Comparison of Cisatracurium Versus Atracurium in Early ARDS

Moore, Leanne; Kramer, C. Joseph; Delcoix-Lopes, Sophie; Modrykamien, Ariel

doi:10.4187/respcare.05102

Cited by 15 publications

(18 citation statements)

References 22 publications

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“…In a retrospective study, cisatracurium was not superior to atracurium [89]. In contrast, the duration of mechanical ventilation and the length of ICU stay were slightly but significantly shorter in patients with or at risk of ARDS who were treated with cisatracurium, compared with those treated with vecuronium [90].…”

Section: Methodsmentioning

confidence: 99%

Formal guidelines: management of acute respiratory distress syndrome

Papazian

Aubron

Brochard

et al. 2019

Ann. Intensive Care

558

480

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Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.

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Section: Methodsmentioning

confidence: 99%

Formal guidelines: management of acute respiratory distress syndrome

Papazian

Aubron

Brochard

et al. 2019

Ann. Intensive Care

558

480

View full text Add to dashboard Cite

show abstract

“…Although cisatracurium is the only NMBA that has been studied in randomized controlled trials, it is unknown if the benefit is confined to cisatracurium, although one single-center retrospective study that compared atracurium to cisatracurium for severe ARDS found no difference in clinical outcomes. 117 Atracurium, rocuronium, and vecuronium are other intermediate-acting NMBA and can be given as continuous infusion and should be considered in contingency care (Table 4). 112 Pancuronium, a long-acting NMBA, can also be considered for continuous infusion in crisis care.…”

Section: Paralysis Strategies In Covid-19 Patientsmentioning

confidence: 99%

Sedation, Analgesia, and Paralysis in COVID-19 Patients in the Setting of Drug Shortages

Ammar

Sacha

Welch

et al. 2020

J Intensive Care Med

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The rapid spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global pandemic. The 2019 coronavirus disease (COVID-19) presents with a spectrum of symptoms ranging from mild to critical illness requiring intensive care unit (ICU) admission. Acute respiratory distress syndrome is a major complication in patients with severe COVID-19 disease. Currently, there are no recognized pharmacological therapies for COVID-19. However, a large number of COVID-19 patients require respiratory support, with a high percentage requiring invasive ventilation. The rapid spread of the infection has led to a surge in the rate of hospitalizations and ICU admissions, which created a challenge to public health, research, and medical communities. The high demand for several therapies, including sedatives, analgesics, and paralytics, that are often utilized in the care of COVID-19 patients requiring mechanical ventilation, has created pressure on the supply chain resulting in shortages in these critical medications. This has led clinicians to develop conservation strategies and explore alternative therapies for sedation, analgesia, and paralysis in COVID-19 patients. Several of these alternative approaches have demonstrated acceptable levels of sedation, analgesia, and paralysis in different settings but they are not commonly used in the ICU. Additionally, they have unique pharmaceutical properties, limitations, and adverse effects. This narrative review summarizes the literature on alternative drug therapies for the management of sedation, analgesia, and paralysis in COVID-19 patients. Also, this document serves as a resource for clinicians in current and future respiratory illness pandemics in the setting of drug shortages.

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“…It has been reported that paralysis can be continued beyond 48 hours without increasing the overall mortality [35], while whether longer or shorter infusions of NMBA would provide additional bene t or change the prevalence of ICUacquired weakness is unknown. Moreover, when compared with vecuronium [36] or atracurium [37], cisatracurium, used in all of our included trials, was not associated with a difference in mortality, which suggest that those short-term positive outcomes were not cisatracurium-speci c. Thus, a more economical selection of neuromuscular blocking agents in clinical settings should be considered in future.…”

Section: Discussionmentioning

confidence: 76%

Early neuromuscular blockade for acute respiratory distress syndrome: a systematic review with meta-analysis and trial sequential analysis

Zhang¹,

Liu²,

Fei-fei³

et al. 2020

Preprint

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Background To assess the effect of neuromuscular blockade on outcomes in adults with acute respiratory distress syndrome who are receiving mechanical ventilation.Methods We searched from inception to 24 may 2019 in MEDLINE, EMBASE and CENTRAL. We included randomized clinical trials comparing early neuromuscular blockade to placebo or usual care in adults with moderate to severe ARDS (PaO2/FiO2≤150mmHg). The primary outcome was 90-day and 28-day mortality. Secondary outcomes included oxygenation, driving pressure, incidence of barotrauma and pneumothorax, ventilator-free days at 28 days and ICU-acquired weakness by 28 days. In addition, a trial sequential analysis was performed.Results Four trials were included with a total of 1437 patients. For the primary outcomes, there was no effect of neuromuscular blocking agent (NMBA) on 90-day mortality [relative risk (RR) 0.91, 95%CI 0.72-1.15, p=0.41] or 28-day mortality [RR 0.55, 95%CI 0.22-1.12, p=0.08], or ventilator-free days at 28 days [mean difference (MD) 0.86, 95%CI -0.61-2.33, p=0.25]. NMBA improved PaO2/FiO2 at 72h [MD 15.21, 95%CI 1.90-28.52, p=0.03]. NMBA reduced the incidence of barotrauma [RR 0.55, 95%CI 0.35-0.85, p=0.007] and pneumothorax [RR 0.46, 95%CI 0.28-0.76, p=0.002] and increased the driving pressure at 24 hours [MD 0.75, 95%CI 0.24-1.26, p=0.004] and 48 hours [MD 0.75, 95%CI 0.08-1.43, p=0.03]. There is no statistically significant difference in ICU-acquired weakness by 28 days [RR 1.20, 95%CI 0.72-1.98, p=0.49].Conclusions In adults with moderate to severe ARDS treated with early neuromuscular blockade, oxygenation increase, incidence of barotrauma and pneumothorax are reduced, ICU-acquired weakness are not increased, but 90-day and 28-day mortality are not decreased. Further large-scale, multicenter studies are needed to confirm our results.Trial Registry PROSPERO (ID: CRD42019137832)

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Comparison of Cisatracurium Versus Atracurium in Early ARDS

Cited by 15 publications

References 22 publications

Formal guidelines: management of acute respiratory distress syndrome

Formal guidelines: management of acute respiratory distress syndrome

Sedation, Analgesia, and Paralysis in COVID-19 Patients in the Setting of Drug Shortages

Early neuromuscular blockade for acute respiratory distress syndrome: a systematic review with meta-analysis and trial sequential analysis

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