Chest

Chest

Volume 126, Issue 4, October 2004, Pages 1267-1273
Journal home page for Chest

Clinical Investigations in Critical Care
A Prospective Randomized Comparison of Train-of-Four Monitoring and Clinical Assessment During Continuous ICU Cisatracurium Paralysis

https://doi.org/10.1378/chest.126.4.1267Get rights and content

Study purpose:

Train-of-four (TOF) monitoring is often recommended during the continuous use of neuromuscular blockade (NMB) [paralysis] in the ICU. Prior study results are conflicting regarding the benefits of TOF monitoring.

Design:

Thirty patients in the medical ICU were randomized to TOF monitoring (n = 16) or to clinical assessment (n = 14) during continuous cisatracurium infusion. TOF monitoring was done at least every 4 h, with the goal being maintenance of one to two twitches. Statistical analysis was performed by two-tailed, unpaired t test (with Bonferroni correction for multiple comparisons), χ2, and Fisher exact test, with p < 0.05 considered significant. Given a power of 80%, and the variance seen in the two groups, we estimate that the sample size used is sufficient to detect a change of ≥ 60 min between groups for recovery time.

Results:

The mean recovery time after cessation of paralytics was no different between TOF and clinical assessment (45 ± 7 min vs 38 ± 10 min, respectively [mean ± SEM]). No differences were noted for mean APACHE (acute physiology and chronic health evaluation) II entry scores, glomerular filtration rates, or use of corticosteroids. No significant differences were noted between TOF monitoring and clinical assessment in mean total paralysis time (4,118 ± 1,012 min vs 3,188 ± 705 min, respectively), mean total cisatracurium dose (920 ± 325 mg vs 715 ± 167 mg), or dosage (2.3 ± 0.2 μg/kg/min vs 2.9 ± 0.2 μg/kg/min).

Conclusions:

TOF monitoring does not lead to improved recovery time or lower cisatracurium dosing compared with monitoring by clinical assessment. We conclude that TOF monitoring is unnecessary, and careful titration of the neuromuscular blocking agent by clinical assessment alone is sufficient in patients undergoing continuous cisatracurium NMB.

Section snippets

Patient Enrollment

All patients aged ≥ 18 years and admitted to the University of Mississippi Medical Center MICU who received continuous infusion NMB with cisatracurium (from December 1997 to September 1999) were enrolled in the study. Patients receiving a one-time bolus of cisatracurium or intermittent bolus therapy were not eligible.

Patients may have been started on NMB for up to 4 h (specifically with cisatracurium) outside of the MICU setting (ie, emergency department, surgical ICU, etc.) and be considered

Results

Patient enrollment is shown in Figure 1. Cisatracurium was the paralytic of choice in our MICU during the study period.

Patient demographics are summarized in Table 1. Considerable overlap in underlying initial diagnoses existed between the two groups, with no difference noted between pulmonary and nonpulmonary diagnoses or between APACHE II scores. Primary pulmonary diagnoses in the TOF group included ARDS (two patients), COPD (two patients), asthma (two patients), pneumonia (one patient),

Discussion

The use of NMB to improve ventilator synchrony remains necessary in some patients despite aggressive sedation.1 Unfortunately, the use of NMB has not come without a price. The occurrence of prolonged paralysis from overdosage of parent drug or active metabolites has been reported with greater frequency since the early 1990s.2 Various strategies to avoid this complication have been suggested including the use of TOF NMB monitoring.212 A 1995 consensus panel recommended peripheral nerve

ACKNOWLEDGMENT

Critical review and editorial assistance by Drs. Charlie Strange (Medical University of South Carolina) and Nancy Collop (Johns Hopkins University) are greatly appreciated.

References (16)

  • C Hanson

    Pharmacology of neuromuscular blocking agents in the intensive care unit

    Crit Care Clin

    (1994)
  • JH Hansen-Flaschen et al.

    Use of sedating drugs and neuromuscular blocking agents in patients requiring mechanical ventilation for respiratory failure: a national survey

    JAMA

    (1991)
  • J Hansen-Flaschen et al.

    Neuromuscular blockade in the intensive care unit: more than we bargained for

    Am Rev Respir Dis

    (1993)
  • MJ Murray et al.

    Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient

    Crit Care Med

    (2002)
  • MI Rudis et al.

    A prospective, randomized, controlled evaluation of peripheral nerve stimulation versus standard clinical dosing of neuromuscular blocking agents in critically ill patients

    Crit Care Med

    (1997)
  • B Zarowitz et al.

    Retrospective pharmacoeconomic evaluation of dosing vecuronium by peripheral nerve stimulation versus standard clinical assessment in critically ill patients

    Pharmacotherapy

    (1997)
  • RC Prielipp et al.

    Comparison of infusion requirements and recovery profiles of vecuronium and cisatracurium 51W89 in intensive care patients

    Anesth Analg

    (1995)
  • C Strange et al.

    Comparison of train-of-four and best clinical assessment during continuous paralysis

    Am J Respir Crit Care Med

    (1997)
There are more references available in the full text version of this article.

Cited by (0)

Supported by a grant from Glaxo Wellcome Pharmaceuticals.

TOF monitors were supplied courtesy of Glaxo Wellcome Pharmaceuticals.

View full text
Copyright © 2004 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.