Clinical Experience and Plasma Laudanosine Concentrations During the Infusion of Atracurium in the Intensive Therapy Unit

Yate, P.M.; Flynn, P. J.; Arnold, R. W.; Weatherly, B.C.; Simmonds, R. J.; Dopson, T.

doi:10.1093/bja/59.2.211

Cited by 91 publications

(16 citation statements)

References 23 publications

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“…The concentrations of atracurium required for neuromuscular paralysis in our patients were much higher than those reported in the product monograph (20) but similar to dose requirements in comparable ICU patients (21). Increased requirements for vecuronium have been reported in similar patients (22).…”

Section: Discussionsupporting

confidence: 80%

“…Tolerance to atracurium required increasing concentrations during the course of a long ICU stay, a phenomenon previously reported (21,24). We can only speculate about the cause but suspect that prolonged occupancy of the cholinergic receptor by a competitive antagonist induces proliferation of extrajunctional cholinergenic receptors that then require more drug (25).…”

Section: Discussionmentioning

confidence: 76%

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Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis

Strange

Vaughan

Franklin

et al. 1997

Am J Respir Crit Care Med

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Train-of-four (TOF) monitoring is recommended in published guidelines during use of continuous-infusion neuromuscular blocking agents (NMB) in the intensive care unit (ICU). To test that recommendation, dual protocols were established in a medical ICU after intensive nursing education. Paralyzed patients received either TOF monitoring with a goal of three twitches or best clinical assessment while receiving atracurium by continuous infusion. Demographics and mean duration of paralysis of 20 patients in the TOF group were no different than that of the 16 patients in the best clinical assessment group. Although most patients demonstrated atracurium tolerance over time, there was no difference between groups in total mg (+/- SEM) infused (10,460 +/- 2,409 versus 9,201 +/- 3,237) or mean microgram/kg/min (15.2 +/- 1.5 versus 12.0 +/- 1.1). The time to clinical recovery was no different between groups (50 +/- 10 versus 45 +/- 12 min). Two complications occurred in the TOF group, with pulmonary emboli despite prophylaxis and an unrecognized cerebrovascular accident in one patient each. We conclude that careful titration of NMB using clinical bedside markers should remain the standard of care with these drugs.

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Section: Discussionsupporting

confidence: 80%

Section: Discussionmentioning

confidence: 76%

Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis

Strange

Vaughan

Franklin

et al. 1997

Am J Respir Crit Care Med

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“…m1-1 following five days of continuous infusion of atracurium in a renal failure patient. 45 Furthermore, in this study of 20 renal failure patients who received infusions ranging from 38 to 269 hr, no evidence of cerebral excitation occurred. On the other hand, laudanosine may promote seizure activity in susceptible patients as suggested by Griffiths et al 46 The use of haemodialysis is ineffective in eliminating serum laudanosine due to its protein binding and high volume of distribution.…”

Section: Metabolism]excretionmentioning

confidence: 50%

The use of muscle relaxants in the intensive care unit

Sharpe

1992

Can J Anaesth

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“…One clinically significant effect of prolonged infusions of atracurium is that of tolerance. Several authors have described tolerance to atracurium in adults and children ( 4, 6) and there may be cross‐resistance to both atracurium and other nondepolarizing neuromuscular blocking agents ( 7). A number of mechanisms have been proposed to explain this finding, and one of particular importance is the formation of extrajunctional acetylcholine receptors ( 8).…”

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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Clinical Experience and Plasma Laudanosine Concentrations During the Infusion of Atracurium in the Intensive Therapy Unit

Cited by 91 publications

References 23 publications

Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis

Comparison of Train-of-Four and Best Clinical Assessment during Continuous Paralysis

The use of muscle relaxants in the intensive care unit

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

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