Moderate-severe ARDS on invasive ventilation (adults)
PaO2/FiO2 below 150 mmHg on PEEP 5 cmH2O or more. Adults only.
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Critical CareManagement
Neuromuscular Blockade in ARDS
Neuromuscular Blockade in ARDS: Moderate-severe ARDS on invasive ventilation (adults) → Optimise ventilation and sedation first → NMBA indicated? → Deep...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Optimise ventilation and sedation first
NMBA is not first-line. Give lung-protective care to every patient.
- Tidal volume 4-8 mL/kg predicted body weight; plateau pressure below 30 cmH2O
- Higher PEEP without prolonged recruitment manoeuvres
- Prone position for more than 12 h a day if PaO2/FiO2 below 150 mmHg; prone position alone is not an NMBA indication
- Adjust ventilator settings and sedation for dyssynchrony
- Treat the cause of ARDS
03Decision NMBA indicated?
Yes if PaO2/FiO2 stays below 150 mmHg with persistent hypoxaemia, or ventilation targets are not met despite sedation and ventilator changes (SCCM 2026). Best evidence: PaO2/FiO2 100 mmHg or less, within 48 h of onset (ATS 2024).
- If Yes
04Warning Deep sedation and analgesia before any NMBA
NMBAs do not sedate. Awareness during paralysis is a serious harm.
- Target RASS -4 to -5 before the first dose
- Keep deep sedation and analgesia for as long as the NMBA acts
- Never give an NMBA to a lightly sedated patient
05Warning Adults only. Check allergy, myasthenia, kidney or liver failure
Children: use a paediatric protocol. With corticosteroids, ICU-acquired weakness is more likely: keep the NMBA course short (48 h or less).
- NMBA allergy: no cisatracurium; seek anaesthetic or allergy advice before any NMBA (cross-sensitivity above 50%)
- Myasthenia gravis: first cisatracurium dose 0.02 mg/kg or less, guided by TOF
- Kidney or liver failure: use cisatracurium; rocuronium and vecuronium can accumulate
06Decision Persistent hypoxaemia or dyssynchrony?
Yes: continuous infusion, as in the trials (48 h). No, only short episodes of dyssynchrony: intermittent boluses. ESICM 2023 recommends against routine continuous infusion to reduce mortality.
- If Yes
07Action Persistent hypoxaemia or dyssynchrony: continuous infusion
Stop by 48 h whenever possible. Keep deep sedation throughout.
- Fixed dose: cisatracurium 15 mg IV, then 37.5 mg/h (adult)
- Or titrated: cisatracurium 3 micrograms/kg/min; range 0.5-10.2 micrograms/kg/min (adult)
- Titrated dose: use TOF with clinical assessment, not TOF alone
- Obesity: dose on ideal or adjusted body weight
08Action Monitoring on NMBA
Never lighten or stop sedation while the NMBA is active.
- Scheduled eye care: lubricant and eyelid closure
- Check sedation and analgesia often
- Prevent unplanned extubation; pressure care
- VTE prophylaxis; structured physiotherapy
- Blood glucose below 10 mmol/L
- Aminoglycosides, magnesium and severe acid-base or electrolyte disorders can change the depth of block
09Decision Daily review: NMBA still needed?
Stop when dyssynchrony and oxygenation improve (in ROSE: FiO2 0.4 or less and PEEP 8 cmH2O or less for 12 h). Aim for 48 h or less. Stop the NMBA before any withdrawal of life support.
- If Yes
10Action Still needed: continue the NMBA
Document the indication every day. Aim to stop by 48 h; longer use is not studied.
- Lowest dose that keeps synchrony
- Continue all monitoring
- Path rejoins step 08Shared downstream outcome
If No11Action Not needed: stop the NMBA first
Keep full sedation and analgesia until the block has worn off.
- Stop boluses or infusion; keep sedation and analgesia
- Confirm recovery (TOF 4 of 4 and breathing effort) before lightening sedation
- Then lighten sedation to the usual target
- Screen for ICU-acquired weakness; early mobilisation
12Outcome Continue ARDS care without NMBA
Lung-protective ventilation, PEEP and prone position as indicated. Lightest effective sedation. Reassess daily.
If No13Action Episodic dyssynchrony: intermittent bolus
Deep sedation (RASS -4 to -5) must be in place before each dose and for its full duration.
- Cisatracurium IV bolus (adult): dose per local ICU protocol or Nimbex product information
- Repeat only if dyssynchrony returns; check sedation first
- Rocuronium only if cisatracurium unavailable; not for NMBA allergy; avoid in kidney or liver failure (accumulates). Dose per product information
- Path rejoins step 08Shared downstream outcome
If No14Action No NMBA indication: continue ARDS care
Routine NMBA use is not recommended.
- Continue lung-protective ventilation and prone position if indicated
- Lightest sedation that controls dyssynchrony
- Reassess NMBA criteria daily if hypoxaemia persists
- Path rejoins step 12Shared downstream outcome
Guideline Source
Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome (2026)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Never give an NMBA without deep sedation and analgesia.
- Guidelines differ: SCCM 2026 and ATS 2024 suggest NMBA in selected severe ARDS; ESICM 2023 recommends against routine continuous infusion to reduce mortality.
- Low-certainty evidence: the ROSE trial (light-sedation control group) found no mortality benefit.
- Risk of ICU-acquired weakness, higher with corticosteroids.
- Does not cover NMBA for intubation, status asthmaticus, raised intracranial pressure or targeted temperature management.
Contraindicated Populations
pediatricchildren under 18 years
Applicable Regions
USEUAUGlobal
AU: Cisatracurium (Nimbex and generics) is on the ARTG. Glucose target in mmol/L.
Global: Based on SCCM 2026 (NMBA in adult ARDS), ATS 2024 ARDS update, ESICM 2023 ARDS guideline and Surviving Sepsis Campaign 2021.
Version 2Next review: 2027-09-30
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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 Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome (2026).
What guideline is the Neuromuscular Blockade in ARDS based on?
This algorithm is based on Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome (2026) (DOI: 10.1097/CCM.0000000000007002).
What are the limitations of the Neuromuscular Blockade in ARDS?
Known limitations include: Adults only. Never give an NMBA without deep sedation and analgesia.; Guidelines differ: SCCM 2026 and ATS 2024 suggest NMBA in selected severe ARDS; ESICM 2023 recommends against routine continuous infusion to reduce mortality.; Low-certainty evidence: the ROSE trial (light-sedation control group) found no mortality benefit.; Risk of ICU-acquired weakness, higher with corticosteroids.; Does not cover NMBA for intubation, status asthmaticus, raised intracranial pressure or targeted temperature management.. Individual patient factors may require deviation from these recommendations.
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