A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients

Newman, P. J.; Quinn, Audrey; Grounds, RM; Hunter, Jennifer M.; Boyd, A. H.; Eastwood, N. B.; Pollard, B. J.; Pearson, Alan; Harper, N.J.N.; Beale, Richard; Sutjarittam, M.; Elliot, J.M.; Bion, Julian

doi:10.1097/00003246-199707000-00013

Cited by 31 publications

(20 citation statements)

References 12 publications

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“…52 Train-of-4 monitoring does not appear to modify recovery time compared with clinical monitoring for 48-hour NMBA paralysis. 51 Finally, the occurrence of muscular weakness associated with 48-hour NMBA paralysis without corticosteroid therapy appears to be very rare.…”

Section: The Practical Aspects Of Neuromuscularblocking Agent Use Durmentioning

confidence: 96%

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The Effects of Neuromuscular-Blocking Agents on Gas Exchange in Patients With Acute Respiratory Distress Syndrome

Forel

Chiche

Papazian

2006

Clinical Pulmonary Medicine

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The use of neuromuscular-blocking agents (NMBA) in ventilated patients with acute respiratory distress syndrome (ARDS) is controversial and largely empiric. Few trials looked at their effectiveness on gas exchange or in improving lung mechanics in patients with ARDS. Only one randomized, controlled trial compared the effects of NMBA on gas exchange in patients with ARDS receiving NMBA as compared with patients receiving placebo throughout a period of 48 hours. In this trial, the early use of NMBA in patients with ARDS was associated with a sustained improvement in oxygenation. The muscular paralysis induced by NMBA could reduce the consumption of oxygen linked to the work of breathing. Muscular paralysis could facilitate mechanical ventilation by preventing spontaneous breaths responsible for the dys-synchrony and worsening of gas exchange. Muscular paralysis could increase compliance of the thoracic wall and improve mechanical ventilation during ARDS. However, these hypotheses are controversial. Finally, preliminary data show that the muscular paralysis could provide better adaptation to mechanical ventilation and better satisfaction with the protective criteria for reduction of ventilator-associated lung injuries by homogenizing the distribution of tidal volume and positive end expiratory pressure. The role of new NMBA (benzylisoquinolines) in the occurrence of critical illness neuromyopathy is largely questioned in the recent literature. It is important to design new studies to explain the mechanisms of the improvement in oxygenation associated with NMBA and to evaluate whether the use of NMBA modifies the outcome of patients with ARDS.

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Section: The Practical Aspects Of Neuromuscularblocking Agent Use Durmentioning

confidence: 96%

“…After 48 hours of administration, it is on average 1 hour 51,52 with a range of 20 to 175 minutes. 52 Train-of-4 monitoring does not appear to modify recovery time compared with clinical monitoring for 48-hour NMBA paralysis.…”

Section: The Practical Aspects Of Neuromuscularblocking Agent Use Durmentioning

confidence: 99%

The Effects of Neuromuscular-Blocking Agents on Gas Exchange in Patients With Acute Respiratory Distress Syndrome

Forel

Chiche

Papazian

2006

Clinical Pulmonary Medicine

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“…This has already been attributed to an up-regulation of acetylcholine receptors, although some authors did not find the same results [13, 22]. The pharmacokinetics of NMBAs in critically ill patients can be affected by many conditions, such as sepsis and/or shock [12].…”

Section: Discussionmentioning

confidence: 99%

Clinical assessment and train-of-four measurements in critically ill patients treated with recommended doses of cisatracurium or atracurium for neuromuscular blockade: a prospective descriptive study

Bouju

Tadié

Barbarot

et al. 2017

Ann. Intensive Care

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Background Despite few studies, a monitoring of a neuromuscular blockade with a train of four (TOF) is recommended in intensive care unit (ICU). Our objective was to compare the results of ulnar and facial TOF measurements with an overall clinical assessment for neuromuscular blockade in ICU patients treated with recommended doses of atracurium or cisatracurium, including patients with acute respiratory disease syndrome (ARDS).MethodsWe prospectively included in two ICUs 119 patients, 94 with ARDS, who required a neuromuscular blockade for more than 24 h. Three levels of neuromuscular blockade were defined: “over-paralyzed” (TOF = 0), “well-paralyzed” (TOF = 1–2), and “under-paralyzed” (TOF = 3–4). Physicians blinded for TOF counts were asked to classify patients clinically as “over-paralyzed,” “well-paralyzed,” or “under-paralyzed”. Patients were assessed two times daily.ResultsFor the whole population 996 ulnar and facial TOF measurements and clinical assessments were obtained (846 with cisatracurium and 150 with atracurium). Proportions of patients classified as over-paralyzed, well-paralyzed, and under-paralyzed based on TOF measurements and clinical assessments differed significantly (p < 0.0001). The number of observed agreements between clinical assessments and facial TOF measurements was of 19.08% (κ = 0.06) and of 17.37% with ulnar TOF measurements (κ = 0.04), while it was of 62.75% between ulnar and facial TOF measurements (κ = 0.45). Results were similar for cisatracurium and atracurium. Repeated facial TOF measurements performed on the first 4 days of mechanical ventilation in ARDS patients showed that the proportion of patients TOF = 1–2 was around 8% and did not vary significantly with time (p = 0.9), proportion of patients TOF = 3–4 increased from 24 to 40% (p = 0.01), proportion of patients TOF = 0 decreased from 71 to 53% (p = 0.005) while objectives for protective ventilation were achieved. Proportions of facial and ulnar TOF = 0 were significantly higher among patients with ICU-acquired weakness (ICU-AW) versus those who did not develop ICU-AW (51 vs. 40%, p = 0.03, and 76 vs. 62%, p = 0.006, respectively).ConclusionsThe study provides data on clinical and TOF monitoring of neuromuscular blockade, which are widely divergent in ICU patients receiving recommended doses of benzylisoquinoliniums.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0234-0) contains supplementary material, which is available to authorized users.

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“…Peripheral oedema, haemodynamic status and hydration frequently vary during an intensive care admission and can produce a variation in TOF response. The results of tactile or visual evaluation of TOF responses are variable ( 14) and even accurately collected TOF data can be of limited value. It is well known that TOF data obtained by stimulation of the ulnar nerve does not accurately reflect the neuromuscular state of the diaphragm; recovery of the diaphragm usually precedes that of the adductor pollicis.…”

Section: Discussionmentioning

confidence: 99%

Duration of action of atracurium when given by infusion to critically ill children

Playfor

Thomas

Choonara

2000

Pediatric Anesthesia

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The aim of the study was to investigate the offset time of atracurium when given by continuous infusion on a paediatric intensive care unit and to look for evidence of tolerance. Over a period of 8 months, 20 mechanically ventilated children had a steady-state infusion of atracurium discontinued to enable the assessment of their level of sedation. The offset time of atracurium was assessed by train-of-four (TOF) stimulation of the ulnar nerve. The initial TOF reading was documented as was the time taken to reach a TOF ratio of 0.9. Thirty-five assessments were carried out. The mean offset time of atracurium was 28.7 min (SEM 1.76 min, range 8-56 min). There was no correlation between the dose of atracurium at discontinuation and the offset time of the infusion. The duration of infusion was negatively correlated with the offset time of atracurium, and this effect was most prominent in children who had received infusions for longer than 48 h. When given by continuous infusion, the offset time of atracurium is very variable between individual patients. Infusions administered for longer than 48 h are associated with a significant reduction in the offset time as a result of increasing tolerance.

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A comparison of cisatracurium (51W89) and atracurium by infusion in critically ill patients

Abstract: Cisatracurium, an isomer of atracurium, appears to be a suitable agent for providing muscle relaxation in critically ill patients.

Cited by 31 publications

References 12 publications

The Effects of Neuromuscular-Blocking Agents on Gas Exchange in Patients With Acute Respiratory Distress Syndrome

The Effects of Neuromuscular-Blocking Agents on Gas Exchange in Patients With Acute Respiratory Distress Syndrome

Clinical assessment and train-of-four measurements in critically ill patients treated with recommended doses of cisatracurium or atracurium for neuromuscular blockade: a prospective descriptive study

Duration of action of atracurium when given by infusion to critically ill children

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