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Practice Guideline
. 2026 Mar 1;54(3):634-643.
doi: 10.1097/CCM.0000000000007002. Epub 2026 Mar 3.

Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome

Brian L Erstad  1 , Miguel A Cobas  2 , Nida Qadir  3 , Fayez Alshamsi  4 , Sameer Sharif  5 , Elizabeth M Devine  6 , Scott T Devine  7 , Sharon Einav  8 , Jennifer Elmer  9 , Alexander C Fort  2 , Christopher G Harrod  10 , Mojdeh S Heavner  11 , Keith D Lamb  12 , Sangeeta Mehta  13 , Dannette A Mitchell  14 , Fathima Paruk  15 , Thomas Piraino  5 , Gretchen Sacha  16 , Hildy M Schell-Chaple  17 , Sharmili Sinha  18 , Susan E Smith  19 , Arzu Topeli  20 , Aarti Sarwal  21
Affiliations
Practice Guideline

Society of Critical Care Medicine Guidelines for the Administration of Neuromuscular Blockade in Adults With Acute Respiratory Distress Syndrome

Brian L Erstad et al. Crit Care Med. .

Abstract

Rationale: Neuromuscular blocking agents (NMBAs) show potential benefits on mortality and other complications of acute respiratory distress syndrome (ARDS) in adult patients. Evidence-based decisions and processes ensure appropriate use of neuromuscular blockade in adult patients with ARDS.

Objectives: The objective of these guidelines was to develop evidence-based recommendations for the administration of NMBAs in critically ill adult patients with ARDS.

Design: The American College of Critical Care Medicine Board convened a 21-member multidisciplinary panel of experts in critical care medicine, nursing, respiratory therapy, pharmacology, surgery, neurology, and anesthesiology. The panel included two expert methodologists specialized in developing evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guidelines development including task force selection and voting.

Methods: The panel members identified and formulated five Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and assessed the certainty of the evidence using the GRADE methodology. We used the GRADE evidence-to-decision framework to formulate the recommendations.

Results: The panel generated two conditional recommendations. One recommendation is to use NMBAs in adults with ARDS with Pao2/Fio2 less than 150. For the other recommendations, there was equipoise in the recommendation for and against using titratable vs. fixed-dose NMBA dosing, a monitoring-based strategy for assessing depth of sedation and analgesia in adults with ARDS before initiating or while receiving neuromuscular blockade, and administration of NMBAs for patients who are proned, due to overall lack of evidence in critically ill patients and due to considerations of patient safety and experience concerns.

Conclusions: These guidelines provide additional perspectives on the use of NMBA in patients with ARDS, recognizing that institutional and patient-specific considerations must help to guide the decision-making process.

Keywords: acute respiratory distress syndrome; critical care; critical illness; intensive care unit; neuromuscular blocking agents; practice guidelines.

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Conflict of interest statement

Ms. Mitchell was a consultant for Baxter International. Dr. Sarwal received device support for her research projects from Butterfly Network and Image Monitoring; she is a consultant for Shinkei and Stimdia Medical. Dr. Fort is a consultant for Posos and is a principal investigator for a phase III clinical trial Inhaled Sedation versus Propofol in Respiratory Failure in the ICU (INSPiRE-ICU2) funded by Sedana Medical AB. Dr. Schell-Chapels is an advisor for Fresenius Medical Center North America. Dr. Paruk was a speaker for Acino, Baxter International, Pfizer, Thermo Fisher Scientific, and an advisor for Novo Nordisk. Dr. Einav is an advisor for Medint. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

    1. Shapiro BA, Warren J, Egol AB, et al.: Practice parameters for sustained neuromuscular blockade in the adult critically ill patient: An executive summary. Society of Critical Care Medicine. Crit Care Med 1995; 23:1601–1605
    1. Murray MJ, Cowen J, DeBlock H, et al.; Task Force of the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM), American Society of Health-System Pharmacists, American College of Chest Physicians: Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2002; 30:142–156
    1. Murray MJ, DeBlock H, Erstad B, et al.: Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med 2016; 44:2079–2103
    1. Rodriguez-Blanco J, Rodriguez-Yanez T, Rodriguez-Blanco JD, et al.: Neuromuscular blocking agents in the intensive care unit. J Int Med Res 2022; 50:3000605221128148
    1. Covidence: Covidence Systematic Review Software. 2014. Available at: www.covidence.org . Accessed August 15, 2024

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