pancuronium and Multiple-Organ-Failure

Critically ill patients represent a very different population from that of the operating theatre, but much of our knowledge of many of the neuromuscular blocking drugs is derived from intraoperative use. The diversity of clinical-practice and case-mix differences in intensive care are probably responsible for the absence of a formal consensus about the use of neuromuscular blocking drugs in the intensive care unit (ICU). Various surveys suggest that these drugs are used comparatively infrequently, but we do not know whether current usage is either safe or appropriate. In addition to the adverse effects which inevitably accompany prolonged paralysis and immobility, the steroidal relaxants, pancuronium and vecuronium, have also been associated with myopathy. This seems to be aggravated by concurrent use of pharmacologic doses of corticosteroids or the aminoglycoside antibiotics. Neither the mechanism nor the validity of the association with steroidal relaxants is known at present. Muscle dysfunction is a common feature of critical illness, and it is possible that neuromuscular blocking drugs interfere with muscle repair and regrowth. Patients with multiple organ failure present a particular challenge both because of the extent of tissue injury and because drug clearance via the liver or kidneys is generally impaired.

Topics: Adrenal Cortex Hormones; Aminoglycosides; Anti-Bacterial Agents; Critical Care; Critical Illness; Diagnosis-Related Groups; Drug Interactions; Humans; Immobilization; Kidney; Liver; Multiple Organ Failure; Muscle, Skeletal; Muscular Diseases; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Pancuronium; Regeneration; Safety; Vecuronium Bromide

A female patient treated by mechanical ventilation with high doses of pancuronium and methylprednisolone for status asthmaticus presented with acute total areflexic and severe amyotrophic tetraplegia; she died after multiple organ failure. Muscle biopsy confirmed the clinical diagnosis of "acute corticosteroid myopathy", precipitated by a corticosteroid "disuse hypersensitivity" after pancuronium. The electromyogram showed a critical illness polyneuropathy, secondary to multiple organ failure. Nerve biopsy was normal. The respective parts played by corticosteroids, curare-like derivatives and intensive care in the genesis of unexplained difficulty in weaning from the ventilator are discussed.

Topics: Acute Disease; Aged; Fatal Outcome; Female; Humans; Methylprednisolone; Multiple Organ Failure; Muscular Diseases; Nervous System Diseases; Neural Conduction; Pancuronium; Respiration, Artificial; Resuscitation; Status Asthmaticus