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

Abstract

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.

Early Neuromuscular Blockade in Children with Pediatric Acute Respiratory Distress Syndrome

“…Most of the studies have evaluated the role of NMBA cisatracurium. 19,20,23,24 Groetzinger et al 25 compared the outcomes associated with the use of vecuronium and cisatracurium in patients with ARDS and found no difference, in terms of mortality, among these patients, with the use of either of the two.…”

“…An arbitrary period of 48 hours of NMBA use was chosen by us, as it is generally observed that majority of antimicrobial drugs take 48 hours to begin to show clinical response in any patient. Most of the studies done in adult patients in past 8,[17][18][19][20]24 have also used a 48-hour cutoff. Sottile et al, 26 however, concluded that even an extended NMB usage for ARDS was not associated with increase in mortality.…”

How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

“…Consequently, the accurate posology of cisatracurium to use during ARDS is unknown. Recently, published data showed that ARDS patients are frequently insufficiently paralyzed when following former recommendations [ 12 ]. Even if high doses of NMBAs are necessary to paralyze the diaphragm, the ACURASYS posology used in all patients might, however, be excessive and associated with high costs.…”

Role of Pharmacologic Paralysis in Acute Respiratory Distress Syndrome

“…62 Another study supported the use of clinical assessment alone, specifically for cisatracurium, 63 further calling into question the need for TOF monitoring. Recent studies also found respiratory objectives for plateau pressure and oxygenation can be obtained in ARDS patients without TOF monitoring, 64 and that TOF monitoring does not correlate with gas exchange indices in moderate to severe ARDS. 65 Regardless of monitoring strategy, appropriate sedation is always necessary.…”