How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study

Abstract

BackgroundNeuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO2/FiO2 ratio less than 120 with a PEEP ≥5 cm H2O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters.ResultsThirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient–ventilator asynchronies occurred in 4 patients.ConclusionA nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block.

Neuromuscular blockade in patients with ARDS: a rapid practice guideline

“…An RCT of 30 patients compared TOF assessment to clinical assessment by bedside nurses and found no difference in the mean total paralysis time, dose of cisatracurium, and mean recovery time after cessation of paralytic agent [ 28 ]. Another study evaluated a nurse-driven protocol based of cisatracurium infusion titration based on TOF monitoring in 30 ARDS patients and identified that nurses were able to decrease the amount of cisatracurium administered without significantly affecting the quality of the neuromuscular block achieved [ 29 ]. The optimal strategy to assess the adequacy of paralysis is unclear, clinicians should use the strategy that they are most comfortable with.…”

Myorelaxants in ARDS patients

“…Monitoring the depth of neuromuscular blockade aims to ensure that objectives for muscle relaxation are reached in an anesthetized patient, that the lowest NMBAs dose is used (which could limit the development of ICU-acquired weakness), and, less frequently, that deleterious residual neuromuscular blockade after extubation is avoided. Different studies have shown that monitoring the level of neuromuscular blockade is associated with a reduction in the amount of NMBAs along with a decreased incidence of persistent neuromuscular weakness and that the management of blockade in ARDS patients by nurses is a secure procedure [ 61 , 62 ]. The depth of neuromuscular blockade should be assessed by repeated clinical and qualitative evaluation in addition to monitoring for adequate sedation and analgesia.…”

“…Monitoring of the TOF 2 : objective 0/4 response at the ulnar site or 2/4 at the facial site [ 61 , 63 ]…”

To Block or Not: Updates in Neuromuscular Blockade in Acute Respiratory Distress Syndrome

“…21 Recently, the TOF-ARDS study evaluated whether a nurse-driven algorithm, based on TOF monitoring, could reduce the exposure of cisatracurium compared with a flat-dose regimen in patients with moderate-severe ARDS (PaO 2 /FiO 2 < 120 mm Hg). 29 The mean final dose was 14 ± 4 mg/h compared with 37.5 mg/h. Additionally, a cost savings of 70 euros per patient was noted with the use of titratable cisatracurium for the duration of treatment.…”

“…Additionally, a cost savings of 70 euros per patient was noted with the use of titratable cisatracurium for the duration of treatment. 29 Additionally, in a retrospective, single-center, observational cohort study, 117 patients with ARDS were categorized to flat-dose or titration-based dosing regimens. 30 No differences in clinical end points, including percentage change in PaO 2 /FiO 2 from baseline to 48 hours, mechanical ventilation days, or mortality, were observed.…”