From the Guidelines
Cisatracurium or atracurium is the recommended muscle relaxant for patients with impaired renal function undergoing dialysis due to their unique metabolism. When considering muscle relaxants for patients with impaired renal function, it is crucial to choose drugs that are not primarily eliminated by the kidneys to avoid accumulation and increased risk of side effects. The study by 1 provides guidance on the use of neuromuscular blocking agents (NMBAs) in critically ill patients, including those with significant renal disease. Key points to consider include:
- The majority of patients can be managed effectively with certain NMBAs, but patients with significant hepatic or renal disease require special consideration.
- Cisatracurium or atracurium is recommended for patients with significant hepatic or renal disease due to their unique metabolism, which reduces the risk of accumulation and toxicity in patients with impaired renal function.
- Patients receiving NMBAs should be closely monitored, both clinically and by train-of-four (TOF) monitoring, to adjust the degree of neuromuscular blockade and minimize the risk of adverse effects.
- The use of NMBAs should be optimized by providing adequate sedation and analgesia, and efforts should be made to discontinue their use as soon as possible, especially in patients receiving corticosteroids.
- Regular monitoring and dose adjustments are critical to prevent drug accumulation and increased side effects, including excessive sedation, hypotension, and respiratory depression. It is essential to consult with a nephrologist before initiating any muscle relaxant therapy in dialysis patients to ensure the best possible outcomes and minimize the risk of adverse effects.
From the FDA Drug Label
Vecuronium is well tolerated without clinically significant prolongation of neuromuscular blocking effect in patients with renal failure who have been optimally prepared for surgery by dialysis
- Vecuronium is suitable for patients with impaired renal function undergoing dialysis.
- The drug label states that vecuronium is well tolerated in patients with renal failure who have been optimally prepared for surgery by dialysis, without significant prolongation of neuromuscular blocking effect 2.
- Key points:
- Vecuronium can be used in patients with renal failure.
- Patients should be optimally prepared for surgery by dialysis.
- No significant prolongation of neuromuscular blocking effect is expected.
From the Research
Muscle Relaxants for Patients with Impaired Renal Function Undergoing Dialysis
- Rocuronium-sugammadex can be used as an alternative to succinylcholine for muscle relaxation in patients undergoing hemodialysis, but the effect of residual sugammadex after hemodialysis on the subsequently administered rocuronium should be considered 3.
- All four muscle relaxants (vecuronium, atracurium, mivacurium, and rocuronium) can be safely used in patients with end-stage renal failure, but the onset of the relaxants may be accelerated and the no-response period of mivacurium may be prolonged in patients with end-stage renal failure undergoing dialysis therapy 4.
- The clearance of rocuronium and sugammadex is reduced in patients with severe to end-stage renal failure, resulting in a longer duration of muscle relaxation and an increased risk of postoperative residual neuromuscular block 5.
- Rocuronium can be used in patients with severe renal failure (creatinine clearance <30 mL/min), but the duration of muscle relaxation is longer and results in an increased risk of postoperative residual neuromuscular block 6.
- Vecuronium can be used in patients with end-stage renal failure, offering advantages such as a shorter duration of action and easy reversibility 7.
Suitable Muscle Relaxants
- Rocuronium-sugammadex: can be used, but with consideration of the effect of residual sugammadex after hemodialysis on the subsequently administered rocuronium 3, 5, 6.
- Vecuronium: can be used, with a shorter duration of action and easy reversibility 4, 7.
- Atracurium: can be safely used in patients with end-stage renal failure, with no significant difference in duration of action or recovery 4.
- Mivacurium: can be safely used in patients with end-stage renal failure, but with a prolonged no-response period 4.