Management of Analgesia and Sedation During Sustained Neuromuscular Blockade

Neuromuscular blocking agents (NMBAs) are commonly used in patients with acute respiratory distress syndrome (ARDS) to facilitate lung-protective ventilation. NMBA use requires concurrent administration of analgesia and sedation to prevent awareness while minimizing adverse effects. Despite guideline recommendations emphasizing a need for adequate sedation, operational direction is limited on agent selection, dosing, and monitoring, particularly in the setting of pharmacologic paralysis where clinical assessment is not possible. Using a case-based approach, this review outlines a practical framework for managing analgesia and sedation during sustained NMBA centered on three key clinical decisions: 1) establishing a stable and sufficiently deep level of analgesia and sedation before NMBA initiation and 2) cautiously titrating and monitoring analgesia and sedation during sustained paralysis using adjunctive tools such as bispectral index (BIS), and leveraging intermittent or paused NMBA administration to reassess sedation adequacy, patient-ventilator interaction, and the ongoing need for paralysis. Core principles include avoiding reliance on recent analgesia and sedative bolus dosing when assessing sedation depth before paralysis, maintaining a consistent minimum sedation strategy during NMBA use, and recognizing the limitations of BIS in guiding dose reduction. 3) Interruptions in neuromuscular blockade provide a critical opportunity to use validated clinical scales, confirm adequacy of prior dosing, and minimize unnecessary drug exposure. Further research is needed to define optimal sedation targets, monitoring strategies, and NMBA use patterns that improve patient-centered outcomes.