What is the use of Cisatracurium (Nimbex) infusion in Intensive Care Unit (ICU)?

From the Guidelines

Cisatracurium (Nimbex) infusion is used in the Intensive Care Unit (ICU) to facilitate mechanical ventilation and improve outcomes in patients with acute respiratory distress syndrome (ARDS).

Indications for Use

• The most common indication for NMBA use in the ICU is to facilitate mechanical ventilation 1
• Cisatracurium infusion has been shown to improve adjusted survival rates and increase organ failure-free days in patients with early ARDS and a PaO2/FIO2 < 150 mm Hg 1
• Neuromuscular blockade may also reduce oxygen consumption by decreasing the work of breathing and respiratory muscle blood flow 1

Benefits and Risks

• Cisatracurium infusion has been associated with improved oxygenation, reduced risk of death at 28 days and at hospital discharge, and reduced risk of barotrauma 1
• However, the use of NMBAs is also linked to an increased risk of ICU-acquired weakness, although recent studies have found that cisatracurium may not increase this risk 1
• The mechanism of benefit of neuromuscular blockade in ARDS remains uncertain, but it may prevent ventilator asynchrony and decrease airway pressures and lung stress 1

Clinical Practice Guidelines

• Recent clinical practice guidelines recommend the use of NMBA infusion in patients with moderate to severe ARDS, based on the results of randomized clinical trials 1
• However, the use of NMBAs should be reserved for patients with the most severe ARDS, mainly in the acute phase and during the first 48 hours of mechanical ventilation 1
• Sedation should be reduced and partial ventilator support can be used to promote respiratory muscle activity whenever gas exchange, respiratory mechanics, and hemodynamic status have improved 1

From the FDA Drug Label

INDICATIONS AND USAGE: Cisatracurium Besylate Injection is an intermediate-onset/intermediate-duration neuromuscular blocking agent indicated for inpatients and outpatients as an adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation in the ICU. Infusion in the Intensive Care Unit (ICU) The principles for infusion of cisatracurium in the OR are also applicable to use in the ICU. An infusion rate of approximately 3 mcg/kg/min (range: 0.5 to 10. 2 mcg/kg/min) should provide adequate neuromuscular block in adult patients in the ICU.

The use of Cisatracurium (Nimbex) infusion in the Intensive Care Unit (ICU) is to provide skeletal muscle relaxation during mechanical ventilation. The recommended infusion rate is approximately 3 mcg/kg/min, with a range of 0.5 to 10.2 mcg/kg/min to achieve adequate neuromuscular block in adult patients 2.

From the Research

Use of Cisatracurium in Intensive Care Unit (ICU)

The use of cisatracurium (Nimbex) infusion in Intensive Care Unit (ICU) is a common practice for facilitating mechanical ventilation in critically ill patients. The following points highlight the use of cisatracurium in ICU:

• Cisatracurium is used to provide muscle relaxation in critically ill patients, particularly those who are not responding to sedatives and analgesics alone 3, 4.
• The infusion rate of cisatracurium varies, with an average rate of 2.6 +/- 0.2 micrograms.kg-1.min-1 and a mean duration of 80 +/- 7 hours 3.
• Cisatracurium has been compared to other neuromuscular blocking agents, such as vecuronium and atracurium, in terms of efficacy and safety 3, 4, 5.
• The recovery of neuromuscular function after discontinuation of cisatracurium infusion is significantly faster compared to vecuronium 3.
• Cisatracurium may be associated with better outcomes in patients with acute respiratory distress syndrome (ARDS) and traumatic brain injury 6, 5.
• However, tachyphylaxis to cisatracurium can occur, particularly during long-term infusion, which may lead to inadequate ventilation and increased risk of dose-dependent side effects 7.

Comparison with Other Neuromuscular Blocking Agents

Cisatracurium has been compared to other neuromuscular blocking agents, including:

• Vecuronium: Cisatracurium has a faster recovery profile and may be associated with better outcomes in patients with ARDS 3, 5.
• Atracurium: Cisatracurium is an isomer of atracurium and has similar efficacy and safety profiles 4.

Clinical Outcomes

The use of cisatracurium in ICU has been associated with various clinical outcomes, including:

• Reduced duration of mechanical ventilation and ICU stay 5.
• Improved outcomes in patients with ARDS and traumatic brain injury 6, 5.
• No significant difference in mortality compared to vecuronium 5.