Sunday, August 23, 2015

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.


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.

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