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Fraj N, Meddeb K, Azouzi A, Romdhani S, Saad HB, Boussarsar M. Compared efficacy and tolerance of the neuromuscular blockade induced by brand-name (Nimbex®) and generic (Cisatrex®) of cisatracurium in mechanically ventilated critically ill patients: a crossover double-blind randomized study. Pan Afr Med J 2020; 37:346. [PMID: 33738034 PMCID: PMC7934181 DOI: 10.11604/pamj.2020.37.346.24986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/12/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction use of generic drugs is common. However, there is still concern among patients and physicians that brand name drugs are more efficient. The aim of the study was to compare efficacy and tolerance between two forms of cisatracurium: brand name versus generic name. Methods it´s a crossover, randomized, double-blind physiological trial. Patients admitted for hypoxemic acute respiratory failure with PaO2/FIO2 < 200mmHg despite optimized ventilation and sedation thus requiring non-depolarizing neuromuscular blocking agents (NMBAs), were enrolled. Patients received consecutively, in a random order, cisatracurium brand name (Nimbex®) and generic (Cisatrex®) over two-hour period separated by one-hour washout period. Neuromuscular function was monitored by a calibrated train-of-four (TOF) stimulation device. Paralysis time delay to reach TOF of 2/4, recovery kinetics and tolerance were monitored. The number needed to demonstrate a significant difference in time delays to reach a TOF of 2/4 between the two forms of cisatracurium was estimated at 22 patients. Results twenty-two patients were included. Eight (36.4%) had acute respiratory distress syndrome; 8(36.4%), acute exacerbation of chronic obstructive pulmonary disease and 3(13.6%), status asthmaticus. Median [IQR] SAPS II at admission, 28.5 [22, 41]. PaO2/FIO2, 121 [81, 156] mmHg. Paralysis time delays were respectively, 80 [50, 112] vs. 87 [65, 115] minutes, in Nimbex® group and Cisatrex® group; (p=0.579). Within the recovery period, the between two-studied drugs´ difference in TOF was at 0.25±0.96; p=0.64. There were no significant hemodynamic differences. Conclusion the present study revealed no significant differences in efficacy nor in tolerance between cisatracurium brand name Nimbex® and generic name Cisatrex® in hypoxemic ventilated patients.
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Affiliation(s)
- Nesrine Fraj
- Medical Intensive Care Unit, Farhat Hached University Hospital, 4000, Sousse, Tunisia.,Research Laboratory N° LR12SP09, Heart Failure Farhat Hached University Hospital, 4000, Sousse, Tunisia
| | - Khaoula Meddeb
- Medical Intensive Care Unit, Farhat Hached University Hospital, 4000, Sousse, Tunisia.,Research Laboratory N° LR12SP09, Heart Failure Farhat Hached University Hospital, 4000, Sousse, Tunisia
| | - Abdelbaki Azouzi
- Medical Intensive Care Unit, Farhat Hached University Hospital, 4000, Sousse, Tunisia
| | - Sana Romdhani
- Medical Intensive Care Unit, Farhat Hached University Hospital, 4000, Sousse, Tunisia
| | - Helmi Ben Saad
- Research Laboratory N° LR12SP09, Heart Failure Farhat Hached University Hospital, 4000, Sousse, Tunisia.,Laboratory of Physiology and Functional Explorations, Farhat Hached University Hospital, 4000, Sousse, Tunisia
| | - Mohamed Boussarsar
- Medical Intensive Care Unit, Farhat Hached University Hospital, 4000, Sousse, Tunisia.,Research Laboratory N° LR12SP09, Heart Failure Farhat Hached University Hospital, 4000, Sousse, Tunisia
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Optimal dose of rocuronium bromide undergoing adenotonsillectomy under 5% sevoflurane with fentanyl. Int J Pediatr Otorhinolaryngol 2017; 101:70-74. [PMID: 28964314 DOI: 10.1016/j.ijporl.2017.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/20/2017] [Accepted: 07/21/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Adenotonsillectomy is a short surgical procedure under general anaesthesia in children. An ideal muscle relaxant for adenotonsillectomy would create an intense neuromuscular block while having a quick recovery time without postoperative morbidity. We compared the effect of different doses of rocuronium for the tracheal intubation in children under 5% sevoflurane and fentanyl. MATERIALS AND METHODS 75 children (aged 3-10 years, ASA I) scheduled for adenotonsillectomy were enrolled. Anaesthesia was induced with propofol 2.5 mg/kg, followed by fentanyl 2 μg/kg. After mask ventilation with 5 vol% sevoflurane in 100% oxygen for 2 min, 2 ml of study drug was administered intravenously, i.e., either normal saline (S Group) or one of two doses (0.15 or 0.3 mg/kg) of rocuronium. We assessed conditions during tracheal intubation and also recorded the surgical condition, the time from discontinuation of sevoflurane to extubation and PAED scale, pain scores in PACU. RESULTS Rocuronium groups (96% and 100%, respectively; P < 0.01) showed statistically superior clinically acceptable intubating conditions than the saline group (72%). The 0.3 mg/kg rocuronium (80%) treatment clearly resulted in excellent intubating conditions compared with the 0.15 mg/kg group (44%; p = 0.028). There was no significant difference in the time to extubation and surgical condition, and in the postoperative measures of emergence delirium, pain, and recovery time among the three groups. CONCLUSION A dose of 0.3 mg/kg rocuronium may provide optimal intubating conditions without delayed recovery in 5% sevoflurane anaesthesia with fentanyl in children undergoing adenotonsillectomy. CLINICAL TRIALS REGISTRY NUMBER NCT02467595.
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Chung YH, Chung IS, Kim MH, Shin J, Park J, Lee JJ. Comparing the effects of vecuronium and cisatracurium on electrophysiologic monitoring during neurosurgery: a randomized controlled study. Anesth Pain Med (Seoul) 2017. [DOI: 10.17085/apm.2017.12.3.213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Yang Hoon Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ik Soo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Hee Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinsub Shin
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Junwoo Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jeong Jin Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Maltz LA, Klugman D, Spaeder MC, Wessel DL. Off-label drug use in a single-center pediatric cardiac intensive care unit. World J Pediatr Congenit Heart Surg 2014; 4:262-6. [PMID: 24327493 DOI: 10.1177/2150135113481042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The frequency of off-label drug use and its association with morbidity and mortality in the cardiac intensive care unit (CICU) has not been previously studied. METHODS Patients less than 18 years of age admitted to the CICU from June to August 2008 were retrospectively identified. Patient demographics were collected for 30 days or until CICU discharge. Off-label drug use was defined as the prescription of a medication that lacked a labeled indication based on patient's age as reported in the Micromedex drug database and electronic Physician's Desk Reference. RESULTS Eighty-two patients were admitted to the CICU during the study period. In all, 40 (46%) patients were male; the median age was 10.6 months. Common diagnoses were left-to-right shunt lesions (20.7%) and single-ventricle lesions (20.7%), with an overall mortality of 2.4%. Of all drugs prescribed, 36% were off-label. In all, 94% of the patients received ≥1 drug off-label. The median number of drugs prescribed off-label was four. Patients receiving more than four off-label medications were younger, had longer CICU lengths of stay (median 9.5 vs 2 days, P < .001), and increased ventilator days (median two vs one day, P < .001). CONCLUSIONS Off-label drug use in the CICU is common. Frequency of use is likely higher in patients with a higher severity of illness. Further safety, efficacy, and pharmaceutical trials are warranted to optimize the use of these drugs to improve outcomes.
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Affiliation(s)
- Lily A Maltz
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA
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Aouad MT, Yazbeck-Karam VG, Mallat CE, Esso JJ, Siddik-Sayyid SM, Kaddoum RN. The effect of adjuvant drugs on the quality of tracheal intubation without muscle relaxants in children: a systematic review of randomized trials. Paediatr Anaesth 2012; 22:616-26. [PMID: 22489622 DOI: 10.1111/j.1460-9592.2012.03845.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Intubation without prior administration of muscle relaxants is a common practice in children. However, succinylcholine may be considered as the golden standard for optimizing intubating conditions. We conducted a systematic review of the literature to identify drug combinations that included induction of anesthesia with sevoflurane or propofol. Our aim was to select drug combinations that yield excellent intubating conditions ≥80%; we identified six combinations in children aged 1-9 years. Sevoflurane with remifentanil (1 or 2 μg·kg(-1) ), lidocaine (2 mg·kg(-1) ), or propofol (2 mg·kg(-1) ) as the adjuvant shared the following characteristics: premedication with midazolam and/or ketamine, long sevoflurane exposure time, high inspired and endtidal sevoflurane concentration, and assisted ventilation. One combination using sevoflurane with propofol (3 mg·kg(-1) ) without premedication, with shorter sevoflurane exposure time, and spontaneous breathing indicated that propofol may be the adjuvant of choice for a rapid sevoflurane induction. The only adjuvant identified in propofol induction was remifentanil (4 μg·kg(-1) ). No serious adverse events were reported with these combinations.
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Affiliation(s)
- Marie T Aouad
- Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon
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Johnson PN, Miller J, Gormley AK. Continuous-infusion neuromuscular blocking agents in critically ill neonates and children. Pharmacotherapy 2012; 31:609-20. [PMID: 21923445 DOI: 10.1592/phco.31.6.609] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Neuromuscular blocking agents (NMBAs) are often administered as a prolonged (> 24 hrs) continuous infusion in infants and children in the intensive care unit for a variety of reasons including facilitation of oxygenation and ventilation. No guidelines on the use of NMBAs in pediatric patients are available yet in the United States; however, pediatric guidelines are available in the United Kingdom. Based on a 2007 U.S. survey, the most commonly used nondepolarizing NMBAs for sustained neuromuscular blockade in critically ill children are pancuronium and vecuronium. Recent national drug shortages involving NMBAs have been reported for atracurium, cisatracurium, pancuronium, rocuronium, and vecuronium. Therefore, to explore alternative options for neuromuscular blockade, we conducted a literature search to identify articles evaluating prolonged use (> 24 hrs) of NMBAs administered by continuous infusion. The search was limited to English-language articles in the MEDLINE (1950-August 2010), EMBASE (1988-August 2010), International Pharmaceutical Abstracts (1970-August 2010), and Cochrane Library (1996-August 2010) databases. Relevant abstracts, reference citations, and manufacturers' product information were also reviewed. A total of 13 reports representing 208 children were included in the analysis. Many of the reports described wide interpatient variability in dosing for the specific NMBAs evaluated. Selection of the most appropriate NMBA should be based on the patient's clinical status, potential adverse effects, and pharmacoeconomics. All patients receiving sustained neuromuscular blockade should be monitored routinely to ensure that dosing is appropriate in order to obtain the desired level of blockade. The goal is to use the lowest dose possible in an effort to limit adverse effects or prolonged blockade.
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Affiliation(s)
- Peter N Johnson
- Department of Pediatrics, College of Medicine, University of Oklahoma, Oklahoma City, Oklahoma, USA
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Playfor S, Jenkins I, Boyles C, Choonara I, Davies G, Haywood T, Hinson G, Mayer A, Morton N, Ralph T, Wolf A. Consensus guidelines for sustained neuromuscular blockade in critically ill children. Paediatr Anaesth 2007; 17:881-7. [PMID: 17683408 DOI: 10.1111/j.1460-9592.2007.02313.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS A set of consensus guidelines was produced including six key recommendations. An evaluation of the existing literature supporting these recommendations is provided. CONCLUSIONS 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.
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Affiliation(s)
- Stephen Playfor
- Paediatric Intensive Care Unit, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK.
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Abstract
PURPOSE OF REVIEW Changes in practice and the development of new anesthetic drugs have influenced the use of muscle relaxants in children. This article reviews these developments, and defines the current role and factors affecting the choice of muscle relaxant drugs in pediatric anesthesia. RECENT FINDINGS The introduction of the laryngeal mask airway as a means of controlling the pediatric airway has reduced the need for muscle relaxants. In cases requiring tracheal intubation, however, a balanced anesthetic technique incorporating a nondepolarizing relaxant provides the best intubating conditions with the minimal potential for adverse effects. The introduction of newer less-toxic, shorter-acting anesthetic drugs has reduced the requirement for muscle relaxants during surgery. Moderate anesthesia with sevoflurane-remifentanil or propofol-remifentanil can keep patients immobile without producing hypotension and facilitate controlled ventilation once the effects of the intubating dose of a muscle relaxant have worn off. SUMMARY Recent developments in clinical practice have reduced or obviated the need for muscle relaxants in pediatric anesthesia. Muscle relaxants are still indicated for intubation and procedures requiring profound muscle relaxation, and to minimize the amounts of anesthetic drugs given to infants and sick children. Specific relaxants and doses can be chosen to suit the clinical circumstances.
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Affiliation(s)
- George H Meakin
- Department of Anaesthesia, Royal Manchester Children's Hospital, Pendlebury, Manchester, UK.
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R. Year in review in intensive care medicine, 2005. III. Nutrition, pediatric and neonatal critical care, and experimental. Intensive Care Med 2006; 32:490-500. [PMID: 16489423 DOI: 10.1007/s00134-006-0068-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2006] [Accepted: 01/08/2006] [Indexed: 01/15/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
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