Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient
Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient
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DOI：
10.1097/ccm.0000000000002027
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发表时间：
2016-11-01
影响因子：
8.8
通讯作者：
Mehta, Sangeeta
中科院分区：
文献类型：
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作者：
Murray, Michael J.;DeBlock, Heidi;Mehta, Sangeeta
目的：更新2002年版的“成人重症患者持续神经肌肉阻滞的临床实践指南”。设计：一个由17名重症医学学会成员组成的工作组，他们在神经肌肉阻滞剂的使用方面具有特殊的专业知识；建议评估、制定和评估分级专家；一位医学作家通过电话会议和三次面对面会议进行会面，并通过电子邮件进行交流，以检查证据并制定这些实践指南。每年，所有成员都会完成利益冲突声明；没有发现任何冲突。这项活动由重症监护医学学会资助，没有提供行业支持。 方法：使用建议评估、制定和评估分级系统，工作组的建议评估、制定和评估分级专家为与 21 个问题中的 6 个问题相关的证据创建了档案，并为这些问题和另外 15 个没有足够证据来创建档案的问题分配了证据质量分数。工作组成员审查了本材料和所有可用证据，并针对这 21 个问题提供了建议、建议或良好实践声明。结果：工作组制定了一项强烈建议：我们建议对接受持续输注神经肌肉阻滞剂的患者进行定期眼部护理，包括滴眼液或凝胶以及闭合眼睑。工作组提出了 10 项薄弱建议。 1) 我们建议 Pao(2)/Fio(2) 低于 150 的患者在急性呼吸窘迫综合征病程早期持续静脉输注神经肌肉阻滞剂。 2) 我们建议不要对机械通气哮喘持续状态患者常规给予神经肌肉阻滞剂。 3) 我们建议在与严重低氧血症、呼吸性酸中毒或血流动力学损害相关的危及生命的情况下试用神经肌肉阻滞剂。 4）我们建议神经肌肉阻滞剂可用于控制治疗性低温中的明显颤抖。 5) 我们建议，四组监测的周围神经刺激可能是监测神经肌肉阻滞深度的有用工具，但前提是将其纳入对患者的更具包容性的评估（包括临床评估）中。 6) 我们建议不要单独使用四人一组的周围神经刺激来监测接受连续输注神经肌肉阻滞剂的患者的神经肌肉阻滞深度。 7) 我们建议接受持续输注神经肌肉阻滞剂的患者接受结构化的物理治疗方案。 8) 我们建议临床医生将接受神经肌肉阻滞剂的患者的血糖水平目标控制在 180 mg/dL 以下。 9）我们建议临床医生在计算肥胖患者的神经肌肉阻滞剂剂量时不要使用实际体重，而应使用一致的体重（理想体重或调整体重）。 10) 我们建议在生命末期或生命支持撤除时停用神经肌肉阻滞剂。在证据缺乏或不足且研究结果模棱两可或最佳临床实践各不相同的情况下，工作组没有对其中九个主题提出建议。 1) 对于急性脑损伤和颅内压升高的患者使用神经肌肉阻滞剂是有益还是有害，我们不提出建议。 2) 我们不建议对心脏骤停后接受低温治疗的患者常规使用神经肌肉阻滞剂。 3）我们不建议使用周围神经刺激来监测接受低温治疗的患者的阻滞程度。 4) 我们不建议使用神经肌肉阻滞来提高机械通气患者血管内容量评估的准确性。 5）我们不建议使用脑电图衍生参数作为连续给药神经肌肉阻滞剂期间镇静的衡量标准。 6) 我们对接受神经肌肉阻滞剂输注的患者的营养需求没有提出建议。 7) 在计算肥胖患者的神经肌肉阻滞剂剂量时，我们不建议使用一种一致体重测量方法而不是另一种测量方法。 8) 我们不建议妊娠患者使用神经肌肉阻滞剂。 9) 我们没有就接受神经肌肉阻滞剂的重症肌无力患者应监测哪个肌肉群提出建议。最后，在证据缺乏或不足但专家一致同意的情况下，工作组制定了六项良好实践声明。 1) 如果使用周围神经刺激，最佳临床实践建议应结合其他临床表现的评估（例如呼吸机的触发和颤抖的程度）来评估接受低温治疗的患者的神经肌肉阻滞程度。 2) 最佳临床实践表明，方案应包括对接受低温治疗的患者使用神经肌肉阻滞剂的指导。 3）最佳临床实践建议在神经肌肉阻滞之前和期间应使用镇痛和镇静药物，以达到深度镇静的目的。 4) 最佳临床实践建议临床医生在床边采取措施，降低接受神经肌肉阻滞剂的患者意外拔管的风险。 5) 最佳临床实践建议，重症肌无力患者应减少神经肌肉阻滞剂的剂量，并且剂量应基于四组监测的周围神经刺激。 6) 最佳临床实践建议在临床确定脑死亡之前停止使用神经肌肉阻滞剂。
Objective: To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient."Design: A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided.Methods: Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions.Results: The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a Pao(2)/Fio(2) less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents.Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.