Download intensive care nurses` knowledge about use of neuromuscular

Pulmonary Critical Care
I
CARE NURSES’
KNOWLEDGE ABOUT USE OF
NEUROMUSCULAR BLOCKING
AGENTS IN PATIENTS WITH
RESPIRATORY FAILURE
NTENSIVE
By Erin N. Frazee, PharmD, Heather A. Personett, PharmD, Seth R. Bauer, PharmD,
Amy L. Dzierba, PharmD, Joanna L. Stollings, PharmD, Lindsay P. Ryder, PharmD,
Jennifer L. Elmer, DNP, APRN, CNS, Sean M. Caples, DO, and Craig E. Daniels, MD
C E 1.0 Hour
Notice to CE enrollees:
A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Identify 2 areas of needed education regarding the
use of neuromuscular blocking agents (NMBAs) in
the intensive care environment.
2. Discuss 2 common methods of titration of
NMBAs.
3. Describe 2 conditions that were associated with
use of NMBAs
To read this article and take the CE test online,
visit www.ajcconline.org and click “CE Articles in
This Issue.” No CE test fee for AACN members.
©2015 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2015397
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Background The recent increase in use of neuromuscular
blocking agents (NMBAs) in patients with acute respiratory distress syndrome is set against a backdrop of concerns about harm associated with use of these high-risk
drugs. Bedside nurses play a pivotal role in the safe and
effective use of these agents.
Objective To describe critical care nurses’ knowledge of
the therapeutic properties, adverse effects, and monitoring parameters associated with NMBAs.
Methods A prospective, multicenter survey of medical
intensive care unit nurses between July 2012 and May
2013. The web-based survey instrument was designed,
pretested, and administered under the direction of a multidisciplinary group of individuals.
Results Responses from 160 nurses (22% of eligible
nurses) were analyzed. Most respondents were able to
identify NMBAs correctly as nonanalgesic (93%) and
nonanxiolytic (83%). The perceived durations of action of
NMBAs varied widely, and few nurses were familiar with
patient-specific considerations related to drug elimination. Most (70%) recognized the independent associations
between NMBAs and footdrop, muscle breakdown, and
corneal ulceration. Pressure ulcers and a history of neuromuscular disease were the characteristics of patients
perceived to most heighten the risk of NMBA use.
Conclusions Critical care nurses are knowledgeable
about the importance of concurrent analgesia and sedation during use of NMBAs. Routes of elimination, duration of action, and adverse effects were less commonly
known and represent areas for focused education and
quality improvement surrounding use of NMBAs in the
intensive care unit. (American Journal of Critical Care.
2015;24:431-439)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5
431
A
knowledgeable critical care nurse is essential to the effective and safe use of neuromuscular blocking agents (NMBAs) in intensive care units (ICUs). The Institute
for Safe Medication Practices considers NMBAs to be high-alert medications
because of the robust historical documentation of harm associated with their
use.1,2 Indeed, prolonged use of these agents contributes to an increased risk for
corneal ulcers, skin breakdown, venous thromboembolism, ventilator-associated pneumonia,
and musculoskeletal debility.3 Furthermore, reports of patients recalling being paralyzed and
the independent association between NMBAs and posttraumatic stress disorder raise concerns
about the safety of routine use of these agents.3-7
Despite these previously documented risks,
interest in the routine use of NMBAs among medical ICU patients has been renewed in the past several
years. Specifically in patients with acute respiratory
distress syndrome (ARDS), we now know that early
continuous infusion of an NMBA improves oxygenation, inflammation, and mortality.8-10 As epidemiological evidence shows,
this practice shift in support of NMBA use could
affect many critically ill
patients.11-13 To minimize
risks for patients, critical
care nurses must have a
keen understanding of the
importance of adequate
concurrent analgesia and
sedation when an NMBA is used and an appreciation
for the factors that contribute to selection of patients,
choice of agent, dose titration, and adverse effects.
Studies14-17 on nurses’ knowledge about the
use of NMBAs are more than a decade old and do
Neuromuscular blocking
agents are high-alert
medications because of
their well-documented
history of causing harm.
About the Authors
Erin N. Frazee and Heather A. Personett are pharmacists
in Hospital Pharmacy Services, Mayo Clinic, Rochester,
Minnesota. Seth R. Bauer is a medical intensive care
unit clinical specialist in the Department of Pharmacy,
Cleveland Clinic, Cleveland, Ohio. Amy L. Dzierba is a
critical care pharmacist in the Department of Pharmacy,
New York Presbyterian Hospital, New York, New York.
Joanna L. Stollings is a critical care pharmacist in the
Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee. Lindsay P.
Ryder is a pharmacist in the Department of Pharmacy,
The Ohio State University Wexner Medical Center, Columbus, Ohio. Jennifer L. Elmer is a critical care clinical
nurse specialist in the Department of Nursing at the
Mayo Clinic. Sean M. Caples and Craig E. Daniels are
intensive care physicians in the Division of Pulmonary
and Critical Care Medicine, Mayo Clinic.
Corresponding author: Erin N. Frazee, PharmD, Mayo Clinic,
200 First St SW, Rochester, MN 55905 (e-mail: frazee.erin
@mayo.edu).
432
not completely assess all aspects of competency.
They also predate recent efficacy publications8-10 in
support of using NMBAs for certain subgroups of
patients. Therefore, to promote the safe and effective
use of NMBAs, we sought in this study to describe
critical care nurses’ knowledge and beliefs about
NMBAs in the modern medical ICU and identify
opportunities for targeted educational initiatives
and to improve practice homogeneity in the future.
Methods
In this multicenter, prospective, cross-sectional
study, ICU nurses at 5 sites (Mayo Clinic, Rochester,
Minnesota; Cleveland Clinic, Cleveland, Ohio;
New York Presbyterian Hospital, New York, New
York; Vanderbilt University Medical Center, Nashville, Tennessee; and The Ohio State University
Wexner Medical Center, Columbus, Ohio) completed a web-based survey between July 2012 and
May 2013. The study protocol was reviewed and
approved by the institutional review board at each
participating site. The questionnaire responses are a
subset of a larger database of survey responses from
licensed providers in multiple disciplines, including nurses, physicians, nurse practitioners, physician
assistants, pharmacists, and respiratory therapists.
For their responses to be eligible for inclusion in
this study, more than 25% of the individual’s clinical practice must have been in an ICU consisting of
more than 50% medical patients at 1 of the 5 large,
academic medical centers involved in the study.
The included academic medical centers each have
approximately 700 to 1400 adult hospital beds and
24 to 65 medical ICU beds. At the time of the study,
all included institutions had an electronic medical record and used computerized provider order
entry (CPOE). Two centers had clinical protocols for
NMBA use that were helpful in selection of patients,
dosing, and monitoring.
A 16-question web-based survey was designed
expressly for this study in conjunction with the
Mayo Clinic Survey Research Support Center. Study
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5
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data were collected and managed in REDCap
(Research Electronic Data Capture) survey software version 1.3.9.18 REDCap is a secure, web-based
application designed to support data capture for
research studies, providing (1) an intuitive interface
for validated data entry, (2) audit trails for tracking data manipulation and export procedures, (3)
automated export procedures for seamless data
downloads to common statistical packages, and (4)
procedures for importing data from external sources.
The survey instrument (see Appendix, available
online only, at www.ajcconline.org) was subdivided
into 2 distinct sections; the first pertained to general
knowledge about NMBAs and the second involved
perceptions of the role of NMBAs in patients with
ARDS. All participants were asked to complete both
sections of the survey. Development of the content
domains included a thorough review of published
reports and input from a multidisciplinary group
of experts. Specific to the knowledge section presented here, the survey instrument was focused on
NMBA pharmacology, pharmacokinetics (duration
of action, methods of elimination), adverse effects,
and titration. Questions referenced both types of
NMBAs: aminosteroidal compounds (eg, vecuronium and pancuronium) and benzylisoquinolinium
compounds (eg, cisatracurium and atracurium).
Response options were closed-ended and used
statements of agreement and Likert scales where possible. Items pertaining to analgesia and anxiolysis
asked nurses to mark agree, disagree, or unsure/no
opinion for a series of statements about NMBA drug
properties. Unsure/no opinion and missing responses
were combined and classified as incorrect responses
for these analyses to identify knowledge gaps. Pharmacokinetic items asked nurses to describe medications’ duration of action in the absence of end-organ
compromise. Response options included short, intermediate, or long duration of action and unsure/no
opinion. Correct responses identified atracurium and
vecuronium each as intermediate duration according
to current guidelines.3 Also, we probed respondents
about the risk of NMBA accumulation in patients
with clinically significant end-organ dysfunction.
In this case, a correct response identified the altered
elimination of the aminosteroidals (vecuronium and
pancuronium) in patients with hepatic and renal dysfunction, respectively, and the end-organ neutrality
of both benzylisoquinolinium NMBAs.3,19 Agents that
affect the central nervous system (CNS-active agents)
but are not NMBAs (eg, fentanyl, hydromorphone,
lorazepam, propofol) were included in survey questions to provide a reference agent for descriptive comparisons to NMBAs.14
Similar to the method of Rhoney and Murry,20
after development, 20 ICU providers (including
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physicians, nurses, and pharmacists from a nonincluded surgical ICU at the primary site) reviewed
and pretested the questionnaire. A structured critique form was given
to each of these individuals upon survey
completion, with specific probes designed
to examine question clarity, response
options, missing or
superfluous survey
items, and overall
length. Two investigators reviewed the
deidentified critiques to identify themes. Questions
and responses were modified to address areas of
ambiguity. Concerns about length and redundancy
resulted in removal of several survey items.
The study team involved investigators from
each of the included sites. These site representatives individually contacted the local medical directors, subspecialty managers (ie, nurse managers),
and administrative staff at their center to acquire
the e-mail addresses of eligible study participants.
The members of the investigative team had various degrees of preexisting professional relationships
with the local ICU leaders. All known members of
the population were surveyed. Eligible individuals
were contacted via e-mail and invited to participate in the survey. By following the survey link in
the electronic communication, providers indicated
their consent to participate. Reminder communication occurred electronically 2 weeks, 3 weeks, and
4 weeks after the initial e-mail, and the study concluded on day 30.
The only demographic identifiers collected pertained to the provider’s self-reported role in the ICU
(eg, nurse, physician, pharmacist) and study site.
Herein we reported the data from all eligible respondents who identified themselves as nurses, including
licensed practical nurses, registered nurses, clinical
nurse specialists, and nurse educators. Information
from nurse practitioners was not included, because
their additional education (formal and informal)
and prescriptive authority may predispose them to
an altered familiarity with medication selection,
clinical protocols, and guideline recommendations.
Responses were otherwise anonymously gathered in
the electronic database and described in aggregate.
Descriptive statistics were used for all survey
responses, with results expressed as frequencies and
percentages. The Pearson r2 test or the Fisher exact
test was used to analyze independent binary outcomes. Assuming 60% concordance with the correct
response, we calculated that at least 150 responders
The survey had 2 sections:
1 on general knowledge
and 1 on perceptions of
use of these agents in
patients with acute respiratory distress syndrome.
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5
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Nurses from the medical intensive care
unit (ICU) for whom contact information
was available from the unit leaders
(n = 717)
Exclusions (n = 557)
No response or did not self-report nursing
as their ICU provider role (n = 553)
No institutional affiliation noted (n = 2)
Multiple ICU provider roles reported (n = 2)
Included respondents
(n = 160, 22% overall)
Figure 1 Participant flowchart.
would be needed to provide a 95% confidence interval of 52% to 68% for the population response. All
analyses were performed with JMP version 9 statistical software (SAS Institute Inc).
Results
Of the 717 eligible medical ICU nurses contacted for participation, 160 (22%) submitted partial or complete responses suitable for analysis
(Figure 1). All knowledge questions were answered
by 155 respondents (97%).
Therapeutic Properties
The aminosteroidal and benzylisoquinolinium
NMBAs studied were correctly identified as nonanalgesic by 95% and 94% of survey respondents, respectively. In a combined analysis, 148 respondents
(92%) were able to identify both agents correctly as
nonanalgesic (see Table). A similar number of participants correctly identified lorazepam as nonanalgesic
(n = 144, 90%). The absence of anxiolytic properties
among NMBAs was significantly less commonly identified by respondents (n = 132, 82%) than the absence
of analgesic properties (P = .007). Unsure/no opinion was the most common answer among incorrect
responses regarding anxiolytic properties of NMBAs
(pancuronium: 19 out of 25 incorrect responses;
atracurium: 13 out of 20 incorrect responses).
Pharmacokinetics
Marked inconsistencies existed among respondents in the perceived duration of action of each
NMBA (Figure 2). Less than half of respondents
correctly identified the intermediate duration of
action of atracurium (46%) and vecuronium (40%),
and the responses showed marked heterogeneity.
In contrast, homogeneity was increased among
the responses to the reference analgesic and sedative agents under study, hydromorphone (65% perceived it to be intermediate duration of action) and
Table
Correct identification of pharmacological properties
of neuromuscular blocking agents (NMBAs)
Survey item
No. (%)
Analgesic
Correctly identified the following NMBA as nonanalgesic
Vecuronium
Cisatracurium
Both NMBAs correct
152 (95)
150 (94)
148 (92)
Anxiolytic
Correctly identified the following NMBAs as nonanxiolytic
Pancuronium
Atracurium
Both NMBAs correct
135 (84)
140 (88)
132 (82)
End-organ elimination
Correctly identified drug elimination properties of the following NMBAs
Aminosteroidals
Vecuronium (primarily hepatic)
Pancuronium (primarily renal)
Both aminosteroidal NMBAs correct
Benzylisoquinoliniums
Atracurium (end-organ neutral)
Cisatracurium (end-organ neutral)
Both benzylisoquinolinium NMBAs correct
434
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5
66 (41)
68 (42)
44 (28)
89 (56)
103 (64)
65 (41)
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Adverse Effects
Four out of every 5 nurses recognized independent associations between NMBAs and both footdrop and muscle breakdown. In only 34% of cases,
nursing staff recognized the independent association
between use of an NMBA and consciousness (Figure 3). We studied whether nurses attributed other
likely unrelated biochemical and clinical effects to
the use of NMBAs. Few nurses inaccurately reported
a relationship between NMBA use and hyperglycemia (8%), infection (11%), or hypomagnesemia
(16%). Lactic acidosis and delirium were incorrectly
identified as independently related to NMBA use in
28% and 32% of responses, respectively.
Respondents were also asked to classify the
degree to which a series of baseline factors and
concurrent therapies modified the risk profile of
continuous infusion of an NMBA. As this pertains
to providers’ perceptions and beliefs, no answers
for these items were considered incorrect. Respondents could select from the following options: substantial increase in risk, slight increase in risk, no
change in risk, or unsure. Among the factors under
study, respondents believed that pressure ulcers
and a history of a neuromuscular disorder most
increased the risks associated with NMBA therapy
(Figure 4). Although concomitant corticosteroids
were perceived to heighten the risk associated with
continuous infusion of an NMBA by 77 respondents (48%), the majority classified this increase
in risk as slight (58 “slight increase” out of 77
responses for increased risk).
Titration
When asked to select the best primary method
to guide titration of a continuous infusion of an
NMBA in patients with ARDS, 82 nurses (51%) preferred degree of ventilator synchrony or other oxygenation/ventilation parameters. Train-of-4 (TOF)
monitoring with peripheral nerve stimulation (PNS)
was selected less often (n = 65, 41%), although this
difference was not statistically significant (P = .06).
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*
75
*
50
*
*
25
on
ol
H
yd
r
om
Pr
or
op
ph
of
iu
m
on
Ve
c
ur
ur
ac
tr
A
e
0
iu
m
Percentage of responses
propofol (82% perceived it to possess a short duration of action). Given the importance of ICU nurses
in individualizing treatment plans and weaning
patients off of CNS-active agents, survey items were
included to investigate the perceived risk of NMBA
accumulation in patients with hepatic or renal dysfunction. Only 8 respondents (5%) correctly identified all 4 NMBA drugs’ elimination considerations.
The end-organ neutrality of benzylisoquinolinium
NMBAs was identified more commonly than were
the implications of renal or hepatic dysfunction
on elimination of aminosteroidal NMBAs (41% vs
28%, respectively; P = .01; see Table).
100
Short
Intermediate
Unsure/no opinion/missing
Long
Figure 2 Perceived durations of action of 2 paralytic agents (atracurium and vecuronium) and 2 reference agents (propofol and
hydromorphone). Fewer than half of respondents identified the
correct duration of action for each paralytic agent (denoted by
an asterisk in the figure). In contrast to the consistent responses
noted with the reference agents, distinct variability existed in the
perceived durations of paralytic activity.
Footdrop
Muscle breakdown
Corneal ulceration
Venous thromboembolism
Consciousness
0
25
50
75
Percentage of responses
100
Figure 3 Percentage of respondents who endorsed an independent
association between major adverse effects and use of neuromuscular blocking agents.
Discussion
Recent evidence suggesting the utility of NMBAs
in patients with ARDS falls on a backdrop of the
potential for serious adverse effects. The bedside
nurse is one of the key team members responsible
for ensuring the safe and effective use of NMBAs
in critically ill patients. It is for this reason that we
sought to evaluate critical care nurses’ knowledge
about NMBAs. Paralytic agents were identified as
nonanalgesic by 92% of nurses, but only 82% of
nurses recognized that NMBAs lack sedative properties. Nurses infrequently identified the correct
method of NMBA elimination, particularly with
aminosteroidal NMBAs. Approximately 20% to 40%
of respondents were unfamiliar with major adverse
effects of the drugs (muscle breakdown, corneal
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435
Pressure ulcers
History of
neuromuscular disorder
Immunosuppression
Coagulopathy
Concomitant
corticosteroids
0
Increased risk
25
50
75
Percentage of responses
No change in risk
100
Unsure/missing
Figure 4 Degree to which baseline factors or concurrent therapies are
perceived to alter the risk profile of neuromuscular blocking agents.
ulceration, and venous thromboembolism). With
respect to monitoring, nurses preferred to use ventilation/oxygenation parameters rather than TOF monitoring to guide dose titration in patients with ARDS.
Although the evidence is limited, researchers
in previous studies have described nurses’ knowledge about NMBA pharmacology. In early work by
Loper and colleagues,14 258 ICU nurses at a single
center were surveyed to assess their knowledge about
NMBAs. Ninety percent of respondents were either
unsure or believed that pancuronium provided anxiolysis. With respect to pain control, one-third of ICU
nurses reported a lack of familiarity or believed that
pancuronium provided analgesia.14 A separate structured needs assessment pertaining to analgesia, sedation, and paralysis in a surgical ICU revealed frequent
insufficiency of sedation and analgesia during use
of NMBAs. The authors identified this as a key clinical issue that adversely affected patient care and outcomes.16 In contrast to previous work, nurses in the
present study more frequently recognized the absence
of analgesic properties among NMBAs, but 1 in 5 still
failed to note the absence of anxiolysis. The explanation for this partial improvement is unknown, but it
may relate to increased awareness of pain, agitation,
and delirium in critically ill patients with the recent
release of updated guidelines.21 Also, the abundant
educational resources and advanced credentials now
available to ICU nurses through national organizations
such as the American Association of Critical-Care
Nurses and the Society of Critical Care Medicine
may have resulted in an increased understanding of
the importance of concomitant analgesia/sedation
when NMBAs are used. The heightened emphasis on
pain assessment and control by The Joint Commission may also explain the difference in familiarity
with analgesia and anxiolysis.22
436
In addition to the therapeutic effects, reviews
and continuing education modules on NMBAs also
highlight the importance of nursing competency in
drug pharmacokinetics, selection of patients and
agents, adverse effects, and titration.16,23-25 Unfortunately, we are unaware of published studies measuring such knowledge. In our study, ICU nurses
commonly misidentified the correct mechanism of
drug elimination, perceived durations of action of
NMBAs varied widely, and certain adverse effects
were underrecognized. The bedside nurse is the multidisciplinary team member most closely involved
with weaning ICU patients off of CNS-active agents
in. Failure to predict the offset of paralytic activity
correctly, particularly in the setting of end-organ
dysfunction, may place patients at increased risk
of exposure to insufficient analgesia and sedation
during the NMBA weaning process. Our findings
suggest that an opportunity also exists to heighten
the emphasis on screening for muscle breakdown,
corneal ulceration, and venous thromboembolism
in the nurses’ daily clinical assessments. Future quality improvement and educational initiatives should
seek to address these knowledge gaps.
Unlike previous studies in which nurses were
surveyed about the NMBA titration practice at
their sites, we instead inquired about NMBA titration preference, specifically in patients with ARDS
because of the recent favorable reports on use of
NMBAs for this indication; the differences were
revealing. Foster and colleagues24 did a survey of
483 critical care nurse managers across the United
States, asking about NMBA use and titration with
a particular focus on PNS. Of the 185 centers that
reported NMBA use, 116 (63%) monitored NMBAs
with PNS, and 111 of those also used the TOF technique. Eighty-three percent of respondents reported
dose titration of NMBA to PNS response, which is in
line with guideline recommendations from 2002.3,15
Although the difference did not reach statistical significance, in the present evaluation, we found that
more nurses favored using titration to respiratory
criteria (51%) rather than TOF (41%) for monitoring effects of NMBAs in patients with ARDS. Studies that have compared TOF-guided NMBA titration
to titration based on subjective clinical assessments
in patients with mixed indications for paralysis
have yielded disparate results. Rudis et al26 reported
that lower doses of NMBAs were used and recovery from paralytic agents was faster in patients randomized to TOF-guided therapy, whereas 2 other
studies27,28 showed no difference between groups in
total paralysis time, recovery time, and amount of
drug used. In a randomized controlled trial29 of 102
patients with ARDS who were given cisatracurium,
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researchers reported no difference in plateau pressure, ratio of PaO2 to fraction of inspired oxygen,
PaCO2, or pH between patients titrated to a TOF of
0/4 versus 2/4, but the authors did note a reduction
in total drug used and recovery time among patients
titrated to a TOF of 2/4. On the basis of these data,
we suggest that providers pair TOF with clinical criteria to develop individualized titration plans that
consider the indication for NMBA therapy. Indeed,
management of an ICU patient with severe respiratory failure most likely requires a different approach
to titration than management of a patient with elevated intracranial pressure.
This study had several possible limitations.
Although the focus of the study is ICU nurses, many
other members of the multidisciplinary team share
responsibility for ensuring safe use of NMBAs in
practice. Coverage error may have existed between
the target population of all medical ICU nurses and
the sampling frame used in this study. The study was
performed at 5 large academic medical centers. Facilities with fewer than 150 hospital beds or fewer than
10 ICU beds provide concurrent analgesia and sedation during NMBA less often and use PNS less often
than larger centers do.15 If present, this bias most
likely resulted in conservative estimates of NMBA
knowledge gaps, but caution should still be used
when generalizing these findings to smaller institutions. The results of this study may also be affected
by nonresponse error. The response rate in this webbased survey was 22%, even after 3 reminder notifications were distributed to study participants by a local
representative. We cannot exclude the possibility that
nonresponders systematically differed from responders, but our findings are similar to the 25% response
rate documented in a paper-and-pencil questionnaire
distributed to physicians on a similar topic.20 Last,
we did not measure baseline academic training,
years of practice experience, postgraduate advanced
credentialing in critical care, or involvement in
national organizations (eg, American Association of
Critical-Care Nurses, Society of Critical Care Medicine) and thus cannot comment on how these factors
may have influenced the responses.
Conclusion
Current medical ICU nurses demonstrated a
keen understanding of the importance of analgesia and sedation during therapeutic paralysis. Future
educational efforts to improve the safe and effective
use of NMBAs should address the knowledge gaps
identified in this study, including adverse effects and
NMBA pharmacokinetics, which may directly affect
dose adjustment and concomitant interventions. Last,
a reappraisal of therapeutic goals of NMBA and titration strategies in patients with ARDS is warranted
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because ventilation and oxygenation should be considered in conjunction with PNS response.
FINANCIAL DISCLOSURES
This study was partially funded by a research grant from
Mayo Clinic Pharmacy Services Discretionary Fund,
Rochester, Minnesota.
eLetters
Now that you’ve read the article, create or contribute to an
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SEE ALSO
For more about neuromuscular blocking agents, visit
the Critical Care Nurse website, www.ccnonline.org,
and read the article by Wilson et al, “Residual Neuromuscular Blockade in Critical Care” (June 2012).
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To purchase electronic or print reprints, contact American
Association of Critical-Care Nurses, 101 Columbia, Aliso
Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
(ext 532); fax, (949) 362-2049; e-mail, [email protected].
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