In this episode, I’ll discuss an article about TOF monitoring vs clinical assessment only in ARDS patients on NMBAs.
The SCCM Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patients give a weak recommendation that peripheral nerve stimulators 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.
Researchers recently published in Anesthesia and Analgesia a Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation.
The intervention compared clinical assessments every 2 hours with or without TOF monitoring every 4 hours in patients who developed ARDS.
38 patients were in the clinical assessment + TOF group and 39 patients were in the clinical assessment only group.
The authors found that the cumulative atracurium dose was higher in the clinical assessment + TOF group by 50%. The mean atracurium daily dose was 0.256 mg/kg/hr higher in the clinical assessment + TOF group.
Measures of mechanical ventilation effectiveness, days on ventilation and mortality were not significantly different between groups.
The authors concluded:
In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.
This small randomized trial supports the emphasis on clinical assessment when monitoring NMBA activity.
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