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

Julie N DiBridge; Ryan M Rivosecchi; Bryan J McVerry; Phillip E Lamberty; Michael P Donahoe; Lara M Groetzinger

doi:10.1016/j.jcrc.2021.07.012

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

J Crit Care. 2021 Dec:66:166-172. doi: 10.1016/j.jcrc.2021.07.012. Epub 2021 Jul 17.

Authors

Julie N DiBridge¹, Ryan M Rivosecchi², Bryan J McVerry³, Phillip E Lamberty⁴, Michael P Donahoe⁵, Lara M Groetzinger⁶

Affiliations

¹ Department of Pharmacy, University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop St., Pittsburgh, PA 15213, USA. Electronic address: Dibridgejn2@upmc.edu.
² Department of Pharmacy, University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop St., Pittsburgh, PA 15213, USA. Electronic address: rivosecchirm@upmc.edu.
³ Associate Professor of Medicine, Associate Professor of Environmental and Occupational Heath, Associate Professor of Clinical and Translational Science, Division of Pulmonary, Allergy, and Critical Care Medicine, 3459 Fifth Avenue, University of Pittsburgh, Pittsburgh, PA 15213, USA. Electronic address: mcverrybj@upmc.edu.
⁴ Associate Professor of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, 3459 Fifth Avenue, University of Pittsburgh, Pittsburgh, PA 15213, USA. Electronic address: lambertype@upmc.edu.
⁵ Executive Vice Chair of Clinical Affairs, Department of Medicine, Professor of Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.. Electronic address: donahoem@upmc.edu.
⁶ Department of Pharmacy, University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop St., Pittsburgh, PA 15213, USA. Electronic address: groetzingerlm@upmc.edu.

Abstract

Purpose: 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.

Methods: 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.

Results: 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.

Conclusion: 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.

Keywords: Acute respiratory distress syndrome; Cisatracurium; Neuromuscular blockade; Ventilator synchrony.

MeSH terms

Atracurium / analogs & derivatives
Drug Utilization
Humans
Respiratory Distress Syndrome* / drug therapy
Retrospective Studies

Substances

Atracurium
cisatracurium