Q: What is the 'rule of thumb' for titrating the neuro-muscular blockade (NMB) infusion in ICU?  

Answer: The depth of neuromuscular blockade should be monitored by peripheral nerve stimulation (PNS), popularly know as 'Train of Four' (TOF). In first 24 hours, it should be assessed every 2 hours and once goal of '2/4 TOF' is achieved, frequency can be decreased to q12 hours. 

As a 'rule of thumb' dose should be reduced approximately 10 percent if TOF is 0/4 or 1/4 - or increased by by 10 percent if TOF level is 3/4 or 4/4. 

Alike concept of 'sedation holiday' daily discontinuation of NMB should be performed to assess clinical progress and decrease complications, particularly critical illness myopathy.



Reference:

Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2002; 30:142.