Methods to monitor and evaluate neuromuscular blockade use in intensive care unit patients with hypoxemic respiratory failure and acute respiratory distress syndrome: a scoping review

AI Summary

Significant variability exists in NMBA monitoring strategies, goals, and dosing; main strategies were train-of-four peripheral nerve stimulation and clinical assessment of ventilatory dyssynchrony.
Protocol-guided NMBA monitoring in nine studies reduced NMBA consumption, achieved target paralysis depth, and shortened recovery time.
No significant differences between monitoring strategies were observed for mortality or mechanical ventilation duration; larger, better powered studies are needed to define optimal monitoring.

Can J Anaesth. 2026 May 22. doi: 10.1007/s12630-026-03127-1. Online ahead of print.

ABSTRACT

PURPOSE: Though neuromuscular blocking agents (NMBAs) are recommended for managing the cases of patients with moderate to severe acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU), current guidelines do not provide clear consensus regarding effective NMBA monitoring strategies. In this scoping review, we aimed to describe NMBA monitoring strategies and their associated outcomes among adults undergoing invasive mechanical ventilation for hypoxemic respiratory failure (HRF) and ARDS.

SOURCE: We conducted a literature search in MEDLINE (Ovid), Embase (Ovid), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Elton B. Stephens Company [EBSCO]), between 2 and 5 July 2021 and updated on 3 October 2023 and 21 August 2025. Two reviewers independently assessed studies for inclusion and extracted study characteristics, design, the NMBA monitoring strategy, and associated outcomes.

PRINCIPLE FINDINGS: In this scoping review, we identified 2,274 records, with 402 undergoing full text review. We included 12 studies (994 patients) for final synthesis. Two monitoring strategies, peripheral nerve stimulation with train-of-four monitoring and clinical assessment, were described. Ventilatory dyssynchrony was the most reported clinical assessment strategy. We found significant variability among monitoring strategies, goals, and NMBA dosing. A protocol guided NMBA monitoring and administration in nine studies. Protocol use was associated with benefits, including reduced NMBA consumption, achieved target depth of paralysis, and shorter recovery time. No significant differences were described between monitoring strategies and patient outcomes including mortality or duration of mechanical ventilation.

CONCLUSIONS: Current evidence suggests the use of a protocol to guide NMBA monitoring and dosing in the ICU may be associated with benefits. Larger and better-powered studies are needed to determine the optimal NMBA monitoring strategy for patients with HRF and ARDS.

PMID:42174355 | DOI:10.1007/s12630-026-03127-1

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