Prolonged weakness after cisatracurium infusion: a case report

Area of Science:

• Critical Care Medicine
• Neuromuscular Pharmacology
• Intensive Care Unit Management

Background:

• Acute respiratory distress syndrome (ARDS) management often requires mechanical ventilation and neuromuscular blocking agents.
• High-dose corticosteroids are sometimes used for severe ARDS, but their interaction with neuromuscular blockers is not fully understood.
• Prolonged paralysis can lead to significant patient morbidity and prolonged intensive care unit (ICU) stays.

Observation:

• A 45-year-old female with ARDS developed prolonged paralysis after receiving cisatracurium infusion and high-dose methylprednisolone.
• Neuromuscular blockade persisted for over 48 hours after discontinuation of cisatracurium, with significant proximal and distal muscle weakness.
• Creatinine kinase levels showed moderate elevation, suggesting muscle injury.

Findings:

• The patient experienced persistent neuromuscular weakness for several weeks, requiring extensive physical and occupational therapy.
• Mechanical ventilation weaning was delayed due to the prolonged paralysis.
• This case represents the first documented instance of myopathy persisting >48 hours with cisatracurium and high-dose corticosteroids.

Implications:

• Clinicians must be aware of the potential for prolonged paralysis with neuromuscular blocking agents, even those with favorable pharmacokinetic profiles like cisatracurium.
• Concomitant use of high-dose corticosteroids may predispose patients to or exacerbate neuromuscular blockade.
• Vigilance and careful monitoring are crucial in critically ill patients receiving combined neuromuscular blocking agents and corticosteroids.