Neuromuscular Blocking Agents and Reversal Agents Usage, and Neuromuscular Blockade Monitoring in the Intensive Care Unit – Review Article

Maciej Szewczyk,1 Aleksandra Bieniecka,2 Kamil Sobolewski,3,4 Łukasz Banasiak,5 Łukasz Grabarczyk6 1Department of Internal Medicine, Rheumatology, Diabetology, Geriatrics and Clinical Immunology with the Department of Gastroenterology, University Clinical Hospital No. 1 in Szczecin, Szczecin, Poland; 2Student Scientific Anesthesiology Society at the Clinic of Anesthesiology and Intensive Therapy, Faculty of Medicine, Collegium Medicum University of Warmia and Mazury, Olsztyn, Poland; 3Department of Microbiology, Faculty of Biological Sciences, University in Wrocław, Wrocław, Poland; 4Independent Public Healthcare Center, Municipal Health Clinic in Barczewo, Barczewo, Poland; 5Department of Plastic Surgery, Voivodeship Specialist Hospital in Olsztyn, Olsztyn, Poland; 6Alarm Clock Clinic, Coma Recovery and Neurorehabilitation Center, Warsaw, PolandCorrespondence: Maciej Szewczyk, Email [email protected]: Neuromuscular blocking agents (NMBAs) are widely used in anesthesiology. However, their use in Intensive Care Units (ICUs) has yet to be fully standardized. Due to numerous conflicting reports or insufficient scientific evidence, there are significant controversies surrounding the use of these drugs, particularly in patients requiring ventilatory support for ARDS, those with increased intracranial pressure, or patients undergoing therapeutic hypothermia (especially after cardiac arrest resuscitation). ICU patients are typically critically ill, often in sepsis, with multiple comorbidities, multi-organ failure, homeostasis disturbances, and requiring multiple medications. These conditions can significantly affect the potency and action of skeletal muscle relaxants. In recent years, the importance of monitoring neuromuscular blockade has been emphasized. Clinical examination, although widely used, has limited applicability in ICU settings. Peripheral nerve stimulation (PNS) and train-of-four (TOF) monitoring are qualitative methods, whereas quantitative techniques, which provide objective measurements, are increasingly recommended for managing neuromuscular blockade. Most guidelines currently focus on perioperative monitoring, and there is a lack of detailed recommendations for using these methods in the ICU. This article discusses existing research on the use of skeletal muscle relaxants, neuromuscular blockade reversal agents, and monitoring methods for neuromuscular blockade in intensive care units.Keywords: intensive care units, neuromuscular blocking agents, neuromuscular monitoring, investigative techniques, peripheral nervous system agents