1115: Fixed Versus Titration-Based Dosing of Cisatracurium in Acute Respiratory Distress Syndrome

Brookbank, Kelly; Winter, Peter de; Foertsch, Madeline; Ernst, Neil; Droege, Chris

doi:10.1097/01.ccm.0000551860.82758.cb

Cited by 4 publications

(4 citation statements)

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“…29 Additionally, in a retrospective, single-center, observational cohort study, 117 patients with ARDS were categorized to flat-dose or titration-based dosing regimens. 30 No differences in clinical end points, including percentage change in PaO 2 /FiO 2 from baseline to 48 hours, mechanical ventilation days, or mortality, were observed. 30 However, those receiving a flat-dose regimen had a higher median total cost of $2760 compared with $1242 in the titration-based regimen ( P < 0.001).…”

Section: Controversiesmentioning

confidence: 90%

“…30 No differences in clinical end points, including percentage change in PaO 2 /FiO 2 from baseline to 48 hours, mechanical ventilation days, or mortality, were observed. 30 However, those receiving a flat-dose regimen had a higher median total cost of $2760 compared with $1242 in the titration-based regimen ( P < 0.001). 30 These 2 studies suggest that the use of titratable cisatracurium with TOF monitoring is appropriate in patients with ARDS and may lead to less overall drug use.…”

Section: Controversiesmentioning

confidence: 90%

“…30 However, those receiving a flat-dose regimen had a higher median total cost of $2760 compared with $1242 in the titration-based regimen ( P < 0.001). 30 These 2 studies suggest that the use of titratable cisatracurium with TOF monitoring is appropriate in patients with ARDS and may lead to less overall drug use.…”

Section: Controversiesmentioning

confidence: 94%

“…Flat-dose NMBAs may lead to excessive exposure with no clear benefit as compared with a titratable dosing scheme. 30 In real-world practice, it is common to bolus with NMBA and assess patient clinical status prior to starting continuous infusion. Given the lack of mortality benefit of continuous infusion NMBA, it may be beneficial to utilize this bolus approach as needed based on clinical examination.…”

Section: Controversiesmentioning

confidence: 99%

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To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

2020

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Objective: To review and evaluate neuromuscular blocking agents (NMBAs) in critically ill patients with acute respiratory distress syndrome (ARDS). Data Sources: A literature search utilizing PubMed was performed (January 1991 to January 2020) using the following search terms: ( neuromuscular blocking agents OR neuromuscular blockade OR cisatracurium OR rocuronium OR vecuronium OR pancuronium OR atracurium) AND * acute respiratory distress syndrome OR acute lung injury). Publications in English were evaluated. Study Selection and Data Extraction: Relevant clinical studies in humans were considered. Data Synthesis: Although NMBAs have been used for decades in the setting of ARDS, questions regarding mortality benefit remain. Early NMBA, within 48 hours of lung injury, have been historically used in critically ill patients with ARDS to aid in increasing alveolar recruitment, improving patient-ventilator synchrony, and promoting oxygenation by the prevention of contraction of respiratory muscles. Until recently, the literature showed an improvement in 90-day adjusted mortality. However, recent literature has demonstrated the lack of a mortality benefit. The continued receipt of NMBAs, with no clear benefit, could potentially lead to increased costs, skin breakdown, corneal abrasions, venous thromboembolisms, intensive care unit acquired weakness, and awareness with inappropriate sedation. Relevance to Patient Care and Clinical Practice: This review aims at discussing the preferred NMBA based on mechanism of action and reviews specific clinical trial data for the use of NMBAs in ARDS, clinical implications of these trial data, complications for the use of NMBAs, and needed future directions. Conclusions: The mortality benefit of NMBAs in ARDS has contradicting evidence with potentially serious adverse effects and notable controversies.

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Section: Controversiesmentioning

confidence: 90%

Section: Controversiesmentioning

confidence: 90%

Section: Controversiesmentioning

confidence: 94%

Section: Controversiesmentioning

confidence: 99%

See 2 more Smart Citations

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

2020

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Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome

Bastin

Smith

Bissell

et al. 2021

Journal of Critical Care

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Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation

DiBridge

Rivosecchi

McVerry

et al. 2021

Journal of Critical Care

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Purpose Three continuous dosing strategies of cisatracurium (CIS) for acute respiratory distress syndrome (ARDS) have been described in the literature. After implementation of a ventilator synchrony protocol (VSP), we sought to determine which continuous CIS dosing strategy utilized the least amount of drug without compromising efficacy. Methods We retrospectively reviewed patients with ARDS receiving continuous CIS from January 1, 2013 to December 31, 2018. We categorized patients into one of three dosing strategies: fixed dose (FD), titration based solely on train-of-four (TOF), or the VSP. We documented drug consumption and determined efficacy by comparing the change in PaO 2 /FiO 2 ratio (P/F) and oxygenation index (OI) from baseline up to 48 h. Results A total of 1047 patients were screened, and 189 met inclusion criteria (VSP = 69, TOF = 99, FD = 21). Drug consumption (mg) was significantly lower in the VSP arm: 415 [IQR 318–528] compared to both the TOF: 665 [IQR 472–927] and the FD arms: 1730 [IQR 1695–1800], p < 0.001 for each. The change in P/F and OI from baseline were statistically equivalent at all time points. Conclusion Without impacting efficacy of gas exchange, a protocol using ventilator synchrony for CIS titration required significantly less drug compared to TOF-based titration and a fixed dosing regimen.

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1115: Fixed Versus Titration-Based Dosing of Cisatracurium in Acute Respiratory Distress Syndrome

Cited by 4 publications

References 0 publications

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

Comparison of fixed dose versus train-of-four titration of cisatracurium in acute respiratory distress syndrome

Comparison of three cisatracurium dosing strategies in acute respiratory distress syndrome: A focus on drug utilization and improvement in oxygenation

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