When to initiate paralytics in a ventilated patient?

Although it is a big deal to start paralytics in a patient, the decision is a relatively simple one. If your patient gets RSI (rapid sequence intubation) then they will have already gotten a dose of a paralytic anyway! The table below highlights the major indications for using a paralytic in the ICU:

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The decision to start a paralytic (neuromuscular blockade agent) is yes if the patient is intubated and flailing about, overbreathing the vent, in tetany, or has increased intracranial pressure.

There is also some evidence that paralytics may be helpful in ARDS (due to decreased chest wall muscle use), and decrease lung inflammation.

The most important thing to remember is that the patient MUST be adequately sedated!! Here is a good overview of analgesia and sedation from Open Anesthesia. Being awake on a paralytic, aware of what’s going on but not being able to move your body, probably counts as a form of torture. Make sure that they are on something like propofol or midazolam. My favorite combination is fentanyl (analgesic) and propofol (sedation).

One thing to remember is that there are depolarizing agents–namely, succinylcholine–and non-depolarizing agents, such as rocuronium. Life in the Fast Lane makes a good case for why non-depolarizing agents are usually better.


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