Analgesia, sedation and delirium

Neuromuscular blockade in the ICU

Reviewed Nov 2026·2 references
New· views rounded down, updated weekly

Indications, deep sedation first, agent choice, train-of-four monitoring, and complications of sustained NMB.

Definition
Sustained NMB abolishes patient effort and shivering. ICU indications: severe ARDS with dyssynchrony or high plateau pressure, refractory intracranial hypertension, shivering during targeted temperature management, status asthmaticus with dyssynchrony, abdominal compartment syndrome.

At the bedside

  1. 1

    Confirm indication

    Use NMB selectively (ROSE: routine early NMB in moderate-severe ARDS did not reduce mortality); consider in PaO2/FiO2 < 150 with dyssynchrony or high pressures despite optimal settings.

  2. 2

    Deep sedation and analgesia first

    Before NMB

    Achieve RASS -5 and adequate analgesia before starting; awareness under paralysis is a serious harm; use BIS where available.

  3. 3

    Choose agent

    Cisatracurium/atracurium (organ-independent Hofmann elimination) preferred in hepatic/renal failure; rocuronium/vecuronium alternatives.

  4. 4

    Monitor

    Train-of-four target 1-2/4 twitches combined with clinical assessment (ventilator synchrony); daily interruption when possible.

  5. 5

    Prevent complications

    Eye care (lubricant, taping), pressure area care, DVT prophylaxis, glucose control, minimise steroids; stop as soon as indication resolves (typically ≤ 48 h).

Severe ARDS / shivering

Cisatracurium (or atracurium)

IV
Dose
0.15-0.2 mg/kg bolus, then 1-3 mcg/kg/min
Preparation
100 mg in 50 mL = 2 mg/mL
Target
TOF 1-2/4
Worked example
70 kg at 2 mcg/kg/min = 140 mcg/min = 8.4 mg/h = 4.2 mL/h
Open infusion calculator

NMB infusion alternative

Rocuronium

IV
Dose
0.6 mg/kg bolus, then 0.3-0.6 mg/kg/h
Worked example
70 kg: 42 mg bolus, then 21-42 mg/h
Red flag · call your senior now
Paralysed patient with tachycardia, hypertension, lacrimation: possible awareness - deepen sedation and analgesia immediately.
Pitfall
Starting NMB before adequate sedation.
Pitfall
Forgetting eye care: corneal abrasions and exposure keratopathy.
Pearl
Peripheral nerve stimulation can be misleading with oedema or hypothermia; combine with clinical end-points.

Calculators for this topic

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

References

  1. 1

    Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2016;44:2079-103.

  2. 2

    National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome (ROSE). N Engl J Med 2019;380:1997-2008.

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