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Cisatracurium infusion for neuromuscular blockade in the pediatric intensive care unit: A dose-finding study
Folafoluwa O. Odetola1, Varsha Bhatt-Mehta, Jihad Zahraa
1Department of Pediatrics and Communicable Diseases, Division of Pediatric Critical Care (FOO, JZ, FWM, JRC), and the College of Pharmacy and the Department of Pharmacy Services, University of Michigan Medical Center, Ann Arbor, MI.
Insights
Cisatracurium besylate is safe and effective for infants aged 0-2 years, showing good efficacy in prolonged neuromuscular blockade. Recovery from neuromuscular blockade was observed without adverse events in this pediatric population.
Area of Science:
- Pediatric intensive care
- Pharmacology
- Anesthesiology
Background:
- Neuromuscular blocking agents are essential in pediatric intensive care.
- Limited data exists on cisatratracurium besylate use in infants.
- Evaluating cisatracurium besylate in this age group is crucial for safe clinical practice.
Purpose of the Study:
- To assess the safety and efficacy of cisatracurium besylate in infants aged 0-2 years.
- To determine appropriate dosing for continuous infusion in this population.
- To monitor recovery profiles and potential adverse events.
Main Methods:
- Open-label study in a tertiary pediatric intensive care unit.
- Eleven infants (0-2 years) received cisatracurium besylate via bolus and continuous infusion.
- Neuromuscular blockade monitored by train-of-four response and electromyography.
- Pharmacokinetic analysis of cisatracurium and laudanosine levels.
Main Results:
- Mean infusion rate was 5.4 ± 3.0 µg/kg/min to maintain blockade.
- Mean infusion duration was 64.5 ± 36 hours.
- Neuromuscular recovery times were 26.6 ± 10.4 min (10%) and 74.8 ± 32 min (100%).
- No significant hemodynamic changes were observed.
- Four patients (37%) had undetectable cisatracurium levels at full recovery.
Conclusions:
- Cisatracurium besylate is a safe and effective neuromuscular blocking agent for infants 0-2 years.
- Longer recovery periods were noted compared to older children, without immediate adverse events.
- Continuous infusion provides reliable neuromuscular blockade in this pediatric population.
Abstract:
OBJECTIVE: To evaluate the safety and efficacy of cisatracurium besylate, a neuromuscular blocking agent in infants zero to 2 yrs of age. DESIGN: An open-label study to evaluate efficacy and safety of cisatracurium as a continuous infusion in infants. SETTING: A tertiary pediatric intensive care unit. PATIENTS: Eleven children, 0-2 yrs of age, requiring prolonged neuromuscular blockade. INTERVENTIONS: Cisatracurium besylate, 0.1 mg/kg, was administered as an intravenous bolus dose and repeated if necessary until a >90% neuromuscular blockade, as determined by train-of-four response, was achieved. Patients were allowed to recover to 90% blockade (I/IV twitch) after the initial bolus and were administered continuous infusion at 2 &mgr;g/kg/min. The continuous infusion rate was adjusted to maintain a train-of-four response of 0-I/IV, with an increase in the rate preceded by a bolus dose of cisatracurium besylate. An electromyographic monitor was used to measure recovery at the end of infusion, when possible. Heart rate and blood pressure were recorded after the initial bolus dose and after changes in infusion rates. Blood samples were drawn at steady-state during cisatracurium infusion at several different times during the study and at the end of infusion for measurement of plasma cisatracurium and laudanosine concentrations. MEASUREMENTS AND MAIN RESULTS: The mean infusion rate of cisatracurium besylate required to maintain train-of-four response of 0-I/iv was 5.4 +/- 3.0 &mgr;g/kg/min. The mean total duration of infusion was 64.5 +/- 36 hrs. Ten percent and complete neuromuscular recovery occurred at 26.6 +/- 10.4 and 74.8 +/- 32 mins, respectively, after discontinuation of infusion. Mean cisatracurium and laudanosine concentrations were 342.5 +/- 169 and 163.3 +/- 116 ng/mL, respectively. Four (37%) patients had undetectable (<5 ng/mL) cisatracurium concentrations at the time of 100% neuromuscular recovery (train-of-four response of IV/IV or no fade at 50 mA on the electromyogram). No significant hemodynamic changes were observed during treatment with cisatracurium besylate (p <.05). CONCLUSIONS: A longer period of recovery from neuromuscular blockade was observed compared with reports of older children. Recovery from neuromuscular blockade after long-term use was not associated with any adverse events in the immediate postinfusion period. Cisatracurium besylate is a safe and effective neuromuscular blocking agent for children 0-2 yrs of age.