From the Guidelines
Cisatracurium is suitable for Rapid Sequence Intubation (RSI) in Acute Respiratory Distress Syndrome (ARDS).
Key Points
- Cisatracurium is the preferred neuromuscular blocking agent (NMBA) for use in ARDS patients, as it has been studied in large randomized controlled trials (RCTs) and has shown to improve oxygenation and reduce mortality 1.
- The recommended dose of cisatracurium is a 15 mg bolus followed by an infusion of 37.5 mg/h for 48 hours, although the dose may be titrated to clinical paralytic effect 1.
- Neuromuscular blockade with cisatracurium has been shown to prevent ventilator asynchrony, decrease airway pressures, and reduce lung stress, which may contribute to its beneficial effects in ARDS patients 1.
- The use of neuromuscular blocking agents should be reserved for patients with severe ARDS, mainly in the acute phase and during the first 48 hours of mechanical ventilation, and requires sustained deep sedation 1.
- Adverse effects of prolonged use of neuromuscular blocking agents, including cisatracurium, include myopathy, deleterious effects on the diaphragm, and ICU-acquired weakness, especially in patients receiving concomitant corticosteroids 1.
Considerations
- The decision to use cisatracurium in ARDS patients should be based on the potential benefits and harms, and clinicians should consider the individual patient's clinical context and response to treatment 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
PRECAUTIONS: Because of its intermediate onset of action, cisatracurium is not recommended for rapid sequence endotracheal intubation. The answer is no, Cisatracurium is not suitable for RSI in ARDS, or any other condition, due to its intermediate onset of action 2.
From the Research
Cisatracurium in RSI for ARDS
- Cisatracurium is a suitable neuromuscular blocking agent (NMBA) for use in critically ill patients, including those with acute respiratory distress syndrome (ARDS) 3.
- The use of cisatracurium has been associated with better outcomes in ARDS, including improved oxygenation and reduced mortality 3, 4.
- Cisatracurium has been compared to other NMBAs, such as vecuronium and atracurium, and has been found to have favorable pharmacological characteristics, including a lower risk of adverse events and improved efficacy 3, 5, 4.
Pharmacokinetics and Safety
- The pharmacokinetics of cisatracurium in patients with ARDS are similar to those in patients without organ failure undergoing elective surgery 6.
- Cisatracurium has been found to be safe and effective for use in critically ill patients, with no significant accumulation of laudanosine, a metabolite associated with seizure activity 6.
- The use of cisatracurium has been associated with a lower risk of adverse events, including anaphylaxis and cardiovascular instability, compared to other NMBAs 3, 4.
Comparison to Other NMBAs
- Cisatracurium has been compared to atracurium in the treatment of ARDS, and has been found to be a safe and effective alternative 5.
- Cisatracurium has also been compared to vecuronium, and has been found to be associated with improved outcomes, including reduced duration of mechanical ventilation and ICU stay 4.
- The use of cisatracurium has been found to be more expensive than comparable agents, including atracurium, but may be associated with improved outcomes and reduced costs in the long term 3, 5.
Dosing and Titration
- The optimal dosing and titration of cisatracurium in patients with ARDS is not well established, but studies suggest that train-of-four titration may be associated with improved outcomes and reduced drug utilization compared to fixed dosing 7.