A fresh look at paralytics in the critically ill: real promise and real concern

Efficacy and Safety of Cisatracurium Compared to Vecuronium for Neuromuscular Blockade in Acute Respiratory Distress Syndrome

PURPOSE

Previous studies analyzing neuromuscular blocking agents (NMBAs) in acute respiratory distress syndrome (ARDS) have evaluated the benefit of cisatracurium with conflicting results, and data evaluating other NMBAs remains limited. The objective of this study was to compare the efficacy and safety of cisatracurium to vecuronium in ARDS.

MATERIALS AND METHODS

A single-center, retrospective, propensity matched review of patients who received cisatracurium or vecuronium continuous infusions between October 1, 2017 and June 30, 2020 for ARDS was conducted. The primary endpoint was duration of mechanical ventilation. Secondary endpoints included change in PaO₂/FiO₂ ratio at 48 h, intensive care unit (ICU) and hospital mortality, and ICU and hospital length of stay (LOS). Safety endpoints included newly developed myopathy, presence of bradycardia or hypotension, and newly developed barotrauma or volutrauma.

RESULTS

Twenty-nine patients were included in each group. There was no statistically significant difference in the primary endpoint of ventilator days between cisatracurium and vecuronium groups (mean 15.9 vs. 20.5 days respectively; p = .2). No statistically significant differences were found in secondary endpoints of ICU mortality (51.7% vs. 51.7%) or length of stay (18.7 vs. 23.9 days, p = .19), hospital mortality (51.7% vs. 55.2%, p = .79) or length of stay (22 vs. 30.6 days, p = .08), or mean change in PaO₂/FiO₂ (29.8 vs. 36.6; p = .74). Statistically significant differences were not observed in safety endpoints of myopathy (37.9% vs. 37.9%), barotrauma or volutrauma (13.8% vs. 3.5%; p = .16), bradycardia (31% vs. 13.8%; p = .12), or hypotension (96.6% vs. 82.8%; p = .08).

CONCLUSIONS

No significant differences were seen in efficacy or safety endpoints between cisatracurium or vecuronium groups, suggesting that vecuronium may be a safe alternative agent for neuromuscular blockade in ARDS. Results of this analysis warrant confirmation in a larger, randomized study.

Neuromuscular Blockade for Cardiac Arrest Patients Treated With Targeted Temperature Management: A Systematic Review and Meta-Analysis

Background: Neuromuscular-blocking agents (NMBA) are often administered to control shivering in comatose cardiac arrest (CA) survivors during targeted temperature management (TTM) management. Thus, we performed a systematic review and meta-analysis to investigate the effectiveness and safety of NMBA in such a patient population. Methods: We searched for relevant studies in PubMed, Embase, and the Cochrane Library until 15 Jul 2021. Studies were included if they reported data on any of the predefined outcomes in adult comatose CA survivors managed with any NMBA regimens. The primary outcomes were mortality and neurological outcome. Results were expressed as odds ratio (OR) or mean difference (MD) with an accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and publication bias were also investigated to test the robustness of the primary outcome. Data Synthesis: We included 12 studies (3 randomized controlled trials and nine observational studies) enrolling 11,317 patients. These studies used NMBA in three strategies: prophylactic NMBA, bolus NMBA if demanded, or managed without NMBA. Pooled analysis showed that CA survivors with prophylactic NMBA significantly improved both outcomes of mortality (OR 0.74; 95% CI 0.64-0.86; I 2 = 41%; p < 0.0001) and neurological outcome (OR 0.53; 95% CI 0.37-0.78; I 2 = 59%; p = 0.001) than those managed without NMBA. These results were confirmed by the sensitivity analyses and subgroup analyses. Only a few studies compared CA survivors receiving continuous versus bolus NMBA if demanded strategies and the pooled results showed no benefit in the primary outcomes between the two groups. Conclusion: Our results showed that using prophylactic NMBA strategy compared to the absence of NMBA was associated with improved mortality and neurologic outcome in CA patients undergoing TTM. However, more high-quality randomized controlled trials are needed to confirm our results.

Intermittent versus continuous neuromuscular blockade during target temperature management after cardiac arrest: A nationwide observational study

PURPOSE

Whether intermittent or continuous neuromuscular-blocking agents (NMBAs) would be appropriate during target temperature management (TTM) after cardiac arrest remains unclear.

MATERIALS AND METHODS

In this retrospective cohort study, we utilized the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2018 and identified patients who received NMBAs during TTM after cardiac arrest on the day of admission. We compared the in-hospital mortality between the propensity-score-matched intermittent and continuous NMBA groups.

RESULTS

We identified 5584 eligible patients; 1488 received intermittent NMBAs and 4096 received continuous NMBAs. After propensity score matching, there was no significant difference in the in-hospital mortality between the intermittent and continuous NMBA groups (32.9% vs. 33.1%; odds ratio, 0.98; 95% confidence interval, 0.82-1.18). In subgroup analyses, in-hospital mortality of the continuous NMBA group was significantly higher than that of the intermittent NMBA group in patients aged ≥65 years (p for interaction = 0.021).

CONCLUSIONS

This large retrospective study did not suggest that intermittent NMBAs may be inferior to continuous NMBAs in terms of mortality reduction in the overall population receiving TTM for cardiac arrest. However, continuous NMBAs may be inferior to intermittent NMBAs for reducing mortality in elderly patients.

Patient and Care Delivery Characteristics Associated With Harm From Neuromuscular Blockade

Objectives:

To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade.

Design:

Retrospective cohort study.

Setting:

Tertiary care teaching hospital in Boston, MA.

Patients:

All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours.

Interventions:

We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration.

Measurements and Main Results:

Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12–2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001).

Conclusions:

Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.

Neuromuscular blockade management in the critically Ill patient

Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use.

It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

Objective: To review and evaluate neuromuscular blocking agents (NMBAs) in critically ill patients with acute respiratory distress syndrome (ARDS). Data Sources: A literature search utilizing PubMed was performed (January 1991 to January 2020) using the following search terms: ( neuromuscular blocking agents OR neuromuscular blockade OR cisatracurium OR rocuronium OR vecuronium OR pancuronium OR atracurium) AND * acute respiratory distress syndrome OR acute lung injury). Publications in English were evaluated. Study Selection and Data Extraction: Relevant clinical studies in humans were considered. Data Synthesis: Although NMBAs have been used for decades in the setting of ARDS, questions regarding mortality benefit remain. Early NMBA, within 48 hours of lung injury, have been historically used in critically ill patients with ARDS to aid in increasing alveolar recruitment, improving patient-ventilator synchrony, and promoting oxygenation by the prevention of contraction of respiratory muscles. Until recently, the literature showed an improvement in 90-day adjusted mortality. However, recent literature has demonstrated the lack of a mortality benefit. The continued receipt of NMBAs, with no clear benefit, could potentially lead to increased costs, skin breakdown, corneal abrasions, venous thromboembolisms, intensive care unit acquired weakness, and awareness with inappropriate sedation. Relevance to Patient Care and Clinical Practice: This review aims at discussing the preferred NMBA based on mechanism of action and reviews specific clinical trial data for the use of NMBAs in ARDS, clinical implications of these trial data, complications for the use of NMBAs, and needed future directions. Conclusions: The mortality benefit of NMBAs in ARDS has contradicting evidence with potentially serious adverse effects and notable controversies.

Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies

Objective:

To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies.

Data Source:

Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials.

Data Summary:

Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients.

Conclusion:

Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.

Neuromuscular blocking agents for acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials

Backgrounds

The aim of this study is investigating the benefits and harms of neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome (ARDS).

Methods

We comprehensively searched PubMed, EMBASE, and Cochrane library for randomized controlled trials comparing NMBAs to any other comparator. We pooled data using relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes, with 95% confidence intervals. We assessed the quality of included studies using the Cochrane tool and levels of evidence using the GRADE method.

Results

Finally, six RCTs (n = 1557 patients) were eligible for analysis. The results showed NMBAs use was not associated with reduced 28 days mortality (RR 0.78; 95% CI, 0.58 to 1.06; P = 0.11), 90 days mortality (RR, 0.92; 95% CI, 0.81 to 1.04; P = 0.16), and intensive care unit (ICU) mortality (RR, 0.90; 95% CI, 0.79 to 1.03; P = 0.13) in patients with ARDS. However, 21–28 days mortality was slightly lower in patients received NMBAs (RR 0.73; 95% CI, 0.54 to 0.99; P = 0.04; I² = 53%). Besides, NMBAs use could improve the PaO₂/FiO₂ ratio at 48 and 72 h, decrease plateau pressure and PEEP at 72 h. Additionally, NMBAs had no significant effects on days free of ventilation at day 28 (WMD, 0.55; 95% CI, − 0.46 to 1.57; P = 0.29), days not in ICU at day 28 (WMD, 0.12; 95% CI, − 0.85 to 1.08; P = 0.82), ICU-acquired weakness (RR, 1.23; 95% CI, 0.99 to 1.93; P = 0.06). Finally, NMBAs use was associated with a lower risk of barotrauma (RR, 0.55; 95% CI, 0.35 to 0.85; P = 0.007).

Conclusion

In patients with respiratory distress syndrome, NMBAs may be beneficial in reverse refractory hypoxemia and may be associated with reduced short-term mortality and incidence of barotrauma. However, there is no significant effects of NMBAs on mid-term and long-term mortality, and further studies are required.

Assessment of Neuromuscular Function in Patients With Prior Cosmetic Procedures: A Case Report

Objective: The use of Botulinum toxin type A (Botox) for cosmetic procedures has become so prevalent that many patients do not always consider it to be a past surgical procedure, and it goes excluded from the medical record. Without the knowledge of prior Botox use, interpretation of facial nerve train-of-four testing may be inaccurate. Methods: We describe a 61-year-old woman with a history of multiple cosmetic procedures whose postoperative course was complicated by multiorgan system failure, requiring neuromuscular blockade while on mechanical ventilatory support. Results: Gauged by facial nerve stimulation, adequate neuromuscular blockade was assumed. However, patient-ventilator dyssynchrony motivated the decision to move the peripheral nerve stimulator to the ulnar nerve, where muscle twitches were observed. This indicated inadequate paralysis. Conclusions: This case report highlights the importance of monitoring neuromuscular function with ulnar nerve testing in patients with a history of cosmetic Botox procedures.

An Observational Study of the Efficacy of Cisatracurium Compared with Vecuronium in Patients with or at Risk for Acute Respiratory Distress Syndrome

RATIONALE

The neuromuscular blocking agent cisatracurium may improve mortality for patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Other neuromuscular blocking agents, such as vecuronium, are commonly used and have different mechanisms of action, side effects, cost, and availability in the setting of drug shortages.

OBJECTIVES

To determine whether cisatracurium is associated with improved outcomes when compared with vecuronium in patients at risk for and with ARDS.

METHODS

Using a nationally representative database, patients who were admitted to the ICU with a diagnosis of ARDS or an ARDS risk factor, received mechanical ventilation, and were treated with a continuous infusion of neuromuscular blocking agent for at least 2 days within 2 days of hospital admission were included. Patients were stratified into two groups: those who received cisatracurium or vecuronium. Propensity matching was used to balance both patient- and hospital-specific factors. Outcomes included hospital mortality, duration of mechanical ventilation, ICU and hospital duration, and discharge location.

MEASUREMENTS AND MAIN RESULTS

Propensity matching successfully balanced all covariates for 3,802 patients (1,901 per group). There was no significant difference in mortality (odds ratio, 0.932; P = 0.40) or hospital days (-0.66 d; P = 0.411) between groups. However, patients treated with cisatracurium had fewer ventilator days (-1.01 d; P = 0.005) and ICU days (-0.98 d; P = 0.028) but were equally likely to be discharged home (odds ratio, 1.19; P = 0.056).

CONCLUSIONS

When compared with vecuronium, cisatracurium was not associated with a difference in mortality but was associated with improvements in other clinically important outcomes. These data suggest that cisatracurium may be the preferred neuromuscular blocking agent for patients at risk for and with ARDS.

The Current State of Pediatric Acute Respiratory Distress Syndrome

Pediatric acute respiratory distress syndrome (PARDS) is a significant cause of morbidity and mortality in children. Children with PARDS often require intensive care admission and mechanical ventilation. Unfortunately, beyond lung protective ventilation, there are limited data to support our management strategies in PARDS. The Pediatric Acute Lung Injury Consensus Conference (PALICC) offered a new definition of PARDS in 2015 that has improved our understanding of the true epidemiology and heterogeneity of the disease as well as risk stratification. Further studies will be crucial to determine optimal management for varying disease severity. This review will present the physiologic basis of PARDS, describe the unique pediatric definition and risk stratification, and summarize the current evidence for current standards of care as well as adjunctive therapies.

Neuromuscular blocking agents for acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) is an acute inflammatory process that impairs the ability of the lungs to oxygenate thereby resulting in respiratory failure. Treatment of ARDS is often a multimodal approach using both nonpharmacologic and pharmacologic treatment strategies in addition to trying to reverse the underlying cause of ARDS. Neuromuscular blocking agents (NMBAs) have been prescribed to patients with ARDS as they are thought to decrease inflammation, oxygen consumption, and cardiac output and help facilitate ventilator synchrony. NMBAs have only been evaluated in patients with early, severe ARDS in three multicenter, randomized, controlled trials (n = 432), but have resulted in decreased inflammation and improved oxygenation, ventilator-free days, and mortality. Despite reports of NMBAs being associated with adverse effects like postparalytic quadriparesis, myopathy, and prolonged recovery, these effects have not been seen in patients receiving short courses of NMBAs for ARDS. A large multicenter, prospective, randomized, placebo-controlled trial is ongoing to confirm benefit of NMBAs in early, severe ARDS when adjusting for limitations of the previous studies. The current available literature suggests that 48 h of NMBA therapy in patients with early, severe ARDS improves mortality, without resulting in additional patient harm.

Continuous neuromuscular blockade infusion for out-of-hospital cardiac arrest patients treated with targeted temperature management: A multicenter randomized controlled trial

Introduction

The aim of this trial was to investigate the effect of a continuous infusion of a neuromuscular blockade (NMB) in comatose out-of-hospital cardiac arrest (OHCA) subjects who underwent targeted temperature management (TTM).

Methods

In this open-label, multicenter trial, subjects resuscitated from OHCA were randomly assigned to receive either NMB (38 subjects) or placebo (43 subjects) for 24 hours. Sedatives and analgesics were given according to the protocol of each hospital during TTM. The primary outcome was serum lactate levels at 24 hours after drug infusion. The secondary outcomes included in-hospital mortality, a poor neurological outcome at hospital discharge, changes in lactate levels, changes in the PaO₂:FiO₂ ratio over time and muscle weakness as assessed by the Medical Research Council (MRC) scale.

Results

Eighty-one subjects (NMB group: median age, 65.5 years, 30 male patients; placebo group: median age, 61.0 years, 29 male patients) were enrolled in this trial. No difference in the serum lactate level at 24 hours was observed between the NMB (2.8 [1.2–4.0]) and placebo (3.6 [1.8–5.2]) groups (p = 0.238). In-hospital mortality and a poor neurologic outcome at discharge did not differ between the two groups. No significant difference in the PaO₂:FiO₂ ratio over time (p = 0.321) nor the MRC score (p = 0.474) was demonstrated.

Conclusions

In OHCA subjects who underwent TTM, a continuous infusion of NMB did not reduce lactate levels and did not improve survival or neurological outcome at hospital discharge. Our results indicated a limited potential for the routine use of NMB during early TTM. However, this trial may be underpowered to detect clinical differences, and future research should be conducted.

The prognostic value of bispectral index and suppression ratio monitoring after out-of-hospital cardiac arrest: a prospective observational study

Background

We investigated the ability of bispectral index (BIS) monitoring to predict poor neurological outcome in out-of-hospital cardiac arrest (OHCA) patients fully treated according to guidelines.

Results

In this prospective, observational study, 77 successfully resuscitated OHCA patients were enrolled in whom BIS, suppression ratio (SR) and electromyographic (EMG) values were continuously monitored during the first 36 h after the initiation of targeted temperature management at 33 °C. The Cerebral Performance Category (CPC) scale was used to define patients’ outcome at 180 days after OHCA (CPC 1–2: good–CPC 3–5: poor neurological outcome). Using mean BIS and SR values calculated per hour, receiver operator characteristics curves were constructed to determine the optimal time point and threshold to predict poor neurological outcome. At 180 days post-cardiac arrest, 39 patients (51%) had a poor neurological outcome. A mean BIS value ≤ 25 at hour 12 predicted poor neurological outcome with a sensitivity of 49% (95% CI 30–65%), a specificity of 97% (95% CI 85–100%) and false positive rate (FPR) of 6% (95% CI 0–29%) [AUC: 0.722 (0.570–0.875); p = 0.006]. A mean SR value ≥ 3 at hour 23 predicted poor neurological with a sensitivity of 74% (95% CI 56–87%), a specificity of 92% (95% CI 78–98%) and FPR of 11% (95% CI 3–29%) [AUC: 0.836 (0.717–0.955); p < 0.001]. No relationship was found between mean EMG and BIS < 25 (R² = 0.004; p = 0.209).

Conclusion

This study found that mean BIS ≤ 25 at hour 12 and mean SR ≥ 3 at hour 23 might be used to predict poor neurological outcome in an OHCA population with a presumed cardiac cause. Since no correlation was observed between EMG and BIS < 25, our calculated BIS threshold might assist with poor outcome prognostication following OHCA.

Review of Continuous Infusion Neuromuscular Blocking Agents in the Adult Intensive Care Unit

The use of continuous infusion neuromuscular blocking agents remains controversial. The clinical benefit of these medications may be overshadowed by concerns of propagating intensive care unit-acquired weakness, which may prolong mechanical ventilation and impair the inability to assess neurologic function or pain. Despite these risks, the use of neuromuscular blocking agents in the intensive care unit is indicated in numerous clinical situations. Understanding pharmacologic nuances and clinical roles of these agents will aid in facilitating safe use in a variety of acute disease processes. This article provides clinicians with information regarding pharmacologic differences, indication for use, adverse effects, recommended doses, ancillary care, and monitoring among agents used for continuous neuromuscular blockade.

Neuromuscular blockade requirement is associated with good neurologic outcome in cardiac arrest survivors treated with targeted temperature management

PURPOSE

We examined the association between neuromuscular blockade (NMB) requirements and outcomes and lactate clearance in cardiac arrest survivors treated with targeted temperature management (TTM).

METHODS

We included consecutive adult cardiac arrest survivors treated with TTM between 2012 and 2015. NMB use was categorized into 3 groups: no NMB, bolus NMB (intermittent bolus use), and continuous NMB (continuous infusion). Serum lactate levels were measured on admission and at 12h, 24h, and 48h after admission. The primary outcome was neurologic outcome at discharge. The secondary outcomes were in-hospital mortality and lactate clearance.

RESULTS

In total, 309 patients were included. Of these, 206 (66.7%) and 73 (23.6%) were discharged with poor neurologic outcome and death, respectively. Multivariate analysis revealed that continuous NMB, as opposed to no NMB use, was associated with decreased poor neurologic outcomes (odds ratio [OR], 0.317; 95% confidence interval [CI], 0.124-0.815) and decreased in-hospital mortality (OR, 0.414; 95% CI, 0.183-0.941). There were no differences in lactate clearance between the NMB groups.

CONCLUSION

Continuous NMB requirement was associated with improved neurologic outcome and decreased in-hospital mortality in cardiac arrest survivors treated with TTM. The NMB requirement was not associated with lactate clearance.

Neuromuscular Blockade in the 21st Century Management of the Critically Ill Patient

Neuromuscular blockings agents (NMBAs) have a controversial role in the ventilatory and medical management of critical illness. The clinical concern surrounding NMBA-induced complications stems from evidence presented in the 2002 clinical practice guidelines, but new evidence from subsequent randomized trials and studies provides a more optimistic outlook about the application of NMBAs in the ICU. Furthermore, changes in the delivery of critical care, such as protocolized care pathways, minimizing or interrupting sedation, increased monitoring techniques, and overall improvements in reducing immobility, have created a modern, 21st century ICU environment whereby NMBAs may be administered safely. In this article we start with a review of the mechanism of action, side effects, and pharmacology of commonly used NMBAs. We then address the rationale for NMBA use for an expanding number of indications (endotracheal intubation, acute respiratory distress syndrome, status asthmaticus, increased intracranial and intra-abdominal pressure, and therapeutic hypothermia after cardiac arrest), with an emphasis on NMBA use in facilitating lung-protective ventilation for respiratory failure. We end with an appraisal over the importance of monitoring depth of paralysis and the concerns of complications, such as prolonged skeletal muscle weakness. In the context of adequate sedation and analgesia, monitored NMBA use (continuous or bolus administration) can be considered for the small number of clinical indications in critically ill patients for which evidence currently exists.

Acquired Muscle Weakness in the Surgical Intensive Care Unit

Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.