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Pulmonary Critical Care

I NTENSIVECARENURSES’
KNOWLEDGE ABOUT USE OF
NEUROMUSCULAR BLOCKING
AGENTS IN PATIENTS WITH
RESPIRATORY FAILURE
By Erin N. Frazee, PharmD, Heather A. Personett, PharmD, Seth R. Bauer, PharmD,
Amy L. Dzierba, PharmD, Joanna L. Stollings, PharmD, Lindsay P. Ryder, PharmD,
Jennifer L. Elmer, DNP, APRN, CNS, Sean M. Caples, DO, and Craig E. Daniels, MD

Background The recent increase in use of neuromuscular


blocking agents (NMBAs) in patients with acute respira-
tory distress syndrome is set against a backdrop of con-
cerns about harm associated with use of these high-risk
drugs. Bedside nurses play a pivotal role in the safe and
effective use of these agents.
Objective To describe critical care nurses’ knowledge of
the therapeutic properties, adverse effects, and monitor-
ing parameters associated with NMBAs.
Methods A prospective, multicenter survey of medical

C E1.0 Hour intensive care unit nurses between July 2012 and May
2013.The web-based survey instrument was designed,
pretested, and administered under the direction of a mul-
Notice to CE enrollees: tidisciplinary group of individuals.
Results Responses from 160 nurses (22% of eligible
A closed-book, multiple-choice examination
nurses) were analyzed. Most respondents were able to
following this article tests your under standing of
identify NMBAs correctly as nonanalgesic (93%) and
the following objectives:
nonanxiolytic (83%). The perceived durations of action of
1. Identify 2 areas of needed education regarding theNMBAs varied widely, and few nurses were familiar with
use of neuromuscular blocking agents (NMBAs) inpatient-specific considerations related to drug elimina-
the intensive care environment. tion. Most (70%) recognized the independent associations
2. Discuss 2 common methods of titration of between NMBAs and footdrop, muscle breakdown, and
NMBAs. corneal ulceration. Pressure ulcers and a history of neu-
3. Describe 2 conditions that were associated withromuscular disease were the characteristics of patients
use of NMBAs perceived to most heighten the risk of NMBA use.
Conclusions Critical care nurses are knowledgeable
To read this article and take the CE test online, about the importance of concurrent analgesia and seda-
visit www.ajcconline.org and click “CE Articles in tion during use of NMBAs. Routes of elimination, dura-
This Issue.” No CE test fee for AACN members. tion of action, and adverse effects were less commonly
known and represent areas for focused education and
quality improvement surrounding use of NMBAs in the
P15 American Association of Critical-Care Nurses intensive care unit.American
( Journal of Critical Care.
doi: http://dx.doi.org/10.4037/ajcc2015397 2015;24:431-439)

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5431
A
knowledgeable critical care nurse is essential to the effective and safe use of neu-
romuscular blocking agents (NMBAs) in intensive care units (ICUs). The Institute
for Safe Medication Practices considers NMBAs to be high-alert medications
because of the robust historical documentation of harm associated with their
1,2
use.
Indeed, prolonged use of these agents contributes to an increased risk for
corneal ulcers, skin breakdown, venous thromboembolism, ventilator-associated pneumonia,
and musculoskeletal debility.3Furthermore, reports of patients recalling being paralyzed and
the independent association between NMBAs and posttraumatic stress disorder raise concerns
about the safety of routine use of these 3-7
agents.

Despite these previously documented risks, not completely assess all aspects of competency.
8-10
interest in the routine use of NMBAs among medi-They also predate recent efficacy publications in
cal ICU patients has been renewed in the past several support of using NMBAs for certain subgroups of
years. Specifically in patients with acute respiratory patients. Therefore, to promote the safe and effective
distress syndrome (ARDS), we now know that early use of NMBAs, we sought in this study to describe
continuous infusion of an NMBA improves oxygen-critical care nurses’ knowledge and beliefs about
8-10
ation, inflammation, and mortality. As epidemi- NMBAs in the modern medical ICU and identify
ological evidence shows, opportunities for targeted educational initiatives
Neuromuscular blocking this practice shift in sup- and to improve practice homogeneity in the future.
port of NMBA use could
agents are high-alert affect many critically ill
11-13
Methods
patients. To minimize In this multicenter, prospective, cross-sectional
medications because of risks for patients, critical study, ICU nurses at 5 sites (Mayo Clinic, Rochester,
their well-documented care nurses must have a Minnesota; Cleveland Clinic, Cleveland, Ohio;
keen understanding of the New York Presbyterian Hospital, New York, New
history of causing harm. importance of adequate York; Vanderbilt University Medical Center, Nash-
concurrent analgesia and ville, Tennessee; and The Ohio State University
sedation when an NMBA is used and an appreciation Wexner Medical Center, Columbus, Ohio) com-
for the factors that contribute to selection of patients, pleted a web-based survey between July 2012 and
choice of agent, dose titration, and adverse effects. May 2013. The study protocol was reviewed and
14-17
Studies on nurses’ knowledge about the approved by the institutional review board at each
use of NMBAs are more than a decade old and doparticipating site. The questionnaire responses are a
subset of a larger database of survey responses from
licensed providers in multiple disciplines, includ-
About the Authors ing nurses, physicians, nurse practitioners, physician
Erin N. Frazee and Heather A. Personett are pharmacists assistants, pharmacists, and respiratory therapists.
in Hospital Pharmacy Services, Mayo Clinic, Rochester, For their responses to be eligible for inclusion in
Minnesota. Seth R. Bauer is a medical intensive care
unit clinical specialist in the Department of Pharmacy, this study, more than 25% of the individual’s clini-
Cleveland Clinic, Cleveland, Ohio. Amy L. Dzierba is a cal practice must have been in an ICU consisting of
critical care pharmacist in the Department of Pharmacy, more than 50% medical patients at 1 of the 5 large,
New York Presbyterian Hospital, New York, New York. academic medical centers involved in the study.
Joanna L. Stollings is a critical care pharmacist in the
Department of Pharmaceutical Services, Vanderbilt Uni- The included academic medical centers each have
versity Medical Center, Nashville, Tennessee. Lindsay P. approximately 700 to 1400 adult hospital beds and
Ryder is a pharmacist in the Department of Pharmacy, 24 to 65 medical ICU beds. At the time of the study,
The Ohio State University Wexner Medical Center, Co- all included institutions had an electronic medi-
lumbus, Ohio. Jennifer L. Elmer is a critical care clinical
nurse specialist in the Department of Nursing at the cal record and used computerized provider order
Mayo Clinic. Sean M. Caples and Craig E. Daniels are entry (CPOE). Two centers had clinical protocols for
intensive care physicians in the Division of Pulmonary NMBA use that were helpful in selection of patients,
and Critical Care Medicine, Mayo Clinic.
dosing, and monitoring.
Corresponding author: Erin N. Frazee, PharmD, Mayo Clinic, A 16-question web-based survey was designed
200 First St SW, Rochester, MN 55905 (e-mail: frazee.erin expressly for this study in conjunction with the
@mayo.edu). Mayo Clinic Survey Research Support Center. Study

432 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5 www.ajcconline.org
data were collected and managed in REDCap physicians, nurses, and pharmacists from a nonin-
(Research Electronic Data Capture) survey soft- cluded surgical ICU at the primary site) reviewed
18
ware version 1.3.9. REDCap is a secure, web-basedand pretested the questionnaire. A structured cri-
application designed to support data capture for tique form was given
research studies, providing (1) an intuitive interface
The survey had 2 sections:
to each of these indi-
for validated data entry, (2) audit trails for track- viduals upon survey
ing data manipulation and export procedures, (3)completion, with spe- 1 on general knowledge
automated export procedures for seamless data cific probes designed
downloads to common statistical packages, and (4) to examine ques- and 1 on perceptions of
procedures for importing data from external sources.
The survey instrument (see Appendix, available
use of these agents in
tion clarity, response
options, missing or
online only, at www.ajcconline.org) was subdivided superfluous survey patients with acute respi-
into 2 distinct sections; the first pertained to general
items, and overall
knowledge about NMBAs and the second involvedlength. Two investi- ratory distress syndrome.
perceptions of the role of NMBAs in patients with gators reviewed the
ARDS. All participants were asked to complete both deidentified critiques to identify themes. Questions
sections of the survey. Development of the content and responses were modified to address areas of
domains included a thorough review of publishedambiguity. Concerns about length and redundancy
reports and input from a multidisciplinary group resulted in removal of several survey items.
of experts. Specific to the knowledge section pre- The study team involved investigators from
sented here, the survey instrument was focused on each of the included sites. These site representa-
NMBA pharmacology, pharmacokinetics (durationtives individually contacted the local medical direc-
of action, methods of elimination), adverse effects, tors, subspecialty managers (ie, nurse managers),
and titration. Questions referenced both types of and administrative staff at their center to acquire
NMBAs: aminosteroidal compounds (eg, vecuro- the e-mail addresses of eligible study participants.
nium and pancuronium) and benzylisoquinoliniumThe members of the investigative team had vari-
compounds (eg, cisatracurium and atracurium). ous degrees of preexisting professional relationships
Response options were closed-ended and usedwith the local ICU leaders. All known members of
statements of agreement and Likert scales where the pos-population were surveyed. Eligible individuals
sible. Items pertaining to analgesia and anxiolysiswere contacted via e-mail and invited to partici-
asked nurses to mark agree, disagree, or unsure/no pate in the survey. By following the survey link in
opinion for a series of statements about NMBA drug the electronic communication, providers indicated
properties. Unsure/no opinion and missing responses their consent to participate. Reminder communica-
were combined and classified as incorrect responses tion occurred electronically 2 weeks, 3 weeks, and
for these analyses to identify knowledge gaps. Phar- 4 weeks after the initial e-mail, and the study con-
macokinetic items asked nurses to describe medica- cluded on day 30.
tions’ duration of action in the absence of end-organ The only demographic identifiers collected per-
compromise. Response options included short, inter- tained to the provider’s self-reported role in the ICU
mediate, or long duration of action and unsure/no(eg, nurse, physician, pharmacist) and study site.
opinion. Correct responses identified atracurium and Herein we reported the data from all eligible respon-
vecuronium each as intermediate duration according dents who identified themselves as nurses, including
3
to current guidelines. Also, we probed respondents licensed practical nurses, registered nurses, clinical
about the risk of NMBA accumulation in patients nurse specialists, and nurse educators. Information
with clinically significant end-organ dysfunction. from nurse practitioners was not included, because
In this case, a correct response identified the alteredtheir additional education (formal and informal)
elimination of the aminosteroidals (vecuronium and and prescriptive authority may predispose them to
pancuronium) in patients with hepatic and renal dys- an altered familiarity with medication selection,
function, respectively, and the end-organ neutrality clinical protocols, and guideline recommendations.
3,19
of both benzylisoquinolinium NMBAs. Agents that Responses were otherwise anonymously gathered in
affect the central nervous system (CNS-active agents) the electronic database and described in aggregate.
but are not NMBAs (eg, fentanyl, hydromorphone, Descriptive statistics were used for all survey
lorazepam, propofol) were included in survey ques- responses, with results expressed as frequencies and
tions to provide a reference agent for descriptive com-
percentages. The Pearsonr 2 test or the Fisher exact
14
parisons to NMBAs. test was used to analyze independent binary out-
20
Similar to the method of Rhoney and Murry, comes. Assuming 60% concordance with the correct
after development, 20 ICU providers (including response, we calculated that at least 150 responders

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5433
Nurses from the medical intensive care
unit (ICU) for whom contact information
was available from the unit leaders Therapeutic Properties
(n = 717) The aminosteroidal and benzylisoquinolinium
NMBAs studied were correctly identified as nonanal-
gesic by 95% and 94% of survey respondents, respec-
Exclusions (n = 557) tively. In a combined analysis, 148 respondents
No response or did not self-report nursing (92%) were able to identify both agents correctly as
as their ICU provider role (n = 553) nonanalgesic (see Table). A similar number of partic-
No institutional affiliation noted (n = 2)
ipants correctly identified lorazepam as nonanalgesic
Multiple ICU provider roles reported (n = 2)
(n = 144, 90%). The absence of anxiolytic properties
among NMBAs was significantly less commonly iden-
tified by respondents (n = 132, 82%) than the absence
Included respondents
of analgesic properties
P=(.007). Unsure/no opin-
(n = 160, 22% overall)
ion was the most common answer among incorrect
responses regarding anxiolytic properties of NMBAs
Figure 1 Participant ”owchart. (pancuronium: 19 out of 25 incorrect responses;
atracurium: 13 out of 20 incorrect responses).
would be needed to provide a 95% confidence inter-
Pharmacokinetics
val of 52% to 68% for the population response. All Marked inconsistencies existed among respon-
analyses were performed with JMP version 9 statisti-
dents in the perceived duration of action of each
cal software (SAS Institute Inc). NMBA (Figure 2). Less than half of respondents
correctly identified the intermediate duration of
Results action of atracurium (46%) and vecuronium (40%),
Of the 717 eligible medical ICU nurses con- and the responses showed marked heterogeneity.
tacted for participation, 160 (22%) submitted par-In contrast, homogeneity was increased among
tial or complete responses suitable for analysis the responses to the reference analgesic and seda-
(Figure 1). All knowledge questions were answeredtive agents under study, hydromorphone (65% per-
by 155 respondents (97%). ceived it to be intermediate duration of action) and

Table
Correct identification of pharmacological properties
of neuromuscular blocking agents (NMBAs)

Survey item No. (%)

Analgesic
Correctly identified the following NMBA as nonanalgesic
Vecuronium 152 (95)
Cisatracurium 150 (94)
Both NMBAs correct 148 (92)
Anxiolytic
Correctly identified the following NMBAs as nonanxiolytic
Pancuronium 135 (84)
Atracurium 140 (88)
Both NMBAs correct 132 (82)
End-organ elimination
Correctly identified drug elimination properties of the following NMBAs
Aminosteroidals
Vecuronium (primarily hepatic) 66 (41)
Pancuronium (primarily renal) 68 (42)
Both aminosteroidal NMBAs correct 44 (28)
Benzylisoquinoliniums
Atracurium (end-organ neutral) 89 (56)
Cisatracurium (end-organ neutral) 103 (64)
Both benzylisoquinolinium NMBAs correct 65 (41)

434 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5 www.ajcconline.org
100
esponses

75 *
propofol (82% perceived it to possess a short dura-
centage
tion of action). Given the importance of ICU nurses of r *
in individualizing treatment plans and weaning 50
*
patients off of CNS-active agents, survey items were *
included to investigate the perceived risk of NMBA 25
Per
accumulation in patients with hepatic or renal dys-
function. Only 8 respondents (5%) correctly identi- 0
fied all 4 NMBA drugs’ elimination considerations.
The end-organ neutrality of benzylisoquinolinium
NMBAs was identified more commonly than were
the implications of renal or hepatic dysfunction
on elimination of aminosteroidal NMBAs (41% vs
28%, respectively;P= .01; see Table). Short Intermediate Long
Unsure/no opinion/missing
Adverse Effects
Four out of every 5 nurses recognized indepen-Figure 2 Perceived durations of action of 2 paralytic agents (atra-
dent associations between NMBAs and both foot- curium and vecuronium) and 2 reference agents (propofol and
drop and muscle breakdown. In only 34% of cases,hydromorphone). Fewer than half of respondents identified the
correct duration of action for each paralytic agent (denoted by
nursing staff recognized the independent association
an asterisk in the figure). In contrast to the consistent responses
between use of an NMBA and consciousness (Fig- noted with the reference agents, distinct variability existed in the
ure 3). We studied whether nurses attributed otherperceived durations of paralytic activity.
likely unrelated biochemical and clinical effects to
the use of NMBAs. Few nurses inaccurately reported
a relationship between NMBA use and hyperglyce-
mia (8%), infection (11%), or hypomagnesemia
Footdrop
(16%). Lactic acidosis and delirium were incorrectly
identified as independently related to NMBA use in Muscle breakdown
28% and 32% of responses, respectively.
Respondents were also asked to classify the Corneal ulceration
degree to which a series of baseline factors and
Venous thromboembolism
concurrent therapies modified the risk profile of
continuous infusion of an NMBA. As this pertains Consciousness
to providers’ perceptions and beliefs, no answers
for these items were considered incorrect. Respon- 0 25 50 75 100
dents could select from the following options: sub- Percentage of responses
stantial increase in risk, slight increase in risk, no
change in risk, or unsure. Among the factors underFigure 3 Percentage of respondents who endorsed an independent
study, respondents believed that pressure ulcers association between major adverse effects and use of neuromus-
and a history of a neuromuscular disorder most cular blocking agents.
increased the risks associated with NMBA therapy
(Figure 4). Although concomitant corticosteroids Discussion
were perceived to heighten the risk associated with Recent evidence suggesting the utility of NMBAs
continuous infusion of an NMBA by 77 respon- in patients with ARDS falls on a backdrop of the
dents (48%), the majority classified this increasepotential for serious adverse effects. The bedside
in risk as slight (58 “slight increase” out of 77 nurse is one of the key team members responsible
responses for increased risk). for ensuring the safe and effective use of NMBAs
in critically ill patients. It is for this reason that we
Titration sought to evaluate critical care nurses’ knowledge
When asked to select the best primary method about NMBAs. Paralytic agents were identified as
to guide titration of a continuous infusion of an nonanalgesic by 92% of nurses, but only 82% of
NMBA in patients with ARDS, 82 nurses (51%) pre- nurses recognized that NMBAs lack sedative prop-
ferred degree of ventilator synchrony or other oxy- erties. Nurses infrequently identified the correct
genation/ventilation parameters. Train-of-4 (TOF) method of NMBA elimination, particularly with
monitoring with peripheral nerve stimulation (PNS) aminosteroidal NMBAs. Approximately 20% to 40%
was selected less often (n = 65, 41%), although this of respondents were unfamiliar with major adverse
difference was not statistically significant
P= .06).
( effects of the drugs (muscle breakdown, corneal

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5435
Pressure ulcers

History of In addition to the therapeutic effects, reviews


neuromuscular disorder and continuing education modules on NMBAs also
highlight the importance of nursing competency in
Immunosuppression drug pharmacokinetics, selection of patients and
16,23-25
agents, adverse effects, and titration. Unfortu-
Coagulopathy nately, we are unaware of published studies mea-
suring such knowledge. In our study, ICU nurses
Concomitant commonly misidentified the correct mechanism of
corticosteroids
drug elimination, perceived durations of action of
NMBAs varied widely, and certain adverse effects
0 25 50 75 100
were underrecognized. The bedside nurse is the mul-
Percentage of responses
tidisciplinary team member most closely involved
Increased risk No change in risk Unsure/missing
with weaning ICU patients off of CNS-active agents
in. Failure to predict the offset of paralytic activity
correctly, particularly in the setting of end-organ
Figure 4 Degree to which baseline factors or concurrent therapies are
perceived to alter the risk profile of neuromuscular blocking agents. dysfunction, may place patients at increased risk
of exposure to insufficient analgesia and sedation
during the NMBA weaning process. Our findings
ulceration, and venous thromboembolism). With suggest that an opportunity also exists to heighten
respect to monitoring, nurses preferred to use ventila- the emphasis on screening for muscle breakdown,
tion/oxygenation parameters rather than TOF moni- corneal ulceration, and venous thromboembolism
toring to guide dose titration in patients with ARDS. in the nurses’ daily clinical assessments. Future qual-
Although the evidence is limited, researchers ity improvement and educational initiatives should
in previous studies have described nurses’ knowl-seek to address these knowledge gaps.
edge about NMBA pharmacology. In early work by Unlike previous studies in which nurses were
14
Loper and colleagues, 258 ICU nurses at a single surveyed about the NMBA titration practice at
center were surveyed to assess their knowledge about their sites, we instead inquired about NMBA titra-
NMBAs. Ninety percent of respondents were either tion preference, specifically in patients with ARDS
unsure or believed that pancuronium provided anxi- because of the recent favorable reports on use of
olysis. With respect to pain control, one-third of ICU NMBAs for this indication; the differences were
24
nurses reported a lack of familiarity or believed that revealing. Foster and colleagues did a survey of
14
pancuronium provided analgesia. A separate struc- 483 critical care nurse managers across the United
tured needs assessment pertaining to analgesia, seda- States, asking about NMBA use and titration with
tion, and paralysis in a surgical ICU revealed frequent a particular focus on PNS. Of the 185 centers that
insufficiency of sedation and analgesia during usereported NMBA use, 116 (63%) monitored NMBAs
of NMBAs. The authors identified this as a key clini- with PNS, and 111 of those also used the TOF tech-
cal issue that adversely affected patient care andnique. out- Eighty-three percent of respondents reported
16
comes. In contrast to previous work, nurses in thedose titration of NMBA to PNS response, which is in
present study more frequently recognized the absence line with guideline recommendations from 3,15 2002.
of analgesic properties among NMBAs, but 1 in 5 still Although the difference did not reach statistical sig-
failed to note the absence of anxiolysis. The explana- nificance, in the present evaluation, we found that
tion for this partial improvement is unknown, but more it nurses favored using titration to respiratory
may relate to increased awareness of pain, agitation, criteria (51%) rather than TOF (41%) for monitor-
and delirium in critically ill patients with the recent ing effects of NMBAs in patients with ARDS. Stud-
21
release of updated guidelines. Also, the abundant ies that have compared TOF-guided NMBA titration
educational resources and advanced credentials now to titration based on subjective clinical assessments
available to ICU nurses through national organizations in patients with mixed indications for paralysis
26
such as the American Association of Critical-Care have yielded disparate results. Rudis reported
et al
Nurses and the Society of Critical Care Medicine that lower doses of NMBAs were used and recov-
may have resulted in an increased understandingery of from paralytic agents was faster in patients ran-
the importance of concomitant analgesia/sedation domized to TOF-guided therapy, whereas 2 other
when NMBAs are used. The heightened emphasisstudies on 27,28 showed no difference between groups in
pain assessment and control by The Joint Commis- total paralysis time, recovery time, and amount of
sion may also explain the difference in familiaritydrug used. In a randomized controlled29trial of 102
22
with analgesia and anxiolysis. patients with ARDS who were given cisatracurium,

436 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5 www.ajcconline.org
researchers reported no difference in plateau pres- because ventilation and oxygenation should be con-
sure, ratio of Pa
O to fraction of inspired oxygen,
2 sidered in conjunction with PNS response.
PaCO 2, or pH between patients titrated to a TOF of
FINANCIAL DISCLOSURES
0/4 versus 2/4, but the authors did note a reductionThis study was partially funded by a research grant from
in total drug used and recovery time among patients Mayo Clinic Pharmacy Services Discretionary Fund,
titrated to a TOF of 2/4. On the basis of these data,
Rochester, Minnesota.
we suggest that providers pair TOF with clinical cri-
teria to develop individualized titration plans that eLetters
consider the indication for NMBA therapy. Indeed, Now that you’ve read the article, create or contribute to an
management of an ICU patient with severe respira- online discussion on this topic. Visit www.ajcconline.org
and click “Submit a response” in either the full-text or PDF
tory failure most likely requires a different approachview of the article.
to titration than management of a patient with ele-
vated intracranial pressure.
This study had several possible limitations. SEE ALSO
Although the focus of the study is ICU nurses, many For more about neuromuscular blocking agents, visit
other members of the multidisciplinary team share the Critical Care Nursewebsite, www.ccnonline.org ,
and read the article by Wilson et al, “Residual Neuro-
responsibility for ensuring safe use of NMBAs in muscular Blockade in Critical Care” (June 2012).
practice. Coverage error may have existed between
the target population of all medical ICU nurses and
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guidelines in a medical intensive care unit: physician and 26. Rudis MI, Sikora CA, Angus E, et al. A prospective, ran-
nurse adherence.Crit Care Med.2000;28(3):707-713. domized, controlled evaluation of peripheral nerve stim-
18. Harris PA, Taylor R, Thielke R, et al. Research electronic data ulation versus standard clinical dosing of neuromuscular
capture (REDCap)--a metadata-driven methodology and blocking agents in critically ill patients.
Crit Care Med.
workflow process for providing translational research infor- 1997;25(4):575-583.
matics support.J Biomed Inform. 2009;42(2):377-381. 27. Strange C, Vaughan L, Franklin C, Johnson J. Com-
19. Greenberg SB, Vender J. The use of neuromuscular block- parison of train-of-four and best clinical assessment
ing agents in the ICU: where are we now? Crit Care Med. during continuous paralysis.Am J Respir Crit Care Med.
2013;41(5):1332-1344. 1997;156(5):1556-1561.
20. Rhoney DH, Murry KR. National survey of the use of sedat- 28. Baumann MH, McAlpin BW, Brown K, et al. A prospective
ing drugs, neuromuscular blocking agents, and reversal randomized comparison of train-of-four monitoring and
agents in the intensive care unit. J Intensive Care Med. clinical assessment during continuous ICU cisatracurium
2003;18(3):139-145. paralysis.Chest.2004;126(4):1267-1273.
21. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guide- 29. Lagneau F, D’Honneur G, Plaud B, et al. A comparison of
lines for the management of pain, agitation, and delirium two depths of prolonged neuromuscular blockade induced
in adult patients in the intensive care unit.Crit Care Med. by cisatracurium in mechanically ventilated critically ill
2013;41(1):263-306. patients.Intensive Care Med.2002;28(12):1735-1741.
22. The Joint Commission. Standard PC.01.02.07: The Hospital
Assesses and Manages the Patient’s Pain. In: Comprehen-
sive Accreditation and Certification Manual. Oakbrook Ter-
race, IL: The joint Commission; 2014.
To purchase electronic or print reprints, contact American
23. Jarpe MB. Nursing care of patients receiving long-term Association of Critical-Care Nurses, 101 Columbia, Aliso
infusion of neuromuscular blocking agents. Crit Care Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050
Nurse. 1992;12(7):58-63. (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

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438 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2015, Volume 24, No. 5 www.ajcconline.org
CE
Test Test
ID A1524052: Intensive Care Nurses’ Knowledge About Use of Neuromuscular Blocking Agents in Patients with Respiratory
Failureobjectives: 1. Identify 2 areas of needed education regarding the use of neuromuscular blocking agents (NMBAs) in the
Learning
2. Discuss
intensive 2 common methods of titration of NMBAs. 3. Describe 2 conditions that were associated with use of NMBAs.
care environment.

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Fee: AACN members, $0; nonmembers, $10 Passing score: 8 correct (73%) Category: CERP A Test writer: Laura Dechant, APN, MSN,
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1. Complications related to prolonged use of neuromuscular
. A new
7 nurse block-
asks how you know when to titrate up the NMBA.
ing agents (NMBAs) include which of the following? You explain that the NMBA is increased when the patient:
a. Musculoskeletal debility, community–acquired pneumonia
a. Experiences ventilator asynchrony
b. Posttraumatic stress disorder, malnutrition, skin breakdown
b. Train-of-4 demonstrates 0 out of 4
c. Corneal abrasions, ventilator-associated pneumonia, c. malnutrition
Follows commands
d. Corneal abrasions, skin breakdown, venous thromboembolism
d. Requires pressure support ventilation

2. The investigators’ questionnaire demonstrated which


8. Which
of theof the following was the total number of responses
following types of reliability? included in the study?
a. Content c. Parallel-Forms a. 717 c. 557
b. External d. Internal b. 160 d. 553

3. Which of the following NMBAs were studied? . A patient


9 is exhibiting signs of renal and liver failure. Which of
a. Atracurium and rocuronium the following is the most appropriate NMBA to use?
b. Cisatracurium and rocuronium a. Cisatracurium
c. Atracurium and vecuronium b. Propofol
d. Tubocurarine and vecuronium c. Vecuronium
d. Pancuronium
4. Exclusion criteria included which of the following?
a. Nonresponse, no identification of intensive care . After
unit
10NMBAs
providerarerole
stopped and a patient is extubated, the nurse
or multiple role identified, no institutional affiliation
needs to reported
monitor for which of the following residual complications
b. Employment in an academic medical center of NMBAs?
c. Completion of only 1 section of the survey a. Hyperglycemia
d. Institution with an electronic medical record b. Infection
c. Posttraumatic stress disorder
5. Which of the following is the preferred method among d. Hypomagnesium
respon-
dents of NMBA titration for acute respiratory distress syndrome?
a. Use of medication half-life 11. Which of the following concurrent conditions did nurses
b. Use of train-of-4 testing identify as increasing the risk profile for NMBAs?
c. Use of respiratory criteria a. Lactic acidosis and hyperglycemia
d. Use of peripheral nerve stimulator b. History of neuromuscular disorder and presence of pressure ulcers
c. Delirium and posttraumatic stress disorder
6. Which of the following were identified as limitations d. of Stress
this study?
ulcer and venous thromboembolism formation
a. Not enough patients receiving NMBAs within trial
b. Too many small institutions (<150 hospital beds) included
c. Not enough large medical centers included
d. High nonresponse rate by providers, lack of collection of baseline
variable such as years of experience