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

Bastin, Melissa L. Thompson; Smith, Rebecca; Bissell, Brittany D; Wolf, Heather N.; Wiegand, Alexandra; Cavagnini, Megan E.; Ahmad, Yahya; Flannery, Alexander H.

doi:10.1016/j.jcrc.2021.05.011

Cited by 3 publications

(2 citation statements)

References 18 publications

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“…Evaluation of patient-ventilator synchrony was deemed to be the preferred NMBI monitoring strategy nearly twice as frequently as train-of-four monitoring and may relate to prospective evidence demonstrating train-offour NMBI monitoring does not improve outcome in ARDS. [20][21][22] Similar to physicians, a lack of ventilator dyssynchrony 1 hour after holding the NMBI was the preferred NMBI discontinuation strategy. Most respondents strongly felt that NMBI use ≥ 48 hours was an important endpoint to consider NMBI discontinuation.…”

Section: Discussionmentioning

confidence: 99%

Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS

et al. 2023

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Background: Current critical care pharmacist (CCP) practices and perceptions related to neuromuscular infusion (NMBI) use for acute respiratory distress syndrome (ARDS) maybe different with the COVID-19 pandemic and the publication of 2020 NMBI practice guidelines. Objective: To evaluate CCP practices and perceptions regarding NMBI use for patients with moderate-severe ARDS. Methods: We developed, tested, and electronically administered a questionnaire (7 parent-, 42 sub-questions) to 409 American College of Clinical Pharmacy (ACCP) Critical Care Practice and Research Network members in 12 geographically diverse states. The questionnaire focused on adults with moderate-severe ARDS (PaO2:FiO2<150) whose causes of dyssynchrony were addressed. Two reminders were sent at 10-day intervals. Results: Respondents [131/409 (32%)] primarily worked in a medical intensive care unit (ICU) 102 (78%). Compared to COVID-negative(-) ARDS patients, COVID positive(+) ARDS patients were twice as likely to receive a NMBI (34 ± 18 vs.16 ± 17%; P < 0.01). Respondents somewhat/strongly agreed a NMBI should be reserved until after trials of deep sedation (112, 86%) or proning (92, 81%) and that NMBI reduced barotrauma (88, 67%), dyssynchrony (87, 66%), and plateau pressure (79, 60%). Few respondents somewhat/strongly agreed that a NMBI should be initiated at ARDS onset (23, 18%) or that NMBI reduced 90-day mortality (12, 10%). Only 2/14 potential NMBI risks [paralysis awareness (101, 82%) and prolonged muscle weakness (84, 68%)] were frequently reported to be of high/very high concern. Multiple NMBI titration targets were assessed as very/extremely important including arterial pH (109, 88%), dyssynchrony (107, 86%), and PaO2: FiO2 ratio (82, 66%). Train-of-four (55, 44%) and BIS monitoring (36, 29%) were deemed less important. Preferred NMBI discontinuation criteria included absence of dysschrony (84, 69%) and use ≥48 hour (72, 59%). Conclusions and Relevance: Current critical care pharmacists believe NMBI for ARDS patients are best reserved until after trials of deep sedation or proning; unique considerations exist in COVID+ patients. Our results should be considered when ICU NMBI protocols are being developed and bedside decisions regarding NMBI use in ARDS are being formulated.

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Section: Discussionmentioning

confidence: 99%

Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS

et al. 2023

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“…Nevertheless, fixed doses were associated with a three-fold increase in the administered dose. 37 By contrast, a study of 38 patients with ARDS showed that the addition of TOF to NMT monitoring did not change mortality in the ICU or the days with mechanical ventilation, but it did increase the consumption of atracurium compared with clinical Figure 2. TOF response patterns according to the level of neuromuscular blockade.…”

Section: Adverse Effects Of Muscle Relaxants In the Icumentioning

confidence: 94%

Neuromuscular blocking agents in the intensive care unit

et al. 2022

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Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.

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Comparison of Fixed Dosing vs Train of Four Titration of Cisatracurium in COVID-19 ARDS Patients

Banerjee,

Elefritz,

Doepker

et al. 2023

Journal of Pharmacy Practice

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Background: Early neuromuscular blockade with cisatracurium has been associated with improved outcomes in moderate-severe acute respiratory distress syndrome (ARDS). Previous studies have demonstrated increased drug utilization without benefits in oxygenation using fixed dose cisatracurium compared to train-of-four (TOF) titration. Objective: We sought to compare a novel, lower fixed dose cisatracurium protocol to TOF titration evaluating the impact on PaO2:FiO2 ratio (P/F). Methods: We conducted a single-center retrospective cohort study comparing fixed dose cisatracurium to TOF titration. We included patients aged 18-89 treated for COVID-19 ARDS with a baseline P/F≤200 who received a cisatracurium infusion for ≥12 h. The primary outcome was change in P/F at 48 h from baseline. Secondary outcomes included change in P/F at 24 h and 7 days, need for mechanical ventilation at day 28, and cisatracurium utilization. Results: Analyses included 125 patients (fixed dose = 65, TOF = 60). Severe ARDS was common with a baseline median P/F of 73.7 vs 79.5, P = .133. The change in P/F at 48 h was larger in the TOF cohort in the adjusted analysis (24.9 vs 70.8, P < .005). The rate and total cumulative dose of cisatracurium were higher in the fixed dose cohort (5 vs 3 mcg/kg/min, P < .001; 1034 vs 612 mg, P < .001) despite similar infusion durations (44.1 h vs 48.5 h, P = .642). Conclusions: Patients in the TOF cisatracurium cohort had improved P/F at 48 h compared to the fixed dose cohort, while also using only 60% of the cumulative dose. Future directions should include analysis of the implications of increased cisatracurium exposure on patient outcomes.

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

Cited by 3 publications

References 18 publications

Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS

Critical Care Pharmacist Attitudes and Perceptions of Neuromuscular Blocker Infusions in ARDS

Neuromuscular blocking agents in the intensive care unit

Comparison of Fixed Dosing vs Train of Four Titration of Cisatracurium in COVID-19 ARDS Patients

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