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Semin Respir Crit Care Med 2016; 37(01): 051-056
DOI: 10.1055/s-0035-1570355
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

What Is the Evidence for Harm of Neuromuscular Blockade and Corticosteroid Use in the Intensive Care Unit?

Djillali Annane
1   Department of Critical Care, Service de Reanimation-Hôpital Raymond Poincare (AP-HP), Health Science Center Simone Veil, University of Versailles SQY, Garches, Paris, France
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Publication History

Publication Date:
28 January 2016 (online)

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Abstract

Neuromuscular blocking agents and corticosteroids are widely used in medicine and in particular in the intensive care unit (ICU). Neuromuscular blockade is commonly used to ease tracheal intubation, to optimize mechanical ventilation and oxygenation in acute respiratory disorders such as status asthmaticus and acute respiratory distress syndrome (ARDS), to prevent shivering during therapeutic hypothermia, and also in patients with elevated intracranial pressure. In the ICU, patients with sepsis, ARDS, community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, severe asthma, or trauma may receive corticosteroids. It is not rare that ICU patients receive concomitantly neuromuscular blocking drugs and corticosteroids. Among the various serious adverse reactions to these drugs, secondary infection and ICU-acquired weakness may place a burden to the health-care system by resulting in substantial cost and long-term morbidity. Both superinfections and ICU-acquired paresis are more likely when high doses of fluorinated corticosteroids are combined with prolonged treatment with a long-acting non-depolarizing neuromuscular blocker. Modern ICU practices favor lower dose of corticosteroids and very short course of short-acting curare for the management of sepsis or ARDS. Recent trials provided no evidence for increased risk of secondary infections or critical illness neuromyopathy in patients with sepsis or ARDS with the use of corticosteroids or neuromuscular blockers.

Keywords

neuromuscular blockade - critical illness neuromyopathy - corticosteroids - ICU
 

  • References

  • 1 Taylor P. Agents acting at the neuromuscular junction and autonomic ganglia. In: Brunton LL, Lazo JS, Parker KL, , eds. Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th ed. New York: McGraw-Hill Companies; 2006: 217-236
    Google Scholar
  • 2 Ramamoorthy S, Cidlowski JA. Exploring the molecular mechanisms of glucocorticoid receptor action from sensitivity to resistance. Endocr Dev 2013; 24: 41-56
    PubMedGoogle Scholar
  • 3 Feldman SA, Fauvel N. Onset of neuromuscular block. In: Pollard BJ, , ed. Applied Neuromuscular Pharmacology. Oxford: Oxford University Press; 1994: 69-84
    Google Scholar
  • 4 Bevan DR. Newer neuromuscular blocking agents. Pharmacol Toxicol 1994; 74 (1) 3-9
    CrossrefPubMedGoogle Scholar
  • 5 Mosier JM, Sakles JC, Stolz U , et al. Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis. Ann Am Thorac Soc 2015; 12 (5) 734-741
    PubMedGoogle Scholar
  • 6 Phipps P, Garrard CS. The pulmonary physician in critical care. 12: Acute severe asthma in the intensive care unit. Thorax 2003; 58 (1) 81-88
    CrossrefPubMedGoogle Scholar
  • 7 Freebairn RC, Derrick J, Gomersall CD, Young RJ, Joynt GM. Oxygen delivery, oxygen consumption, and gastric intramucosal pH are not improved by a computer-controlled, closed-loop, vecuronium infusion in severe sepsis and septic shock. Crit Care Med 1997; 25 (1) 72-77
    CrossrefPubMedGoogle Scholar
  • 8 Papazian L, Forel JM, Gacouin A , et al; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363 (12) 1107-1116
    CrossrefPubMedGoogle Scholar
  • 9 Alhazzani W, Alshahrani M, Jaeschke R , et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care 2013; 17 (2) R43
    CrossrefPubMedGoogle Scholar
  • 10 Abroug F, Ouanes I, Abroug S , et al. Systemic corticosteroids in acute exacerbation of COPD: a meta-analysis of controlled studies with emphasis on ICU patients. Ann Intensive Care 2014; 4: 32
    CrossrefPubMedGoogle Scholar
  • 11 Alía I, de la Cal MA, Esteban A , et al. Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support. Arch Intern Med 2011; 171 (21) 1939-1946
    CrossrefPubMedGoogle Scholar
  • 12 Walters JA, Tan DJ, White CJ, Gibson PG, Wood-Baker R, Walters EH. Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2014; 9: CD001288
    PubMedGoogle Scholar
  • 13 Shafiq M, Mansoor MS, Khan AA, Sohail MR, Murad MH. Adjuvant steroid therapy in community-acquired pneumonia: a systematic review and meta-analysis. J Hosp Med 2013; 8 (2) 68-75
    CrossrefPubMedGoogle Scholar
  • 14 Annane D. Corticosteroids and pneumonia: time to change practice. Lancet 2015; 385 (9977) 1484-1485
    CrossrefPubMedGoogle Scholar
  • 15 Funk D, Doucette S, Pisipati A, Dodek P, Marshall JC, Kumar A. Cooperative Antimicrobial Therapy of Septic Shock Database Research Group. Low-dose corticosteroid treatment in septic shock: a propensity-matching study. Crit Care Med 2014; 42 (11) 2333-2341
    CrossrefPubMedGoogle Scholar
  • 16 Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for treating sepsis. Cochrane Database Syst Rev 2004; (1) CD002243
    PubMedGoogle Scholar
  • 17 Ruan SY, Lin HH, Huang CT, Kuo PH, Wu HD, Yu CJ. Exploring the heterogeneity of effects of corticosteroids on acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care 2014; 18 (2) R63
    CrossrefPubMedGoogle Scholar
  • 18 Marik PE, Meduri GU, Rocco PR, Annane D. Glucocorticoid treatment in acute lung injury and acute respiratory distress syndrome. Crit Care Clin 2011; 27 (3) 589-607
    CrossrefPubMedGoogle Scholar
  • 19 Edwards P, Arango M, Balica L , et al; CRASH trial collaborators. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet 2005; 365 (9475) 1957-1959
    CrossrefPubMedGoogle Scholar
  • 20 Roquilly A, Mahe PJ, Seguin P , et al. Hydrocortisone therapy for patients with multiple trauma: the randomized controlled HYPOLYTE study. JAMA 2011; 305 (12) 1201-1209
    CrossrefPubMedGoogle Scholar
  • 21 Asehnoune K, Seguin P, Allary J , et al; Corti-TC Study Group. Hydrocortisone and fludrocortisone for prevention of hospital-acquired pneumonia in patients with severe traumatic brain injury (Corti-TC): a double-blind, multicentre phase 3, randomised placebo-controlled trial. Lancet Respir Med 2014; 2 (9) 706-716
    CrossrefPubMedGoogle Scholar
  • 22 Dellinger RP, Levy MM, Rhodes A , et al; Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39 (2) 165-228
    CrossrefPubMedGoogle Scholar
  • 23 de Lange DW, Meulenbelt J. Do corticosteroids have a role in preventing or reducing acute toxic lung injury caused by inhalation of chemical agents?. Clin Toxicol (Phila) 2011; 49 (2) 61-71
    CrossrefPubMedGoogle Scholar
  • 24 Venet F, Plassais J, Textoris J , et al. Low-dose hydrocortisone reduces norepinephrine duration in severe burn patients: a randomized clinical trial. Crit Care 2015; 19: 21
    CrossrefPubMedGoogle Scholar
  • 25 Mauger B, Marbella A, Pines E, Chopra R, Black ER, Aronson N. Implementing quality improvement strategies to reduce healthcare-associated infections: a systematic review. Am J Infect Control 2014; 42 (10, Suppl): S274-S283
    CrossrefPubMedGoogle Scholar
  • 26 Hamele M, Stockmann C, Cirulis M , et al. Ventilator-associated pneumonia in pediatric traumatic brain injury. J Neurotrauma 2015; . doi:10.1089/neu.2015.4004
    PubMedGoogle Scholar
  • 27 Al-Dorzi HM, El-Saed A, Rishu AH, Balkhy HH, Memish ZA, Arabi YM. The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia. Am J Infect Control 2012; 40 (9) 794-799
    CrossrefPubMedGoogle Scholar
  • 28 Lascarrou JB, Le Gouge A, Dimet J , et al. Neuromuscular blockade during therapeutic hypothermia after cardiac arrest: observational study of neurological and infectious outcomes. Resuscitation 2014; 85 (9) 1257-1262
    CrossrefPubMedGoogle Scholar
  • 29 Keh D, Boehnke T, Weber-Cartens S , et al. Immunologic and hemodynamic effects of “low-dose” hydrocortisone in septic shock: a double-blind, randomized, placebo-controlled, crossover study. Am J Respir Crit Care Med 2003; 167 (4) 512-520
    CrossrefPubMedGoogle Scholar
  • 30 Lamontagne F, Briel M, Guyatt GH, Cook DJ, Bhatnagar N, Meade M. Corticosteroid therapy for acute lung injury, acute respiratory distress syndrome, and severe pneumonia: a meta-analysis of randomized controlled trials. J Crit Care 2010; 25 (3) 420-435
    CrossrefPubMedGoogle Scholar
  • 31 Sprung CL, Annane D, Keh D , et al; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med 2008; 358 (2) 111-124
    CrossrefPubMedGoogle Scholar
  • 32 De Jonghe B, Sharshar T, Lefaucheur JP , et al; Groupe de Réflexion et d'Etude des Neuromyopathies en Réanimation. Paresis acquired in the intensive care unit: a prospective multicenter study. JAMA 2002; 288 (22) 2859-2867
    CrossrefPubMedGoogle Scholar
  • 33 De Jonghe B, Bastuji-Garin S, Durand MC , et al; Groupe de Réflexion et d'Etude des Neuromyopathies en Réanimation. Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med 2007; 35 (9) 2007-2015
    CrossrefPubMedGoogle Scholar
  • 34 Sharshar T, Bastuji-Garin S, Stevens RD , et al; Groupe de Réflexion et d'Etude des Neuromyopathies En Réanimation. Presence and severity of intensive care unit-acquired paresis at time of awakening are associated with increased intensive care unit and hospital mortality. Crit Care Med 2009; 37 (12) 3047-3053
    CrossrefPubMedGoogle Scholar
  • 35 MacFarlane IA, Rosenthal FD. Severe myopathy after status asthmaticus. Lancet 1977; 2 (8038) 615
    PubMedGoogle Scholar
  • 36 Watling SM, Dasta JF. Prolonged paralysis in intensive care unit patients after the use of neuromuscular blocking agents: a review of the literature. Crit Care Med 1994; 22 (5) 884-893
    CrossrefPubMedGoogle Scholar
  • 37 Lacomis D, Giuliani MJ, Van Cott A, Kramer DJ. Acute myopathy of intensive care: clinical, electromyographic, and pathological aspects. Ann Neurol 1996; 40 (4) 645-654
    CrossrefPubMedGoogle Scholar
  • 38 Schakman O, Kalista S, Barbé C, Loumaye A, Thissen JP. Glucocorticoid-induced skeletal muscle atrophy. Int J Biochem Cell Biol 2013; 45 (10) 2163-2172
    CrossrefPubMedGoogle Scholar
  • 39 Puthucheary Z, Rawal J, Ratnayake G, Harridge S, Montgomery H, Hart N. Neuromuscular blockade and skeletal muscle weakness in critically ill patients: time to rethink the evidence?. Am J Respir Crit Care Med 2012; 185 (9) 911-917
    CrossrefPubMedGoogle Scholar
  • 40 Thapa S, Brull SJ. Succinylcholine-induced hyperkalemia in patients with renal failure: an old question revisited. Anesth Analg 2000; 91 (1) 237-241
    PubMedGoogle Scholar
  • 41 Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant hyperthermia. Orphanet J Rare Dis 2007; 2: 21
    CrossrefPubMedGoogle Scholar
  • 42 Warrington TP, Bostwick JM. Psychiatric adverse effects of corticosteroids. Mayo Clin Proc 2006; 81 (10) 1361-1367
    CrossrefPubMedGoogle Scholar