Ensure that patient and health care provider safety standards are met during this procedure including:

  • Risk assessment and appropriate PPE
  • 4 Moments of Hand Hygiene
  • Procedural Safety Pause is performed
  • Two patient identification
  • Safe patient handling practices
  • Biomedical waste disposal policies


  1. Safety
  2. Drug Monitoring
  3. Analgesia, Sedation, Drug Initiation
  4. Neurological Monitoring
  5. Temperature Monitoring
  6. Corneal Protection
  7. Joint/Limb Protection
  8. Pulmonary Care
  9. DVT Prevention



Safety Monitoring

Ensure patient is fully ventilated on a controlled rate of breathing  before administration of a Neuromuscular Blocker (NMB).

Patient requires an arterial line and End Tidal CO2 Monitoring.

Ensure ECG, oxygen saturation, End Tidal CO2 and arterial pressure alarms are on with appropriate alarm settings.

Monitor and document vital signs q1h and prn.


Drug Monitoring

The routine use of a peripheral nerve stimulator (TOP) to titrate infusions is no longer required.

Infusion orders should identify either:

  1. Identify the titration end-point (such as "no spontaneous ventilation trigger", "no shivering" or "temperature 32-34C")


  1. Include the statement "Do not titrate".

Cisatracurium is metabolized and cleared independent of the kidney or liver. Rocuronium is renally excreted and paralysis.


Sedation and Analgesia

Maintain continuous analgesia and sedation during administration of neuromuscular blocking agents. Continue to explain all procedures to the patient.

Initiate neuromuscular blockade as follows:

  • Bolus and initiate continuous analgesia and sedation to achieve VAMAAS and CPOT scores for facial movement, body movement and muscle tension of 0.
  • Patient should have no response to glabellar tap.
  • Once sedation and analgesia targets are met, initiate neuromuscular blocking agent.

NMBs produce temporary paralysis without any analgesic, sedative effect or hearing effect. It should be assumed that the patient is awake and alert; analgesics and sedatives should be given accordingly.

Lacrimation (tearing), hypertension and tachycardia may be a sign of awareness/awakefullness.


Neurological Monitoring

Assess pupil size and reactivity q1-4h. Do not assess for responsiveness to pain, or perform cold caloric testing (oculovestibular reflex).


If NMBs are used in the setting of a neurological diagnosis (e.g., to treat raised ICP), Continuous EEG monitoring should be considered.

Pupils reactivity is preserved with NMBs and provides the only method for neurological assessment. Eye movement is paralyzed with NMBs, blocking the oculovestibular response. Patients could potential experience discomfort/nausea despite an inability to respond. Motor function is paralyzed but pain is sensation preserved.

NMB agents will mask the muscule activity associated with seizures, making detection more difficult.


Temperature Monitoring

Monitor temperature q1h. Assess core temperature (rectal, pulmonary artery, bladder or esophageal) if oral temperature is <36 or if a cooling blanket is in use.

NMBs paralyze muscle activity and decrease heat production. They may be used to control metabolic rate, prevent shivering and/or facilitate hypothermia.

When used for other purposes, hypothermia may develop as a result of decreased heat production and inability to shiver. The use of a cooling blanket increases the potential for rapid and precipitous temperature drop.


Provide Corneal Protection

Obtain order for eye lubricant q 2 h and prn. Keep eyelids closed at all times. Lubricating ointments (e.g., lacrilube) may be sufficient to keep eyelids closed and corneas moist.

If eyes must be patched to maintain a closed position, caution is required to ensure the lids remain closed at all times under any patch.

Blink reflex is paralyzed and lacrimation blocked.. If eyelids are open or partially open,

If eyes should open under a patch, the dry gauze would come in contact with the cornea, causing further injury.


Protect Against Joint/Limb Injury

Maintain careful alignment of joints and spine. Use spinal precautions during turning. Use pillows to maintain lateral neck alignment and hip abduction during repositioning.

Passive range of motion should be provided by a physiotherapist only.

If NMB is required during skeletal traction, notify ortho/trauma. Traction weight should be reduced during paralysis.

Paralysis decreases joint and limb protection and increases risk for joint dislocation or spinal trauma.

The lack of muscle resistance increases risk to conduct range of motion beyond normal range.


Pulmonary Care

Provide oral care per procedure q 2 h and prn and keep HOB elevated > 30 degrees as tolerated.

Suction a minimum of q6h using an assisted cough technique. If abdominal surgery/contraindication to diaphragm pressure, provide assisted cough through rib cage support. Please refer to the Interdisciplinary Suctioning Guidelines

Paralysis of swallowing and gag reflex increases collection of oral secretions and risk for aspiration.

Paralysis of the diaphragm suppresses the cough reflex and ability to clear secretions.


DVT Prophylaxis

Maintain DVT prophylaxis with TED/SCDs and/or prophylactic anticoagulant therapy.

Suction a minimum of q6h using an assisted cough technique. If abdominal surgery/contraindication to diaphragm pressure, provide assisted cough through rib cage support.

Paralysis of leg muscles, vasodilating nature of drug and patient immobility decreases venous return and increase risk for thrombosis.


Last Update: January 20, 2017

Revised: January 20, 2017, November 7, 2018. Reviewed: February 2, 2020 (BM)