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Continuous Infusion Versus Intermittent Boluses of Cisatracurium in the Early Management of Pediatric Acute
Mohamed K Talaat1, Hanan M Ibrahim2, Hebatallah A Bedair3
1Department of Clinical Pharmacy, Faculty of Pharmacy, Tanta University, Tanta, Egypt.
Insights
Continuous cisatracurium infusion improved outcomes for pediatric acute respiratory distress syndrome (PARDS) patients, particularly those with moderate-to-severe disease. This method led to earlier mechanical ventilator (MV) extubation and shorter pediatric intensive care unit (PICU) stays compared to intermittent boluses.
Area of Science:
- Critical Care Medicine
- Pediatric Pulmonology
- Pharmacology
Background:
- Pediatric acute respiratory distress syndrome (PARDS) presents significant morbidity and mortality challenges.
- Neuromuscular blocking agents (NMBAs) have shown controversial efficacy in adult ARDS, with limited data in pediatric populations.
- Understanding optimal NMBA administration is crucial for managing severe pediatric respiratory failure.
Purpose of the Study:
- To compare the efficacy of continuous cisatracurium infusion versus intermittent bolus administration in pediatric patients with PARDS.
- To evaluate the impact of different cisatracurium administration methods on mechanical ventilation duration and other critical care outcomes.
- To identify specific PARDS severity subgroups that may benefit most from continuous infusion therapy.
Main Methods:
- A multicenter randomized controlled study involving pediatric patients diagnosed with PARDS.
- Patients were randomized into two groups: intermittent cisatracurium boluses (Group I) and continuous 24-hour intravenous infusion (Group II).
- Primary outcome was duration on mechanical ventilation (MV); secondary outcomes included ventilatory parameters and pediatric intensive care unit (PICU) length of stay.
Main Results:
- Continuous cisatracurium infusion (Group II) was associated with significantly higher extubation rates from MV compared to intermittent boluses (Group I), especially in moderate-to-severe PARDS.
- Patients receiving continuous infusion experienced earlier PICU discharge, with a more pronounced effect in moderate-to-severe disease.
- In moderate-to-severe PARDS, continuous infusion led to improved oxygenation by day 7, evidenced by lower fraction of inspired oxygen, mean airway pressure, and oxygenation index.
Conclusions:
- Continuous cisatracurium infusion offers superior outcomes in pediatric acute respiratory distress syndrome (PARDS) compared to intermittent boluses.
- Benefits include enhanced oxygenation, earlier mechanical ventilation (MV) extubation, and reduced pediatric intensive care unit (PICU) length of stay.
- These advantages are primarily observed in patients with moderate-to-severe PARDS; outcomes are similar in mild PARDS.
Objectives:
Pediatric acute respiratory distress syndrome (PARDS) is a critical condition associated with considerable morbidity and mortality. Trials in adults showed controversial results about neuromuscular blocking agents (NMBAs) use in adult acute respiratory distress syndrome. With limited data in PARDS, we sought to compare the outcomes of continuous cisatracurium infusion versus intermittent bolus administration in children with PARDS.
Methods:
This multicenter randomized controlled study was performed on patients with PARDS. Enrolled patients were categorized into: group I: patients treated with intermittent boluses of cisatracurium and group II: patients treated with intravenous infusion of cisatracurium for 24h. The primary outcome was the duration on mechanical ventilator (MV). Additional results included changes in ventilatory parameters, and length of pediatric intensive care unit (PICU) stay.
Results:
Group II was associated with a significantly higher extubation from MV compared to group I, after accounting for death as a competing event. This association was confined to moderate-to-severe PARDS (subdistribution hazard ratio (SHR) 3.25, 95% CI 1.69-6.25, p<0.001) and not observed in mild PARDS. Similar with earlier PICU discharge, with stronger effect in moderate-to-severe disease (SHR 3.16, 95% CI 1.64-6.11, p<0.001). By day 7, patients with moderate-to-severe PARDS in group II showed lower fraction of inspired oxygen, mean airway pressure, and oxygenation index.
Conclusions:
In PARDS, cisatracurium infusion was associated with better oxygenation, earlier extubation from MV and shorter PICU stay compared to intermittent boluses, with benefits limited to moderate-to-severe disease. Outcomes were similar in mild PARDS.
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