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

• Published in: Journal of critical care Vol. 66; pp. 166 - 172
• Main Authors: DiBridge, Julie N., Rivosecchi, Ryan M., McVerry, Bryan J., Lamberty, Phillip E., Donahoe, Michael P., Groetzinger, Lara M.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-12-2021; Elsevier Limited
• Subjects: Acute respiratory distress syndrome; Anesthesia; Atracurium - analogs & derivatives; Cisatracurium; Clinical medicine; Drug dosages; Drug Utilization; Humans; Intensive care; Mortality; Neuromuscular blockade; Oxygen saturation; Patient positioning; Performance evaluation; Regression analysis; Respiratory distress syndrome; Respiratory Distress Syndrome - drug therapy; Retrospective Studies; Ventilator synchrony; Ventilators; Acute respiratory distress syndrome; Cisatracurium; Pplat; PEEP; P/F; FiO2; TOF; mPaw; S/F; CIS; DP; LOS; SOFA; VSP; Ventilator synchrony; Neuromuscular blockade; ICU; NMBA; OI; T0; ARDS; FD; VT
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2021.07.012

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.
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 PaO2/FiO2 ratio (P/F) and oxygenation index (OI) from baseline up to 48 h.
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.
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.
•Cisatracurium infusions improve oxygenation parameters for patients with ARDS.•Protocolized titration to ventilatory synchrony decreases drug consumption.•Train-of-four only titration increases bedside monitoring and nursing workload.•A fixed-dose strategy significantly increases drug consumption and costs.•Improvement in oxygenation is equivalent despite dosing strategy utilized.