How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study View Full Text


Ontology type: schema:ScholarlyArticle      Open Access: True


Article Info

DATE

2017-08-02

AUTHORS

Sami Hraiech, Jean-Marie Forel, Christophe Guervilly, Romain Rambaud, Samuel Lehingue, Mélanie Adda, Pierre Sylla, Sabine Valera, Julien Carvelli, Marc Gainnier, Laurent Papazian, Jérémy Bourenne

ABSTRACT

BACKGROUND: Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO2/FiO2 ratio less than 120 with a PEEP ≥5 cm H2O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters. RESULTS: Thirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p < 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p < 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient-ventilator asynchronies occurred in 4 patients. CONCLUSION: A nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block. More... »

PAGES

79

Identifiers

URI

http://scigraph.springernature.com/pub.10.1186/s13613-017-0305-2

DOI

http://dx.doi.org/10.1186/s13613-017-0305-2

DIMENSIONS

https://app.dimensions.ai/details/publication/pub.1090955543

PUBMED

https://www.ncbi.nlm.nih.gov/pubmed/28770545


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11 schema:description BACKGROUND: Neuromuscular blocking agents (NMBAs) have been shown to improve the outcome of the most severely hypoxemic, acute respiratory distress syndrome (ARDS) patients. However, the recommended dosage as well as the necessity of monitoring the neuromuscular block is unknown. We aimed to evaluate the efficiency of a nurse-directed protocol of NMBA administration based on a train-of-four (TOF) assessment to ensure a profound neuromuscular block and decrease cisatracurium consumption compared to an elevated and constant dose regimen. A prospective open labeled study was conducted in two medical intensive care units of two French university hospitals. Consecutive ARDS patients with a PaO<sub>2</sub>/FiO<sub>2</sub> ratio less than 120 with a PEEP ≥5 cm H<sub>2</sub>O were included. Cisatracurium administration was driven by the nurses according to an algorithm based on TOF monitoring. The primary endpoint was cisatracurium consumption. The secondary endpoints included the quality of the neuromuscular block, the occurrence of adverse events, and the evolution of ventilatory and blood gas parameters. RESULTS: Thirty patients were included. NMBAs were used for 54 ± 30 h. According to this new algorithm, the initial dosage of cisatracurium was 11.8 ± 2 mg/h, and the final dosage was 14 ± 4 mg/h, which was significantly lower than in the ACURASYS study protocol (37.5 mg/h with a constant infusion rate (p &lt; 0.001). The overall cisatracurium dose used was 700 ± 470 mg in comparison with 2040 ± 1119 mg for patients had received the ACURASYS dosage for the same period (p &lt; 0.001). A profound neuromuscular block (TOF = 0, twitches at the ulnar site) was obtained from the first hour in 70% of patients. Modification of the cisatracurium dosage was not performed from the beginning to the end of the study in 60% of patients. Patient-ventilator asynchronies occurred in 4 patients. CONCLUSION: A nurse-driven protocol based on TOF monitoring for NMBA administration in ARDS patients was able to decrease cisatracurium consumption without significantly affecting the quality of the neuromuscular block.
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18 schema:keywords ACURASYS study protocol
19 ARDS patients
20 French university hospital
21 NMBA
22 NMBA administration
23 PAO
24 PEEP
25 Secondary endpoints
26 TOF monitoring
27 University Hospital
28 acute respiratory distress syndrome patients
29 administration
30 adverse events
31 agents
32 algorithm
33 assessment
34 block
35 blood gas parameters
36 care unit
37 cisatracurium
38 cisatracurium administration
39 cisatracurium consumption
40 consecutive ARDS patients
41 constant dose regimen
42 consumption
43 decrease cisatracurium consumption
44 distress syndrome (ARDS) patients
45 dosage
46 dose regimen
47 efficiency
48 endpoint
49 events
50 evolution
51 evolution of ventilatory
52 final dosage
53 gas parameters
54 hospital
55 initial dosage
56 intensive care unit
57 medical intensive care unit
58 monitoring
59 necessity
60 neuromuscular block
61 new algorithm
62 nurse-directed protocol
63 nurses
64 occurrence
65 outcomes
66 parameters
67 patients
68 primary endpoint
69 profound neuromuscular block
70 protocol
71 quality
72 ratio
73 regimen
74 respiratory distress syndrome patients
75 study
76 study protocol
77 syndrome patients
78 train
79 units
80 ventilatory
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