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Neuromuscular Blocking Agent Continuous Infusion - Adult - Inpatient/Emergency Department [51]

Neuromuscular Blocking Agent Continuous Infusion - Adult - Inpatient/Emergency Department [51] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Page 1 of 4
Delegation Protocol Number: 51

Delegation Protocol Title:
Neuromuscular Blocking Agent Continuous Infusion - Adult - Inpatient/Emergency Department

Delegation Protocol Applies To:
UW Health adult intensive care (ICU) inpatients and emergency department (ED) patients

Target Population:
Any adult intensive care inpatients and emergency department patients requiring a titratable neuromuscular
blocking agent infusion as identified in Table 1.

Delegation Protocol Champions:
Douglas Coursin, MD – Depatrment of Anesthesia
Jonathan T. Ketzler, MD – Department of Anesthesia
Josh Medow, MD – Department of Surgery – Neurological Surgery

Delegation Protocol Workgroup:
Anna Krupp, MSN, RN, CNS – Trauma Life Support
Jeff Fish, PharmD – Pharmacy
Margaret Murray RN, CNS – Cardiothoracic Surgery
Stephanie Kraus RN, CNS - Cardiology

Responsible Department:
Pharmacy Department

Purpose Statement:
To delegate authority from the ordering provider to Registered Nurses (RNs) in the intensive care units and
emergency department to titrate neuromuscular blocking agents infusions in critically ill adults and to provide
a framework for the ordering, initiation, and titration of these agents.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) in an adult ICU or ED trained in the use of this protocol.

Guidelines for Implementation:
1. A provider enters an order for a neuromuscular blocking agent (NMBA) infusion as described in Table 1.
The order must include directions for titration per Adult Neuromuscular Blocking Agent Continuous
Infusion Protocol.
2. The order must include a targeted clinical response for titration with the highest possible train of four
(TOF) as identified by peripheral nerve stimulation testing per the UWHC Departmental Policy 8.36AP-
Peripheral Nerve Stimulation (Adult and Pediatric). Examples of clinical targets include ventilator
synchrony, patient immobility, ICPs, and inhibition of shivering (for hypothermic protocols)
3. If the patient’s status necessitates initial infusion rates above the criteria for the Second Notification
Value listed in Table 1, the protocol cannot be initiated.
4. The current rate of infusion for medications listed in Table 1 will be assessed and documented on the
IV/IV MAR no less frequently than every 2 hours and at the time of each dosage rate titration.
5. The rate and frequency of dose titration will depend upon the patient’s individual requirements and
clinical status but will not occur more frequently than indicated in Table 1.
6. If the agent used reaches the “First Notification Value” as indicated in Table 1, then a prescribing
provider (such as a physician, advanced practice nurse prescriber, or physician assistant) must be
notified for consideration of alternate agent(s), or continuation of the infusion to the “Second Notification
Value.”
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Page 2 of 4
7. If the agent used reaches the “Second Notification Value” indicated in Table 1, the infusion rate cannot
be further increased per protocol. Upon reaching the “Second Notification Value,” a provider must be
contacted for consideration of alternate agent(s), and must provide an order before further titration of the
current agent can occur. As long as the patient is receiving infusion rates above the “Second Notification
Value,” each subsequent rate increase will also require a provider order.
8. The RN will document notification of the appropriate provider when the patient is treated with “First
Notification Value” and “Second Notification Value” doses by adding a progress note to the electronic
medical record.
9. Infusion of NMBAs may be discontinued with or without a taper. Providers enter nursing communication
orders to discontinue or wean NMBAs. If the order is to discontinue, the infusion will be turned off
without a taper. If the order is to wean, the NMBAs are to be weaned off as indicated in the titration
column of Table 1.
10. After discontinuation of neuromuscular blocking agent infusion, train of four monitoring will continue
every 2 hours until the patient demonstrates 4 out of 4 twitches. A confirmatory train of four will then be
performed 15 to 30 minutes later. If the patient has 4 out of 4 twitches upon this second check,
monitoring may be discontinued. If the patient is not found to have 4 out of 4 switches, every 2 hour
monitoring shall continue until the patient demonstrates an initial and confirmatory 4 out of 4 twitches.



Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Page 3 of 4
Table 1. Neuromuscular Blocking Agent Dose Titration

Drug
Typical
Dose Range
Typical Starting Dose
Titration Dose to
Achieve Objective
Goal
Rate of
Titratio
n
First
Notification
Value
(Provider must
be notified
when dose
reached)

Second Notification
Value
(Provider must be
notified when dose
reached, order needed
to exceed dose)
Atracurium
4-15
mcg/kg/min
Initial
Bolus
Dose:
0.4-0.5
mg/kg
Infusion Dose:
4 mcg/kg/min
1 mcg/kg
15
minutes
12 mcg/kg/min 15 mcg/kg/min
Cisatracurium
0.3-10
mcg/kg/min
Initial
Bolus
Dose:
0.15-0.2
mg/kg
Infusion Dose:
0.3
mcg/kg/min
When
Infusion
Rate 0.3-
1.8
mcg/kg/mi
n: titrate
by 0.25
mcg/kg
When
Infusion
Rate >
1.8
mcg/kg/
min:
titrate by
1 mcg/kg
15
minutes
8 mcg/kg/min 10 mcg/kg/min
Rocuronium
3-12.5
mcg/kg/min
Initial
Bolus
Dose:
100-1200
mcg/kg
Infusion Dose:
5 mcg/kg/min
1 mcg/kg
15
minutes
12 mcg/kg/min 17 mcg/kg/min
Vecuronium
0.4-3
mcg/kg/min
Initial
Bolus
Dose:
0.04-0.1
mg/kg
4

Infusion Dose:
1 mcg/kg/min
0.3 mcg/kg
15
minutes
2.6
mcg/kg/min
3 mcg/kg/min

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Page 4 of 4
References:

1. Baumann MH, McAlpin BW, Brown K, et al. A prospective randomized comparison of train-of-four
monitoring and clinical assessment during continuous ICU cisatracurium paralysis. Chest.
2004;126(4):1267-1273.
2. Bowman WC. Neuromuscular block. Br J Pharmacol. 2006;147:S277-S286.
3. Hall JB, Schweickert W, Kress JP. Role of analgesics, sedatives, neuromuscular blockers, and
delirium. Crit Care Med. 2009:37(10):S416-S421.
4. Jacobi J, Gilles F, Coursin D, et al. Clinical practice guidelines for the sustained use of sedatives and
analgesics in the critically ill adult. Crit Care Med. 2002;30(1):119-141.
5. Murray MJ, Cowen J, DeBlock H, et al. Clinical practice guidelines for sustained neuromuscular
blockade in the adult critically ill patient. Crit Care Med. 2002;30(1):142-156.
6. Robinson BRH, Mueller EW, Henson K, Branson R, Barsoum S, Tsuei BJ. An analgesia-delirium-
sedation protocol for critically ill trauma patients reduces ventilator days and hospital length of stay. J
Trauma. 2008;65:517-526.

Collateral Documents/Tools:
UWHC Departmental Policy 8.36AP- Peripheral Nerve Stimulation (Adult and Pediatric)Continuous Infusion
Neuromuscular Blocking Agents (NMBAs) – Adult – Inpatient – Clinical Practice Guideline

Approved By:
UWHC Critical Care Committee: May 2011, August 2014 (expedited process)
UWHC Pharmacy Practice Committee: April 2011, August 2014 (expedited process)
UWHC Pharmacy & Therapeutics Committee: June 2011, August 2014
UWHC Medical Board: July 2011, August 2014

Effective Date: August 2014

Scheduled for Review: August 2016

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org