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Table 2 Studies of NMBAs related to prolonged weakness, CIP, and CIM

From: A fresh look at paralytics in the critically ill: real promise and real concern

NMBA Author Subjects Study design Motor Sensory EMG Muscle biopsy Prolonged weakness, CIP, and CIM
Benzylisoquinolinium
Cisatracurium
Human studies
  Fodale et al. [36] 1 Case report Y N Y N NMBA and CS for 7 days in patient with chest wall trauma led to quadriplegia consistent with CIM.
  Davis et al. [35] 1 Case report Y N N N NMBA and CS for 6 days with 6 additional days of NMBA in 45-year-old with ARDS led to CIM.
Atracurium
Human studies
  Tousignant et. al. [38] 1 Case report Y N Y N 18-year-old asthmatic with 7 days of NMBA and CS develops acute quadriparesis 3 days after cessation of NMBA consistent with CIM.
  Meyer et al. [37] 2 Case report Y N Y N 38-year-old receiving CS and 8 days of NMBA developed CIM. 25-year-old with good pastures receiving CS and NMBA for 6 days develop CIM.
Aminosteriods
Pancuronium
Human studies
  Behbehani et al. [26] 86 Retrospective Cohort Y N Y N Asthmatics receiving NMBA and CS. Pancuronium, vecuronium used in 30 with 9 developing CIM. All nine received pancuronium.
  de Lemos et al. [39] 30 Prospective Observational Cohort Y N Y N Study of recovery time in continuous infusion versus bolus groups. Six patients with CIM, five of which received continuous infusion. No statistical difference in total dose between groups.
  Giostra et al. [30] 9 Prospective Cohort Y Y Y Y Over 2 years, nine patients with respiratory failure requiring mechanical ventilation and NMBA developed CIP. Eight of nine received concomitant NMBA and CS.
Rocuronium
Animal Studies
  Maes et al. [40] Rat / 27 Prospective Randomize N/A N/A Y Y 1 dose of CS added to 24 hours of NMBA results in decreased CIM of diaphragm than NMBA alone.
  Testelmans et al. [33] Rat / 24 Prospective Randomize N/A N/A Y Y 24 hours of rocuronium associated with worse CIM than cisatracurium.
  Testelmans et al. [32] Rat / 34 Prospective Randomize N/A N/A Y Y 24 hours of NMBA associated with increased CIM than mechanical ventilation alone.
Vecuronium
Human Studies
  Garnacho- Montero et al. [25] 73 Prospective Cohort Y Y Y N In septic cohort with more than 2 organ failure, 9 of 10 patients who got NMBA developed CIP. 6 received vecuronium and 3 received atracurium
  Rudis et al. [34] 77 Prospective Randomized Single-Blind Y N Y N Use of peripheral nerve stimulator resulted in half dose of NMBA given. 16 patients with prolonged blockade and 4 with CIP. More prolonged blockade and CIP in group with more NMBA.
  Prielipp et al. [41] 58 Prospective Randomized Double-Blind Y Y Y Y Prolonged recovery in 13 patients with vecuronuim versus 2 with cisatracurium (p=0.002). CIP in 1 vecuronuim patient.
  Douglass et al. [27] 25 Prospective Cohort Y N N N 22 patients received NMBA and CS. 9 developed CIM. CIM associated with time ventilated and dose of NMBA received.
  Kupfer et al. [31] 28 Prospective Cohort Y 1/5 Y N 50% of patient without sepsis or multi-organ failure with more than 6 hours of NMBA infusion developed weakness. 1 CIPM, 4 CIM. CIPM and CIM ssociate with increase dose.
  Danon et al. [42] 1 Case report Y N N Y 20 year old asthmatic who received CS and NMBA for 10 days developed CIM.
  1. Y, yes; N, no; N/O, not obtained; CS, corticosteroid; CIP, critical illness polyneuropathy; CIM, critical illness myopathy; CIPM, critical illness polyneuromyopathy; NMBA, neuromuscular blocking agent; ARDS, acute respiratory distress syndrome [2527, 3038, 4448].