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Neuromuscular Blockade in ARDS

Neuromuscular Blockade in ARDS: Moderate-Severe ARDS on Mechanical Ventilation → Optimize Ventilation & Sedation First → Ventilator Dyssynchrony Despite...

Pathway Overview

14 steps

Algorithm Steps

14 total

  1. 01Start

    Moderate-Severe ARDS on Mechanical Ventilation

    P/F ≤150 despite lung protective ventilation

  2. 02Action

    Optimize Ventilation & Sedation First

    NMBA is NOT first-line

    • Lung protective ventilation (Vt 4-8 mL/kg PBW)
    • Adequate sedation (RASS -4 to -5 if NMBA planned)
    • Optimize PEEP per protocol
    • Address reversible causes
  3. 03Decision

    Ventilator Dyssynchrony Despite Deep Sedation?

    Patient-ventilator asynchrony causing harm

    • High plateau pressures
    • Flow dyssynchrony
    • Double triggering
    • Breath stacking
  4. 04Action

    Continue Without NMBA

    NMBA not routinely recommended

    • Continue lung protective ventilation
    • Optimize sedation
    • Consider prone positioning
    • Daily reassessment
  5. 05Decision

    Consider NMBA in Select Patients

    ATS 2024: Conditional recommendation

    • Severe ARDS (P/F <100)
    • Dyssynchrony despite optimal sedation
    • High driving pressures
    • Early ARDS (<48h)
  6. 06Warning

    ⚠️ CRITICAL: Ensure Deep Sedation FIRST

    Awareness during paralysis is catastrophic

    • Target RASS -4 to -5
    • BIS monitoring if available (target 40-60)
    • Adequate analgesia
    • NEVER paralyze without deep sedation
  7. 07Decision

    NMBA Strategy

    Intermittent bolus vs continuous infusion

  8. 08Action

    Intermittent Bolus (Preferred if Light Sedation)

    May be safer if light sedation maintained

    • Cisatracurium 0.1-0.2 mg/kg PRN
    • Or rocuronium 0.6-1 mg/kg PRN
    • For brief periods of dyssynchrony
    • Lower risk of prolonged weakness
  9. 09Action

    Monitoring on NMBA

    Essential safety checks

    • Train-of-four q4h (target 1-2/4)
    • BIS if available (40-60)
    • Eye protection (artificial tears)
    • DVT prophylaxis
    • Daily sedation/paralysis vacation trial
  10. 10Decision

    Daily Assessment: Still Needed?

    Goal: shortest duration possible

  11. 11Action

    Discontinue NMBA

    When dyssynchrony resolved or ARDS improving

    • Stop infusion, allow to wear off
    • Ensure TOF 4/4 before lightening sedation
    • Monitor for residual weakness
    • Begin early mobilization protocol
  12. 12Outcome

    NMBA Discontinued

    Continue ARDS management without paralysis

  13. 13Action

    Continue NMBA

    Ongoing indication present

    • Document clear indication daily
    • Minimize dose to achieve synchrony
    • Plan for discontinuation
  14. Path rejoins step 09Shared downstream outcome
  15. 14Action

    Continuous Infusion

    For persistent severe dyssynchrony

    • Cisatracurium: 1-3 mcg/kg/min
    • Monitor TOF (train-of-four): target 1-2/4
    • Daily interruption to assess need
    • Limit duration <48h if possible
  16. Path rejoins step 09Shared downstream outcome
  17. Path rejoins step 04Shared downstream outcome

Guideline Source

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline

DOI: 10.1164/rccm.202311-2011STView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Evidence is conflicting (ACURASYS vs ROSE trials)
  • Requires deep sedation - must optimize sedation first
  • Risk of ICU-acquired weakness with prolonged use
  • Train-of-four monitoring recommended
  • Does not address NMBA for intubation

Contraindicated Populations

pediatric

Applicable Regions

USEUGlobal

Global: Based on ATS 2024 guidelines

Version 1Next review: 2028-01-01

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Frequently Asked Questions

What is the Neuromuscular Blockade in ARDS?

The Neuromuscular Blockade in ARDS is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline.

What guideline is the Neuromuscular Blockade in ARDS based on?

This algorithm is based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline (DOI: 10.1164/rccm.202311-2011ST).

What are the limitations of the Neuromuscular Blockade in ARDS?

Known limitations include: Evidence is conflicting (ACURASYS vs ROSE trials); Requires deep sedation - must optimize sedation first; Risk of ICU-acquired weakness with prolonged use; Train-of-four monitoring recommended; Does not address NMBA for intubation. Individual patient factors may require deviation from these recommendations.

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