Related Experiment Videos
Increased cis-atracurium requirements during prolonged administration to a child
1Department of Child Health, University of Missouri, Columbia 65212, USA.
Insights
Critically ill infants receiving prolonged cis-atracurium infusions for neuromuscular blockade may require significantly increased doses. Continuous monitoring with a peripheral nerve stimulator is essential for dose titration.
Area of Science:
- Critical Care Medicine
- Pediatric Anesthesiology
- Pharmacology
Background:
- Prolonged mechanical ventilation in infants necessitates neuromuscular blockade.
- Cis-atracurium is a commonly used neuromuscular blocking agent.
- Previous studies in adults showed stable cis-atracurium requirements over shorter durations.
Observation:
- A seven-month-old infant required mechanical ventilation and neuromuscular blockade for six weeks due to multi-system organ failure.
- Cis-atracurium infusion rates were adjusted based on train-of-four monitoring.
- Initial infusion requirements of 2.8 mcg/kg/min increased to 22.3 mcg/kg/min by day 40.
Findings:
- Significant increases in cis-atracurium infusion requirements were observed during prolonged administration in a critically ill infant.
- The dose escalation was necessary to maintain adequate neuromuscular blockade over a six-week period.
- This contrasts with findings in adult patients with shorter infusion durations.
Implications:
- Clinicians should anticipate and monitor for escalating cis-atracurium requirements in infants undergoing prolonged mechanical ventilation.
- Peripheral nerve stimulator monitoring is crucial for accurate dose titration and patient safety.
- Further research is warranted to understand the mechanisms behind increased cis-atracurium tolerance in pediatric critical care settings.
Purpose:
To report increase infusion requirements of cis-atracurium during prolonged infusion (six weeks) to provide neuromuscular blockade in a child during prolonged mechanical ventilation. Despite a previous study in adult patients which demonstrated no increase in infusion requirements over five days, we noted a considerable increase over six weeks.
Clinical Features:
A seven month old infant required prolonged mechanical ventilation and neuromuscular blockade following an episode of multi-system organ failure from pseudomembranous colitis. The infusion of cis-atracurium was adjusted according to the train-of-four response obtained with a peripheral nerve stimulator using standard train-of-four monitoring. Initial infusion requirements which were 2.8 micrograms.kg-1 min-1 on day #1 increased to 22.3 micrograms.kg-1 min-1 on day #40.
Conclusion:
Increased infusion requirements were necessary during the prolonged administration of cis-atracurium to a critically ill infant. Titration of the dose based on monitoring with a peripheral nerve stimulator is recommended.