
  • Reverse non-depolarizing agents with neostigmine or edrophonium (acetylcholinesterase inhibitors). DO NOT USE THESE WITH succinylcholine.  They make succ induced paralysis worse.
 OnsetDurationT 1/2 
Succinylcholine30-60 sec4-6 m < 1minSucc is the only depolarizing agent.
Do NOT use neostigmine with succ.
Atracurium2-3 m20-35 m2-20 m no renal or hepatic dosing
Pancuronium2-3 m60-100 m110 mthe longest duration of action
Rocuronium1-2 m30 m60-70 mcaution in pulmonary HTN
Vecuronium3-5 m45-65 m65-70 m 
Cisatracurium2-3 m20-35 m22-29 m does not release histamine

Filed Under: Critical Care Tagged With: intubation, sedation

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020