2016年11月号的《Critical Care Medicine》刊登了Murray MJ等作者的
《临床指南：成人重症患者的持续神经阻滞 》
Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Critical Care Medicine，2016；44：2079–2103.
关于这次指南，需要介绍的背景：
新指南是对2002年指南的更新；
新指南工作组共17位委员；
证据评价按照GRADE进行；
通过电子会议及面对面形式进行讨论；
本次指南由SCCM单一学会组织完成，并由SCCM旗下的ACCM（The American College of Critical Care Medicine，美国重症医学学院）、SCCM、ASHP（American Society of Health-System Pharmacists，美国医疗药师协会）及CCM杂志的专家委员会进行外部审阅。而2002版指南还有ACCP（美国胸科医师学院）的参与；
否认利益冲突和厂商支持。
具体内容（按照摘要进行编译）：
工作组强烈推荐：
持续输注神经组织（NMBAs）时应进行预排的眼部护理，包括润眼的滴剂或油膏以及闭合眼缘。
The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents.
工作组的10个弱级推荐：
1）建议对氧合指数（ PaO2/FIO2）低于150mmHg的ARDS患者的病程早期持续静点NMBAs。
1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150.
2）反对对机械通气的哮喘持续状态患者常规应用NMBAs。
2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus.
3）对于因严重低氧、呼吸性酸中毒或血流动力学代偿的致命性情况，建议可开展一次NMBAs的临床研究。
3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise.
4）治疗性低体温的全身寒战或可使用NAMBs。
4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia.
5）可以通过对外周神经的四个成串刺激监测阻滞的深度，但必须与包括临床评价在内方法合并为更具兼容性的评估。
5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment.
6）持续静点NMBAs者不建议外周神经的四个成串刺激监测阻滞深度。
6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents.
7）持续静点NMBAs者建议接受结构化的理疗方案
7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen.
8）建议持续静点NMBAs者的血糖控制目标位为低于180mg/dl.
8) We suggest that clinicians target a blood glucose level of less than 180?mg/dL in patients receiving neuromuscular-blocking agents.
9）在计算肥胖者NMBAs的剂量时不建议用实际体重，而应该以一致体重（理想体重或校正体重）计算。
9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients.
10）撤离生命支持治疗或临终期时建议停用NMBAs。
10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn.
证据缺如或不足以及研究结果模棱两可或相关临床实践变化不定，工作组对以下9种情况不做推荐。
In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics.
1）对急性脑损伤及颅压升高者，NMBAs是否有益或有害工作组不做推荐。
1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure.
2）对心跳骤停后行治疗性低体温者是否常规使用NMBAs不做推荐。
2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest.
3）对治疗性低体温者是否行外周神经刺激以监测阻滞深度不做推荐。
3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia.
4）是否使用NMBAs以提升血管内容量的评价准确度不做推荐。
4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients.
5）持续NMBAs输注中是否使用脑电图指标以评估镇静不做推荐。
5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents.
6）输注NMBAs患者是否有专门的营养需求不做推荐
6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents.
7）计算肥胖者NMBAs用量的一致体重是否存在一个优于另外一个的情况并无推荐。
7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients.
8）怀孕患者不建议使用NMBAs。
8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients.
9）接受NMBAs治疗的重症肌无力患者需要对何组肌群进行监测并无推荐。
9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents.
最后，对于证据缺乏或不足但专家组却有一致性共识者，工作组推出6条良好实践主张：
Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements.
1）使用外周神经监测时，良好的操作应是结合其他的临床评估（呼吸机触发或寒颤的程度）以评价治疗性低体温患者的神经阻滞程度。
1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia.
2）建立对治疗性低体温者使用NMBAs指引的规程
2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia.
3）神经阻滞之前及期间应该使用镇静和镇静，并达到深度镇静的程度
3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation.
4）床旁医生对接受NMBAs者应有相关实施措施以减少意外脱机的风险。
4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents.
5）重症肌无力的神经阻滞剂量应减少，所用的剂量应基于外周神经四个成串刺激的效果。
5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring.
6）在临床确定脑死亡前应停用NMBAs。
6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.
到这里指南的意见就结束了，但是具体用什么药物进行神经肌肉阻滞，以及各药物之间的比较、药物副作用以及目前比较时髦的神经阻滞剂造成的ICU获得肌无力在本指南中都没有提及，莫名的....
而2002版指南中对上述问题都有陈述，不如截图如下：
表1 ICU常用NMBAs（苄基异喹啉类）
表1 续 ICU常用NMBAs（季铵类）
ICU无力的病因与症状
NMBAs的药物相互作用
ICU内NMBAs的潜在并发症
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