Holly Lanham
Duke University Medical Center
Durham, North Carolina
Disclosure information not submitted.
Erica Konopka, PharmD
Pharmacist
Duke University Health System, United States
Disclosure information not submitted.
Anne Mathews, MD
Division of Pulmonary, Allergy & Critical Care Medicine
Duke University Hospital, United States
Disclosure information not submitted.
Craig Rackley, MD
Physician
Duke University Hospital, United States
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Lexie Zidanyue Yang, MB
Statistician
Duke University Hospital, United States
Disclosure information not submitted.
.jpg "Bridgette Kram, BCCCP, BCPS, PharmD photo")
Bridgette Kram, BCCCP, BCPS, PharmD
MICU Clinical Pharmacist
Duke University Hospital
Durham, North Carolina
Disclosure information not submitted.
Title: Evaluating Rocuronium as an Alternative to Cisatracurium in Acute Respiratory Distress Syndrome
INTRODUCTION/HYPOTHESIS: Neuromuscular blockers (NMBs) are utilized in acute respiratory distress syndrome (ARDS) for refractory hypoxemia although the mortality benefit is unclear. Continuous infusion cisatracurium use is well-described in critically ill patients; however, rocuronium has limited safety and efficacy data in this population. The purpose of this study is to determine the comparative safety of cisatracurium and rocuronium in the management of patients with moderate-severe ARDS receiving continuous neuromuscular blockade.
Methods: This single-center, retrospective cohort study included patients with a continuous infusion (CI) NMB ordered for an indication of ARDS between September 2019 and December 2020. Both CI NMBs were titrated every 30 minutes to cessation of respiratory effort and to maintain train of four (TOF) between 2 to 4 twitches out of 4 stimulations as the goal range for safety. Included patients were 18 years of age or older admitted to the medical or surgical intensive care unit. The primary endpoint was the proportion of TOF documented within goal range.
Results: A total of 115 patients were included in the analysis (cisatracurium n=86, rocuronium n=29). Patients remained on NMBs for a median of 2 days in both groups with median infusion rates of 2.5 mcg/kg/min and 5 mcg/kg/min for cisatracurium and rocuronium, respectively. Overall, the median proportion of TOF within goal range was higher for the cisatracurium group than the rocuronium group, but the difference was not statistically significant (50% vs 43%, p=0.26). The median TOF documented 4 out of 4 twitches was 25% in the cisatracurium group and 17% in the rocuronium group. The cisatracurium group appeared to have an increasing incidence of TOF within goal range over time and was titrated at a relatively stable rate between 2 and 3 mcg/kg/min, whereas rocuronium titration rates were more widely variable between 3.5 and 6 mcg/kg/min.
Conclusions: A non-statistically significant difference in the proportion of TOF within goal range was observed between cisatracurium and rocuronium. Continuous infusion rocuronium may be a reasonable alternative to cisatracurium for patients with moderate to severe ARDS requiring continuous NMB.