Neuromuscular Blockers

Pancuronium (Pavulon): relatively long acting, can accumulate if given continuously (often given in intermittent doses), has a vagolytic effect, and must be reduced in renal failure. If hepatic and renal function are intact, may be the preferred agent in the ICU [Crit Care Med 30: 142, 2002; Crit Care Med 32: S554, 2004]

Rocuronium (Zemuron): rapid onset and devoid of cardiovascular effects. Eliminated in bile and must be reduced in liver failure

Cisatracurium (Nimbex): preferred over atracurium because it does not cause histamine release, does not cause cardiac depression, and generates less laudanosine (neuroexcitatory). Rapidly degraded, and not affected by liver or kidney failure [Clin Pharmacokin 36: 27, 1999]. Still, it can cause tachyphylaxis and possible seizures. [Andrews]

Succinylcholine (Anectine): do NOT use in the neuro ICU [Anes 94: 523, 2001] especially in the presence of denervation injury, rhabdomyolysis, hemorrhagic shock, thermal injury, or chronic mobility.

Monitor with the train of four 2 Hz pulses – desired goal is 1-2 twitches (NOT zero twitches). Use NM blockers in moderation. They require significant sedation, may lead to prolonged weakness, hypostatic pneumonia, and require DVT prophylaxis.