rocuronium and Critical-Illness

This study was done to determine the safety, efficacy, dosing requirements, and spontaneous recovery profiles of prolonged infusions of rocuronium bromide in the critically ill.. This multicenter, prospective, nonrandomized, open label trial enrolled 32 patients at two university-based medical centers. Patients who were determined to require neuromuscular blockade for at least 24 hours received a bolus of 0.6 mg/kg of rocuronium. After subsequent recovery of two responses (T2) to the TOF stimulation, an infusion of rocuronium was begun at 10 microg/kg/min and continued for 24 to 120 hours as required by the patients' clinical status.. Patients were divided into multiple organ failure (MOF) and non-multiple organ failure (non-MOF) groups on enrollment. The mean infusion rates for the MOF and non-MOF groups were 0.2 and 0.5 mg/kg/hour, respectively.. The mean infusion rate of rocuronium that provides approximately 90% blockade is less for critically ill patients with MOF. Spontaneous recovery was prolonged in patients with MOF.

Topics: Adult; Androstanols; Critical Illness; Drug Monitoring; Female; Humans; Infusions, Intravenous; Injections, Intravenous; Male; Metabolic Clearance Rate; Middle Aged; Multiple Organ Failure; Neuromuscular Nondepolarizing Agents; Prospective Studies; Respiration, Artificial; Rocuronium; Time Factors

In mechanically ventilated patients, awareness with paralysis (AWP) can have devastating consequences, including post-traumatic stress disorder (PTSD), depression, and thoughts of suicide. Single-center data from the emergency department (ED) demonstrate an event rate for AWP factors higher than that reported from the operating room. However, there remains a lack of data on AWP among critically ill, mechanically ventilated patients. The objective was to assess the proportion of ED patients experiencing AWP and investigate modifiable variables associated with its occurrence.. An a priori planned secondary analysis of a multicenter, prospective, before-and-after clinical trial.. The ED of three academic medical centers.. Mechanically ventilated adult patients that received neuromuscular blockers.. None.. All data related to sedation and analgesia were collected. AWP was the primary outcome, assessed with the modified Brice questionnaire, and was independently adjudicated by three expert reviewers. Perceived threat, in the causal pathway for PTSD, was the secondary outcome. A total of 388 patients were studied. The proportion of patients experiencing AWP was 3.4% ( n = 13), the majority of whom received rocuronium ( n = 12/13; 92.3%). Among patients who received rocuronium, 5.5% ( n = 12/230) experienced AWP, compared with 0.6% ( n = 1/158) among patients who did not receive rocuronium in the ED (odds ratio, 8.64; 95% CI, 1.11-67.15). Patients experiencing AWP had a higher mean ( sd ) threat perception scale score, compared with patients without AWP (15.6 [5.8] vs 7.7 [6.0]; p < 0.01).. AWP was present in a concerning proportion of mechanically ventilated ED patients, was associated with rocuronium exposure in the ED, and led to increased levels of perceived threat, placing patients at greater risk for PTSD. Studies that aim to further quantify AWP in this vulnerable population and eliminate its occurrence are urgently needed.

Topics: Adult; Critical Illness; Emergency Service, Hospital; Humans; Paralysis; Prospective Studies; Rocuronium

Recent medication shortages of the neuromuscular blocking agent (NMBA) cisatracurium have forced the prescribing of aminosteroidal agents such as rocuronium. There are limited data on the use and dosing of continuous infusion (CI) rocuronium in critically ill patients outside of the operating room.. We sought to describe the use of CI rocuronium for sustained neuromuscular blockade in intensive care unit (ICU) patients by characterizing the dosing, utilization, and safety profile in patients with multiple organ failure (MOF) and non-MOF.. This was a retrospective review of patients in mixed ICUs from 2 tertiary medical centers who received CI rocuronium between January 2018 and July 2019.. A total of 46 unique rocuronium infusions were utilized for 40 patients during the evaluation period. Of these, 37% had MOF, and 41% had at least 1 organ fail during the rocuronium infusion. The median starting and maximum dose was 8 µg/kg/min. Overall, 64% of train of 4 (TOF) measurements were a TOF 0 (T0) or TOF 1 (T1), with a higher percentage of T0 or T1 in the MOF group compared with the non-MOF group (75% vs 50%). The median time to recovery was more than twice as long for the MOF compared with the non-MOF group (10 vs 4.6 hours). ICU-acquired weakness was diagnosed in 27% of survivors.. In ICU patients with MOF, continuous rocuronium infusions were associated with deep levels of paralysis and prolonged recovery times. If neuromuscular blockade is required for critically ill patients, alternative strategies could be considered.

Topics: Adult; Androstanols; Critical Illness; Humans; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Retrospective Studies; Rocuronium

Neuromuscular blockade in ICU patients has become less popular, in particular since non-invasive methods of artificial respiration have been introduced. Succinylcholine has numerous side effects. Due to its short onset, Rocuronium may be an alternative. The advantage of Atracurium and Cis-Atracurium is a largely organ-independent metabolism. In ICU patients, neuromuscular monitoring should be applied. Prolonged action and critical illness neuropathy are the most prominent side effects of neuromuscular blockade.

Topics: Androstanols; Atracurium; Critical Illness; Humans; Hypothermia, Induced; Intensive Care Units; Motor Endplate; Nervous System Diseases; Neuromuscular Blockade; Neuromuscular Blocking Agents; Neuromuscular Depolarizing Agents; Neuromuscular Nondepolarizing Agents; Pneumonia; Rocuronium; Sepsis; Succinylcholine; Thromboembolism; Vecuronium Bromide

The United Kingdom Paediatric Intensive Care Society Sedation, Analgesia and Neuromuscular Blockade Working Group is a multidisciplinary expert panel created to produce consensus guidelines on sedation, analgesia and neuromuscular blockade in critically ill children and forward knowledge in these areas. Neuromuscular blockade is recognized as an important element in the care of the critically ill and adult clinical practice guidelines in this area have been available for several years. However, similar clinical practice guidelines have not previously been produced for the critically ill pediatric patient.. A modified Delphi technique was employed to allow the Working Group to anonymously consider draft recommendations in up to three Delphi rounds with predetermined levels of agreement. This process was supported by a total of four consensus conferences and once consensus had been achieved, a systematic review of the available literature was carried out.. A set of consensus guidelines was produced including six key recommendations. An evaluation of the existing literature supporting these recommendations is provided.. Multidisciplinary consensus guidelines for maintenance neuromuscular blockade in critically ill children (excluding neonates) have been successfully produced and are supported by levels of evidence. The Working Group has highlighted the paucity of high quality evidence in these important clinical areas and this emphasizes the need for further randomized clinical trials in this area.

Topics: Androstanols; Atracurium; Child; Critical Care; Critical Illness; Humans; Monitoring, Intraoperative; Neuromuscular Blockade; Neuromuscular Nondepolarizing Agents; Pancuronium; Rocuronium; Vecuronium Bromide