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November 27, 1991, Vol 266, No. 20 >
ARTICLE | November 27, 1991

Use of Sedating Drugs and Neuromuscular Blocking Agents in Patients Requiring Mechanical Ventilation for Respiratory Failure: Title and subTitle BreakA National Survey FREE

John H. Hansen-Flaschen, MD; Shari Brazinsky, MD; Carol Basile, RN; Paul N. Lanken, MD
[+] Author Affiliations

Reprint requests to Department of Medicine, Pulmonary and Critical Care Department, Hospital of the University of Pennsylvania, 874 Maloney Bldg, 3600 Spruce St, Philadelphia, PA 19104 (Dr Hansen-Flaschen).


JAMA. 1991;266(20):2870-2875. doi:10.1001/jama.1991.03470200082040
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References

Objective.  —To assess current use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation at US hospitals that participate in the training of pulmonary fellows.

Design.  —Surveys were mailed in September 1990 to the head nurses of medical intensive care units at 265 US hospitals that were listed in an annual guide listing pulmonary fellowship training programs. In the survey, sedating drugs were defined as medications prescribed to treat anxiety, agitation, or sleeplessness. These included opiates, anesthetics, or neuroleptic agents when used for any of these purposes.

Survey Respondents.  —Surveys were received from nurses at 164 hospitals (62% response rate) representing 93 medical schools and 100 pulmonary fellowship training programs. Nearly half of the respondents worked at university hospitals. Most worked as head nurses in medical (70%) or medical-surgical (21%) intensive care units (ICUs).

Results.  —Sedating drugs were given to patients undergoing mechanical ventilation at virtually all the ICUs surveyed, and 36% used these drugs routinely (>70% of patients). Opiates and benzodiazepines were employed most commonly; haloperidol lactate was widely used as well. Intermittent intravenous injection was the preferred method of administration; 62% of the ICUs also gave these drugs by continuous intravenous infusion. Neuromuscular blocking agents were also used at nearly all the ICUs surveyed; however, most gave these drugs to fewer than 20% of patients experiencing respiratory failure. Orders for the use of sedating drugs and neuromuscular blocking agents were written exclusively by house staff at 65% of the ICUs surveyed.

Conclusions.  —Sedating drugs and neuromuscular blocking agents are widely used for patients requiring mechanical ventilation in ICUs at US teaching hospitals. There is considerable variation in the choice, frequency, and method of administration. Given the expense (up to $1000 a day) and the potential hazards to patients of prolonged deep sedation and paralysis, more research is warranted to determine optimal use of these drugs during mechanical ventilation.(JAMA. 1991;266:2870-2875)

REFERENCES

1 +
Harris CE, Grounds RM, Murray AM, Lumley J, Rosston D, Morgan M.  Propofol for long-term sedation in the intensive care unit. Anaesthesia . 1985;;45:366-372.
2 +
Crippen DW.  The role of sedation in the ICU patient with pain and agitation. Crit Care Clin . 1990;;6:369-392.
3 +
Figge H, Huang V, Kaul AF, Demling RH.  The pharmacotherapy of the behavioral manifestations of the ICU syndrome. J Crit Care . 1987;;2:199-205.
4 +
Hansen-Flaschen JH.  The agitated patient in respiratory failure.  In: Fishman AP, ed. Pulmonary Diseases and Disorders: Update . New York, NY: McGraw-Hill International Book Co; 1991;:383-400.
5 +
Gramsted L, Lilleaasen P.  Neuromuscular blocking effects of atracurium, vecuronium, and pancuronium during bolus and infusion administration. Br J Anaesth . 1985;;57:1052-1059.
6 +
Wadon AJ, Dogra S, Anand S.  Atracurium infusion in the intensive care unit. Br J Anaesth . 1986;;58( (suppl 1) ):64S-67S.
7 +
Farina ML, Levati A, Tognoni G.  A multicenter study of drug utilization. Intensive Care Med . 1981;;7:125-131.
8 +
Bion JF, Ledingham IM.  Sedation in intensive care: a postal survey. Intensive Care Med . 1987;;13:215-216.
9 +
Merriman HM.  The techniques used to sedate ventilated patients: a survey of methods used in 34 ICUs in Great Britain. Intensive Care Med . 1981;;7:217-224.
10 +
Miller-Jones CMH, Williams JH.  Sedation for ventilation: a retrospective study of 50 patients. Anaesthesia . 1980;;35:1104-1107.
11 +
American Thoracic Society.  Training programs in adult respiratory disease. Am Rev Respir Dis . 1990;;142:955-982.
12 +
American Hospital Association Guide to the Health Care Field . Chicago, Ill: American Hospital Association; 1989;.
13 +
Rogers RM, Petty TL, Hudson LD, Briggs DD.  Critical care medicine certification and pulmonary disease trainees. Am Rev Respir Dis . 1990;;142:495-496.
14 +
Kendall MJ, Clarke SW.  Prolonged coma after tetanus. BMJ . 1972;;2:354-355.
15 +
Martyn J.  Clinical pharmacology and drug therapy in the burned patient. Anesthesiology . 1986;;65:67-75.
16 +
Stevens DS, Edwards WT.  Management of pain in the critically ill. J Intensive Care Med . 1990;;5:258-291.
17 +
Veselis RA.  Intravenous narcotics in the ICU. Crit Care Clin . 1990;;6:295-313.
18 +
Menza MA, Murray GB, Holmes VF, Rafuls WA.  Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines. Heart Lung . 1988;;17:238-241.
19 +
Aitkenhead AR, Pepperman ML, Willatts SM, et al.  Comparison of propofol and midazolam for sedation in critically ill patients. Lancet . 1989;;2:704-709.
20 +
Parker CJ, Jones JE, Hunter JM.  Disposition of infusions of atracurium and its metabolite, laudanosine, in patients with renal and respiratory failure in an ITU. Br J Anaesth . 1988;;61:531-540.
21 +
Segredo V, Matthay MA, Sharma ML, Gruenke LD, Caldwell JE, Miller RD.  Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients. Anesthesiology . 1990;;72:566-570.
22 +
Slater RM, Pollard BJ, Doran BR.  Prolonged neuromuscular blockade with vecuronium in renal failure. Anaesthesia . 1988;;43:250-251.
23 +
Griffiths RB.  Atracurium infusions in patients with renal failure on an ITU. Anaesthesia . 1986;;41:375-381.
24 +
Fishman AP, ed. Pulmonary Diseases and Disorders . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988;.
25 +
Shoemaker WC, Ayres S, Grenvik A, Holbrook PR, Thompson WL, eds. Textbook of Critical Care . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1989;.
26 +
Bevan DR, Bevan JC, Donati F. Muscle Relaxants in Clinical Anesthesia . Chicago, Ill: Year Book Medical Publishers Inc; 1988;.
27 +
Viby-Mogensen J.  Clinical assessment of neuromuscular transmission. Br J Anaesth . 1982;; 54:209-223.
28 +
Nagashima H, Nguyen HD, Conforti M, Duncalf D, Goldiner PL, Foldes FF.  A simple method for monitoring muscular relaxation during continuous infusion of vecuronium. Can J Anaesth . 1988;;35:134-138.
29 +
Beemer GH.  Continuous infusions of muscle relaxants: why and how. Anaesth Intensive Care . 1987;;15:83-89.
30 +
American Board of Internal Medicine. 1991 ABIM Examination in Critical Care Medicine . Portland, Ore: American Board of Internal Medicine; Spring-Summer, 1991;. Newsletter.
31 +
Oldenhof H, de Jong M, Steenhoek A, Janknegt R.  Clinical pharmacokinetics of midazolam in intensive care patients: a wide interpatient variability? Clin Pharmacol Ther . 1989;;43:263-269.
32 +
Peat SJ, Potter DR, Hunter JM.  The prolonged use of atracurium in a patient with tetanus. Anaesthesia . 1988;;43:962-963.
33 +
Parker MM, Schubert W, Shelhamer JH, Parillo JE.  Perceptions of a critically ill patient experiencing therapeutic paralysis in an ICU. Crit Care Med . 1984;;12:69-71.
34 +
Durbin CG.  Neuromuscular blocking agents and sedating drugs: clinical uses and toxic effects in the critical care unit. Crit Care Clin . 1991;;7:489-506.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Harris CE, Grounds RM, Murray AM, Lumley J, Rosston D, Morgan M.  Propofol for long-term sedation in the intensive care unit. Anaesthesia . 1985;;45:366-372.
2 +
Crippen DW.  The role of sedation in the ICU patient with pain and agitation. Crit Care Clin . 1990;;6:369-392.
3 +
Figge H, Huang V, Kaul AF, Demling RH.  The pharmacotherapy of the behavioral manifestations of the ICU syndrome. J Crit Care . 1987;;2:199-205.
4 +
Hansen-Flaschen JH.  The agitated patient in respiratory failure.  In: Fishman AP, ed. Pulmonary Diseases and Disorders: Update . New York, NY: McGraw-Hill International Book Co; 1991;:383-400.
5 +
Gramsted L, Lilleaasen P.  Neuromuscular blocking effects of atracurium, vecuronium, and pancuronium during bolus and infusion administration. Br J Anaesth . 1985;;57:1052-1059.
6 +
Wadon AJ, Dogra S, Anand S.  Atracurium infusion in the intensive care unit. Br J Anaesth . 1986;;58( (suppl 1) ):64S-67S.
7 +
Farina ML, Levati A, Tognoni G.  A multicenter study of drug utilization. Intensive Care Med . 1981;;7:125-131.
8 +
Bion JF, Ledingham IM.  Sedation in intensive care: a postal survey. Intensive Care Med . 1987;;13:215-216.
9 +
Merriman HM.  The techniques used to sedate ventilated patients: a survey of methods used in 34 ICUs in Great Britain. Intensive Care Med . 1981;;7:217-224.
10 +
Miller-Jones CMH, Williams JH.  Sedation for ventilation: a retrospective study of 50 patients. Anaesthesia . 1980;;35:1104-1107.
11 +
American Thoracic Society.  Training programs in adult respiratory disease. Am Rev Respir Dis . 1990;;142:955-982.
12 +
American Hospital Association Guide to the Health Care Field . Chicago, Ill: American Hospital Association; 1989;.
13 +
Rogers RM, Petty TL, Hudson LD, Briggs DD.  Critical care medicine certification and pulmonary disease trainees. Am Rev Respir Dis . 1990;;142:495-496.
14 +
Kendall MJ, Clarke SW.  Prolonged coma after tetanus. BMJ . 1972;;2:354-355.
15 +
Martyn J.  Clinical pharmacology and drug therapy in the burned patient. Anesthesiology . 1986;;65:67-75.
16 +
Stevens DS, Edwards WT.  Management of pain in the critically ill. J Intensive Care Med . 1990;;5:258-291.
17 +
Veselis RA.  Intravenous narcotics in the ICU. Crit Care Clin . 1990;;6:295-313.
18 +
Menza MA, Murray GB, Holmes VF, Rafuls WA.  Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines. Heart Lung . 1988;;17:238-241.
19 +
Aitkenhead AR, Pepperman ML, Willatts SM, et al.  Comparison of propofol and midazolam for sedation in critically ill patients. Lancet . 1989;;2:704-709.
20 +
Parker CJ, Jones JE, Hunter JM.  Disposition of infusions of atracurium and its metabolite, laudanosine, in patients with renal and respiratory failure in an ITU. Br J Anaesth . 1988;;61:531-540.
21 +
Segredo V, Matthay MA, Sharma ML, Gruenke LD, Caldwell JE, Miller RD.  Prolonged neuromuscular blockade after long-term administration of vecuronium in two critically ill patients. Anesthesiology . 1990;;72:566-570.
22 +
Slater RM, Pollard BJ, Doran BR.  Prolonged neuromuscular blockade with vecuronium in renal failure. Anaesthesia . 1988;;43:250-251.
23 +
Griffiths RB.  Atracurium infusions in patients with renal failure on an ITU. Anaesthesia . 1986;;41:375-381.
24 +
Fishman AP, ed. Pulmonary Diseases and Disorders . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1988;.
25 +
Shoemaker WC, Ayres S, Grenvik A, Holbrook PR, Thompson WL, eds. Textbook of Critical Care . 2nd ed. Philadelphia, Pa: WB Saunders Co; 1989;.
26 +
Bevan DR, Bevan JC, Donati F. Muscle Relaxants in Clinical Anesthesia . Chicago, Ill: Year Book Medical Publishers Inc; 1988;.
27 +
Viby-Mogensen J.  Clinical assessment of neuromuscular transmission. Br J Anaesth . 1982;; 54:209-223.
28 +
Nagashima H, Nguyen HD, Conforti M, Duncalf D, Goldiner PL, Foldes FF.  A simple method for monitoring muscular relaxation during continuous infusion of vecuronium. Can J Anaesth . 1988;;35:134-138.
29 +
Beemer GH.  Continuous infusions of muscle relaxants: why and how. Anaesth Intensive Care . 1987;;15:83-89.
30 +
American Board of Internal Medicine. 1991 ABIM Examination in Critical Care Medicine . Portland, Ore: American Board of Internal Medicine; Spring-Summer, 1991;. Newsletter.
31 +
Oldenhof H, de Jong M, Steenhoek A, Janknegt R.  Clinical pharmacokinetics of midazolam in intensive care patients: a wide interpatient variability? Clin Pharmacol Ther . 1989;;43:263-269.
32 +
Peat SJ, Potter DR, Hunter JM.  The prolonged use of atracurium in a patient with tetanus. Anaesthesia . 1988;;43:962-963.
33 +
Parker MM, Schubert W, Shelhamer JH, Parillo JE.  Perceptions of a critically ill patient experiencing therapeutic paralysis in an ICU. Crit Care Med . 1984;;12:69-71.
34 +
Durbin CG.  Neuromuscular blocking agents and sedating drugs: clinical uses and toxic effects in the critical care unit. Crit Care Clin . 1991;;7:489-506.

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