.jpg "Caitlin Thomas, BCCCP, PharmD photo")
Caitlin Thomas, BCCCP, PharmD
Clinical Pharmacy Specialist
AdventHealth Orlando
Orlando, Florida
Disclosure information not submitted.
Julie Willmon, BCCCP, BCPS, PharmD
Clinical Pharmacy Specialist
AdventHealth Winter Park, United States
Disclosure information not submitted.
Tracey Smith, PharmD
Clinical Pharmacist
Advent Health, United States
Disclosure information not submitted.
Eric Pyles, BCCCP, PharmD
Critical Care Pharmacy Specialist
Florida Hospital Orlando, United States
Disclosure information not submitted.
Title: Fixed Dose vs. Titratable Strategy for Cisatracurium Continuous Infusion for Ventilator Management
Introduction: Neuromuscular blocking agents are often used in patients to improve ventilator synchrony and therefore improve oxygenation; however, dosing strategy and monitoring remain an ongoing controversy. Several randomized controlled trials used a relatively high dose, fixed-dosing strategy as a methodological strategy in order to maintain blinding of the studies. The objective of this study was to compare a fixed dose vs. titratable dosing strategy on ventilator management.
Methods: A retrospective review compared continuous infusion (CI) cisatracurium on a fixed-dose strategy with a titratable strategy. Patients were included in the study if they were males or non-pregnant females at least 18 years of age, on mechanical ventilatory support, and received a CI of cisatracurium. Patients were excluded if they were transferred from an outside hospital already on cisatracurium CI. The primary end point was improvement in oxygenation within 120 hours of cisatracurium CI initiation as evidenced by the PaO2/FiO2 ratio as a surrogate marker. Secondary endpoints included total duration of infusion, total average daily dose of cisatracurium received, the number of adjustments made over the course of therapy, ICU length of stay, and mortality.
Results: From January 2017 through December 2019, 80 patients were screened, and 37 patients were included in each group. Baseline characteristics were similar between groups. No difference was found in oxygenation within 120 hours of cisatracurium CI initiation between the two groups measured by the PaO2/FiO2 ratio as a surrogate marker (p = 0.439). The total average daily dose of cisatracurium CI was 386.9 mg vs. 278.5 mg (p = 0.009). The average number of adjustments made during the duration of cisatracurium CI were 0.4 vs. 7.1 (p = 0.000034). There were no differences in other secondary endpoints.
Conclusion: Utilizing a fixed-dosing strategy vs. titrateable resulted in a much larger cumulative dose of cisatracurium and lower monitoring requirements and nurse adjustments. Utilizing a titration strategy based on clinical assessment without the use of PNS and TOF may be an optimal strategy to reduce the total cumulative dose of cisatracurium administration while also reducing frequency of manipulations based solely on PNS and TOF monitoring without sacrificing clinical efficacy.