What weight should be used to calculate the initial rate of a cisatracurium drip in the setting of ARDs or targeted temperature management?

Comment by InpharmD Researcher

There is no available data designating between ideal body weight (IBW), actual body weight (ABW), or adjusted body weight (AdjBW) for cisatracurium titrated drip dosing in the setting of acute respiratory distress syndrome (ARDs) or targeted temperature management. Guidelines for cisatracurium recommend a flat dosing strategy over a period of 48 hours, however, the cited recommendations were not derived from studies specifically on ARDS or targeted temperature management.

Background

Per the 2020 Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) guideline on the use of neuromuscular blocking agents (NMBA) in adults with the acute respiratory syndrome (ARDS), cisatracurium should be the preferred agent among NMBA agents for use in ARDS patients given that cisatracurium has been studied in large randomized controlled trials (RCTs). It was discussed that two large RCTs administered cisatracurium at a fixed dose of 15 mg bolus followed by an infusion of 37.5 mg/h for 48 hours. Both compared a continuous 48 hours infusion of cisatracurium with standard care. The guideline states that clinicians may titrate the dose to clinical paralytic effect due to the uncertain dose-dependent effect of cisatracurium. [1]

Consistent with the above recommendation, the Intensive Care Medicine and Intensive Care Society guideline panel suggests the use of cisatracurium besylate by continuous 48 hours infusion in patients suffering early moderate to severe ARDS (P/F ≤20 kPa: GRADE Recommendation: weakly in favor) given that the evidence is only available for cisatracurium in the setting on ARDS. [2]

The 2016 update of the clinical practice guidelines for sustained neuromuscular blockade in critically ill adult patients suggests clinicians avoid using actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating NMBA doses for obese patients (body mass index ≥ 30 kg/m^2) (weak recommendation, low quality of evidence). [3]

Cited studies specific to cisatracurium within this 2016 update investigated the neuromuscular effects of cisatracurium in morbidly obese patients in the setting of bariatric laparoscopic gastric banding or for the general operating room administration. [4], [5]

Twenty obese female patients (body mass index [BMI] > 40) undergoing bariatric surgery were randomized to receive either 0.2 mg/kg of cisatracurium based on real body weight (RBW) (Group 1; n=10) or based on ideal body weight (IBW) (Group 2; n=10). The control group of non-obese patients (BMI 20-24) (n=10) received the dose of cisatracurium based on RBW. Cisatracurium dosing based on RBW resulted in a significantly longer duration of action in Group 1 than that in the control group with normal body weight (74.6 minutes vs. 59.1 minutes; P=0.01). However, the duration of action was significantly shorter in the IBW group than that in the control group (45.0 minutes versus 59.1 minutes, P=0.016). Based on these findings, the authors concluded that compared to non-obese patients, the duration of action of cisatracurium was significantly prolonged in morbidly obese patients when dosed according to RBW but significantly shortened when dosed according to IBW. The clinical significance of this either prolonged or shortened blockade was not further investigated in the study. [5]

References:

[1] Alhazzani W, Belley-Cote E, Møller MH, et al. Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Med. 2020;46(11):1977-1986. doi:10.1007/s00134-020-06227-8.
[2] Griffiths MJD, McAuley DF, Perkins GD, et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019;6(1):e000420. doi: 10.1136/bmjresp-2019-000420.
[3] Murray MJ, DeBlock H, Erstad B, et al. Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient. Crit Care Med. 2016;44(11):2079-2103. doi: 10.1097/CCM.0000000000002027.
[4] Salihoĝlu Z, Demiroluk S, Köse Y, et al. Neuromuscular effects of cisatracurium in morbidly obese patients. Middle East J Anaesthesiol. 2008;19(4):831-839.
[5] Leykin Y, Pellis T, Lucca M, et al. The effects of cisatracurium on morbidly obese women. Anesth Analg. 2004;99(4):1090-1094, table of contents. doi: 10.1213/01.ANE.0000132781.62934.37.
Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

What weight should be used to calculate the initial rate of a Cisatracurium drip in the setting of ARDS or targeted temperature management?

Level of evidence

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Please see Table 1 for your response.

 

Rate Tables for Continuous Infusion (from package insert)

Table 1. Cisatracurium Besylate Injection Infusion Rates for Maintenance of Neuromuscular Blockade During Opioid/Nitrous Oxide/Oxygen Anesthesia with a Concentration of 0.1 mg/mL
 

Drug Delivery Rate (mcg/kg/minute)
1 1.5 2 3

5
Patient Weight 

Infusion Delivery Rate (mL/hour)

10 kg

 6 9 12 18 30
45 kg

27

 41 54 81 135
70 kg

42

 63 84 126 210
100 kg

60

 90 120 180 300

 

Table 2. Cisatracurium Besylate Injection Infusion Rates for Maintenance of Neuromuscular Blockade During Opioid/Nitrous Oxide/Oxygen Anesthesia with a Concentration of 0.4 mg/mL

 

Drug Delivery Rate (mcg/kg/minute)

1

 1.5 2 3 5

Patient Weight

 Infusion Delivery Rate (mL/hour)

10 kg

 1.5 2.3 3 4.5 7.5 

45 kg

 6.8 10.1  13.5 20.3 33.8 

70 kg

 10.5 15.8  21 31.5  52.5

100 kg

 15  22.5 30  45  75

The intravenous infusion rate depends upon the Cisatracurium Besylate Injection concentration, the desired dose, the patient's weight, and the contribution of the infusion solution to the fluid requirements of the patient. Tables 1 and 2 provide guidelines for the Cisatracurium Besylate Injection infusion rate, in mL/hour (equivalent to microdrops/minute when 60 microdrops = 1 mL), in concentrations of 0.1 mg/mL or 0.4 mg/mL, respectively.

 

 

References:

Cisatracurium [prescribing information]. Lake Forest, IL: Hospira, Inc.; 2021