Patient and Care Delivery Characteristics Associated With Harm From Neuromuscular Blockade

OBJECTIVES: To identify the prevalence of and evaluate factors associated with down-titration of sedation in patients receiving neuromuscular blockade. DESIGN: Retrospective cohort study. SETTING: Tertiary care teaching hospital in Boston, MA. PATIENTS: All patients over 18 years old admitted to the medical, surgical, or cardiac ICUs from 2013 to 2016, and who received cisatracurium for at least 24 hours. INTERVENTIONS: We examined patients for whom sedation was decreased despite accompanying ongoing neuromuscular blockade administration. MEASUREMENTS AND MAIN RESULTS: Of the 300 patients who met inclusion criteria (39% female, mean age of 57 yr old), 168 (56%) had sedation down-titrated while receiving neuromuscular blockade with a mean decrease in sedation dose of 18.7%. Factors associated with down-titration of sedation were bispectral index usage (90/168 [53.6%] vs 50/168 [29.8%] patients; p < 0.01; odds ratio, 1.82; 1.12–2.94), and bolus dose of neuromuscular blockade prior to continuous infusion (138/168 [82.1%] vs 79/168 [47.0%] patients; p < 0.0001). CONCLUSIONS: Down-titration of sedation among mechanically ventilated patients receiving neuromuscular blockade was common and was correlated with bispectral index monitor usage. Clinicians should be aware of the limitations of quantitative electroencephalography monitoring devices and recognize their potential to cause inappropriate down-titration of sedation. Substantial opportunity exists to improve the quality of care of patients receiving neuromuscular blockade through development of guidelines and standardized care pathways.