Monitoring the administration of neuromuscular blockade in critical care.

The future direction of neuromuscular blockade (NMB) in critical care will be characterized by prudent utilization and quality monitoring. With the potential for persistent paralysis and less than optimal outcomes, this direction makes sense. Prudent utilization can be further defined as exhausting other therapies prior to NMB utilization. When NMB is necessary, the agents should be titrated consistently according to a protocol, using the minimally effective dose to produce the least amount of NMB in order to facilitate patient management. Quality monitoring requires that peripheral nerve stimulator (PNS) monitoring become the standard for monitoring the administration of NMB agents and also that monitoring be accurate. Inherent to prudent utilization and quality monitoring is an adequate knowledge related to all aspects of NMB. The purpose of this article is to provide the necessary knowledge base for practitioners to understand normal and altered neuromuscular junction function, perform accurate PNS monitoring, and titrate NMB therapy according to the individual and desired response.